Terry S. Axelrod

Scaphoid Nonunion with Avascular Necrosis of the Proximal Pole Treatment with a vascularized bone graft from the dorsum of the distal radius

Scaphoid nonunion with avascular necrosis of the proximal pole remains a difficult problem. We have endeavoured to heal the fracture, restore scaphoid height and revascularize the proximal pole of the scaphoid by means of a vascularized dorsal interposition graft from the distal radius. The procedure has resulted in union of six of ten fractures. Fractures that healed had not been treated by a previous bone grafting procedure. Dissatisfaction was due to loss of motion in patients who had healed fractures, and pain in those patients with persistent non-unions.

Splint-top fracture of the forearm : a description of an in-line skating injury associated with the use of protective wrist splints

Upper extremity injuries are commonly seen in the sport of in-line skating. The use of protective equipment, including wrist splints, has been advocated as a means to decrease both the incidence and severity of upper extremity injuries in this sport. We report on four cases of open forearm fractures in the in-line skaters that occurred adjacent to the proximal border of the wrist splints. The unusual nature of these injuries and the location of the fractures in relation to the location of the splints suggest that the two may be mechanistically related. The splint and distal forearm may act as a single unit to convert the impact from the level of the wrist to a torque moment, with the fulcrum located at the proximal border of the splint. The energy from the fall is then dissipated by the fracturing of the forearm bones at this level. These cases suggest that the use of wrist splints may be associated with their own specific set of injury patterns.

ATROPHIC NONUNION OF THE CLAVICLE: TREATMENT BY COMPRESSION PLATE, LAG-SCREW FIXATION AND BONE GRAFT

We describe a new surgical treatment of atrophic nonunion of the clavicle. The nonunion is excised by cuts at 45 degrees to the long axis and repair uses 3.5 mm pelvic reconstruction or dynamic compression plates, with a lag screw to provide interfragmentary compression. The site is grafted with cancellous bone. We have been successful in all seven patients, with early return to normal function. The consequent narrowing of the shoulder girdle is fully acceptable for appearance and function.

Traumatic Injuries of the Distal Radioulnar Joint

Traumatic injuries of the distal radioulnar joint (DRUJ) may give rise to complex wrist pathologies. Substantial ongoing disability can arise should these injuries go unrecognized resulting in sub-optimal treatment and lack of appropriate rehabilitation. Injuries of the DRUJ may occur in isolation but more commonly are found with a fracture of the radius. These challenging DRUJ injuries may be simple or complex (irreducible or severe instability), acute or chronic. An adequate knowledge of the stabilizers of the DRUJ is essential in understanding treatment options. Traumatic instability of the DRUJ is reviewed and the anatomy and stabilizing factors are discussed. An algorithm to guide selection of treatment options in complex cases is presented.

Isolated volar distal radioulnar joint dislocation.

CASE REPORT A 54-year-old right hand dominant manual laborer injured his non-dominant forearm, after it was compressed between machinery roller’s positioned 3 inches apart. This injury was associated with pain, distal forearm swelling, and loss of rotation. The initial X-ray films showed no fracture, however, mal-alignment of the DRUJ was seen on the lateral view Figure 1, A and B. Appreciation of this mal-alignment was not noted until physiotherapy was commenced at 5 weeks. The absence of forearm rotation initiated further investigation. A computed tomography (CT) scan at 5 weeks postinjury, revealed an impaction fracture of the ulna head, which was trapped by the palmer lip of the distal radio-ulna articular surface (Figure 2, A and B). A closed reduction and crossed radioulnar pinning was then performed at 6 weeks. The initial intraoperative imaging of the reduction looked satisfactory (Figure 3, A and B), however, a follow-up CT scan revealed complete displacement of a portion of the ulnar head through the impaction defect (Figure 4, A and B). The patient was referred to our institution for further management. At 8-week postinjury, the senior author performed an open reduction of the DRUJ. The ulna head was exposed through the extensor carpi ulnaris subsheath. The displaced articular segment of the ulna head was exposed with care taken to preserve the volar radioulnar ligament. The articular segment was volarly dislocated. The large osteochondral fragment was reduced to its anatomic position and held with two 2-mm lag screws. The extensor carpi ulnaris subsheath was then repaired and wrist stability assessed. The DRUJ was found to be stable. Postoperative care consisted of a wrist splint with early forearm rotation. At 4-month follow-up 90% of pronation and 80% of supination had been achieved with no DRUJ instability. X-ray films at 4 months showed the fracture that had healed with no evidence of avascular changes to the previously displaced articular head segment (Figure 5). The hardware has been subsequently removed with no complications and the patient is satisfied with the outcome and has returned to manual work (Figure 6).

Management of Complex Dislocations of the Distal Radioulnar Joint

The authors reviewed their experience in the treatment of complex dislocations of the distal radioulnar joint. Six cases of complex dislocations were treated between 1990 and 1993. An algorithm for the treatment of these injuries has been developed. In most cases, complex dislocations are associated with an avulsion fracture of the ulnar styloid. The authors prefer to treat these by fixation of the ulnar styloid using a tension band wiring technique. Cases in which the ulnar styloid fragment is small, or in which there is no styloid fracture, are treated with open reduction and repair of the triangular fibrocartilage complex if the distal radioulnar joint is irreducible, or by ulnoradial transfixion pinning if the distal radioulnar joint is reducible but unstable. Good results were obtained in five of six cases using this algorithm.

Exposures of the elbow.

This article describes the basic bony, ligamentous, and neurologic anatomy of the structures about the elbow. The surgical exposures of the elbow joint are described, providing details of the various posterior, lateral, and medial approaches to the articular segments. Clinical applications describing the potential benefits of each surgical exposure are provided as examples.

Madelung's Deformity: radial opening wedge osteotomy and modified Darrach procedure using the ulnar head as trapezoidal bone graft

Surgery may be indicated in treating Madelung’s deformity and numerous techniques have been described. This study reports the early clinical and radiological results of a radial biplanar opening wedge osteotomy and modified Darrach procedure, using the excised ulnar head as a trapezoidal bone graft. Between 2000 and 2008, five adult wrists with symptomatic Madelung’s deformity underwent surgery. All patients were female, with an average age at surgery of 34 years. Assessment included range of movement, grip strength, DASH scores and radiological imaging. All patients improved both subjectively and objectively with regards to pain, functional range of movement, and appearance at mean follow-up of 55 months (range 14—113). All osteotomies united. One patient required removal of hardware for restricted rotation. This technique provided satisfactory results that are comparable to other studies, and avoids the use of iliac crest bone graft.

Mycobacterium chelonae Infection Following Silicone Arthroplasty of the Metacarpophalngeal Joints: A Case Report

We present a case of infection caused by an uncommon pathogen, Mycobacterium chelonae, in a patient that underwent Swanson silicone arthroplasty of the metacarpophalangeal joints for rheumathoid arthritis. This is the first report of an infection caused by nontuberculous Mycobacteria in flexible silicone implants in the hand. The patient was successfully treated with implant removal, debridement, and antimicrobials tailored to the results of in vitro susceptibility testing.

The fulcrum axis: an accurate measure of glenoid version on radiographs and computed tomography

Background Proper glenoid position in total shoulder arthroplasty (TSA) is important. However, traditional glenoid version (GV) measurements overestimate retroversion on radiographs (XR) and computed tomography (CT). The fulcrum axis (FA) uses palpable surface landmarks and may be useful as an intra-operative guide. Also, the FA has not yet been validated on XR or CT in an arthritic population. Methods Four observers measured FA and GV on the XR, CT and three-dimensional CT (3DCT) of 40 patients who underwent TSA at a single institution from 2009 to 2015. Reliability and accuracy of FA and GV were calculated for XR and CT, using 3DCT as the gold standard. Results The mean FA and GV were 7.768° and 18.910° on XR; 6.23° and 12.920° on CT; and 8.100° and 7.740° on 3DCT, respectively. FA and GV were significantly different for XR and CT (p < 0.001) but not for 3DCT (p = 0.725). The inter-rater reliability, intra-rater reliability and accuracy of FA were not significantly different from GV and were 0.929 to 0.948, 0.779 to 0.974 and 0.674 to 0.705, respectively. However, the absolute difference of FA was closer to the gold standard (3DCT) than GV for XR (0.330° versus 11.172°) and CT (1.871° versus 5.178°) (p < 0.001). Conclusions FA showed comparable reliability and accuracy to GV. However, FA more accurately reflected the gold standard.