Waleed Riad Saleh

Tendon transfer around the shoulder in obstetric brachial plexus paralysis: clinical and computed tomographic study.

Abstract: One hundred nine obstetrical palsy patients with defective shoulder abduction and external rotation had subscapularis release and transfer of teres major to infraspinatus with or without pedicle transfer of the clavicular head of pectoralis major to deltoid. The age at surgery averaged 67 months (11-192) and follow-up averaged 36 months (12-80). Thirty-nine cases had follow-up CT scan of both shoulders. Improvement of abduction averaged 64 degrees and that of external rotation 50 degrees, 100% and 290% gain, respectively. Both negatively correlated with the age at surgery (P < 0.001), and were significantly higher in patients operated younger than 4 years. On computed tomographic scans, the degree of glenoid retroversion positively correlated (P < 0.001) with the age at surgery, and was significantly higher in patients operated older than 4 years. The degree of posterior subluxation showed no significant difference between different ages. There was no significant difference between the operated and normal sides in patients operated younger than 4years with regard to glenoid retroversion and in those operated younger than 2 years with regard to posterior subluxation. The operation is useful for correction of defective shoulder abduction and external rotation in obstetric palsy. It is best performed before the age of 2 to get maximal improvement in motion and prevent secondary bone changes. Between the ages of 2 and 4, it also resulted in significant improvement in motion and prevented glenoid retroversion, but not posterior subluxation. After the age of 4, the improvement in motion was not significant and secondary bone changes were not prevented.

Delayed selective neurotization for restoration of elbow and hand functions in late presenting obstetrical brachial plexus palsy.

The published experience of obstetrical brachial plexus palsy (OBPP) cases with poor recovery and late neurosurgical intervention are sparse. This study included 19 cases who presented after the age of 1 year with poor recovery of elbow and/or hand function and electrophysiological evidence of reinnervation. Age at surgery averaged 41 months, and the follow-up averaged 50 months. Distal neurotization was performed for restoration of elbow flexion in 11 cases, elbow extension in 3 cases, and finger flexion and/or sensibility in 5 cases. Active elbow flexion increased from an average of 2.7 to 91.8 degrees with an average gain of 89 degrees. Active elbow extension increased from an average of 10 to 56.7 degrees with an average gain of 46.7 degrees. Although, three out of five cases (60%) showed satisfactory recovery of finger flexion, all cases scored<2 using Raimondi score. Four cases gained protective sensation and one case gained discriminative sensation. The results of neurotization in late OBPP are variable. The best and most consistent results are obtained by necrotizing the biceps by the intercostal nerves or, in selected cases, by the flexor carpi ulnaris fascicle of the ulnar nerve. Delayed neurotization is the only way to recover sensory function in the hand.

Free functioning gracilis transplantation for reconstruction of elbow and hand functions in late obstetric brachial plexus palsy

Background: In late obstetric brachial plexus palsy (OBPP), restoration of elbow and hand functions is a difficult challenge. The use of free functioning muscle transplantation in late OBPP was very scarcely reported. In this study, we present our experience on the use of free functioning gracilis transfer for restoration of elbow and hand functions in late cases of OBPP. Patients and Methods: Eighteen patients with late OBPP underwent free gracilis transfer for reconstruction of elbow and/or hand functions. The procedure was indicated when there was no evidence of reinnervation on EMG and in the absence of local donors. Average age at surgery was 102.5 months. Patients were evaluated using the British Medical Research Council (MRC) grading system and the Toronto Active Movement Scale. Hand function was evaluated by the Raimondi scoring system. Results: The average follow‐up was 65.8 ± 41.7 months. Contraction of the transferred gracilis started at an average of 4.5 ± 1.03 months. Average range of elbow flexion significantly improved from 30 ± 55.7 to 104 ± 31.6 degrees (P <0.001). Elbow flexion power significantly increased with an average of 3.8 grades (P = 0.000147). Passive elbow range of motion significantly decreased from an average of 147 to 117 degrees (P = 0.003). Active finger flexion significantly improved from 5 ± 8.3 to 63 ± 39.9 degrees (P < 0.001). Finger flexion power significantly increased with an average 2.7 grades (P < 0.001). Only 17% achieved useful hand (grade 3) on Raimondi hand score. Triceps reconstruction resulted in an average of M4 power and 45 degrees elbow extension. Conclusion: Free gracilis transfer may be a useful option for reconstruction of elbow and/or hand functions in late OBPP.

Arthroscopic grading of common wrist disorders and its role in management.

Palmer devised a classification system to guide treatment of triangular fibrocartilage complex tears in 1989. The main division is between traumatic Type I and atraumatic Type II tears. The wrist arthroscopy makes diagnosis and treatment of ulnar impaction syndrome possible in a less invasive way. Arthroscopy is the most valuable tool for diagnosis and treatment of acute scapholunate and lunotriquetral dissociation. Arthroscopic grading of Kienböcks disease better describes articular damage compared with plain radiographs and can help surgical treatment. The wrist arthroscopy generally makes it possible to make the diagnosis of the chondral lesion before they are visible by the usual imaging.

Conservative treatment of the isolated dislocation of the pisiform bone

Abstract We report isolated dislocation of the right pisiform bone dislocated distal and medial to the triquetrum bone in a young adult after a fall. Manipulation and closed reduction under intravenous regional anaesthesia resulted in full functional recovery and a good radiological outcome.

Acute carpal tunnel syndrome secondary to calcific tendinitis: case report.

Acute carpal tunnel syndrome (CTS) secondary to calcific deposition is rarely reported. In this article we describe a case of acute CTS in the dominant hand of a 94-year-old female patient secondary to calcific tendinitis within the carpal tunnel. Diagnosis was difficult clinically and radiologically. Urgent complete median nerve decompression led to a good clinical recovery.

Extensor tendon splitting versus extensor tendon sparing approach for miniplate fixation of extraarticular proximal phalangeal fractures

Background:Unstable phalangeal fractures constitute a challenge for surgeons with many options for operative treatment. Miniplate fixation of these fractures has the advantages of stability and neutralization of bending, rotational, and shear forces. To our knowledge, this is the first study to compare the functional results of an extensor tendon splitting approach with an extensor tendon sparing approach in extraarticular proximal phalangeal fractures fixed with a miniplate and screws. Methods:In a randomized prospective study we compared two groups of patients: group A, patients treated with an extensor tendon splitting approach (24 fractures in 21 patients with average age 31.9 yr) and group B, patients treated with an extensor tendon sparing approach (26 fractures in 19 patients with average age 30.8 yr). The final results were assessed with total active range of motion (TAM), grade of TAM, grip strength and Quick Disability of the Arm, Shoulder, and Hand (DASH) Score. Results:A TAM of 220 degrees or more was achieved in 79.2% (19/24) and 84.6% (22/26) of fractures in group A and B, respectively. There was a significant reduction in grip strength in group A compared to group B (45.9±8.4 kg vs. 51.7±7.3 kg; P<0.025). Other parameters showed slightly better results in group B compared with group A but the differences were statistically insignificant in regard to time to union (5.3+1 wk vs. 5.6+1.1 wk), TAM (226.8+18.4 degrees vs. 233.2+17.5 degrees), grading of TAM (excellent score 75% vs. 80.8%) and QuickDASH score (12±9.2 vs. 11.5±8.3). Conclusions:Meticulous surgical dissection, anatomical closure of layers, and early active mobilization are the keys to success in fixation of phalangeal fractures, regardless of the approach chosen.

DUPUYTREN'S DISEASE CONFINED TO THE INTERPHALANGEAL JOINTS: A CASE REPORT

A typical case of Dupuytrens contracture confined to the interphalangeal joints of the right little finger, occurred in a 79-year-old man. No past history of risk factors or family history of Dupuytrens disease could be detected. Excisions of the abnormal cords lead to good clinical outcome.