William D. Engber

Proximal row carpectomy in advanced kienbock's disease

Sixteen patients with advanced Kienböcks disease (Lichtman stage IIIa and IIIb) were treated with proximal row carpectomy. Two patients were lost to follow-up study. The remaining 14 patients were followed for 3 years (range, 1 to 8 years) and all experienced less pain. Wrist motion was improved or unchanged in 12. Grip strength averaged 72% of the unaffected side. All patients returned to their previous jobs. Proximal row carpectomy in this group of patients provided satisfactory results.

Long term evaluation of repaired distal biceps brachii tendon ruptures.

A long term evaluation was performed on 8 patients who had rupture of the distal biceps tendon repaired using the 2-incision technique. The length of followup ranged from 1 to 11 years with an average of 6 years. Goniometric range of motion and isokinetic strength testing were performed on all patients. All patients attained a full arc of elbow flexion and extension. Supination was diminished more than 30° in 3 patients and pronation was diminished more than 30° in 1 patient. Subjectively, 6 of 8 patients were completely satisfied with the function of their involved arm. Strength and work performed during repetitive exercise were regained to the expected normal levels in elbow flexion. Six of 8 patients continued to have less strength in supination of the injured arm than the uninjured arm. All 8 patients performed less total work with repetitive supination of the injured arm than the uninjured arm.

Ganglions of the wrist and digits: results of treatment by aspiration and cyst wall puncture

In a prospective study, 87 carpal and digital ganglions were aspirated, multiply punctured, and digitally ruptured. Fifty percent of wrists and digits were immobilized for 3 weeks and 50% were mobilized early. Mean follow-up was 22 months. Thirty-six percent (31/87) of all ganglions treated showed a successful outcome. Twenty-seven percent (16/60) of dorsal carpal, 43% (6/14) of palmar carpal, and 69% (9/13) of palmar digital ganglions did not recur. Immobilization significantly improved the results of treatment of dorsal carpal ganglions. Forty percent (12/30) of those in the immobilization group and 13% (4/30) of those in the early mobilization group had a successful outcome (p less than 0.05).

Palmar cutaneous branch of the ulnar nerve

With recent attention being placed on the median palmar cutaneous nerve, a surgical approach, ulnar to the axis of the ring finger ray, has been advocated for median nerve decompression at the wrist. Painful hypothenar neuromas have developed in two patients with this type of incision. After dissecting 21 cadaver forearms and hands, three classic and two variants of the ulnar palmar cutaneous nerve were identified and found to emerge in the subcutaneous tissue ulnar to the ring finger ray. The terminal branches supplied the hypothenar skin and extended radially to the ring finger ray axis. Because of these anatomic findings, we recommend an incision in line with the ring finger ray axis in an attempt to avoid injury to both ulnar and median palmar cutaneous nerves.

Metastatic breast cancer in the femur. A search for the lesion at risk of fracture.

Clinical records and radiographs of 203 female patients with 516 metastatic breast lesions located in the proximal femur were examined retrospectively to determine: the dimensions of those lesions that were at risk of fracture; and the relationship of other variables (bone pain, body habitus, age, and radiation treatment) with the occurrence of a pathologic fracture. Twenty-three patients sustained 26 pathologic fractures. Their average age, height, and weight were not significantly different from the 180 patients without fractures. Similarly, moderate to severe bone pain was experienced by a great majority of the total patient population, yet only 11% sustained fractures. Fifty-six patients received radiation treatment of a femoral metastasis. Ten of these patients subsequently sustained fractures. Radiation treatment relieved bone pain but did not have any consistent curative effect on the lesion itself. Finally, the authors were unable to identify either a specific percent involvement of the bone or a critical diameter for metastases that fractured because: 296 (57%) of the 516 metastases were permeative lesions and unmeasurable; 14 (54%) of the 26 pathologic fractures observed occurred through unmeasurable lesions; and the 12 measurable lesions that fractured had the same range of percent involvement as the 208 measurable lesions that did not fracture. Breast metastases at risk of fracture cannot be identified by measurements obtained from standard radiographs alone.

Surgical treatment of mallet finger fractures by tension band technique.

A retrospective review was performed of 19 patients with irreducible mallet finger fractures after failed splinting. The patients were treated with open reduction and a tension band technique. Follow-up results were available for 18 patients (95%) at an average 8.2 years postoperatively. Eighty-nine percent of patients had no clinical mallet deformity, troublesome pain, or major functional disability. Distal interphalangeal range of motion averaged 1 degree hyperextension to 69 degrees flexion. All fractures healed with a congruent articular surface. Minor nonmechanical complications were encountered in 11% of cases in which a suture was used as the tension band material. Successful treatment may thus be achieved surgically in this select subset of mallet finger fractures when this technique is employed.

Retrograde Herbert screw fixation for treatment of proximal pole scaphoid nonunions

Most nonunions of the carpal scaphoid bone can be treated with a high rate of success by use of conventional bone grafting techniques. However, fractures with a small proximal pole fragment may be difficult to treat by use of these techniques. Nine patients with nonunion and three patients with unstable proximal pole fractures were treated with retrograde dorsal Herbert screw fixation and adjunctive bone grafting. Follow-up averaged 25 months. Of the 12 patients, the fracture healed in 11 and one fracture remained ununited. This technique has been successful in our practice and should be considered in the treatment of small proximal pole nonunions and displaced proximal pole fractures.

Double-entrapment radial tunnel syndrome

A symptomatic double-level entrapment of the posterior interosseous branch of the radial nerve is described. In addition to the more common level of compression at its entrance into the supinator, the posterior interosseous nerve may be entrapped at its exit from the supinator or at multiple levels.

Biomechanical and Histological Evaluation of the Herbert Screw

The Herbert screw has been demonstrated to have widespread clinical applicability. A biomechanical and histological evaluation of the Herbert screw was conducted to better define its applications. When subjected to pull-out, toggle, and compression testing, in a cancellous bone calf model, it was demonstrated to be biomechanically inferior to the 4.0 mm ASIF cancellous screw. The use of two Herbert screws minimized but did not eliminate this difference. Articular cartilage healing in a rabbit model was consistently demonstrated if the Herbert screw was buried deep to the osteochondral junction. However, toluidine blue histochemical staining showed that the hyaline-like repair cartilage differed qualitatively from normal cartilage. Utilization of the Herbert screw should include an understanding of the limitations of its fixation potential and a recognition of the repair response after intraarticular applications.

Biomechanical analysis of mallet finger fracture fixation techniques

A biomechanical study was conducted to determine the best fixation technique for mallet finger fracture among four commonly used methods. Considerations were technical complications, biomechanical properties, and maintenance of reduction. Techniques tested included Kirshner wire, figure-of-eight wire, tension band wire, and tension band suture. Technical complications were frequent with both the Kirschner wire and tension band wire techniques. Biomechanical testing yielded significantly greater energy absorbed to failure and a trend toward greater peak loads to failure for both the figure-of-eight wire and tension band suture techniques. Irreversible loss of reduction during testing occurred in all of the Kirschner wire-fixed fractures, in 60% of the tension band wire-fixed fractures, and in 50% of the figure-of-eight wire-fixed fractures. No irreversible failure occurred in the tension band suture group.