Posterior interoseous nerve (PIN) syndrome is an entrapment of the deep branch of the radial nerve just distal to the elbow joint. It may result in the paresis or paralysis of the fingers and thumb extensor muscles.

We present a review of 26 cases of PIN entrapment syndrome, diagnosed an treated over a ten years period form 1996 to 2005. Their ages ranged form 12 to 57 years, they were 18 men and 8 women. The interval between, the onset or paralysis and operation ranged from 4 months to 1 year. All the patients were diagnosed preoperatively as having PIN palsy from physical examination and electromyographic (EMG) studies of the posterior interoseous innervated muscles and all were treated by operation.

The cause of compression was, ganglia in four cases, fascia thickening at the arcad of frohse in six cases, the radial recurrent vessels in three cases, lipoma in four cases, dislocated head of the radius in two cases, infamed synovium in four cases, tumour in two cases, and Intraneural Perineurioma in one case. The periods of postoperative observation were from 1 to 10 years. The paralysis recovered completely by the six postoperative months in all cases except one girl with intraneural peri-neurioma.

Three patients developed mild reflex sympathetic dystrophy which resolved with physiotherapy and auxilary blocks. Two patients developed hyperaesthesia in the distribution of the superficial radial nerve which recovered in a few weeks.

Having arrived at a diagnosis of PIN syndrome, it is important to select the correct level for the release of the radial nerve. Fair or poor results can be due to incorrect diagnosis, incomplete release or irreversible nerve injury.

Acute fractures of the humeral shaft are usually managed conservatively. The rate of union is high, whereas that of nonunion ranges from 1 – 6%. Various risk factors for nonunion have been identified, including the following: open fracture, mid shaft fracture, transverse or short-oblique fracture, comminuted fracture, unstable fixation, fracture gap.

This paper evaluates the results of treatment of humeral shaft fracture by open reduction and internal fixation with DCP, supplemented with cancelous bone graft but not in all cases.

One hundred and five cases of nonunion of a humeral shaft fracture between 1988 and 2006 were analyzed retrospectively. The study population comprised 66 males and 39 females with an average of 46.2 years (range, 17 – 81 years). Sixty seven fractures were defined as atrophic nonunion, and 20 as hypertrophic nonunion, whereas 18 could not be defined clearly. All the fractures were managed by open reduction and internal fixaztion with DCP and cancelous bone graft. The mean follow up period was 20 months (range, 14 – 28 months).

All nonunion fractures united within an average of 16 weeks (range 10–26 weeks).

Complications included 4 patients with temporary radial nerve palsies, and 3 patients with wound infections. At the final follow-up shoulder and elbow functions of the operated limbs were all satisfactory.

Fixation by DCP with supplemental cancellous bone graft is a reliable and effective treatment for nonunion of a humeral shaft fracture

Introduction: About 5–12 percent of scaphoid fractures are associated with other fractures, and approximately 1 percent of scaphoid fractures are bilateral.

Materials and Methods: Three hundred fifty patients sought treatment for established scaphoid non-union at the author’s department. All patients routinely underwent plain radiographs, taken with both hands in neutral position for preoperative measurement of scapholunate angle and scaphoid length. Unexpectedly however, radiological examination revealed a bilateral scaphoid Herbert type D2 pseudoarthrosis (24 waist) in 12 patients (5 females, 7 males with mean age 25 years, range 14 to 48). No patient was aware of the mechanism of controlateral injury or had previously complained of controlateral wrist pain. All patients received treatment for both sides. The scaphoid was exposed through a volar approach. The fracture was anatomically reduced and fixed with a Herbert screw. Iliac bone graft was used. Mean follow-up was 43 months (range, 25 to 68) using the modified Mayo wrist score.

Results: Fracture union was confirmed both clinically and radiographically and union rates were 96 percent. Mean union time was 7 months (range 4 to 12 months). Non-union occurred in 1 patient. According to the Mayo wrist score, excellent results were achieved in 17 cases, good in 6 and poor in 1.

Conclusion: Bilateral scaphoid pseudoarthrosis has a very rare incidence, and experience showed us that patients do not always complain of both sides. Routine pre-operative evaluation at our institution includes a set of comparative plain radiographs of the wrists and we strongly recommend this policy to avoid missing bilateral injuries.

Complex injuries of upper extremity are among the most challenging cases for the treating physician, especially when comminuted fractures, neurovascular injuries or extensive soft tissue loss are accompanied with. Reconstruction of the skeleton is usually very difficult since plates, screws, or external fixation do not always provide sufficient stability. Recently, flexible titanium intramedullary nails that initially developed for pediatric trauma, were introduced in treatment of open and complex injuries of upper extremity.

From 1995 – 2001 20 patients (16 male, 4 female) with a mean age 28 years (15–60 years) were managed at our department with flexible titanium intramedullary nailing. 12 sustained forearm fractures, humeral ones, as well as 4 concomitant fractures of forearm and humerus.Nailing was performed either closed with image intensifier or open through the wound with minimal stripping. Postoperatively a splint was applied. Rehabilitation regime was adjusted to soft tissue care; when severe soft tissue wasn’t encountered, early mobilization of the arm was applied.

Union rate was conceivably high, in a relative short time. In 3 cases of segmental fractures of radius, nail removal and subsequent fixation with plate and screws due to nonunion of distal site, was necessitated.

Operative technique is simple, fast and reliable providing satisfactory reduction, stable fixation with minimal further tissue trauma and mostly early mobilization

Over the last decade 18 patients with thoracic outlet syndrome (T.O.S.) were treated at our department by scalenectomy through transverse supraclavicular approach.Preoperatively all of the patients had experienced pain, paresthesias and tingling of neck and shoulder with radiation to the ipsilateral arm, whereas 8 of them had additionally vascular symptoms.

Postoperatively (6 months – 2 years) 12 patients were still suffering or they had a deterioration of symptoms. 9 were male (80%) whereas 3 were female (20%).

Resection of the first rib through transaxillary approach was performed and six months later they all had returned back to work, reporting complete relief (80%) or significant improvement (20%).After 4 years of follow up there were no recurrences.

In one case there was a long thoracic nerve palsy that spontaneously recovered after 6 months.

Whilst the cause of recurrence remains controversial, many authors suggest that this is due to adhesions of scar tissue to the nerves and vessels at the axilla. Therefore, intervention should be planned and performed by an experienced surgeon, avoiding complications and minimizing tissue trauma.

In conclusion, prevention is the best way of managing recurrences; accurate clinical evaluation, careful preoperative planning and meticulous dissection are the cornerstones of a successful outcome.

378 patients have been studied since 1988 when we started the investigation of scaphoid fractures and pseudarthrosis. 306 patients were scaphoid pseudarthrosis and 72 scaphoid fractures or control of fracture healing. This study consists of 3 groups:

Group l: 72 patients with acute injury of the carpus are examined radiographically and no scaphoid fracture was observed. A scaphoid cast is applied in these patients for 10 days. In follow up, the cast is removed and new comparative radiologic examination is performed. In 30 of these patients a scaphoid fracture was observed and the limb was inmmobilized in a scaphoid cast for 4 weeks. In the remaining 42 patients, in whom a fracture line could not be observed in a simple x-Ray, but continued to have clinical findings, a CT-scan was performed in 2 planes. In 26 patients with no fracture in the CT-scan were discharged, while in the remaining 16 patients with obvious fracture in the CT-scan a scaphoid cast was applied for 4 weeks.

Group 2: 30 patients with scaphoid fracture, from which the cast was removed and the fracture line was still visible in a simple X-Ray were examined with CT-scan in 2 different planes. In 18 we found intense healing of the fracture in all the width of the scaphoid and the patients were discharged . The remaining 12 displayed delayed non union with obvious fracture line in all the width of the scaphoid. These patients were treated operatively, by compressing the fracture line with a Herbert screw.

Group 3: This is the largest group of patients concerning the scaphoid pseudarthrosis and consists a topic of a different study. In conclusion the computer tomography scan in two different planes is the most reliable method for the investigation not only of scaphoid fractures but also of the efficiency of the callus. The contribution of the above method in the study of the scaphoid pdeudarhrosis is very important and valuable.

In this report we present the results of the primary suture of the flexor tendons in zone II, in 198 patients who were operated in our department between 1998 and the first months of 2001. 142 were male from 16 to 65 years old and 56 were female between 14 to 60 years old. Children below 14 years old are not included in this report.

The majority of patients in this review reported an accident during dancing and late night activities. Patients with complex injuries such as fractures of phalanges, phalangeal dislocations and extensive soft tissue laceration were excluded. The majority of the patients operated immediately within the first 48 hours and only 28 patients (14, 5%) were operated with a delay ranging between 1 – 5 weeks. The suturing technique was variable in all cases. A Bruner (zig-zag) incision was utilized to facilitate. The tendon was sutured using a standard Kleinert technique and 4.0 nylon sutures as supportive sutures, 5.0 nylon sutures were used to suture the epitendon in a continuous fashion. A dorsal splint holding the wrist in 40° of flexion and the MP joints in 70° of flexion and PIPs and DIPs in extension was used postoperatively. Early mobilization was initiated (shortly after surgery, 3 – 4 days) and lasted 4 weeks. After this period the patient underwent a program of full active motion for an additional 4 weeks. They finally allowed to perform freely after a 12-week postoperative period.

We used the Kleinert score to evaluate the surgical results. According to this score results were found to be: Excellent in 80 patients (40%), good in 60 pts (30%), fair in 22 (12%) and poor in 16 pts (8%). Despite the satisfactory overall results we observed a high incidence of tendon ruptures (10%) in 20 patients and this may be related to poor follow up and rehabilitation conditions. No other complications (infection, hematoma formation, and skin slough) were observed in these patients.

Thoracic outlet syndrome (TOS) is characterized by a series of symptoms, which arise from the compression of the neurovascular bundle between the supraclavicular space and its entry to the axilla. The type and intensity of symptoms is relative to the site of compression and the anatomic structures involved.

Between 1990 and 2001, 42 patients were operated for thoracic outlet syndrome utilizing a supra-clavicular incicion (8 bilateral). 12 were male and 30 female. Ages ranged from 21 to 55 years (mean 31). The time interval between the onset of first symptoms and operation was 7 to 12 months in 16 patients and 1 to 4 years in 26 patients. All patients had neurologic symptoms with pain, paresthesias and numbness in the lateral neck, shoulder or arm. The duration and intensity of symptoms was variable. 12 of them had symptoms arising from the arterial compression. Preoperative evaluation included a formal clinical and neurologic examination, radiographs of the chest and cervical spine, Electromyography was often performed if a carpal tunnel syndrome was suspected. Angiography was performed in patients with vascular symptoms. MRI scan of the cervical spine and supraclavicular spaces were routine practice. Most of the patients had undergone prolonged conservative treatment including medication (muscle relaxants and analgesics), physiotherapy, exercises and cervical brace immobilization. This approach produced only temporary improvement or even aggravation of their neurologic complaints.

Intraoperativelly we found: Hypertrophy of the scalene muscle with aberrant or broad insertion on the first rib (31 pts), perineural fibrosis (5 pts), long type cervical rib (2 pts), fibromuscular bands between the 7 transverse process and the first rib (4 pts), vascular bridge pinching the lower trunk (4 pts). In four cases no obvious anatomic finding within the thoracic outlet affecting the brachial plexus could be found. The follow up period ranged from 6 months to 10 years (mean 6 years). Results were classified as excellent in 16, who were free of symptoms. Good in 12, who complained of mild symptoms on daily activities but were significantly improved. Poor in 6 who had persistent or aggravation of their symptoms. 4 patients from the poor results group were treated by 1st rib excision, on a later stage and experienced significant improvement.

The operative complications include one case of pneumothorax and a temporary dysfunction of the phrenic and XI cranial (accessory) nerve. No postoperative complications were found and the average hospitalization period ranged between 24 – 48 hours.

Humeral shaft fractures are among the most frequent fractures encountered in Orthopaedic Traumatology. Their treatment can be either conservative or operative depending on the location (proximal, middle or distal third), type (spiral, oblique, or transverse), radial nerve involvement, concomitant presence of thoracic injuries that preclude general anesthesia, as well as surgeon’s experience. Non union or delayed union complicates some of the conservatively and very few of the operatively treated fractures.

We report of our experience with the management of humeral shaft non unions in 28 patients treated at our institution from 1990 to 2000. Six were male and twelve female aging from 21 to 68 years (mean 45 years).The interval between initial injury and operation varied from 6 months to 3 years (average 10 months).Regarding the location of non union,20 cases were located in the middle, 6 cases in the upper and 2 cases in the distal third.

Operative technique: under general anesthesia using anterolateral approach for middle and distal third and deltopectoral approach for proximal third , the site of pseudarthrosis was exposed. In transverse and slightly oblique fractures a self compression plate was implanted without resection of pseudarthrosis or excessive soft tissue detachment .In spiral and true oblique fractures reduction performed initially, maintained with k-wires and fixated with self compression plate. Upon completion of osteosynthesis suction drain was put ,followed by wound closure and elastic bandage.

Postoperatively a colar cuff was used for 2 weeks .Follow up examination with radiographic evaluation was done after 3 and 6 months.

Signs of incomplete callus formation were obtained after 3 months whereas solid union was achieved after 6 months in all patients without any serious complication.