The August 2014 Wrist &
Hand Roundup360 looks at: Trapeziectomy superior to arthrodesis;
Between 1995 and 2006, five intra-articular osteotomies of the head of the radius were performed in patients with symptomatic healed displaced articular fractures. Pre-operatively, all patients complained of persistent painful clicking on movement. Only patients with mild or no degenerative changes of the radial head and capitellum were considered for osteotomy. The operations were performed at a mean of 8.2 months (4 to 13) after injury and the patients were reviewed at a mean of 5.5 years (15 months to 12 years) after the osteotomy. The average Mayo Elbow Performance Index Score improved significantly from 74 before to 88 after operation, with four patients rated as good or excellent (p <
0.05). The subjective patient satisfaction score was 8.4 on a ten-point scale. All osteotomies healed and there were no complications. In this small series intra-articular osteotomy of the head of the radius was a safe and effective treatment for symptomatic intra-articular malunion without advanced degenerative changes.
We undertook a retrospective analysis of 306
procedures on 233 patients, with a mean age of 12 years (1 to 21),
in order to evaluate the use of somatosensory evoked potential (SSEP)
monitoring for the early detection of nerve compromise during external
fixation procedures for limb lengthening and correction of deformity.
Significant SSEP changes were identified during 58 procedures (19%).
In 32 instances (10.5%) the changes were transient, and resolved
once the surgical cause had been removed. The remaining 26 (8.5%)
were analysed in two groups, depending on whether or not corrective
action had been performed in response to critical changes in the
SSEP recordings. In 16 cases in which no corrective action was taken,
13 (81.2%, 4.2% overall) developed a post-operative neurological
deficit, six of which were permanent and seven temporary, persisting
for five to 18 months. In the ten procedures in which corrective
action was taken, four patients (40%, 1.3% overall) had a temporary
(one to eight months) post-operative neuropathy and six had no deficit. After appropriate intervention in response to SSEP changes, the
incidence and severity of neurological deficits were significantly
reduced, with no cases of permanent neuropathy. SSEP monitoring
showed 100% sensitivity and 91% specificity for the detection of
nerve injury during external fixation. It is an excellent diagnostic
technique for identifying nerve lesions when they are still highly
reversible.
We retrospectively reviewed 89 consecutive patients
(45 men and 44 women) with a mean age at the time of injury of 58
years (18 to 97) who had undergone external fixation after sustaining
a unilateral fracture of the distal humerus. Our objectives were
to determine the incidence of heterotopic ossification (HO); identify
risk factors associated with the development of HO; and characterise
the location, severity and resultant functional impairment attributable
to the presence of HO. HO was identified in 37 elbows (42%), mostly around the humerus
and along the course of the medial collateral ligament. HO was hazy
immature in five elbows (13.5%), mature discrete in 20 (54%), extensive
mature in 10 (27%), and complete bone bridges were present in two
elbows (5.5%). Mild functional impairment occurred in eight patients,
moderate in 27 and severe in two. HO was associated with less extension
(p = 0.032) and less overall flexion-to-extension movement (p =
0.022); the flexion-to-extension arc was <
100º in 21 elbows
(57%) with HO compared with 18 elbows (35%) without HO (p = 0.03).
HO was removed surgically in seven elbows. The development of HO was significantly associated with sustaining
a head injury (p = 0.015), delayed internal fixation (p = 0.027),
the method of fracture fixation (p = 0.039) and the use of bone
graft or substitute (p = 0.02).HO continues to be a substantial
complication after internal fixation for distal humerus fractures. Cite this article:
We reviewed 15 patients, nine girls and six boys, with chronic anterior dislocation of the radial head which was treated by ulnar osteotomy, external fixation and open reconstruction of the elbow joint but without repair of the annular ligament. Their mean age was 9.5 years (5 to 15) and the mean interval between the injury and reconstruction was 22 months (2 months to 7 years). All radial heads remained reduced at a mean follow-up of 20 months (6 months to 5 years). Normal ranges of movement for flexion, extension, pronation and supination were unchanged in 96.1% (49/51) and worse in 3.9% (2/51). Limited ranges of movement were improved in 77.8% (7/9), unchanged in 11% (1/9) and further decreased in 11% (1/9).There were two superficial pin-track infections and two cases of delayed union but with no serious complications. Reconstruction of the radiocapitellar joint is easier using external fixation since accurate correction of the ulna can be determined empirically and active functional exercises started immediately. Only patients with a radial head of normal shape were selected for treatment by this method.
This study reports our experience with total elbow replacement for fused elbows. Between 1982 and 2004, 13 patients with spontaneously ankylosed elbows were treated with a linked semi-constrained non-custom total elbow implant. The mean age at operation was 54 years (24 to 80). The stiffness was a result of trauma in ten elbows, juvenile rheumatoid arthritis in one, and rheumatoid arthritis in two. The patients were followed for a mean of 12 years (2 to 26) and were evaluated clinically using the Mayo Elbow Performance Score, as well as radiologically. A mean arc from 37° of extension to 118° of flexion was achieved. Outcomes were good or excellent for seven elbows at final review. Ten patients felt better or much better after total elbow replacement. However, there was a high complication rate and re-operation was required in over half of patients. Two developed peri-operative soft-tissue breakdown requiring debridement. A muscle flap with skin grafting was used for soft-tissue cover in one. Revision was undertaken in one elbow following fracture of the ulnar component. Three patients developed a deep infection. Three elbows were manipulated under anaesthesia for post-operative stiffness. Prophylactic measures for heterotopic ossification were unsuccessful. Total elbow replacement for the ankylosed elbow should be performed with caution. However, the outcome can be reliable in the long term and have a markedly positive impact on patient function and satisfaction. The high potential for complications must be considered. We consider total elbow replacement to be an acceptable procedure in selected patients with reasonable expectations.
We examined the outcomes and levels of patient
satisfaction in 202 consecutive cases of ultrasound-guided supraclavicular
brachial plexus block (SBPB) in upper limb surgery performed between
September 2007 and March 2010. All blocks were performed by orthopaedic surgeons using ultrasound
visualisation with a high-frequency linear probe. The probe was
placed in the coronal–oblique plane in the supraclavicular fossa,
and the puncture was ‘in-plane’ from lateral to medial. Most of
the blocks were performed with 0.75% ropivacaine/1% lidocaine (1:1),
with or without adrenaline in 1:200 000 dilution. In 201 patients
(99.5%) the brachial plexus block permitted surgery without conversion
to general anaesthesia. The mean procedure time for block was 3.9
min (2 to 12), the mean waiting time for surgery was 34.1 min (10
to 64), the mean surgical time was 75.2 min (6 to 232), and the
mean duration of post-anaesthetic analgesia was 437 min (171 to
992). A total of 20 patients (10%) developed a transient Horner’s syndrome.
No nerve injury, pneumothorax, arterial puncture or systemic anaesthetic
toxicity were recorded. Most patients (96.7%) were satisfied with
ultrasound-guided SBPB. This study demonstrates the efficacy and
safety of ultrasound-guided SBPB for orthopaedic surgery on the
upper limb. Cite this article:
The April 2014 Wrist &
Hand Roundup360 looks at: diagnosis of compressive neuropathy; relevant reviews; the biomechanics of dorsal PIP fracture dislocation; the more strands the better; and state of mind the best predictor of outcome.
The objective of this retrospective study was to correlate the Bado and Jupiter classifications with long-term results after operative treatment of Monteggia fractures in adults and to determine prognostic factors for functional outcome. Of 63 adult patients who sustained a Monteggia fracture in a ten-year period, 47 were available for follow-up after a mean time of 8.4 years (5 to 14). According to the Broberg and Morrey elbow scale, 22 patients (47%) had excellent, 12 (26%) good, nine (19%) fair and four (8%) poor results at the last follow-up. A total of 12 patients (26%) needed a second operation within 12 months of the initial operation. The mean Broberg and Morrey score was 87.2 (45 to 100) and the mean DASH score was 17.4 (0 to 70). There was a significant correlation between the two scores (p = 0.01). The following factors were found to be correlated with a poor clinical outcome: Bado type II fracture, Jupiter type IIa fracture, fracture of the radial head, coronoid fracture, and complications requiring further surgery. Bado type II Monteggia fractures, and within this group, Jupiter type IIa fractures, are frequently associated with fractures of the radial head and the coronoid process, and should be considered as negative prognostic factors for functional long-term outcome. Patients with these types of fracture should be informed about the potential risk of functional deficits and the possible need for further surgery.
Between January 1995 and December 2000, 112 children with a closed displaced supracondylar fracture of the humerus without vascular deficit, were managed by elevated, straight-arm traction for a mean of 22 days. The final outcome was assessed using clinical (flexion-extension arc, carrying angle and residual rotational deformity) and radiographic (metaphyseal-diaphyseal angle and humerocapitellar angle) criteria. Excellent results were achieved in 71 (63%) patients, 33 (29%) had good results, 5 (4.4%) fair, and 3 (2.6%) poor. All patients with fair or poor outcomes were older than ten years of age. Elevated, straight-arm traction is safe and effective in children younger than ten years. It can be effectively used in an environment that can provide ordinary paediatric medical care and general orthopaedic expertise. The outcomes compare with supracondylar fractures treated surgically in specialist centres.
We hypothesised that the use of pulsed electromagnetic
field (PEMF) bone growth stimulation in acute scaphoid fractures
would significantly shorten the time to union and reduce the number
of nonunions in a randomised, double-blind, placebo-controlled multicentre
trial. A total of 102 patients (78 male, 24 female; mean age 35
years (18 to 77)) from five different medical centres with a unilateral
undisplaced acute scaphoid fracture were randomly allocated to PEMF
(n = 51) or placebo (n = 51) and assessed with regard to functional
and radiological outcomes (multiplanar reconstructed CT scans) at
6, 9, 12, 24 and 52 weeks. The overall time to clinical and radiological healing
did not differ significantly between the active PEMF group and the
placebo group. We concluded that the addition of PEMF bone growth
stimulation to the conservative treatment of acute scaphoid fractures
does not accelerate bone healing. Cite this article:
A relationship between social deprivation and the incidence of fracture in adolescents has not previously been shown. We have used a complete fracture database to identify adolescents who sustained fractures in 2000. The 2001 Scottish census was used to obtain age-specific population and deprivation data according to the Carstairs score. Regression analysis determined the relationship between the incidence of fractures and social deprivation. We analysed 1574 adolescents with fractures (1083 male, 491 female). The incidence of fractures in this group was 21.8 per thousand (31.0 male, 13.1 female). Social deprivation predicted the incidence in adolescent males and females. The incidence of fractures of the proximal upper limb and distal radius in females was overwhelmingly influenced by socioeconomic factors. Males of 15 to 20 years of age were more likely to sustain fractures of the hand and carpus if they lived in economically depressed neighbourhoods.
Bone mineral density (BMD) around the femoral component has been reported to decrease after total knee replacement (TKR) because of stress shielding. Our aim was to determine whether a cemented mobile-bearing component reduced the post-operative loss of BMD. In our study 28 knees receiving a cemented fixed-bearing TKR were matched with 28 receiving a cemented mobile-bearing TKR. They underwent dual-energy x-ray absorptiometry, pre-operatively and at three weeks and at three, six, 12, 18 and 24 months post-operatively. The patients were not taking medication to improve the BMD. The pre-operative differences in the BMD of the femoral neck, wrist, lumbar spine and knee in the two groups were not significant. The BMD of the femur decreased postoperatively in the fixed-bearing group, but not the mobile-bearing group. The difference in the post-operative change in the BMD in the two groups was statistically significant (p <
0.05) at 18 and 24 months. Our findings show that a cemented mobile-bearing TKR has a favourable effect on the BMD of the distal femur after TKR in the short term. Further study is required to determine the long-term effects.
We describe a rare variant of mirror hand in a 20-year-old man who presented with multiple fingers. Radiographs revealed two ulnae (one vestigial) and a radius. There was duplication of the humeral head. The unique features of this case are the age of patient before the start of treatment and extension of the duplication proximal to the elbow.
The use of passive stretching of the elbow after
arthrolysis is controversial. We report the results of open arthrolysis in
81 patients. Prospectively collected outcome data with a minimum
follow-up of one year were analysed. All patients had sustained
an intra-articular fracture initially and all procedures were performed
by the same surgeon under continuous brachial plexus block anaesthesia
and with continuous passive movement (CPM) used post-operatively
for two to three days. CPM was used to maintain the movement achieved
during surgery and passive stretching was not used at any time.
A senior physiotherapist assessed all the patients at regular intervals.
The mean range of movement (ROM) improved from 69° to 109° and the
function and pain of the upper limb improved from 32 to 16 and from
20 to 10, as assessed by the Disabilities of the Arm Shoulder and
Hand score and a visual analogue scale, respectively. The greatest
improvement was obtained in the stiffest elbows: nine patients with
a pre-operative ROM <
30° achieved a mean post-operative ROM
of 92° (55° to 125°). This study demonstrates that in patients with
a stiff elbow after injury, good results may be obtained after open
elbow arthrolysis without using passive stretching during rehabilitation.
Recent recommendations by the National Institute
for Health and Care Excellence (NICE) suggest that all patients undergoing
elective orthopaedic surgery should be assessed for the risk of
venous thromboembolism (VTE). Little is known about the incidence of symptomatic VTE after
elective external fixation. We studied a consecutive series of adult
patients who had undergone elective Ilizarov surgery without routine
pharmacological prophylaxis to establish the incidence of symptomatic
VTE. A review of a prospectively maintained database of consecutive
patients who were treated between October 1998 and February 2011
identified 457 frames in 442 adults whose mean age was 42.6 years
(16.0 to 84.6). There were 425 lower limb and 32 upper limb frames.
The mean duration of treatment was 25.7 weeks (1.6 to 85.3). According to NICE guidelines all the patients had at least one
risk factor for VTE, 246 had two, 172 had three and 31 had four
or more. One patient (0.23%) developed a pulmonary embolus after surgery
and was later found to have an inherited thrombophilia. There were
27 deaths, all unrelated to VTE. The cost of providing VTE prophylaxis according to NICE guidelines
in this group of patients would be £89 493.40 (£195.80 per patient)
even if the cheapest recommended medication was used. The rate of symptomatic VTE after Ilizarov surgery was low despite
using no pharmacological prophylaxis. This study leads us to question
whether NICE guidelines are applicable to these patients. Cite this article:
We evaluated 56 patients for neurological deficit after enucleation of a histopathologically confirmed schwannoma of the upper limb. Immediately after the operation, 41 patients (73.2%) had developed a new neurological deficit: ten of these had a major deficit such as severe motor or sensory loss, or intolerable neuropathic pain. The mean tumour size had been significantly larger in patients with a major neurological deficit than in those with a minor or no deficit. After a mean 25.4 months (12 to 85), 39 patients (70%) had no residual neurological deficit, and the other 17 (30%) had only hypoaesthesia, paraesthesiae or mild motor weakness. This study suggests that a schwannoma in the upper limb can be removed with an acceptable risk of injury to the nerve, although a transient neurological deficit occurs regularly after the operation. Biopsy is not advised. Patients should be informed pre-operatively about the possibility of damage to the nerve: meticulous dissection is required to minimise this.
Low-energy fractures of the proximal humerus indicate osteoporosis and it is important to direct treatment to this group of patients who are at high risk of further fracture. Data were prospectively collected from 79 patients (11 men, 68 women) with a mean age of 69 years (55 to 86) with fractures of the proximal humerus in order to determine if current guidelines on the measurement of the bone mineral density at the hip and lumbar spine were adequate to stratify the risk and to guide the treatment of osteoporosis. Bone mineral density measurements were made by dual-energy x-ray absorptiometry at the proximal femur, lumbar spine (L2-4) and contralateral distal radius, and the T-scores were generated for comparison. Data were also collected on the use of steroids, smoking, the use of alcohol, hand dominance and comorbidity. The mean T-score for the distal radius was −2.97 ( The assessment of osteoporosis must include measurement of the bone mineral density at the distal radius to avoid underestimation of osteoporosis in the upper limb.
Non-accidental injury (NAI) in children includes orthopaedic trauma throughout the skeleton. Fractures with soft-tissue injuries constitute the majority of manifestations of physical abuse in children. Fracture and injury patterns vary with age and development, and NAI is intrinsically related to the mobility of the child. No fracture in isolation is pathognomonic of NAI, but specific abuse-related injuries include multiple fractures, particularly at various stages of healing, metaphyseal corner and bucket-handle fractures and fractures of ribs. Isolated or multiple rib fractures, irrespective of location, have the highest specificity for NAI. Other fractures with a high specificity for abuse include those of the scapula, lateral end of the clavicle, vertebrae and complex skull fractures. Injuries caused by NAI constitute a relatively small proportion of childhood fractures. They may be associated with significant physical and psychological morbidity, with wide- ranging effects from deviations in normal developmental progression to death. Orthopaedic surgeons must systematically assess, recognise and act on the indicators for NAI in conjunction with the paediatric multidisciplinary team.