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Recurrent symptoms of CTS have been shown to occur in 0% to 19% of patients following CTR, with up to 12% requiring re-exploration. Common causes of recurrent CTS are incomplete release of the TCL, fibrous proliferation, or recurrent tenosynovitis. The prognosis for re-exploration is fair; improvement can be achieved in many cases, but prognosis is not as favorable as in primary CTR. The most predictable improvement seems to be in patients with CTS caused by granulomatous infections, in which proper surgery and medical therapy can usually result in a satisfactory outcome. For the heavily scarred carpal tunnel with fibrous proliferation, many operative options are available. These procedures include external nerve lysis and mobilization, followed by application of local muscle flaps, fat grafts, or vein wrapping. There appear to be higher recurrence rates and poorer outcomes in patients with occupation-related CTS.

Hand infections can be associated with considerable morbidity. Expeditious treatment is needed to minimize permanent dysfunction, loss of work, and medical cost. Hand infections can affect the skin, subcutaneous tissues, fascia, subfascial and synovial spaces, joints, and bone. Pathogens include a variety of bacteria, viruses, yeasts, fungi, and mycoplasmata. Management frequently involves rest, elevation, incision and drainage, and appropriate antibiotic therapy. The orthopaedic surgeon must be knowledgeable about the pertinent anatomy and how this influences the behavior of specific types of infections, the role of immunocompromise, and the importance of early mobilization.

Clinically, phenol is used often as a neurolytic agent to treat pain and spasticity. The purpose of this study was to examine the time course of denervation and recovery in several hindlimb muscles following application of a 5% aqueous solution of phenol to the sciatic nerve. Phenol was applied to the sciatic nerve of adult female rats either by intraneural or perineural injection. Axonal degeneration was evident within the sciatic nerve 2 days following phenol application, although variable amounts of damage were observed. By 2 weeks, the soleus and tibialis anterior had atrophied to 63% and 51% of control. Reinnervation of hindlimb muscles occurred between 2 and 4 weeks following the nerve block. Following denervation, the soleus became slower in that all of the fibers expressed the slow myosin heavy chain (MHC). At 5 months, maximum tension of the soleus was 74% of control and the muscle consisted of more fast fibers on average, some of which expressed IIx MHC. These data suggest that 5% phenol causes an injury to the nerve that is more severe than a crush injury, and that reinnervation of denervated muscles may be by motoneurons other than those that originally innervated the muscles.

A variety of clinical presentations can be encountered following compartment syndrome of the leg and foot. Deformity and functional impairment in the foot and ankle secondary to ischemia are determined by: 1) which leg compartments have been affected and to what degree extrinsic flexor or extensor "overpull" is exhibited, 2) degree of nerve injury sustained causing weakness or paralysis of extrinsic or intrinsic foot and ankle muscles, 3) which foot compartments have been affected and to what degree intrinsic "overpull" is exhibited, and 4) degree of sensory nerve injury leading to anesthesia, hypoesthesia, or hyperesthesia of the foot. Nonoperative therapy attempts to obtain or preserve joint mobility, increase strength, and provide corrective bracing and accommodative foot wear. Operative management is undertaken for treatment of residual nerve compression or refractory problematic deformities. Established surgical protocols are performed in a stepwise fashion, and include: 1) release of residual or secondary nerve compression; 2) release of fixed contractures, using infarct excision, myotendinous lengthening, muscle recession, or tenotomy; 3) tendon transfers or arthrodesis to increase function; and 4) osteotomy or amputation for severe, non-salvageable deformities.

The halo skeletal fixator provides the most rigid cervical immobilization of all orthoses. However, complications such as pin loosening and infection are common. Appreciation of local anatomy and adherence to established application guidelines should minimize pin-related problems. A relatively safe zone for anterior pin placement is located 1 cm above the orbital rim and superior to the lateral two thirds of the orbit. Posterior pin-site locations are less critical; positioning on the posterolateral aspect of the skull, diagonal to the contralateral anterior pins, is generally desirable. Pins should enter the skull perpendicular to the cortex, with the ring or crown sitting below the widest portion of the skull and passing about 1 cm above the helix of the ear. Pins are inserted at a torque of 8 in-lb and retightened once to 8 in-lb at 48 hours. A loose pin can be retightened to 8 in-lb if resistance is met; otherwise, a loose pin should be replaced at a nearby site. Superficially infected pins are managed with local pin care and oral antibiotics. Persistent or severe infections require pin replacement to a nearby site, parenteral antibiotic therapy, and incision and drainage as needed. In-ability to maintain acceptable cervical reduction with a halo fixator is an indication for alternative treatment, such as internal fixation or traction.

Regan and Morrey proposed a 3-type coronoid fracture classification observing that the incidence of concommitant elbow dislocation was proportional to fragment size. Elbow instability associated with coronoid fractures presumably is related to disrupted bony architecture and ineffective stabilizers attached to the free fragment. Twenty cadaveric elbows were dissected, measuring medial collateral ligament, anterior capsule, and brachialis muscle insertion loci on the coronoid. Radiographs were taken after radiopaque labeling of the stabilizer insertions. The anterior bundle of the medial collateral ligament insertion averaged 18.4 mm dorsal to the coronoid tip. Only in Type III fractures would it be attached to the free fragment. The capsule inserted an average of 6.4 mm distal to the coronoid tip. Rarely should Type I fractures result from a capsular avulsion, because only 3 of 20 specimens had the capsule inserting on the tip. The brachialis had a musculoaponeurotic insertion onto the elbow capsule, coronoid, and proximal ulna. The bony insertion averaged 26.3 mm in length, with its proximal margin averaging 11 mm distal to the coronoid tip. In only Type III fractures is the fragment large enough to include the brachialis bony insertion.

Injury to the deep peroneal nerve in the foot and ankle may result from trauma, repetitive mechanical irritation, or iatrogenic harm. The nerve is most susceptible to injury along its more distal anatomic course. Dissection of 17 cadaver specimens was undertaken to describe the course of the deep peroneal nerve and quantify its branch patterns. In the distal one third of the leg, the nerve was located superficial to the anterior tibial artery between the tibialis anterior and extensor hallucis longus muscles. Typically, the nerve crossed deep to the extensor hallucis longus tendon to enter the interval between the extensor hallucis longus and extensor digitorum longus at an average distance of 12.5 mm proximal to the ankle. A proximal bifurcation was usually present at an average distance of 12.4 mm distal to the mortise. The lateral terminal branch penetrated the deep surface of the extensor digitorum brevis to provide motor innervation. The medial terminal branch passed over the talonavicular joint capsule, and coursed an average of 2.9 mm lateral to the first tarsometatarsal joint. Within the forefoot, it passed deep to the extensor hallucis brevis tendon, bifurcated in the midmetatarsal region, and then arborized, supplying sensibility to the first toe interspace and the adjacent sides of the first and second toes.

Fibrotic contracture of skeletal muscle can follow weeks or months after the severe ischemic insult of compartment syndrome. Commonly known as Volkmann's ischemic contracture, the affected limb often becomes dysfunctional and painful, and may lose sensibility. The pathogenesis of the muscle contracture includes prolonged ischemia, myonecrosis, fibroblastic proliferation, contraction of the cicatrix, and myotendinous adhesion formation. Resultant shortening or overpull of involved muscles leads to stiffness and deformity. Simultaneously, nerve injury from initial ischemia or subsequent soft tissue fibrotic compression leads to muscle paresis or paralysis of the involved compartment and of those muscles more distally innervated. The resultant deformity is thus a combination of varying degrees of contracture and weakness depending on which muscles and nerves are affected. Deformity and functional impairment in the foot and ankle secondary to ischemia are determined by many factors, including: (1) which leg compartment, if any, has been affected and to what degree extrinsic flexor or extensor overpull is exhibited, (2) degree of nerve injury sustained causing weakness or paralysis of extrinsic or intrinsic foot and ankle muscles (3) which foot compartment, if any, has been affected and to what degree intrinsic overpull is exhibited, and (4) degree of sensory nerve injury leading to anesthesia, hypoesthesia, or hyperesthesia of the foot. Therefore, a variety of clinical presentations can be encountered following compartment syndrome of the leg and foot. Treatment is based on an appreciation of the pathoanatomy of the deformity. Nonoperative therapy is aimed at obtaining or preserving joint mobility, increasing strength, and providing corrective bracing and accommodative footwear. Operative management is usually reserved for treatment of residual nerve compression or severe and problematic deformities. Established surgical protocols are performed in a stepwise fashion, to include: (1) release of residual or secondary nerve compression, (2) release of fixed contractures, using infarct excision, myotendinous lengthening, muscle recession, or tenotomy, (3) tendon transfers or arthrodesis to increase function, and (4) ostectomy or amputation for severe, refractory deformities.

The halo device provides the most rigid cervical immobilization of all cervical orthoses. Despite its established efficacy, reported complications include pin loosening (36% to 60%), pin-site infection (20% to 22%), severe pin discomfort (18%), ring migration (13%), pressure sores (4% to 11%), unacceptable scars (9% to 30%), nerve injury (2%), dysphagia (2%), prolonged bleeding at pin sites (1%), and dural puncture (1%). Appreciation of skull anatomy and established application guidelines can help minimize these complications. A relative "safe zone" for anterior pin placement is located 1 cm above the orbital rim, superior to the lateral two thirds of the orbit. This position avoids injury to the nearby frontal sinus (medially), temporalis fossa (laterally), and sensory nerves (supraorbital and supratrochlear nerves medially, and zygomaticotemporal nerve laterally). Posterior pin positions are less critical, located roughly diagonal to the contralateral anterior pins. Pins should enter the skull perpendicular to the cortex, with the ring or crown sitting below the equator of the skull, passing about 1 cm above the helix of the ear. Pins are inserted at 8 in-lbs and re-tightened once at 48 hours. A loose pin can be re-tightened to 8 in-lbs if resistance is met; otherwise, a loose pin requires replacement in a nearby site. Superficially infected pins are managed with oral antibiotics and local pin care. Refractory infections require pin removal, parenteral antibiotics, and incision and drainage as indicated. Dysphagia (difficulty in swallowing), produced by exaggerated cervical extension, may necessitate repositioning of the C-spine. Dural pin puncture is managed with hospitalization, antibiotics, and elevation of the head of the bed to decrease cerebrospinal fluid pressure and allow dural healing.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of phenol motor nerve blocks is advantageous in the early period of acquired spasticity (ie, that occurring following traumatic brain injury or incomplete spinal cord injury), when increased muscle tone is often the most severe. Because acquired spasticity is dynamic and usually improves slowly, a temporary treatment method used to ameliorate increased muscle tone is desirable. Phenol nerve infiltration provides a temporary motor nerve block that lasts for weeks or months. It allows passive limb mobilization in a comprehensive rehabilitation program that attempts to prevent fixed soft tissue contractures. Permanent or irreversible methods such as operative tendon lengthening, muscle release or recession, or neurectomy are usually best delayed until the spasticity has become static, when the need for surgical correction becomes more firmly indicated, and outcomes of operative intervention are more predictable. Although phenol nerve blocks were initially administered at the spinal cord level to control spasticity, the potential side effects have caused a loss of popularity of this method of administration. The safer and more common use of phenol infiltration at the peripheral nerve level is now more accepted for brain injury and spinal cord injury patients. This report reviews the indications, current concepts, and development of the different methods used to administer phenol nerve blocks. Comparisons to other methods to control spasticity are discussed.

The extensor tendons to the fingers were dissected in 43 adult hands. The most common distribution pattern of the extensor tendons of the fingers was: (1) a single extensor indicis proprius (EIP) tendon that inserted ulnar to the extensor digitorum communis (EDC) of the index; (2) a single EDC-index; (3) a single EDC-long; (4) a double EDC-ring; (5) an absent EDC-small; and (5) a double extensor digiti quinti (EDQ) with a double insertion. Frequent variations included, a double EIP tendon; a double or triple EDC-long tendon; a single or triple EDC-ring tendon; and a single or double EDC-small tendon. The extensor medii proprius was noted in 5 specimens. Increased multiplicity of any tendon was not associated with multiplicity of any other tendon, but was associated with a thinner (type 1) junctura tendinum between EDC-index and EDC-long. An absent EDC-small was related to an increased incidence of a double EDC-ring and the presence of a thick type 3 junctura tendinum between the EDC-ring and the EDQ or dorsal aponeurosis of the small finger. Knowledge of potential tendon multiplicity and variations may help in the identification and repair of these structures.

Wrist arthroscopy has become an accepted diagnostic technique, and it is starting to be a useful therapeutic tool. Extensor tendons, the radial artery, and dorsal sensory nerve branches are at risk of injury during this procedure; however, understanding periportal anatomy should make wrist arthroscopy safer. Wrist arthroscopic portals were established in 19 fresh cadaver wrists, after which the limbs were dissected and periportal anatomy was described and quantified. The 1-2, 6R, and 6U portals were the most perilous, while the midcarpal, 3-4, 4-5, and distal radioulnar joint portals were relatively safe. Even "safe" portals had occasional adjacent sensory nerve branches and tendons. A safe technique of establishing wrist arthroscopy portals is emphasized.

Operative procedures and traumatic injuries of the lateral foot and ankle place the sural nerve and its branches at risk. Anatomic studies quantifying the course of this nerve are sparse. In this study, 17 cadaver specimens were dissected to clarify its course and branching patterns. Despite multiple variations of the nerve and its branches, description of the course of a "typical" nerve trunk was possible. The nerve was found to lie in close proximity to the Achilles tendon at a level of 7 cm above the tip of the lateral malleolus. In the hindfoot, the nerve coursed 14 mm posterior and 14 mm inferior to the malleolus. Distally, it crossed superficial to the peroneus longus and brevis tendons. An anastomotic branch coursing into the sinus tarsi area was observed in 24% of specimens. An understanding of the course and distribution of the sural nerve may lessen the risk of iatrogenic injury.

The subcutaneous (sensory) portion of the superficial peroneal nerve was dissected in 25 cadaver lower limbs under loupe magnification. Three distinct branching pattern types were noted. Type A (72%) consisted of a pattern where the nerve penetrated the crural fascia to become subcutaneous at an average distance of 12.3 cm proximal to the ankle joint, then divided at a mean distance of 4.4 cm proximal to the ankle into two major branches: a large medial dorsal cutaneous nerve and a smaller more laterally located intermediate dorsal cutaneous nerve. Type B (16%) consisted of a pattern where both the medial and intermediate dorsal cutaneous nerve arose independently from the superficial peroneal nerve, with the medial dorsal cutaneous nerve having a similar course to that found in Type A, while the intermediate dorsal cutaneous nerve penetrated the crural fascia posterior to the fibula 5.5 cm proximal to the ankle joint and coursed medially to cross the lateral aspect of the fibula at mean distance 4.5 cm above the ankle joint. Type C (12%) consisted of a pattern where the medial dorsal cutaneous nerve and the intermediate dorsal cutaneous nerve arose independently and the medial dorsal cutaneous nerve coursed similar to that in Type A; however, the intermediate dorsal cutaneous nerve penetrated the crural fascia anterior to the fibula an average of 4.9 cm above the ankle joint and continued in close proximity to the anterior fibular border. In all patterns the mean diameters of the medial dorsal cutaneous nerve and intermediate dorsal cutaneous nerve at the ankle were 2.9 mm and 2 mm, respectively. At the level of the malleoli, the medial dorsal cutaneous nerve was located approximately one half the distance from the lateral malleolus to medial malleolus while the intermediate dorsal cutaneous nerve was approximately one third the distance. Appreciation of these branch patterns and the quantified relationships should assist nerve protection during surgical procedures as well as aid rapid nerve isolation for exploration or decompression. Branches especially at risk for iatrogenic injury include: (1) the intermediate dorsal cutaneous nerve of Type B where the nerve crosses the lateral surface of the distal fibula; (2) the intermediate dorsal cutaneous nerve of Type C where the nerve travels adjacent to the anterior border of the fibula; and (3) the intermediate dorsal cutaneous nerve and the medial dorsal cutaneous nerve at the level of the ankle, where they are at risk during anterior ankle arthrotomy or arthroscopy.

Management of the persistent, acquired, neurogenic equinovarus foot may be a confounding rehabilitative dilemma. Victims of cerebrovascular accidents and traumatic brain injury commonly develop this neurogenic deformity. The plantarflexed and inverted foot position results from an imbalance of forces about the hindfoot due to exaggerated muscle tone and hyperactive stretch reflexes. Significant functional impairment may ensue if a plantigrade foot position cannot be achieved and maintained. Surgical correction may be necessary if conservative measures fail. Determination of the dynamic and static components contributing to the equinovarus deformity is difficult. Gait analysis and dynamic electromyographic studies are valuable adjuncts for operative planning. The wide-ranging goals of surgery vary from improving transfer and ambulation skills, to assisting wheelchair positioning, to facilitating use of braces and/or shoe wear.

The surgical treatment of a young adult with a localized defect in the articular cartilage of the knee most commonly employs arthroscopic shaving and/or subchondral drilling. Fresh osteochondral allografting is an alternative that is being performed with increasing frequency. As of June 1993, fresh osteochondral allografts have been used in 90 knees in our institution. Thirty-eight of these knees have been evaluated two or more years postoperatively, and a successful result was obtained in 76%. If the lesion was confined to the medial condyle, the success rate was 86%, but when both reciprocal surfaces were replaced (bipolar) the success rate was 56%.

A new apparatus was developed to compress the anterior compartment selectively and reproducibly in humans. Thirty-five normal volunteers were studied to determine short-term thresholds of local tissue pressure that produce significant neuromuscular dysfunction. Local tissue fluid pressure adjacent to the deep peroneal nerve was elevated by the compression apparatus and continuously monitored for 2-3 h by the slit catheter technique. Elevation of tissue fluid pressure to within 35-40 mm Hg of diastolic blood pressure (approximately 40 mm Hg of in situ pressure in our subjects) elicited a consistent progression of neuromuscular deterioration including, in order, (a) gradual loss of sensation, as assessed by Semmes-Weinstein monofilaments, (b) subjective complaints, (c) reduced nerve conduction velocity, (d) decreased action potential amplitude of the extensor digitorum brevis muscle, and (e) motor weakness of muscles within the anterior compartment. Generally, higher intracompartmental pressures caused more rapid deterioration of neuromuscular function. In two subjects, when in situ compression levels were 0 and 30 mm Hg, normal neuromuscular function was maintained for 3 h. Threshold pressures for significant dysfunction were not always the same for each functional parameter studied, and the magnitudes of each functional deficit did not always correlate with compression level. This variable tolerance to elevated pressure emphasizes the need to monitor clinical signs and symptoms carefully in the diagnosis of compartment syndromes. The nature of the present studies was short term; longer term compression of myoneural tissues may result in dysfunction at lower pressure thresholds.

Markers placed along palmar skin creases of 53 hands radiographically demonstrated creases superimposed on osseous anatomy. The distal and middle digital creases were found to be consistently proximal to associated interphalangeal joints by 7 to 8 mm and 2 to 3 mm, respectively. Proximal digital creases were consistently distal to associated metacarpophalangeal (MCP) joints by 14 to 20 mm. Distances between the distal transverse palmar crease and associated MCP joints were 6.8 to 10.3 mm. Distances between the proximal palmar crease and the associated MCP joints were 9.1 to 22.1 mm. Mean perpendicular distances between the distal wrist crease and center of selected carpal structures or joints were as follows: scaphoid, 0.7 mm; pisiform, 3.4 mm; lunate, 9.2 mm; hamate hook, 12.6 mm; ulnar styloid, 11.7 mm; trapeziometacarpal joint, 19.4 mm; radioscapholunate joint, 13.5 mm; and distal radioulnar joint, 21.1 mm. Quantification of these relationships should assist in hand examination and placement of surgical incisions and provide further insight into anatomic and functional relationships of the hand.

Ulnar collateral ligament (UCL) injury of the first metacarpophalangeal joint (gamekeeper thumb) is common. If the UCL becomes displaced superficially to the adductor pollicis aponeurosis, surgical treatment has been advocated. Radiography cannot help differentiate between displaced and nondisplaced tears. The authors investigated the use of magnetic resonance (MR) imaging in the evaluation of UCL injury. Ten displaced and six nondisplaced UCL tears were surgically created in 16 nonembalmed cadaveric specimens. Twelve unaltered specimens served as controls. Coronal MR images were obtained and interpreted by two observers. The MR images were compared with corresponding anatomic slices. MR imaging depicted UCL displacement in all 10 specimens with displaced tears. A displaced tear was interpreted in one control specimen. Non-displaced tears were diagnosed in four control specimens. Although MR imaging was only 67% specific for all tears, it was 100% sensitive and 94% specific for depicting UCL displacement and, therefore, may be useful for evaluating gamekeeper thumb.

To determine the role of the long extensors and soft tissues in the extension and interaction of the fingers, we applied traction to the extensors and measured the angles of the finger joints. The tendons, juncturae tendinum and intertendinous fascia, and the web between the fingers were sequentially sectioned, and the effects on the joints were again determined with tendon traction. Traction produced hyperextension of the metacarpophalangeal joints and some extension of the interphalangeal joints, although the latter remained partially flexed, producing a clawhand. Cutting the long extensor tendons had no effect on the interaction between adjacent fingers. Traction on the extensor digitorum communis to the index and the extensor indicis proprius produced the same extension of index finger joints and adjacent digits. Traction on the extensor digitorum communis to the index produced 32% of the maximal extension of the long finger MP joint. We reduced this to 22% by cutting the juncturae and intertendinous fascia and to 5% by cutting the web. The interaction between fingers was greater on the ulnar half of the hand because of the juncturae but was similarly reduced by ablative cuts of these structures.

At least three fracture types occur in the proximal fifth metatarsal: the Jones' fracture, the proximal diaphysial stress fracture, and the tuberosity avulsion fracture. Each has distinct characteristics. The diaphysial stress fracture is commonly confused with the Jones' fracture, thereby obscuring vital differences in prognosis and treatment. Anatomical and biomechanical characteristics, as well as vascular studies of the proximal portion of the fifth metatarsal, are discussed in an attempt to better understand their diverse healing potentials. Guidelines for treatment are controversial, and must frequently be individualized. Although surgical intervention for certain proximal fifth metatarsal fracture types may speed recovery time, most fractures heal with immobilization. Treatment of displaced, intra-articular fractures, delayed unions, and nonunions usually requires operative methods.

Two cases of posttraumatic radioulnar synostosis treated with excision and low-dose radiation are presented. Routine postoperative hand therapy was employed. Nearly full range of motion was restored in both cases. No wound healing problems were encountered. We suggest that low-dose radiation may be a useful method of prophylaxis against recurrence after excision of radioulnar synostosis.

In order to measure the energy cost of immobilization of the foot and ankle during ambulation, 14 healthy male volunteers exercised while wearing various immobilization devices. Oxygen consumption, oxygen cost, cardiac output, minute ventilation, heart rate, stroke volume, stride length, and stride frequency were determined at a steady state of exercise as the subjects walked on a treadmill at 80 m/min (equivalent to the comfortable walking speed of approximately 3 mi/h). Each subject was tested with three different types of immobilization devices: a short leg walking cast, a prefabricated lower leg orthosis, and a rigid-soled surgical shoe. The results were compared with those for the same men ambulating without an immobilization device. Ambulation with the short leg walking cast and the prefabricated lower leg orthosis required significantly more energy in comparison with control values (all p values < 0.006) in terms of oxygen cost, cardiac index, oxygen consumption, and minute ventilation. However, when the rigid-soled surgical shoe was worn, energy consumption as measured by all parameters was not significantly increased compared with control values. Comparison of the findings for the short leg walking cast and the prefabricated lower leg orthosis showed no significant differences in any parameter of energy consumption. Stride length, however, was significantly shorter in the short leg walking cast compared with all immobilizers tested.

Use of the lowest possible cuff inflation pressure should minimize the pathogenic effects of compression beneath the pneumatic tourniquet. Curved tourniquets (designed to fit conically shaped limbs) and wider tourniquets were associated with significantly lower arterial occlusion pressure (AOP) than standard, straight tourniquets on the arms and legs of 26 normal volunteers. These tourniquets were used with an integrated tourniquet inflation system in 29 upper-extremity and 31 lower-extremity surgeries. Mean tourniquet inflation pressures of 183.7 mm Hg and 208 mm Hg were used during various surgical procedures of the arm and leg, respectively. Incomplete hemostasis was associated with elevated systolic blood pressure in several cases, but acceptable surgical hemostasis was achieved by incremental increase of the cuff inflation pressure. Curved cuffs, wide cuffs, and an integrated cuff inflation system should facilitate the use of lower tourniquet inflation pressures in extremity surgery.

The palmaris longus (n = 10), plantaris (n = 11), and extensor digitorum longus (n = 10) tendons were harvested from cadaver limbs for morphologic and biomechanical comparisons. Eleven flexor digitorum profundus tendons from the index finger were also harvested for comparison of biomechanical properties of the free graft tendons with those of a typical digital flexor. Maximal tendon length, cross-sectional area, volume, stiffness, and modulus of elasticity were determined by measurement, laser micrometry, and tensile testing. The plantaris and extensor digitorum longus yielded the longest grafts, 334 and 325 mm, respectively, compared with the palmaris longus, which yielded only 161 mm of length. Cross-sectional areas were as follows: palmaris longus, 3.1 mm2; plantaris, 1.4 mm2; extensor digitorum longus, 3.3 mm2; and flexor digitorum profundus, 10.6 mm2. Mean volumes were as follows: palmaris longus, 529 mm3; plantaris, 557 mm3; and extensor digitorum longus, 1006 mm3. The palmaris longus and the extensor digitorum longus showed greater stiffness, 42.0 and 47.8 N/mm, respectively, than the plantaris, which had a stiffness of 25.5 N/mm. However, the flexor digitorum profundus showed significantly greater stiffness than all of the graft tendons. The modulus of elasticity ranged from 1161.6 to 1673.0 MPa, with no significant difference between tendons tested. The findings in this study provide data that may be useful in the selection of a specific donor for free tendon grafting.

Twenty fresh cadaver extremities were dissected to delineate and quantify the course of the superficial branch of the radial nerve. This branch bifurcated from the radial nerve at the level of the lateral humeral epicondyle in eight specimens, and in all specimens the bifurcation was no more than 2.1 cm from the lateral epicondyle. It continued distally, deep to the brachioradialis and became subcutaneous a mean of 9.0 cm proximal to the radial styloid, traversing between the tendons of the brachioradialis and extensor carpi radialis longus. The superficial branch of the radial nerve branched a mean of 5.1 cm proximal to the radial styloid. Distally, at the level of the extensor retinaculum, the closest branches to the center of the first dorsal compartment and to Lister's tubercle were mean distances of 0.4 and 1.6 cm, respectively. In the hand, the superficial branch of the radial nerve most commonly supplied branches to the thumb, the index finger, and the dorsoradial aspect of the long finger. Knowledge of the course of the superficial branch of the radial nerve will help prevent injury during operative procedures on the radial side of the hand, wrist, and forearm and will aid in its localization in treatment of traumatic injuries or performance of nerve blocks in its distribution.

The architectural features of twenty different muscles (18 intrinsics and 2 thumb extrinsics, n = 180 total muscles) were studied. Muscle length, mass, fiber pennation angle, fiber length, and sarcomere length were determined. From these values, physiologic cross-sectional area and fiber length/muscle length ratio were calculated. Intrinsic muscle lengths were relatively similar to one another, which we interpreted as representing a space constraint within the hand. However, several specialized architectural designs were observed: lumbrical muscles had an extremely high fiber length/muscle length ratio, implying a design toward high excursion. The first dorsal interosseous and adductor pollicis had physiologic cross-sectional areas comparable to those of extrinsic muscles and much greater than those of the other intrinsic muscles. The interosseous muscles had relatively high physiologic cross-sectional areas with low fiber length/muscle length ratios, suggesting their adaptation for high force production and low excursion. Taken together, these observations illustrate the underlying structural basis for the functional capacities of the intrinsic muscles.

The architectural features of twenty-one different forearm muscles (n = 154 total muscles) were studied. Muscles included the extensor digitorum communis to the index, middle, ring, and small fingers, the extensor digit quinti, the extensor indicis proprius, the extensor pollicis longus, the flexor digitorum superficialis, the flexor digitorum profundus, the flexor pollicis longus, the pronator quadratus, the palmaris longus, the pronator teres, and the brachioradialis. Muscle length, mass, fiber pennation angle, fiber length, and sarcomere length were determined with the use of laser diffraction techniques. From these values, physiologic cross-sectional area and fiber length/muscle length ratio were calculated. The individual digital extensor muscles were found to be relatively similar in architectural structure. Similarly, the deep and superficial digital flexors were very similar architecturally, with the exception of the small finger flexor digitorum superficialis, which was much smaller and shorter than the rest of the digital flexors. The brachioradialis and the pronator teres had dramatically different architectural properties. While the masses of the two muscles were nearly identical, the muscles had significantly different predicted contractile properties based on their different fiber arrangement. The brachioradialis, with its long fibers arranged at a small pennation angle, had a physiologic cross-sectional area that was only one third that of the pronator teres, with its short fibers that were more highly pennated. Using these architectural data and the statistical method of discriminant analysis, we provide additional information that might be useful in the selection of potential donor muscles to restore thumb flexion, thumb extension, finger extension, and finger flexion.

A retrospective review of patients treated with internal fixation of fractures or dislocations of the hand or wrist over a four-year period was undertaken to determine the complication rates of pin fixation for stabilization of these injuries. One hundred thirty-seven patients who received 422 pins were studied. All pins were unthreaded, measured 0.035-0.069 inches (0.9-1.8 mm) in diameter, were placed with a power drill, and were left protruding through the skin. The mean time that pins were left in place was 6.5 weeks, (range, two days to 24 weeks). Minimum follow-up time was 43 days after pin removal. Thirty-four complications occurred in 24 patients, and the overall complication rate was 18%. Forty-five of the 422 pins were involved (11%). Complications included infections in ten patients (7%), pin loosening without infection in six (4%), loss of reduction in six (4%), symptomatic nonunion in six (4%), impaled flexor tendon in two (2%), asymptomatic pseudarthrosis in one (1%), pin migration in one (1%), median nerve injury in one (1%), and radial artery injury in one (1%). Osteomyelitis developed in two of the patients with infections. Pin tract infection occurred at a mean time of ten weeks and aseptic loosening at a mean time of eight weeks. The frequent complication rates emphasize the need for meticulous pin placement, adequate intraoperative evaluation of pin position, and satisfactory patient compliance. Despite the frequency of these complications, serious permanent sequelae did not occur in most patients.

The trapezial ridge is a longitudinal projection of bone on the palmar surface of the trapezium and serves as an attachment for a portion of the transverse carpal ligament. It can be fractured from a fall onto the outstretched palm. Presented here is a case report of a young woman who sustained a fracture of the trapezial ridge. Point tenderness was a key initial symptom. Standard anteroposterior, lateral, and oblique roentgenograms did not demonstrate the fracture, and the diagnosis was repeatedly missed. The carpal tunnel view was obtained seven weeks after the original injury and showed a nondisplaced fracture through the trapezial ridge. Cast immobilization initiated at that time was not successful in obtaining fracture union. The delay in diagnosis and subsequent nonunion resulted in chronic discomfort and weakness of pinch and grasp. Careful clinical examination for point tenderness over the palmar surface of the trapezium and proper roentgenographic analysis should minimize delays in diagnosis and treatment of this fracture.

The extensor medii proprius is a muscle analogous to the extensor indicis proprius in that it has a similar origin, but inserts into the long finger. The extensor indicis et medii communis muscle is an extensor indicis proprius muscle that splits to insert into both the index and long fingers. The extensor tendons to the fingers were dissected in 58 adult hands to determine the incidence and anatomy of the extensor medii proprius and extensor indicis et medii communis. The incidence of the extensor medii proprius was 10.3% and the incidence of the extensor indicis et medii communis was 3.4% in this series. The extensor medii proprius and extensor indicis proprius muscles had a common origin in all cases. The insertion of the extensor medii proprius into the dorsal aponeurosis was palmar and ulnar to the extensor digitorum communis of the long finger, but in one case, the extensor medii proprius inserted into the deep fibrous tissue proximal to the metacarpophalangeal joint. The tendon slip of the extensor indicis et medii communis inserting into the long finger did not insert into the dorsal aponeurosis, but into the deep fibrous tissue near the metacarpophalangeal joint. Both the extensor medii proprius and the extensor indicis et medii communis may represent evolutionary remnants. Awareness of their potential presence and anatomy should be helpful in extensor identification, repair, and transfer.

The purpose of this study was to delineate the motor point region of the gluteus medius muscle to aid in placing epimysial electrodes for functional electrical stimulation. Seven surgically dissected gluteus medius muscles were studied in five patients. The lateral surface of the muscle was sequentially probed with an electrical stimulator. The motor point region, which responded maximally to an applied electric current, was located on the posterolateral aspect of the muscle, adjacent to the superior margin of the piriformis, 3 cm lateral to the greater sciatic notch; it was rectangular or oval, measuring approximately 3.5 cm by 3.0 cm. The mean threshold current that produced a contraction was 14 mA (range = 2 to 26 mA). The mean minimum current required to produce a maximum contraction was 34 mA (range = 11 to 60 mA). This information provides guidelines for the placement of electrodes for functional electrical stimulation of this deeply situated muscle, and it provides electrical stimulation parameters required for adequate muscle activation.

Benign, soft-tissue masses of the hand are common. A vascular leiomyoma is an unusual tumor of smooth-muscle origin. In a 62-year-old man, the tumor arose from within a digital artery. Persistent symptoms prompted an excisional biopsy, requiring resection of a portion of the artery. Adequate collateral circulation preempted the need for a vascular graft. Vascular repair or grafting may be necessary if collateral circulation is not adequate.

The use of a temporary metal foil stent after primary repair of acute nail bed injuries is a simple and dependable method for restoration of the smooth nail bed. The stent prevents adherence of the proximal nail fold to the underlying matrix, promoting patient comfort during subsequent dressing changes.

The dorsal branch of the ulnar nerve was dissected in 24 cadavers. The nerve arose from the medial aspect of the ulnar nerve at an average distance of 6.4 centimeters from the distal aspect of the head of the ulna and 8.3 centimeters from the proximal border of the pisiform. Its mean diameter at origin was 2.4 millimeters. The nerve passed dorsal to the flexor carpi ulnaris and pierced the deep fascia. It became subcutaneous on the medial aspect of the forearm at a mean distance of 5.0 centimeters from the proximal edge of the pisiform. The nerve gave an average of five branches with diameters between 0.7 and 2.2 millimeters. A better understanding of the anatomy of this nerve may help prevent nerve injury during surgical procedures, and can help in locating the nerve for repair of lacerations or administration of local anesthetics for regional nerve blocks.

Three distinct morphologic types of juncturae tendinum of the extensor tendons were identified in the dissection of 40 cadaver hands. Type 1 juncturae consists of filamentous regions within the intertendinous fascia that attached to the extensor tendons on either side of the intermetacarpal space in a transverse or oblique direction. The second type, consists of much thicker and well-defined connecting bands. Type 3 juncturae consist of tendon slips from the extensor tendons and were subclassified into "y" or "r" subtypes depending on shape. Type 1 juncturae were present in 88% of the second intermetacarpal spaces and in 28% of the third intermetacarpal spaces. Type 2 juncturae were present in 40% of the third intermetacarpal spaces and in 23% of the fourth intermetacarpal spaces. Type 3 juncturae were present in 33% of the third intermetacarpal spaces and in 80% of the fourth intermetacarpal spaces. Juncturae were absent in all of the first intermetacarpal spaces and in 12% of the second intermetacarpal spaces; they were present in all other spaces. The extensor indicis proprius did not receive a junctural connection, whereas extensor digiti quinti tendons did receive junctural connections. Intertendinous fascia was present between all extensor digitorum communis tendons regardless of presence of juncturae.

The architectural features of 25 wrist flexor and extensor muscles were studied. Muscles included the flexor carpi ulnaris, the flexor carpi radialis, the extensor carpi ulnaris, the extensor capri radialis brevis, and the extensor carpi radialis longus. Muscle length, mass, fiber pennation angle, fiber length, and sarcomere length (by use of laser diffraction techniques) were determined. In addition, physiological cross-sectional area and fiber length/muscle length ratio were calculated. The muscles were found to be highly specialized, with architectural features of same muscles very similar. The fiber length/muscle length ratio, muscle length, and pennation angle represented the major differences between muscles. Thus using these parameters in discriminant analysis permitted correct identification of each of the 25 muscles. In terms of size and intrinsic design, these individual muscles were highly specialized for their function.

A canine flexor tendon repair model was used to study the magnitude of early tendon excursion, the consistency of tendon gliding, and the amount of repair site elongation when protected early motion techniques were used. Tendon excursion of 3.8 +/- 1.1 mm was maintained with limited passive flexion and extension movements on a consistent basis throughout the first 14 days. There was no significant repair site deformation in 11 of 12 tendons and little variation in the range of tendon gliding during this period.

Cerebrovascular accidents remain one of the most serious medical problems in the United States. They are responsible for 200,000 deaths per year and are the leading cause of hemiplegia in the adult. The purpose of these reports is to review the orthopaedic aspects of stroke rehabilitation, with emphasis on functional defects, evaluation of the patient, and methods of treatment. Part I will discuss the pathophysiologic changes and patient evaluation. Part II will discuss the surgical and nonsurgical management of extremity deformities.

Carpal bone fractures comprise an important group of injuries that present difficulties in both diagnosis and treatment. These fractures may be missed for the following reasons: physician's low index of suspicion, the carpal bones' irregular contours and degree of overlap on radiographs making the fractures difficult to visualize, and the common occurrence of concomitant fractures of neighboring metacarpals, distal radius, or scaphoid, which misdirects the examiner. A high index of suspicion with careful clinical examination and elicitation of point tenderness is key to making the correct diagnosis (Fig. 14). Swelling, loss of motion, deformity, and crepitus are often minimal and are not reliable in distinguishing carpal fractures. Specific radiographic projections, tomograms, computerized tomographic scans, or bone scans are often required and should be considered in any wrist injury where the diagnosis is in question. A greater awareness of the fracture types, methods of diagnosis, and choices of treatment is essential for optimal management of these injuries.

Fourteen patients with 58 severe forearm muscle belly lacerations had muscle repair using tendon grafts. At mean follow-up of 14 months, results of manual muscle testing (N = 58) were: grade 5, 42%, grade 4, 14%, grade 3, 9%, grade 2, 9%, grade 1, 12%, and grade 0, 15%. Mean grip strength of the injured extremity, in pounds per square inch, was 33.5 compared with 83.4 on the noninjured side. Tendon excursion and joint mobility were maintained, and there were no postoperative complications. Tendon grafting of severe muscle lacerations is an effective method to overcome extensive defects.

This study evaluates the time required for grip and pinch strength to return to preoperative levels after carpal tunnel release. Grip strength was 28% of preoperative level at 3 weeks; 73% by 6 weeks, and returned to the preoperative level by 3 months. At 6 months grip strength was found to increase to 116%. Pinch strength returned sooner being 74% of preoperative level at 3 weeks and 96% by 6 weeks. By 3 months an increase to 108% was seen and at 6 months an increase to 126% of preoperative levels was found. This data should prove useful in predicting when patients may be able to return to their previous level of occupational-related activity.

Osteomyelitis and intracranial abscess are among the most serious complications that have been reported in association with the use of the halo device. The cases of five patients who had formation of an intracranial abscess related to the use of a halo cervical immobilizer are described. All of the infections resolved after drainage of the abscess, débridement, and parenteral administration of antibiotics. Meticulous care of the pin sites is essential to avoid this serious complication. Additionally, since all of the infections were associated with prolonged halo-skeletal traction, this technique should be used with caution and with an awareness of the possible increased risks of pin-site infection and of formation of a subdural abscess.

Five different intertarsal arthrodeses were simulated in 15 fresh cadaver feet/ankles utilizing external fixation. Pin placement was verified radiographically. Range of motion measurements were performed before pin placement, after pin placement, and after simulated arthrodesis. The deficit in foot motion created by selected limited intertarsal fusions was then measured. The prearthrodesis range of motion measurements were found to be dorsiflexion (DF), 27 degrees; plantarflexion (PF), 57 degrees; total inversion (INVT), 29 degrees; eversion total (EVT), 22 degrees; hindfoot varus (VRH), 16 degrees; hindfoot valgus (VLH), 12 degrees. The deficits in motion after arthrodesis were as follows. Ankle (tibiotalar): DF, 50.7%; PF, 70.3%; INVT, 8.7%; EVT, 9.4%; VRH, 34.6%; VLH, 27.8%. Hindfoot arthrodesis (Tibiotalar calcaneal): DF, 53%; PF, 71.3%; INVT, 49.5%; EVT, 47.6%, VRH, 100%; VLH, 100%. Pantalar (Tibotalar calcaneal cuboid navicular): DF, 62.8%; PF, 82.2%; INVT, 71.7%; EVT, 67.4%; VRH, 100%; VLH, 100%. Triple (Talocalcaneal cuboid navicular): DF, 12.5%; PF, 15.5%; INVT, 50%; EVT, 51.4%; VRH, 60.5%; VLH, 60.5%. Total tarsal arthrodesis: DF, 78.5%; PF, 90.2%, INVT, 87.5%; EVT, 83.6%; VRH, 100%; VLH, 100%.

It has been recommended that halo torque screwdrivers be used only once. To determine if this advice is justified on biomechanical grounds, five commercially available torque screwdrivers were cycled 1,600 times each in an Instron testing machine over a 7-day period. The screwdrivers displayed an initial error from the dial reading at both 6 and 10 in-lb of only +/- 0.3 in-lb. After cyclic loading and retesting, the percent deviation from original calibration was 8% at both 6 and 10 in-lb. These data demonstrate the accuracy and dependability of the torque screwdrivers and imply that repeated use of these devices should be safe.