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Purpose: The aim of the study was to examine triangular fibrocartilage (TFCC) injury patterns associated with unstable, extra-articular dorsally displaced distal radius fractures., Methods: Twenty adult patients with an Arbeitsgemeinschaft für Osteosynthesefragen (AO), type A2 or A3, distal radius fracture with an initial dorsal angulation greater than 20° were included. Nine had a tip fracture (distal to the base) of the ulnar styloid and 11 had no such fracture. They were all openly explored from an ulnopalmar approach and TFCC injuries were documented. Eleven patients also underwent arthroscopy and intra-articular pathology was recorded., Results: All patients had TFCC lesions of varying severity, having an extensor carpi ulnaris subsheath avulsion in common. Eighteen out of 20 also displayed deep foveal radioulnar ligament lesions, with decreasingly dorsal fibres remaining. The extent of this foveal injury could not be appreciated by radiocarpal arthroscopy., Conclusions: Severe displacement of an extra-articular radius fracture suggests an ulnar-sided ligament injury to the TFCC. The observed lesions concur with findings in a previous cadaver study. The lesions follow a distinct pattern affecting both radioulnar as well as ulnocarpal stabilisers., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

A 14-year-old male neutered Burmese cat presented for investigation of right fore limb lameness that was non-responsive to anti-inflammatory drugs and opioids. Thoracic radiography showed multiple pulmonary soft tissue nodules and a larger cavitated mass. Right elbow radiographs revealed marked peri-articular proliferation of new bone and periosteal reaction primarily affecting the ulna. Histopathological examination of an incisional biopsy of the right ulna revealed neoplastic proliferation of epithelial cells; this was confirmed as a poorly differentiated carcinoma with immunohistochemistry. Amputation of the right fore limb was performed at the owner's request. After surgery, radiographs of the limb showed progression of bone proliferation. Repeat pathological analysis confirmed a metastatic carcinoma. The cat deteriorated 3 days after surgery and was euthanased a week later as a result of severe respiratory distress. This case represents an unusual case of metastasis of a suspected primary lung tumour to the ulna in a Burmese cat.

The T-box transcription factor Tbx3 plays multiple roles in normal development and disease. In order to function in different tissues and on different target genes, Tbx3 binds transcription factors or other cofactors specific to temporal or spatial locations. Examining the development of the mammary gland, limbs, and heart as well as the biology of stem cells and cancer provides insights into the diverse and common functions that Tbx3 can perform. By either repressing or activating transcription of target genes in a context-dependent manner, Tbx3 is able to modulate differentiation of immature progenitor cells, control the rate of cell proliferation, and mediate cellular signaling pathways. Because the direct regulators of these cellular processes are highly context-dependent, it is essential that Tbx3 has the flexibility to regulate transcription of a large group of targets, but only become a active on a small cohort of them at any given time or place. Moreover, Tbx3 must be responsive to the variety of different upstream factors that are present in different tissues. Only by understanding the network of genes, proteins, and molecules with which Tbx3 interacts can we hope to understand the role that Tbx3 plays in normal development and how its aberrant expression can lead to disease. Because of its myriad functions in disparate developmental and disease contexts, Tbx3 is an ideal candidate for a systems-based approach to genetic function and interaction., (Copyright © 2012 Wiley Periodicals, Inc.)

Purpose: The optimal reconstructive method after resection of malignant bone tumours of the proximal ulna is unknown.We report the outcome of endoprosthetic replacement in a young patient population., Methods: This was a retrospective review of four patients[three males and one female; mean age 17.5 (range 11–31)years] who underwent limb salvage with a proximal ulnar endoprosthetic replacement following excision of malignant bone tumour. Mean follow-up was 85 (range 14–194) months., Results: All patients were alive at final follow-up and reported an improvement in pain. One patient required transhumeral amputation for intralesional excision complicating a local recurrence at one month. Two patients developed fixed flexion deformities of the elbow, one of whom required radial-head excision. Mean Musculoskeletal Tumour Society (MSTS)score and Toronto Extremity Salvage Score (TESS) were 27(range 25–28) and 81 (73–88), respectively., Conclusions: Custom-made proximal ulna endoprosthetic replacement following resection of malignant bone tumours in young patients provides a stable reconstruction option with satisfactory function and without apparent compromise in patient survival.

Osteocyte apoptosis is required to initiate osteoclastic bone resorption following fatigue-induced microdamage in vivo; however, it is unclear whether apoptotic osteocytes also produce the signals that induce osteoclast differentiation. We determined the spatial and temporal patterns of osteocyte apoptosis and expression of pro-osteoclastogenic signaling molecules in vivo. Ulnae from female Sprague-Dawley rats (16-18weeks old) were cyclically loaded to a single fatigue level, and tissues were analyzed 3 and 7days later (prior to the first appearance of osteoclasts). Expression of genes associated with osteoclastogenesis (RANKL, OPG, VEGF) and apoptosis (caspase-3) were assessed by qPCR using RNA isolated from 6mm segments of ulnar mid-diaphysis, with confirmation and spatial localization of gene expression performed by immunohistochemistry. A novel double staining immunohistochemistry method permitted simultaneous localization of apoptotic osteocytes and osteocytes expressing pro-osteoclastogenic signals relative to microdamage sites. Osteocyte staining for caspase-3 and osteoclast regulatory signals exhibited different spatial distributions, with apoptotic (caspase 3-positive) cells highest in the damage region and declining to control levels within several hundred microns of the microdamage focus. Cells expressing RANKL or VEGF peaked between 100 and 300μm from the damage site, then returned to control levels beyond this distance. Conversely, osteocytes in non-fatigued control bones expressed OPG. However, OPG staining was reduced markedly in osteocytes immediately surrounding microdamage. These results demonstrate that while osteocyte apoptosis triggers the bone remodeling response to microdamage, the neighboring non-apoptotic osteocytes are the major source of pro-osteoclastogenic signals. Moreover, both the apoptotic and osteoclast-signaling osteocyte populations are localized in a spatially and temporally restricted pattern consistent with the targeted nature of this remodeling response., (Copyright © 2012. Published by Elsevier Inc.)

Objective: To describe the computed tomography (CT) findings in dogs with severe elbow incongruity combined with a fragmented medial coronoid process (FCP) and compare these with normal joints and congruent joints affected by FCP., Study Design: Clinical study., Animals: Client-owned dogs with elbow lameness (n = 40) and purpose bred dogs (n = 5; controls)., Methods: The CT features of 32 severely incongruent joints with concomitant FCP were compared with those of 32 congruent elbow joints affected with FCP and 10 normal joints., Results: In severely incongruent elbow joints, a radioulnar step and widened joint spaces were visible on each CT plane. Additional features typically seen in severely incongruent elbows were a cyst at the radioulnar transition and fragmentation of the axial border of the medial coronoid incisure. None of these features appeared in normal or in congruent FCP joints., Conclusion: On CT, several features associated with severe elbow incongruity and concomitant FCP were detected, which were not found in normal joints or congruent joints affected by FCP., (Copyright 2012 by The American College of Veterinary Surgeons.)

To treat large bone defects is a clinically challenging problem and utilizing tissue engineering technology is an attractive approach for overcoming such a problem. Previously, a biodegradable sponge incorporating bone morphogenic protein-2 (BMP-2), which can control the release of BMP-2 for a prolonged time in an in vivo environment, was reported. In addition, a biodegradable sponge composed of gelatin and β-tricalcium phosphate (βTCP), gelatin-βTCP sponge to develop a more ideal scaffold for enhancing bone regeneration was also created and previously reported. The purpose of this study was to investigate the effectiveness of the gelatin-βTCP sponge for the promotion of bone regeneration in a critical-sized bone defect site in vivo. Apparent bone regeneration was induced by the gelatin sponge incorporating BMP-2 and the gelatin-βTCP sponge with BMP-2 incorporation. In contrast, no apparent bone formation was induced by either the gelatin sponge only or the gelatin-βTCP sponge without BMP-2. To investigate the quality of the regenerated bone, we conducted a biomechanical evaluation with a three-point bending test. We found no significant difference between the gelatin sponge incorporating BMP-2 and the gelatin-βTCP sponge incorporating BMP-2 groups. Incorporation of βTCP into the gelatin sponge was expected to enhance biomechanical strength during the initial bone regeneration. However, our observations showed that the gelatin-βTCP sponge did not significantly improve the quality of regenerated bone from the viewpoint of biomechanical assessment, even though it did not impair the effectiveness of the promotion of bone regeneration by BMP-2 in the bone defect., (Copyright © 2011 John Wiley & Sons, Ltd.)

Background: More than 140,000 new cases of cancer are diagnosed annually in Canada, nearly half of which metastasize to bone. The implications for orthopedic oncology services are potentially huge. We reviewed the experience in a major Canadian orthopedic trauma centre treating long bone metastases. The primary aim was to quantify the caseload, and the secondary aim was to report on the methods of fixation., Methods: We conducted a retrospective review of all patients treated for pathologic lesions or fracture secondary to metastatic disease over a 20-year period from July 1987 to March 2007., Results: The mean number of cases treated annually was 13. Most patients came from the local oncology centre. The median length of stay in hospital was 11 days. In-hospital mortality was 14%. The fatal pulmonary embolus rate was 5% for femoral lesions. The revision rate for the operative intervention was 3%., Conclusion: The caseload was much lower than anticipated, likely owing to under-referring from oncology services. The high mortality rate may reflect delay in seeking orthopedic opinion, but overall the fixation methods appeared durable.

Osteogenesis imperfecta (OI) is a genetic disease of collagen or collagen-related proteins that adversely impacts bone mass and fracture resistance. Little is known regarding the role that microdamage plays in OI and whether or not OI bone is more prone to damage accumulation than bone with unaffected collagen. The Brtl/+ mouse is a heterozygous model for OI which contains a Gly349Cys substitution in one COL1A1 allele, and demonstrates a low ductility phenotype. At 8 weeks of age, Brtl/+ demonstrates an increase in osteoclast number, which mimics the upregulated bone turnover often found in OI patients. We hypothesize that upregulated osteoclast activity in Brtl/+ is due, in part, to increased remodeling associated with microdamage repair. In the present study, we used Brtl/+ to investigate the susceptibility of OI bone to microdamage. The mouse ulnar loading model was used to induce microdamage and to test the hypothesis that Brtl/+ is more susceptible to damage accumulation than age-matched wild type (WT) counterparts. Linear elastic fracture mechanics (LEFM) was used to investigate the fracture toughness properties of both Brtl/+ and WT bones to determine if there is any correlation with toughness and the degree of microdamage. Results show that Brtl/+ ulnae subject to normal cage activity demonstrate an inherently larger amount of microdamage than WT controls. Following axial compressive loading, Brtl/+ ulnae are more prone to damage than WT counterparts despite demonstrating a greater resistance to whole-bone deformation. Fracture toughness results demonstrate that Brtl/+ specimens, despite not exhibiting a significant difference, display a trend toward lower fracture toughness values than their WT counterparts. Correlations show that microdamage levels tend to increase as fracture toughness decreases. Together, these findings may have strong clinical implications for explaining increased fragility and remodeling activity in OI patients., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background Aims: Stromal vascular fractions (SVF) from adipose tissue have heterogeneous cell populations, and include multipotent adipose-derived stem cells. The advantages of using of SVF include the avoidance of an additional culture period, a reduced risk of extensive cell contamination, and cost-effectiveness., Methods: Unilateral 20-mm mid-diaphyseal segmental defects in rabbit ulna were treated with one of the following: polylactic glycolic acid (PLGA) scaffold alone (group 1, control), a PLGA scaffold with undifferentiated SVF cells (group 2), or a PLGA scaffold with osteogenically differentiated SVF cells (group 3). At 8 weeks after implantation, five rabbits in each treatment group were killed to assess bone defect healing by plain radiography, quantitative microcomputed tomography and histology., Results: The SVF cells were well grown on PLGA scaffolds and expressed type I collagen and alkaline phosphatase (ALP). The intensity of ALP and OPN gene expressions in osteogenic medium culture were increased from 14 days to 28 days. In vivo evaluations at 8 weeks showed that treatment of SVF cells with or without osteogenic differentiation resulted in more bone formation in the critically sized segmental defects than PLGA scaffold alone. Osteogenically differentiated SVF cells significantly enhanced bone healing compared with undifferentiated SVF cells., Conclusions: Adipose-derived stromal SVF showed osteogenic potential in vitro. Accordingly, SVF could provide a cell source for bone tissue engineering. However, treatment with uncultured SVF cells on bone healing was not satisfactory in the in vivo animal model.

Pain on the ulnar side of the wrist is a complex diagnostic dilemma. This is mainly due to the small size and complexity of the anatomical structures. The issue is compounded by the occurrence of positive imaging findings that are clinically asymptomatic. This pictorial essay deals with the imaging manifestations of different causes of ulnar-sided wrist pain., (Copyright © 2012 Canadian Association of Radiologists. Published by Elsevier Inc. All rights reserved.)

Intraoperative consultation via frozen section is an important part of modern day surgical pathology. Recognizing fungi in tissues on frozen and permanent sections is not always a simple task, and correctly identifying the agent can be a significant challenge, even for experienced microscopists. We present a case of a 17-year-old boy with chronic osteomyelitis involving the right proximal ulna. During an irrigation and debridement operation, a frozen section was sent to surgical pathology for evaluation. A limited patient history coupled with sparse organisms present in the frozen section led to the diagnosis of fungal osteomyelitis, favor Coccidioides . Follow-up permanent sections with special staining and successful fungal culture clarified the causal agent to be Blastomyces dermatitidis . The role of frozen sections is not to perfectly speciate the fungal pathogen but to describe the morphology and infectious process and provide a differential diagnosis of the candidate fungi. The importance of intraoperative culture in infectious cases cannot be understated, and it is the responsibility of pathologists to inform surgeons that tissue is needed for culture. A brief overview of Blastomyces , including histopathologic features and key microscopic differences from Coccidioides and Cryptococcus , is discussed.

Purpose: Atraumatic multifocal osteonecrosis is defined as the occurrence of atraumatic osteonecrosis in 3 or more anatomic locations, and it is rare. We identified 6 patients with osteonecrotic lesions in the distal ulna, radius, or both. The purposes of this study were to describe the clinical manifestations of atraumatic multifocal osteonecrosis affecting these bones, to identify risk factors for developing the disease in these locations, and to evaluate the success of treatment by percutaneous drilling., Methods: A total of 10 wrists in 6 women with a mean age of 41 years had symptomatic osteonecrosis. Patients were treated by percutaneous drilling after they had failed nonoperative modalities. Clinical evaluation included preoperative and postoperative Michigan Hand Questionnaire scores plain radiographs, and MRI evaluations were performed to characterize the disease. The incidence of risk factors was recorded., Results: There was disease occurrence in the radius in all 10 wrists and in the ulnas of 4 wrists. All patients presented with symptomatic osteonecrosis of the large joints (primarily knee or hip), presumably secondary to corticosteroid use. These patients later developed symptomatic pain in the distal ulna, radius, or both that impaired daily activities. Other risk factors included alcohol or tobacco use, blood dyscrasias, and systemic lupus erythematosus. Treatment consisted of percutaneous drilling of the distal radius (and ulna when affected). One patient required additional bilateral drillings and had further improvement in her Michigan Hand Questionnaire scores. At a mean follow up of 35 months, there was no disease progression as evident radiographically., Conclusions: The distal radius and ulna are rare sites of osteonecrosis associated with multifocal disease. The clinical presentation and risk factors are similar to osteonecrosis in the large joints. Magnetic resonance imaging identifies necrotic lesions. The present study suggests that disease in these sites can be safely and effectively treated with percutaneous drilling., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Aneurysmal bone cysts are non-neoplastic, expansile, osteolytic tumor-like conditions. All bones may be involved, but the most commonly affected is the metaphysis of the long bones, especially the tibia, humerus and femur. We present a 13-year-old female patient with a cystic lesion with cortical continuity and a large bone cyst in the coronoid process of the ulna. The bone cyst was treated with curettage, phenol application and cement implantation following cyst debulking. Aneurysmal bone tumors are rare tumor-like conditions and localization at the coronoid process of the ulna with mechanical block of the elbow motion has yet to be reported. Debulking and curettage of the lesion and bone cement implantation are useful methods for local control of aneurysmal bone cysts.

Physeal fractures of the distal forearm are common injuries in children and adolescents. However, Salter-Harris type III and type IV fractures of the distal ulnar epiphysis are often high-energy injuries that require open reduction for restoration of anatomical alignment. These injuries are uncommon and there are few descriptions of them in the contemporary literature. Here we report the case of a 13-year-old boy with a type IV distal ulna fracture not diagnosed with standard radiography. After closed manipulation, an incompletely reduced physis was suspected on the basis of fluoroscopic imaging and comparison radiographs of the contralateral wrist. Computed tomography showed a large, displaced physeal fragment. The patient underwent open reduction and internal fixation. Thorough radiographic assessment should be conducted when there is a high suspicion for these fracture patterns. Appropriate diagnosis can lead to expedient reduction and expectant management of sequelae associated with these injuries.

A girl was born with a deformed position of the left forearm in pronation. On examination, supination was highly limited. Conventional radiography revealed a proximal radioulnar synostosis. The right forearm showed no abnormalities. Radioulnar synostosis is a pathological connection between the radius and the ulna, usually located in the proximal forearm. In 60% of the patients, this congenital lesion presents bilaterally.

Objective: The anatomical variations of the extensor carpi ulnaris (ECU) muscle can cause a functional impairment of the wrist and the little finger. The aim of this study was to determine the number, thickness and type of accessory tendon arising from the ECU., Methods: The presence of an accessory tendinous slip from the ECU muscle was examined in terms of gross appearance, size, shape, thickness, location and distribution in 54 cadaveric forearms., Results: The accessory slips arising from the ECU muscle were observed in three specimens (5.6%) (two left, one right). These slips ran to the ulnar side of the extensor digiti minimi tendon, originated from the head of the ECU, and ended on the extensor apparatus of the fifth finger. The mean width of the tendinous slips was 1.4±0.01 mm., Conclusion: This anatomic variation of the ECU should be considered in diagnostic and surgical procedures involving the dorsum of the hand. Its clinical importance in the treatment of tenosynovitis and subluxation of joints is also stressed.

Objective: To quantify humeroulnar incongruity on elbow radiographs in Labrador Retrievers with or without medial coronoid disease (MCD)., Study Design: Retrospective study of 92 elbows., Sample Population: Radiographic projections of elbow joints from Labrador Retrievers with MCD (n = 42 elbows; 26 dogs) and without MCD (n = 50 elbows; 25 dogs)., Procedure: The congruity of the humeroulnar joint was measured using an index of subluxation (SI) for each elbow. SI was defined as the distance between the centers of 2 circles drawn along the margins of the incisura trochlearis and the trochlea of humerus on mediolateral digital radiographic projections, normalized by the radius of the circle circumscribing the humeral trochlea. SI was compared between right and left elbows with and without pathology using a Wilcoxon test for paired data, and between normal and abnormal groups with a Wilcoxon test for unpaired data. Mismatch between ulnar curvature and curvature of humeral trochlea and radioulnar incongruency were also noted (Wilcoxon test). The intraobserver repeatability, correlation between SI and radioulnar incongruency, and between SI and mismatch elbow curvature were estimated with a Pearson's correlation coefficient., Results: Intraobserver repeatability of SI measurement was high (r = 0.97). Mean ± SD humeroulnar incongruity (SI) was greater in elbows with MCD (18.5 ± 6.6) than in the normal elbows (1.7 ± 2.0, P < 0.001). The difference between the diameters of the curvatures of the ulnar and humeral trochlea was greater in elbows with MCD (12.5 ± 4.4) than in the normal group (10.7 ± 4.1, P < 0.05). A moderate correlation was found between the degree of humeroulnar incongruity and a radioulnar step (r = 0.63); however, no correlation was identified between SI and the difference between the diameters of the curvatures of the ulnar and humeral trochleae (r = 0.14)., Conclusion: We propose a radiographic index to measure humeroulnar incongruity on mediolateral digital radiographic projections. This index (SI) supports the presence of humeroulnar incongruity in Labrador Retrievers with MCD. Further evaluation of its reproducibility and clinical importance are warranted. Although there is a moderate correlation between humeroulnar incongruity and radioulnar incongruency, causation has not been established., (© Copyright 2011 by The American College of Veterinary Surgeons.)

Background: To compare the MR findings of the ulnar collateral ligament (UCL) injury in baseball players between rehabilitation and reconstruction surgery., Materials and Methods: Thirty nine baseball players with clinical evidence of a UCL injury based on medial elbow pain and valgus instability were included. All patients received the rehabilitation treatment for more than six weeks. The elbow MR images of 27 patients not responding to rehabilitation treatment were reviewed that consequently had reconstruction surgery; in addition to 12 patients with improved symptoms with only rehabilitation treatment. The MR imaging was compared between the two treatment groups using the Pearson's chi-square test, and linear-by-linear association for the following features: the degree, signal intensity and site of the UCL injury on fat suppressed T2-weighted images., Results: High-grade partial tears and complete tears were more commonly seen in the group that had surgery (14 out of 27 patients, 52%; 8 out of 27 patients, 30%), and low-grade partial tears and intact continuity were more common in the group that had rehabilitation only (5 out of 12 patients, 42%; 5 out of 12 patients, 42%) (p=0.001). The injured UCL showed a fluid-like bright high or intermediate high signal intensity in the group that had surgery more frequently (14 out of 27 patients, 52%; 12 out of 27 patients, 44%), and intermediate high or low signal intensity was more frequent in the rehabilitation group (7 out of 12 patients, 58%; 3 out of 12 patients, 25%) (p=0.013). The UCL injury at the origin site was most commonly seen in both groups (23 out of 27 patients, 85%; 11 out of 12 patients, 92%, respectively) (p=0.496)., Conclusion: Preoperative MR imaging is useful for predicting the rehabilitation outcome of UCL injuries in baseball players., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Bone sarcomas are uncommon tumours, of which osteosarcoma is the least rare, as well as the third most common malignant tumour in childhood, appearing usually between the 10 and 20 years of age. The case the authors present in this work is of a patient suffering from a long-standing condition encompassing skin and soft tissue lesions. After multiple medical treatments, the patient was diagnosed with squamous osteosarcoma, which required aggressive surgical management and chemotherapy.

Non-invasive quantification of bone shape is crucial in orthopaedic research. The primary objective of this study was to develop an automated statistical morphometry method for comparing the cross-sectional images of normal and diseased bones. The secondary objective involved demonstrating the effectiveness of the proposed method in distinguishing AIS patients from normal controls. This framework is composed of bone segmentation followed by measurements of maximum and minimum bone diameters, inter-group and intra-group statistical morphometry, and statistical analysis of bone thickness. The proposed framework was applied to detect bone morphological abnormality in adolescent idiopathic scoliosis (AIS) patients. The forearm bones in cross-sectional peripheral quantitative computed tomography (pQCT) images from 23 AIS patients and 16 normal controls were analyzed. The radius outer contour was found to be rounder and the radius cortical bone was thinner in AIS patients compared to normal controls., (Copyright © 2011 IPEM. All rights reserved.)

Purpose: The triangular fibrocartilage complex (TFCC) with its ulnar foveal attachment is the primary stabilizer of the distal radioulnar joint (DRUJ). The purpose of this study was to describe a technique for measuring the degree of subluxation of the DRUJ in wrist magnetic resonance imaging (MRI) examinations to predict tears involving the foveal attachment of the TFCC., Methods: We measured DRUJ geometry in wrist MRI examinations of 34 patients who were found to have foveal TFCC tears at surgery. We compared the results with DRUJ geometry in 11 asymptomatic controls. Subluxation of the ulnar head was assessed using transaxial MRI images obtained at the level of the DRUJ with the wrist in pronation. We quantified subluxation with a line spanning the sigmoid notch of the radius and a perpendicular line through the center of curvature of the articulating surface of the ulna. We calculated the ratio of the lengths of the dorsal and volar segments and normalized it to the center of the sigmoid notch., Results: A total of 34 patients with intraoperatively confirmed tears of the foveal attachment of the TFCC had a mean dorsal ulnar subluxation measurement of 16% ± 4%, whereas the 11 controls had a mean subluxation measurement of 5% ± 4%., Conclusions: The results confirm the hypothesis that subluxation of the ulnar head relative to the sigmoid notch of the radius, as assessed by MRI with the wrist in pronation, is a predictor of tears of the foveal attachment of the TFCC., Type of Study/level of Evidence: Diagnostic II., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The choice of an appropriate carrier and its microarchitectural design is integral in directing bone ingrowth into the defect site and determining its subsequent rate of bone formation and remodeling. We have selected a three-dimensional polycaprolactone (PCL) scaffold with an interconnected honeycomb-like porous structure to provide a conduit for vasculature ingrowth as well as an osteoconductive pathway to guide recruited cells responding to a unique triphasic release of osteoinductive bone morphogenetic proteins (BMP) from these PCL scaffolds. We hypothesize that the use of recombinant human bone morphogenetic protein 2 (rhBMP2)-PCL constructs promotes rapid union and bone regeneration of a large defect. Results of our pilot study on a unilateral 15 mm mid-diaphyseal segmental rabbit ulna defect demonstrated enhanced bone healing with greater amount of bone formation and bridging under plain radiography and microcomputed tomography imaging when compared with an empty PCL and untreated group after 8 weeks postimplantation. Quantitative measurements showed significantly higher bone volume fraction and trabecular thickness, with lower trabecular separation in the rhBMP2-treated groups. Histology evaluation also revealed greater mature bone formation spanning across the entire scaffold region compared with other groups, which showed no bone regeneration within the central defect zone. We highlight that it is the uniqueness of the scaffold having a highly porous network of channels that promoted vascular integration and allowed for cellular infiltration, leading to a discontinuous triphasic BMP2 release profile that mimicked the release profile during natural repair mechanisms in vivo. This study serves as preclinical evidence demonstrating the potential of combining osteoinductive rhBMP2 with our PCL constructs for the repair of large defects in a large animal model., (© Mary Ann Liebert, Inc.)

Background: We are reporting the results of single-stage treatment for patients with forearm deformity and radial head luxation due to hereditary multiple exostosis using distraction osteogenesis., Method: Six patients with a mean age of 12 years were treated. Morphological evaluation was made according to Masada (3 of the cases were 2a and 3; 2b). Angular deformities of forearm and wrist were evaluated as described by Fogel (distal radial joint angle was 27°, ulnar variance was 12.8 mm and carpal slip was 71.3%). Mean forearm pronation was 48.4° whilst mean supination was 19.2°. Mean elbow range of motion was 26.6°-103.4° and the mean DASH score was 75. Common surgical procedures were deformity correction, ulnar lengthening and gradual radial head reduction using external fixators., Results: Mean follow-up period was 4.2 years and mean external fixation time was 6 months. Mean amount of ulnar lengthening was 2.9 cm and the distraction index was 14.9 cm/day. Mean radial articular angle was 14.3°, ulnar variance 2.3 mm, carpal slip 55%, forearm pronation 65.9° and supination was 55°. Mean elbow range of motion was 15.8°-119.2°. In the last follow-up, the mean value of DASH score was 8.1. Major and minor complications were seen during the follow ups., Conclusions: Single-stage deformity correction, ulnar lengthening and radial head reduction technique that we have used provide satisfactory functional and cosmetic results. Early surgical correction may lead to even better results.

Proximal ulna fractures are common injuries in the upper extremity. The severity of injury ranges from isolated olecranon fractures to complex elbow fracture dislocations. Relevant anatomic features of the proximal ulna for fracture management are presented in the first part of this article. Furthermore, standard and recent techniques of surgical treatment are described in detail for olecranon and Monteggia fractures as well as for fractures of the coronoid process. Functional outcome and complications of fracture treatment are discussed., (© Georg Thieme Verlag KG Stuttgart · New York.)

Bizarre Parosteal Osteochondromatous Proliferation (BPOP) is a benign tumor-like lesion that has recently been reported to have an association with a specific translocation t(1:17)(q32;q21)[1]. Like other reactive periosteal lesions, BPOP can be diagnostically challenging, with the ever-present possibility of a potentially devastating erroneous diagnosis of malignancy. These lesions are often clinically, radiologically and histopathologically ambiguous, with rapid but circumscribed, non-infiltrative growth patterns, and histological atypia, but without overt features of malignancy. However, recent published reports have better characterized radiological [2] as well as histological features that aid in making an accurate diagnosis. In spite of all these advances, one of the biggest challenges in making the correct diagnosis still remains the inexperience of the practicing pathologist with this lesion, simply due to its rarity. We present a case of Nora's lesion in the distal ulna of an 8 year-old girl, in which, besides the histological features, we were able to demonstrate the translocation t(1:17)(q32;q21). Thus, we would like to emphasize the utility of cytogenetic studies in the correct and rapid diagnosis of clinically and radiologically ambiguous periosteal-based lesion.

Purpose: Traumatic and degenerative disc lesions cause ulnar-sided wrist pain. To date, anatomical investigations of cadaver triangular fibrocartilage discs examining the innervation of the triangular fibrocartilage complex have found no evidence of nerve fibers in the healthy disc. In this study, we immunohistologically investigated biopsies from patients with either central traumatic or degenerative disc lesions, to determine the existence of nerve fibers. We hypothesized that an ingrowth of nerve fibers causes ulnar-sided wrist pain associated with traumatic and degenerative disc lesions., Methods: We included 32 patients with a traumatic Palmer 1A lesion and 17 patients with a degenerative Palmer 2C lesion in the study. We obtained a biopsy of each patient and stained the specimen with protein gene product 9.5 for nerve fiber detection., Results: There were no nerve fibers in either traumatic or degenerative disc lesions. In addition, the marginal areas of the biopsies showed no evidence of nerve fibers., Conclusions: Traumatic and degenerative disc lesions show no ingrowth of nerve fibers., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The presence of the residual stresses in bone tissue has been noted and the authors have reported that there are residual stresses in bone tissue. The aim of our study is to measure the residual stress distribution in the cortical bone of the extremities of vertebrates and to describe the relationships with the osteon population density. The study used the rabbit limb bones (femur, tibia/fibula, humerus, and radius/ulna) and measured the residual stresses in the bone axial direction at anterior and posterior positions on the cortical surface. The osteons at the sections at the measurement positions were observed by microscopy. As a result, the average stresses at the hindlimb bones and the forelimb bones were 210 and 149 MPa, respectively. In the femur, humerus, and radius/ulna, the residual stresses at the anterior position were larger than those at the posterior position, while in the tibia, the stress at the posterior position was larger than that at the anterior position. Further, in the femur and humerus, the osteon population densities in the anterior positions were larger than those in the posterior positions. In the tibia, the osteon population density in the posterior position was larger than that in the anterior position. Therefore, tensile residual stresses were observed at every measurement position in the rabbit limb bones and the value of residual stress correlated with the osteon population density (r=0.55, P<0.01)., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

We present the first report of the development of characteristic radiologic appearances of long bones during the first year of life in an infant with type V osteogenesis imperfecta (OI). We show the evolution of metaphyseal abnormalities from a rickets-like appearance to the classically described dense metaphyseal bands. These abnormalities suggest that the underlying defect in type V OI may involve a molecule common to both bone and cartilage that is involved in the regulation of growth plate development and metadiaphyseal ossification. Our findings provide new insights into skeletal development in type V OI and potentially yield useful clues to the identity of the defect underpinning the condition., (Copyright © 2011 American Society for Bone and Mineral Research.)

Objective: To determine the accuracy of ultrasonography (US) in the evaluation of degenerative changes in the distal radioulnar joint (DRUJ)., Methods and Materials: Ten cadaveric specimens were obtained. US evaluation of cartilage degeneration and thickness was performed by two independent and blinded readers (R1 and R2). Gross anatomy and MR arthrography evaluated by two readers in consensus served as the reference standard. The joint surface not accessible to US was measured., Results: US interreader agreement was non-existent for cartilage thickness measurements and moderate for cartilage degeneration grading (weighted kappa = 0.41). Comparing US and MR imaging evaluation, there was no correlation between US R1 and MR imaging (Pearson correlation coefficient [PCC] = 0.352) and a moderate correlation between US R2 and MR imaging (PCC = 0.570) concerning cartilage thickness measurements. Concerning cartilage degeneration grading, there was a moderate to strong (R1 Spearman correlation coefficient [SCC] = 0.729)/R2 SCC = 0.767) correlation concerning cartilage degeneration grading. Comparing US and gross anatomic evaluation, there was no correlation for US R1 (PCC = 0.220) and a strong correlation for US R2 (PCC = 0.922) concerning cartilage thickness measurements, and a strong to moderate correlation (R1 SCC = 0.808/R2 SCC = 0.597) concerning cartilage degeneration grading. The mean sector of the articular surface of the ulna head not accessible to US was 13°., Conclusion: In conclusion the DRUJ is accessible to US except in the central 13° sector of the joint surface. US was approved to be sufficient in demonstrating advanced stages of cartilage degeneration. Thus, US of the DRUJ is recommended in patients suffering from ulnar-sided wrist pain., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

This report describes a 6 year-old boy who was treated with one-bone forearm procedure for acquired pseudoarthrosis of the ulna combined with radial head dislocation after radical ulna debridement for osteomyelitis. At more than 20 years of follow-up, the patient had a nearly full range of elbow movements with a few additional surgical procedures. Pronation and supination was restricted by 45°, but the patient had near-normal elbow and hand functions without the restriction of any daily living activity. This case shows that one-bone forearm formation is a reasonable option for forearm stability in longstanding pseudoarthrosis of the ulna with radial head dislocation in a child.

Background: Previous studies have documented increased posteromedial contact forces with the elbow at lower flexion angles associated with valgus extension overload; however, the authors believe that posteromedial elbow impingement in association with valgus laxity is a complex pathological process that may occur throughout the entire throwing motion in the form of ulnohumeral chondral and ligamentous overload., Hypothesis: Valgus laxity with the elbow at 90° of flexion may lead to chondromalacia secondary to a subtle shift in the contact point between the tip of the olecranon and the distal humeral trochlea., Study Design: Controlled laboratory study., Methods: Six fresh human cadaveric elbows were dissected and subjected to a static valgus load. Pressure-sensitive Fuji film measured the contact pressure, contact area, and shift in contact area across the posteromedial elbow before and after sectioning the anterior bundle of the ulnar collateral ligament., Results: The contact pressure between the tip of the olecranon process and the medial crista of the posterior humeral trochlea significantly increased, from an average of 0.27 ± 0.06 kg/cm² to 0.40 ± 0.08 kg/cm². The contact area also significantly decreased, from an average of 30.34 ± 9.17 mm² to 24.59 ± 6.44 mm², and shifted medially on the medial humeral crista, which corresponds to the position of the posteromedial chondral lesions that was observed in throwing athletes in the authors' clinical practice., Conclusion: While simulating the early acceleration phase of the throwing motion with the elbow in 90° of flexion, the results illustrate that abnormal contact may occur as a result of valgus laxity through increased contact pressures across the posteromedial elbow between the medial tip of the olecranon and medial crista of the humeral trochlea. In addition, congruency of the ulnohumeral joint changed, as there was a statistically significant medial shift of the olecranon on the posterior humeral trochlea with the elbow at 90° of flexion after sectioning the anterior bundle of the ulnar collateral ligament., Clinical Relevance: In the throwing athlete who continues the repetitive, throwing motion despite valgus laxity from ulnar collateral ligament insufficiency, the authors believe that these results provide a plausible mechanism for injury throughout the entire throwing motion secondary to ulnohumeral chondral and ligamentous overload. As throwing athletes may produce a tremendous amount of force and subsequent chondromalacia within the posteromedial aspect of the elbow, the findings of this study illustrate the importance of prompt clinical recognition of ulnar collateral ligament insufficiency.

Background: Forearm rotation is an indispensable activity of daily living and comprises complex motions with rotational and translational components. It is thought that changes in these motions with injury or disease may affect diagnostic indices. Several studies have assessed in vivo forearm kinematics with static conditions, but dynamic forearm kinematics have not yet been reported. The purpose of this study was to analyze forearm kinematics during dynamic rotation using radiographic 3D-2D registration methods., Methods: Ten forearms of five healthy males with the mean age of 37 years old were enrolled. Lateral fluoroscopic images were taken during forearm rotation from maximum supination to maximum pronation with their elbows flexed to approximately 45°. Geometric bone models were created from CT scans of the humerus, the radius and the ulna. Three-dimensional kinematics were determined using 3D-2D model registration techniques with the images and models, and the arc of axial rotation of the radius, volar/dorsal translation of the ulna at the distal radioulnar joint and rotation axis of forearm were computed., Findings: The radial rotation arc was 157°. The ulna translated 3.9 mm (SD 1.5mm) dorsally during activity. The rotation axis of the forearm passed through the center of the radial head and the ulnar head at the 1.9 mm (SD 0.7 mm) posterior from its geometric centroid., Interpretation: The posteriorly deviated rotation axis at the ulnar head may result in the ulnar head translating dorsally during pronation. These data provide a basis for objective assessment of pathological forearm function., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Triangular fibrocartilage complex injuries are one of the most common causes of ulnar-sided wrist pain. Although pain and discomfort may improve with simple immobilization for a short period of time, a significant number of patients eventually require surgical intervention. The purpose of this study was to investigate the incidence of surgical intervention on patients with a clinical diagnosis of a triangular fibrocartilage complex injury. A retrospective chart review was performed to identify patients with ulnar-sided wrist pain identified with the appropriate ICD-9 code from September 2005 to September 2007. All patients were evaluated and treated by a board-certified, fellowship-trained hand surgeon. Any patients with associated pathology were excluded from the study. All patients were initially treated with a minimum of 4 weeks of either a volar wrist splint worn all the time or a short-arm cast. Magnetic resonance images were obtained on patients without symptomatic relief, and in these cases, surgical arthroscopy was performed. Of the 84 patients identified, 36 patients required surgical intervention. All 36 patients had evidence of triangular fibrocartilage complex injury during arthroscopy. All patients had symptomatic improvement postoperatively. The use of short-arm cast versus a splint did not affect the rate of surgical intervention (P=.38). Among the patients with clinical diagnosis of triangular fibrocartilage complex injury, the rate of surgical intervention required after a minimum 4 weeks of immobilization was 43%. The use of a short-arm cast or volar wrist splint did not affect the rate of surgical intervention., (Copyright 2010, SLACK Incorporated.)

Ulnar impaction syndrome is a common source of ulnar-sided wrist pain. It is a degenerative condition that occurs secondary to excessive load across the ulnocarpal joint, resulting in a spectrum of pathologic changes and symptoms. It may occur in any wrist but is usually associated with positive ulnar variance, whether congenital or acquired. The diagnosis of ulnar impaction syndrome is made by clinical examination and is supported by radiographic studies. Surgery is indicated if nonoperative treatment fails. Although a number of alternatives exist, the 2 primary surgical options are ulnar-shortening osteotomy or partial resection of the distal dome of the ulna (wafer procedure). This article discusses the etiology of ulnar impaction syndrome, and its diagnosis and treatment., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Aims: Bone defects induced by different causes are difficult to replace and repair. We sought to repair bone defects by transplantation of genetically modified adipose-derived stem cells (ADSC) and acellular bone matrix (ACBM)., Methods: We constructed the biologic material of ACBM and evaluated its mechanical properties, general biocompatibility and biosafety. ADSC isolated from minipigs were cultured in vitro and then transfected by recombinant human bone morphogenetic protein-2 (rhBMP-2) and recombinant human vascular endothelial growth factor (rhVEGF) plasmids, respectively. Subsequently, the compounds of ACBM/ADSC/rhBMP-2/rhVEGF were used to repair bone defects of the ulna in minipigs. X-ray examination, radionuclide bone imaging and single photon emission computerized tomography (SPECT) were employed to monitor the therapeutic effects 2, 4, 8 and 12 weeks after operation. Histologic experiments were carried out 12 weeks after operation., Results: ACBM had no or weak antigenicity and the natural mechanical properties of ACBM were preserved. In vitro, ADSC transfected by rhBMP-2 and rhVEGF, respectively, could release rhBMP-2 or rhVEGF for at least 4 weeks. The X-ray, radionuclide bone imaging and SPECT examinations indicated that the compound of ACBM/ADSC/rhBMP-2/rhVEGF had better treatment effects on bone defects compared with the controls., Conclusions: Scaffolds, seed cells and bioactive factors are key points in tissue engineering. This research indicates that ACBM is a good biologic material for tissue repair, and ACBM/ADSC/rhBMP-2/rhVEGF can accelerate bone formation significantly.

Recent experiments point to two predominant forms of fatigue microdamage in bone: linear microcracks (tens to a few hundred microns in length) and "diffuse damage" (patches of diffuse stain uptake in fatigued bone comprised of clusters of sublamellar-sized cracks). The physiological relevance of diffuse damage in activating bone remodeling is not known. In this study microdamage amount and type were varied to assess whether linear or diffuse microdamage has similar effects on the activation of intracortical resorption. Activation of resorption was correlated to the number of linear microcracks (Cr.Dn) in the bone (R(2)=0.60, p<0.01). In contrast, there was no activation of resorption in response to diffuse microdamage alone. Furthermore, there was no significant change in osteocyte viability in response to diffuse microdamage, suggesting that osteocyte apoptosis, which is known to activate remodeling at typical linear microcracks in bone, does not result from sublamellar damage. These findings indicate that inability of diffuse microdamage to activate resorption may be due to lack of a focal injury response. Finally, we found that duration of loading does not affect the remodeling response. In conclusion, our data indicate that osteocytes activate resorption in response to linear microcracks but not diffuse microdamage, perhaps due to lack of a focal injury-induced apoptotic response., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Natural polymer chitosan and synthetic polymer poly(lactide-co-glycolide) (PLAGA) have been investigated for a variety of tissue engineering applications. We have previously reported the fabrication and in vitro evaluation of a novel chitosan/PLAGA sintered microsphere scaffold for load-bearing bone tissue engineering applications. In this study, the in vitro degradation characteristics of the chitosan/PLAGA scaffold and the in vivo bone formation capacity of the chitosan/PLAGA-based scaffolds in a rabbit ulnar critical-sized-defect model were investigated. The chitosan/PLAGA scaffold showed slower degradation than the PLAGA scaffold in vitro. Although chitosan/PLAGA scaffold showed a gradual decrease in compressive properties during the 12-week degradation period, the compressive strength and compressive modulus remained in the range of human trabecular bone. Chitosan/PLAGA-based scaffolds were able to guide bone formation in a rabbit ulnar critical-sized-defect model. Microcomputed tomography analysis demonstrated that successful bridging of the critical-sized defect on the sides both adjacent to and away from the radius occurred using chitosan/PLAGA-based scaffolds. Immobilization of heparin and recombinant human bone morphogenetic protein-2 on the chitosan/PLAGA scaffold surface promoted early bone formation as evidenced by complete bridging of the defect along the radius and significantly enhanced mechanical properties when compared to the chitosan/PLAGA scaffold. Furthermore, histological analysis suggested that chitosan/PLAGA-based scaffolds supported normal bone formation via intramembranous formation., (2010 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)

Pain at the ulnar aspect of the wrist is a diagnostic challenge for hand surgeons and radiologists due to the small and complex anatomical structures involved. In this article, imaging modalities including radiography, arthrography, ultrasound (US), computed tomography (CT), CT arthrography, magnetic resonance (MR) imaging, and MR arthrography are compared with regard to differential diagnosis. Clinical imaging findings are reviewed for a more comprehensive understanding of this disorder. Treatments for the common diseases that cause the ulnar-sided wrist pain including extensor carpi ulnaris (ECU) tendonitis, flexor carpi ulnaris (FCU) tendonitis, pisotriquetral arthritis, triangular fibrocartilage complex (TFCC) lesions, ulnar impaction, lunotriquetral (LT) instability, and distal radioulnar joint (DRUJ) instability are reviewed.

Objective: To demonstrate how radial and ulnar deviation of the wrist can affect the visualization of the intrinsic intercarpal ligaments using magnetic resonance (MR) imaging, MR arthrography and gross anatomic inspection in cadavers., Materials and Methods: The detectability of the intrinsic intercarpal ligaments of ten fresh human wrists was analyzed in coronal, axial and sagittal images in the neutral position and in radial and ulnar deviation with MR imaging and MR arthrography. The findings were then correlated with gross anatomic inspection. Additionally, quantitative measurements including the radiocarpal distances and capitate angles were performed., Results: Differences were noted in the visual conspicuity of only the intercarpal ligaments of the proximal carpal row with different techniques and wrist positions. The average width of the radiocarpal joint was 0.62 mm, 1.55 mm and 2.0 mm (radial side) and 3.78 mm, 2.25 mm and 1.16 mm (ulnar side) in radial deviation, neutral position, and ulnar deviation of the wrist, respectively. Statistically, these maneuvers produced significant opening in the ulnar side during radial deviation (Student's t-test; P = 0.0005) and in the radial side in ulnar deviation (P = 0.007)., Conclusion: Significant differences in the width of the radiocarpal joint were observed during radial and ulnar deviation of the wrist, influencing the visualization of the intrinsic ligaments, mainly the scapholunate and lunotriquetral ligaments. The use of MR arthrography with radial and/or ulnar deviation has the potential to improve diagnosis in clinical cases in which injury to one or both of these ligaments is suggested.

This study was aimed to investigate the effects of Parathyroid hormone (PTH) and alendronate (ALN) on stress fracture repair. Stress fractures were induced in the ulnae of female adult rats. Animals were treated daily with vehicle, PTH (40 microg/kg) or alendronate (2 microg/kg), respectively. Bone mineral content (BMC) and bone mineral density (BMD) of bilateral ulnae were measured at two, four and eight weeks following induction of stress fracture. Histology at the ulna midshaft was undertaken at 2 and 4 weeks and mechanical testing was done at 8 weeks after stress fracture. PTH increased BMC significantly by 7% at 4 weeks and BMD and BMC significantly by 10% and 7% at 8 weeks compared to the control. Alendronate did not change BMD or BMC in comparison with the control. PTH significantly stimulated bone formation by 114% at 2 weeks, increased intracortical resorption area by 23% at 4 weeks, and enhanced the ultimate force of the affected ulnae by 15% at 8 weeks compared to the control. Alendronate significantly suppressed bone formation rate by 44% compared to the control at 4 weeks. These data indicate that PTH may accelerate intracortical bone remodeling induced by microdamage and alendronate may delay intracortical bone remodeling during stress fracture repair in rats. This study suggests that PTH may be used to facilitate stress fracture repair whereas bisphosphonates may delay tissue level repair of stress fractures., (Copyright 2010 Elsevier Inc. All rights reserved.)

Ulnar-sided wrist pain is a common complaint that presents a diagnostic challenge. Determining the cause of ulnar-sided wrist pain is difficult, largely due to the complexity of the anatomic and biomechanical properties of the ulnar side of the wrist. Osteoid osteoma is a benign skeletal neoplasm of unknown etiology that is composed of osteoid and woven bone. Its incidence is 11% of benign tumors and 3% of all primary bone tumors, with 6% to 13% of all cases occurring in the hand. Osteoid osteoma of the hamate can produce ulnar-sided wrist pain in the dorsal or volar aspect of the wrist, depending on the location of the tumor in the bone. In its classical and most frequent form, the osteoma may settle in the cortex or the spongiosa. A third rare form appears subperiosteally. Occasionally it destroys the articular cartilage by erosion or penetration. Most of the tumors will produce dorsal pain. A tumor located in the hook will produce volar pain. This article describes a case of ulnar-sided wrist pain due to a rare case of osteoid osteoma of the hamate. We recommend marking the nidus with a needle intraoperatively with the aid of radiography., (Copyright 2010, SLACK Incorporated.)

We report a case of dual nontuberculous mycobacterial infections complicating an open distal radius and ulna fracture after polytrauma in a 35-year-old man. There was persistent wound discharge after definitive fixation of this fracture, but microbiological cultures did not yield any organism. The patient underwent multiple debridement, and subsequent tissue grew Mycobacterium chelonae and Mycobacterium fortuitum. Despite appropriate chemotherapy and surgical debridement the infection persisted until radical bone excision and tissue debridement were done. This case indicates that nontuberculous mycobacterial infections should be considered when conventional microbiological assays fail to identify the infecting agent in suspected osteomyelitis following open fracture. A combination of radical debridement, including removal of infected bone, and prolonged antimicrobial therapy are required to eradicate the infection completely.

Between 1997 and 2006, radiographs of 66 scaphoid fractures were retrospectively reviewed to evaluate ulnar variance. Twenty-one (31.8%) patients had an 'ulna neutral' wrist, six (9.1%) had an 'ulna plus' and 39 (59.1%) had an 'ulna minus' wrist. The mean ulnar variance was -1.3 (SD 1.8) mm (range -5.5, 2.5). We observed a significant difference in the distribution of ulnar variance (P < 0.00001) and in the proportion of cases with ulna minus (OR = 5.0; 95% CI: 2.7, 9.3) compared to previous publications.

Introduction: Pain is the main problem in patients suffering from cerebral palsy, particularly in adults. The upper limbs are affected in 25% of cases. Here, we report the case of a patient with Kienböck's disease., Method: Clinical case and literature review. A 28-year-old man suffering from dystonic quadriplegia consulted for progressively worsening pain in the right wrist. Kienböck's disease was diagnosed and conservative treatment with botulinum toxin in the flexor carpi radialis recommended. A good result was obtained with a decrease in pain. This result was still present two years later., Discussion: Although few references are made to it in literature, Kienböck's disease in cerebral palsy is probably underestimated. Maintenance of the wrist in a permanent flexed position and muscular hypertonia may be risk factors. Knowledge of this particular clinical picture will enable it to be detected promptly and thus enable conservative treatment to be organised with a maximum chance of therapeutic success, preventing the need for surgery., (2009 Elsevier Masson SAS. All rights reserved.)