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The optimal treatment of minimally displaced or nondisplaced fractures of the scaphoid is unclear. Traditionally, management of these fractures has been unpredictable with a significant risk of nonunion when treated conservatively. This study examined the results from 32 patients who underwent percutaneous screw fixation using a 3.0-mm AO/ASIF cannulated screw for a nondisplaced or minimally displaced fracture of the scaphoid waist. Eighteen patients were available for final follow up (average 3.2 years) including administration of the DASH questionnaire, a physical examination, and final radiographs. Sixteen (89%) healed successfully after the index procedure. There were two complications consisting of nonunions, both of which required revision open reduction and internal fixation for fracture union. These also went on to heal, resulting in an ultimate union rate of 100%. No significant differences were found between operative and nonoperative extremities with regard to radial-ulnar deviation arc of motion, grip, or pinch strength. The average DASH score was 7.4, indicating no disability. Percutaneous fixation of acute, nondisplaced scaphoid fractures with 3.0-mm AO/ASIF cannulated screw is a safe, effective technique that minimizes the need for long-term wrist immobilization, allows an expeditious return to vocational activity, and results in reliable rates of union.

We describe 4 patients who were treated for symptomatic triggering of the index and small fingers with pain on the dorsum of the hand and were found to have impingement of an extensor tendon on the extensor retinaculum at the wrist. All cases were treated by release of the extensor retinaculum and excision of pathologic structures.

Wound healing is a complicated and dynamic process. The aim of this study was to determine whether systemic administration of common anticoagulants retards or delays wound healing in an animal model.

Recent literature suggests that, in older children, acute cases of septic arthritis may be treated with aspiration and intravenous antibiotics. However, when surgical decompression is required, the technique described in this report has several advantages. It can be performed with an incision of approximately 1 to 2 inches and a posterior stab wound of <1 cm; it preserves anatomic planes and poses less risk to the circumflex femoral vessels (as with the anterior approach); and it allows fluid to drain when the patient is supine (as with the posterior approach).

Treatment of infected orthopaedic hardware usually requires the removal of the appliance. When the device is removed and immediately replaced, persistent infection frequently complicates this exchange procedure. We modeled the exchange procedure in rats by passing a wire suture through a posterior spinous process and then contaminating the wound with Staphylococcus aureus. We then investigated whether a sequence of surfactant enriched irrigation solutions (Castile soap followed by benzalkonium chloride, sequential surfactant irrigation) had a greater capacity to eradicate Staphylococcus aureus from the experimental wound than did the standard wound irrigant, normal saline. When we left the wire in place through the 2-week course of the study, sequential surfactant irrigation showed only a modest advantage over normal saline (staphylococci recovered from 39% versus 58% of wound cultures respectively). Simple removal of the wire 24 hours after implantation and bacterial contamination prevented wound infection in most animals (with the wire removed, 38% of the animals remained infected versus 85% with the wire left in place), without regard to the irrigation solution. Alternatively, when we removed the wire after 24 hours, irrigated the wound, and then placed a fresh wire back into the wound, sequential surfactant irrigation showed a significant advantage over NS (54% of the animals irrigated with sequential surfactants remained infected versus 100% of the animals irrigated with normal saline). Our findings confirm the importance of a contaminated medical device for promoting foreign body infection; our findings also show that sequential surfactant irrigation has therapeutic value in a rat model of orthopaedic device infection; this irrigation protocol should be studied further as a potential agent for the treatment of infected orthopaedic wounds.

The primary purpose of irrigation is to remove bacterial contaminants from the wound. Surfactants do that by disrupting the bonds of the organism to the surface. The use of this wound care strategy was studied in a series of investigations spanning several years. In vitro experiments revealed that surfactant irrigation was superior to saline or antibiotic solutions for removal of adherent bacteria from metallic surfaces, from bone, and from bovine muscle. An in vivo model of the complex orthopedic wound was developed. The superiority of surfactant irrigation over saline or antibiotic solution was demonstrated in animal wounds containing metal, bone injury, and soft tissue damage. Specificity of different surfactant irrigations for various bacterial species was demonstrated. A sequential surfactant irrigation protocol was developed and shown effective in the polymicrobial wound with established infection.

Deep wound infection involving an implanted biomaterial is a devastating complication in orthopaedic surgery. Two-thirds of such infections are monomicrobial and the most commonly isolated bacteria in human osteomyelitis and orthopaedic device infection are Staphylococcus aureus and Staphylococcus epidermidis. The purpose of the current study was to examine the effectiveness of the previously reported sequential surfactant irrigation protocol against human-isolated clinical strains of Staphylococcus aureus and Staphylococcus epidermidis in the rat model of orthopaedic implant contamination. The infectivity rate of human-isolated clinical strains of Staphylococcus aureus in a contaminated complex orthopaedic wound was reduced effectively by a sequential surfactant irrigation protocol. Also, in this model, the infectivity of Staphylococcus epidermidis was reduced by normal saline irrigation alone when compared with no irrigation. Therefore, the sequential surfactant irrigation protocol may represent an effective method of wound irrigation in monomicrobial Staphylococcus aureus orthopaedic implant contamination, and normal saline irrigation may suffice in cases of monomicrobial Staphylococcus epidermidis contamination. Additional studies are necessary to determine the clinical use of surfactant irrigation.

Background: We observed an interaction in animals inoculated concomitantly with Staphylococcus aureus and Pseudomonas aeruginosa during a study of the efficacy of surfactants for disinfection of orthopaedic wounds. This led us to investigate whether synergy could be demonstrated between Staphylococcus aureus and Pseudomonas aeruginosa in a rat model of complex orthopaedic wounds., Methods: A wire was implanted into the spinous process of a lumbar vertebra of Sprague-Dawley rats through a dorsal incision. Animals were divided into two groups: group one was inoculated with either Staphylococcus aureus or Pseudomonas aeruginosa, and group two received a polymicrobial inoculation with both test organisms in varying concentrations. After inoculation, the wounds were irrigated and closed. On postoperative day 14, all animals were killed and specimens from the wounds were cultured. The number of colony-forming units (CFU) of Staphylococcus aureus or Pseudomonas aeruginosa needed to cause infection in 50% of the animals (ID50) was determined with use of the Reed-Muench method. The infection rate associated with each inoculum combination was calculated, and the two groups were compared., Results: The ID50 was 2.8 x 10(4) CFU for Staphylococcus aureus and 4.8 x 10(5) CFU for Pseudomonas aeruginosa. The combination of 10(3) CFU of Staphylococcus aureus with low concentrations (10(2), 10(3), or 10(4) CFU) of Pseudomonas aeruginosa yielded infection rates that were higher than those found with either organism alone at the same concentrations. The combination of 10(3) CFU of Staphylococcus aureus and 10(3) CFU of Pseudomonas aeruginosa yielded a 75% infection rate, which was significantly higher (p = 0.004) than that associated with 10(3) CFU of either organism alone. As the Pseudomonas aeruginosa concentration was increased (to 10(5), 10(6), and 10(7) CFU), this trend reversed, and the infection rate decreased to 33% (p = 0.004). Low concentrations of Pseudomonas aeruginosa (0 to 10(5) CFU) combined with 10(6) CFU of Staphylococcus aureus yielded infection rates ranging from 83% to 100%. At the higher concentrations of Pseudomonas aeruginosa (10(6) and 10(7) CFU), however, the infection rate again decreased, to 33% (p = 0.005). Only Staphylococcus aureus was isolated from the cultures of the specimens from the animals that had received a polymicrobial inoculum., Conclusions: Synergy between Staphylococcus aureus and Pseudomonas aeruginosa was demonstrated when low levels of each organism were present in the wound. As the Pseudomonas aeruginosa concentration was increased, the infection rates fell well below what would be anticipated, suggesting that low concentrations of Pseudomonas aeruginosa enhance the ability of Staphylococcus aureus to cause infection in this orthopaedic wound model. At the same time, the presence of Staphylococcus aureus in the ratios tested decreased the rate of infection by Pseudomonas aeruginosa., Clinical Relevance: Staphylococcus aureus is a pathogen commonly seen in orthopaedic patients. The pathogenicity of Staphylococcus aureus was shown to be increased in the presence of anaerobic bacteria. This study is the first one that we are aware of that demonstrated synergy between Staphylococcus aureus and Pseudomonas aeruginosa, at low concentrations, in a wound model while at the same time showing that Staphylococcus aureus lowers the rate of Pseudomonas aeruginosa infection.

Hand surgeons have a rich heritage of stewardship to the community through volunteer medical work. There is a wide breadth of service opportunities that can be accomplished at home and overseas. The challenges of volunteerism are balanced by the personal and professional rewards.

Complications with open reduction and internal fixation of distal radius fractures have led to the development of the AO/titanium Pi-plate. This was designed to be a low-profile plate to decrease its intrusion into surrounding soft tissues. Recent case reports are revealing an association of tendon ruptures with failures of this plate. This case report demonstrates extensor tendon rupture without plate failure or prominent screw heads.

Objective: The purpose of the present study was to determine the effects of cleaning a contaminated orthopaedic wound with different classes of wound irrigation solutions., Study Design: Rats with a contaminated orthopaedic wound were randomized into treatment groups: normal saline (NS), castile soap (CS), benzalkonium chloride (BzC), bacitracin (Abx), or sequential irrigation with BzC, CS, and NS., Intervention: Pseudomonas aeruginosa [P. aeruginosa; 1 x 10(6) colony-forming units (CFU)], or Staphylococcus aureus (S. aureus; 1 x 10(6) CFU) were placed into a paravertebral wound (containing a wire implant placed through a spinous process) and allowed to incubate for fifteen minutes. The wound was then irrigated with three liters of either NS, 0.05 percent CS, 0.03 percent BzC, Abx (33,000 units per liter) or underwent a sequential irrigation treatment (one liter each of BzC, CS, NS)., Main Outcome Measurements: The animals were observed daily for wound complications for fourteen days and then killed, and cultures of the wound were obtained., Results: Pseudomonas aeruginosa: Both CS and the sequential irrigation treatment significantly lowered the rate of positive wound cultures when compared with NS (p < 0.05). Irrigation with BzC resulted in a higher rate of positive wound cultures and complications. The sequential irrigation treatment prevented the wound complications associated with irrigation with BzC alone. Staphylococcus aureus: Only BzC irrigation significantly lowered the rate of positive wound cultures when compared with NS (p < 0.05)., Conclusion: The rate of positive wound cultures due to P. aeruginosa is effectively reduced by irrigation with CS alone or by the sequential irrigation treatment. When used alone, the antiseptic BzC results in a higher rate of positive wound cultures and wound complications. The wound complications seen with irrigation with BzC alone are prevented by the sequential irrigation treatment (BzC followed by CS and NS). The rate of positive wound cultures in this model due to S. aureus is not decreased by irrigation with CS; however, the rate of positive wound cultures is safely and effectively decreased with the use of BzC.

This investigation sought to determine the capacity of irrigation solutions in decontaminating orthopedic wounds challenged with a polymicrobial inoculum. Rats were divided into two groups, a control group and a treatment group. After creation of a dorsolumbar incision and placement of a wire through the spinous process, rats were inoculated with Staphylococcus aureus and Pseudomonas aeruginosa. Wounds were irrigated with control or treated solutions. At 2 weeks, cultures were obtained. There were statistically significant differences between groups regarding total number of culture positive sites (P < 0.001), culture-positive animals (P = 0.02), and quantitative cultures (P < 0.02). Sequential irrigation with surfactants lowers bacteria counts recovered from polymicrobial wounds.

The efficacy of benzalkonium chloride was evaluated as an irrigating solution for the eradication of Staphylococcus aureus from a contaminated orthopaedic wound. Thirty Sprague Dawley rats were randomized into two groups. A stainless steel wire was placed in a lumbar spinous process, and the wound was inoculated with 10(7) or 10(6) colony forming units of Staphylococcus aureus. The wound was irrigated with 1 L of normal saline or 0.1% benzalkonium chloride solution. The animals were sacrificed, and cultures were obtained. Rats inoculated with 10(7) colony forming units of Staphylococcus aureus and irrigated with benzalkonium chloride had a significant decrease in the total number of positive cultures, deep wound cultures, and stainless steel wire cultures. Rats inoculated with 10(6) colony forming units of Staphylococcus aureus and irrigated with benzalkonium chloride also had a significant decrease in the total number of positive cultures, deep wound cultures, and stainless steel wire cultures. In a parallel noninoculation study, histologic evaluation of tissues did not show toxicity in the rats irrigated with benzalkonium chloride. This study shows that benzalkonium chloride is more effective than normal saline as an irrigating agent for eradicating Staphylococcus aureus from a contaminated orthopaedic wound.

This investigation seeks to determine whether surfactants or detergents can be used to clean and disinfect orthopaedic wounds with implanted hardware. Thus, a stepwise investigation of biocompatible surfactants and detergents was performed to identify an irrigation agent for disinfecting orthopaedic wounds. Bacterial adhesions assays, irrigation studies, and bactericidal assays determined that benzalkonium chloride showed the greatest efficacy. Testing involved stainless steel screws colonized with a preformed biofilm of Staphylococcus epidermidis, Staphylococcus aureus, or Pseudomonas aeruginosa, which were immersed in benzalkonium chloride solutions for various time intervals under static conditions. After 10 minutes, benzalkonium chloride achieved a minimum 4 log kill (10,000-fold) for all 3 strains of bacteria. Additional studies demonstrated that the high mechanical energy of jet irrigation improved the disinfecting properties of this agent. With jet lavage, both 1:1000 and 1:5000 concentrations of benzalkonium chloride achieved a minimum 2 log kill (100-fold) for all 3 bacteria. The results or this study suggest that at tissue compatible concentrations, benzalkonium chloride has significant disinfection properties for in vitro colonized orthopaedic devices, and these properties may be enhanced via jet lavage.

To determine the rate of healing of the osteotomy, we studied the cases of 10 patients who had transverse osteotomy of the olecranon for surgical exposure of a complex distal humerus fracture. The average age of the patients was 48 years, and the average follow-up was 24 months. Nine of the fractures were complex supracondylar/intercondylar fractures. All of the humerus fractures were treated with bone plates and screws, and nine of the osteotomies of the ulna were reconstructed with a large lag screw and tension band wire. Smooth pins and a tension band wire were used in 1 patient with osteoporotic bone. Union of the ulnar osteotomy occurred in 7 patients, and 3 of the patients had a nonunion. The average time of healing of the distal humerus fractures was 3.5 months, and the average time of healing of the ulnar osteotomies was 5.2 months. Six of the patients developed a gap at the osteotomy site by displacement or resorption of it, and two of these progressed to a nonunion. The patients whose ulnar osteotomy healed had an average extension lag of 33 degrees, and the average flexion at their elbows was 122 degrees. The patients who had a fibrous nonunion of the ulnar osteotomy had an average extension lag of 27 degrees at the elbow, and all 3 patients had full flexion of the elbow joint. Because of the nonunion rate of 30% in our patients, we no longer use a transverse osteotomy of the olecranon to expose distal humerus fractures at surgery.

Two patients with complicated giant cell tumors of the distal ulna were treated by resection of 7.5 and 5.5 cm of the ulna, respectively. The proximal ulnar stump was stabilized with a lasso tendon graft, which allowed the patients to return to presurgery activities. The technique described is a modification of a tendon loop reconstruction used by Bunnell.

We did a retrospective analysis of 28 patients who were treated with the Orthofix external fixation system for complex fractures of the distal radius to study complications associated with screw size. The 14 patients in group 1 had a 4.5/3.5-mm tapered screw placed in the metacarpal bone; the 14 patients in group 2 had a 3.5/3.3-mm tapered screw placed in the metacarpal bone. Both groups had 4.5/3.5-mm tapered screws placed in the radius. Two patients in group 1 had metacarpal pin tract infections; no patients in group 2 had a distal pin tract infection. Two patients in group 1 had a fracture of the metacarpal; only one patient in group 2 had a fracture of the metacarpal. In both groups two patients had proximal pin tract infections at the radius screw fixation site. There was no screw breakage in either group. The unique design of the tapered Orthofix screw allows it to be removed almost painlessly in the clinic. At installation in the operating room, however, the surgeon must remember not to back the threaded pin out for fine adjustment of bony penetration. Any reverse excursion of the threaded shaft will loosen the tapered screw and cause early failure of the fixation. We no longer use the 4.5/3.5-mm screw when managing wrist fractures with the Orthofix external fixation system. It is now our policy to use the 3.5/3.3-mm screw for fixation of the Orthofix external frame to both the metacarpal bone and the radius.

Because hypertrophic and symptomatic scarring is not infrequent from a lazy S incision across the antecubital fossa, a new surgical approach to the pronator tunnel has been developed. Preliminary experience with this modified incision has proven to be encouraging in seven cases (five patients). The exposure is composed of two off-set linear incisions which allow visualization of the median nerve and brachial artery distal and proximal to the lacertus fibrosis. An intact bridge of skin at the antecubital fossa protects the medial cutaneous nerves of the arm and forearm from injury. The median nerve is exposed by splitting the pronator teres along its length, and fractional step cutting of the pronator aponeurosis relaxes the muscle. Postoperative scar management with a compressive wrap and elastomer insert is helpful for cosmetic healing of the incisions.

Arthrodesis of the wrist with intramedullary rod fixation is a simple technique that provides the opportunity for performing concomitant procedures. Iliac bone graft usually is not required with this technique, as the intramedullary rod is a load-sharing construct that allows compression at the fusion site and facilitates union. Rod removal usually is optional, and the long intramedullary beam effect of the rod can function as an internal splint if fibrous or hypoplastic union occurs. Early mobilization is possible, sometimes with only minimal splinting. The results with use of this technique over a ten year period of time in ten wrists (nine patients) with endstage radiocarpal joint instability are reported.

Resectional arthroplasty with interposition of a rolled tendon spacer was used to treat posttraumatic arthritis of the fifth metacarpal-hamate joint in eight patients. The average follow-up was 5 years. All of the patients subjectively rated the functional capability and the cosmetic appearance of their hands as good or excellent. After operation, there was a net increase of 30% in the average grip strength of the study group. The motion preserved at the small finger carpometacarpal joint facilitated power function of the hand.

Pronator compression testing is a valuable clinical feature of median nerve entrapment diagnosis. Of 10 patients with this disorder, all developed paresthesias preoperatively in the hand after 30 seconds or less of manual compression of the median nerve at or near the pronator muscle. Eight patients had a positive Tinel's sign at the impingement site, but only one patient had a positive electromyographic result. More than 50% of the patients had undergone previous carpal tunnel release or were diagnosed at presentation with double crush syndrome. All patients had a good or excellent result from surgical decompression of the median nerve in the forearm, except for one workers' compensation case who had excellent postoperative strength testing but multiple residual complaints. Pronator compression testing is a helpful and dependable physical sign in the diagnosis of pronator syndrome.

Twelve patients with complex fractures of the distal radius were treated with the Orthofix external fixation system (EBI Medical Systems, Fairfield, NJ). On follow up physical examination, the average wrist dorsiflexion was 46 degrees, and the average volar flexion was 55 degrees. The average grip strength in the involved hand was 38 lb force. The average final radial angle was 18 degrees, and the average residual radial height was 12 mm. Average volar tilt was 3 degrees. The complication rate was 42%. Very rigid axial stability is afforded by the fixator, but the large 3.5 mm tapered bone screw diameter precludes redrilling for screw adjustment. The apparatus needs frequent monitoring to reconfirm the security of the locking nuts and cam mechanisms, and the Orthofix system can be reused only four times.

Unrecognized entrapment of the median nerve and its anterior interosseous branch in the midportion of the forearm occurred in a 12-year-old girl following reduction of a closed both-bone fracture. Following delayed diagnosis, treatment required secondary neurolysis and microscopic neurorrhaphy. Meticulous prereduction and postreduction neurovascular examination is recommended to prevent this unique complication.

In 123 cancer patients with metastatic disease, 129 pathologic fractures of long bones were assessed to determine the rate of osseous union. Bony healing was observed in 67% of malignant fractures from multiple myeloma, in 44% of fractures secondary to metastatic hypernephroma, and in 37% of neoplastic fractures from breast carcinoma. No patient with a pathologic fracture secondary to lung carcinoma demonstrated bony repair, and none of these patients lived for more than six months after fracture. The overall fracture healing rate for the entire study population was 35%. In the group that survived longer than six months, 74% of fractures united. A life expectancy of longer than six months was the primary factor determining osseous healing in all patients. A total radiotherapy dose of 3000 rad or less did not inhibit callus formation. Internal fixation improved the rate of fracture union by 23% as compared with cast immobilization.

Metastatic bone disease in 322 patients was analyzed to assess the frequency and behavior of disseminated carcinoma to the vertebral column. Breast, lung, and prostate neoplasms were the most frequent tumors of origin in the 55% of patients who had vertebral lesions. The lumbar spine was the site of the greatest number of metastases. Back pain did not occur in 36% of the 179 patients with spinal disease. Cord compression occurred in 20% of the patients with vertebral involvement, and prostate tumors were the most frequent neoplasm to cause epidural spinal cord impingement. Hypernephroma was the most common cancer to present as a neurologic deficit secondary to an undetected primary malignancy.

Fifty-seven digits in 18 hands of 14 patients with rheumatoid disease were retrospectively evaluated after surgical correction of swan-neck deformity. Release of each hyperextension deformity was done via a previously described lateral band mobilization technique with temporary pin fixation of the proximal interphalangeal (PIP) joint and primary skin closure. Extension block splinting was used for 1 month after pin removal. Follow-up averaged 24 months. Twenty-two percent of the patients were enthusiastic about their results, 56% were satisfied, 22% were equivocal, and none were dissatisfied. Maximum active flexion at the PIP joint averaged 55 degrees, and maximum extension averaged--10 degrees. The average distance from fingertip to distal palmar crease was 32 mm. Average grip strength was 10 kg of force in men and 4 kg in women. Step-cut lengthening of the central slip was associated with the development of a boutonniere deformity and an unsatisfactory result in three digits. Even with narrowing of the PIP joint or articular erosions, which were found on 91% of roentgenograms, lateral band mobilization to correct swan-neck deformity can predictably improve the function and cosmesis of rheumatoid hands.

A modified osteocutaneous digital fillet flap was used to reconstruct the thumb of a fifty-three year old male with a severe gunshot wound to the dominant hand. An arthrodesis in the central portion of the bone graft sustained a fatigue fracture that progressed to union without treatment. The one stage procedure avoided the immobilization of a distant pedicle flap, revisional surgery of a complex free flap, and donor site morbidity.

Reduction of distal radius fractures is often difficult to maintain with plaster casting alone. Achieving this goal with an easily executed technique which carries a low morbidity is desirable, especially in multiply injured patients. Between July 1977 and September 1980, 24 high-energy fractures of the distal radius in 22 patients were treated by percutaneous pinning of the radial styloid fragment to the opposite radial cortex. Roentgenograms at the time of pinning and 8 weeks or more in followup demonstrating healing were available in 20 patients (22 fractures). Using a previously described method of roentgenographic grading, these cases were evaluated. At followup five fractures were felt to anatomically excellent, 16 good, and one poor. Five fractures in review were felt to be not ideally pinned and these represented three of the five fractures that lost a grade of evaluation rating during healing. One superficial pin tract infection developed and two patients complained of local pin discomfort. These complications resolved with pin removal. If guidelines for pinning are followed properly, percutaneous pinning provides a simple and useful method for maintaining reduction in unstable distal radius fractures in multiply injured patients.

The arthroscope was employed to install a continuous closed tube irrigation system in four septic knees in three patients who had complex medical problems. This simple technique may be accomplished by the orthopedic surgeon with limited arthroscopic expertise. In the open drainage versus closed aspiration dilemma that surrounds the management of septic arthritis, this semi-invasive procedure offers promise as an alternative treatment in complicated cases of pyarthrosis of the knee.

Twenty-six cases of waterskiing-related injuries, including four deaths, were studied and the case histories classified into four categories. Injury was caused by a fall into unobstructed water, by boat propeller blades, by collisions with obstacles or a boat, and by the tow rope. Injuries sustained in falls were comparable to trauma seen in vigorous contact sports. Boat propeller blades inflicted devastating battlefield-type wounds, and collisions produced trauma similar to that seen in motor vehicle accidents. The shearing action of an accelerating tow rope imparted trauma unique to this sporting activity. There is limited recognition of the potential for serious injury that attends this recreational sport, and it is concluded that the prevention of injury depends on the nuclear trio of participants: boat operator, operator, observer, and skier.

Thirty-six digits with an intra-articular fracture of the dorsal aspect of the distal phalanx that involved one-third or more of the articular surface were treated by open reduction and internal fixation with Kirschner wires. After an average length of follow-up of forty-six months, roentgenograms of the distal joint in twenty-six digits appeared essentially normal. Ten digits had minor roentgenographic changes but, with the exception of one digit, the joint space was congruous and free of significant abnormalities. The average loss of extension of the distal joint was 2 degrees, and the average arc of flexion of the distal joint was 69 degrees. The average strength of pinch in all digits that were operated on was essentially equal to the strength of pinch in the contralateral digit. Exact reduction and internal fixation using the technique described resulted in excellent motion and function.

A lymphocyte proliferation assay (LPA) for cellular immune responses to osteosarcoma antigens is described and applied to an examination of peripheral blood lymphocytes (PBL) taken from osteosarcoma patients. The antigen preparations were derived from 3 M KC1 solubilized osteosarcoma, taken from a limited number of patients. Lymphocytes from most tumor-bearing patients were stimulated to significant proliferation when cultured in normal human serum. Such stimulation was observed whether or not the lymphoid cells were preincubated 24 hours at 37 degrees C prior to addition of antigen. Patients whose lesion had been resected and who were without evidence of disease for 5-70 months had diminished proliferative responses. Lymphocytes from normal subjects, from patients having other types of sarcoma, and patients having carcinomas rarely responded to the soluble osteosarcoma antigens. When responsive PBL taken from tumor-bearing patients were cultured in autologous serum, the proliferative responses were abrogated or blocked. Serial assays made in the course of bearing this tumor under a variety of therapeutic regimens, including an immunotherapy protocol, suggest that the LPA may be useful in monitoring clinical progress of the disease and possibly in other immunotherapy protocols for osteosarcoma.

The diagnosis of suppurative arthritis is a challenging task complicated by many pitfalls. The physician must rely on the basic skills of a history, physical examination, and index of suspicion to properly decipher the differential diagnosis, and the perceptive analysis of laboratory studies is essential. Prompt institution of treatment with antibiotics and effective cleansing of the joint are the key factors in achieving a good result.

Three patients who had delayed primary repair of a severed flexor digitorum profundus in the finger were found to have proximal coiling of the tendon in the palm. These patients' hands had been inadequately immobilised during the interval between injury and surgery. The most likely pathomechanics of this unusual finding is secondary retraction and coling of the severed tendon from unrestrained muscle contraction after division of the tendon. Precautions should be taken when retrieving the tendon stump for tenorrhaphy.

Thirty-three wrists in 25 patients with rheumatoid arthritis were followed for an average of 3.8 years after resection of the distal ulna. These patients, including those who had adjunctive implantation of a silicone rubber cap, manifested considerable amounts of carpal collapse, carpal translocation, rotational change of the wrist, and radial shift of the ulna. The progression of these complications was unpredictable. Four patients required revision. Three of these four patients had no articular contact between the lunate and radius on their preoperative x-ray film. Excision of less than 20 mm of the distal ulna is an acceptable range of resection. In 15% of the wrists, an osseous carpal stabilizer was seen on the preoperative x-ray film as a reliable radiographic indicator of radiocarpal stability. Another 12% of patients developed a bony carpal stabilizer during the postoperative period.

The throw and its modifications are integral components of many sports. This study correlates case histories of acute injuries in throwing with a biomechanical analysis of the throwing mechanism. Comparisons are made with a similar analysis of the kick analyzed by the same film technique and computer program. Just prior to ball release, the pitching arm extends through an arc of about 73 degress in 40 msec, beginning with the elbow flexed at 80 degrees. This produces an axial load on the humerus and coincides with a pulse of external torque at the shoulder. This acts as stress protection to the humerus which is developing an internal torque of 14,000 inch-lb prior to ball release. The change in angular velocity, or the angular acceleration, during the throw is acquired in a much shorter time than in the kick. Torque is directly proportional to angular acceleration. This necessitates the development of substantially higher torques in the humerus during the throw than about the knee during a kick. The kinetic energy in the arm is 27,000 inch-lb during the throw. This is much higher than the kinetic energy in the kicking leg because the kinetic energy varies proportionally with the square of the angular velocity of the extremity. The angular velocity of the arm is about twice that of the leg. Thus, the pitching arm contains about four times as much kinetic energy as the kicking leg. These severe overloading conditions predispose the upper extremity to injury in the throwing mechanism.

The management of ten patients with fracture of the humeral diaphysis and concomitant injury to the brachial artery was analyzed retrospectively for examination of the factors contributing to preservation of limb viability and function. Of ten treated fractures, eight were rigidly stabilized with either a plate or an external fixation device. Seven of the vascular injuries required an interpositional graft. Three arteries were repaired with an end-to-end anastomosis. Two of these repairs failed in patients whose fractures were not rigidly stabilized, and one of these patients required amputation. Fasciotomy was performed in five cases. Seven patients retained normal or functional extremities despite ligation of the brachial artery in two individuals. Preoperative arteriography was of equivocal value, and it doubled the patient's transit time from the emergency room to surgery. The use of a temporary intraluminal vascular shunt to perfuse the limb at surgery and the semi-invasive rigid stability afforded by contemporary external fixators are important advances in the management of these complex injuries. In civilian practice, the prioritized guidelines the authors suggest for care of combined major skeletal and vascular trauma to the arm are: resuscitation of the patient; arteriogram, which is nonessential in open injuries but helpful in closed trauma; intraoperative perfusion of the limb with a temporary shunt; rigid bony stabilization; wound debridement; vascular repair with an autogenous vein graft; neurorrhaphy; and assessment of the need for fasciotomy.

Thirty-five feet in 21 patients, who had had metatarsal head resection for painful rheumatoid forefoot deformities, were analyzed retrospectively. All patients but one were allowed to ambulate 48 hours after surgery. The follow-up period averaged 29 months. A grading system was devised to assess the clinical results based upon pain relief, capacity to ambulate, shoe wear, cosmesis, and use of walking aids. Using this system, the results were 46% excellent, 34% good, 17% fair, and 3% poor. One patient developed a superficial wound infection, which healed uneventfully. Bony impingement was observed on follow-up roentgenograms of 67% of the resectional arthroplasties. This finding was generally asymptomatic, and it did not correlate with the clinical outcome. Smooth wire fixation was used in some of the feet, but it did not improve the results either roentgenographically or clinically.

A 27-year-old man fell on his flexed wrist and simultaneously sustained a posteriorly dislocated hamate and a laterally dislocated pisiform. The hamate was openly reduced and fixed, and the pisiform was excised. The result was excellent.

The mechanism of upper extremity trauma in three patients from a round hay baler is analyzed in relation to previously described experimental models of wringer or roller injury. One patient sustained an avulsive injury with typical tearing of the soft tissues. Thermal insult from roller friction heat and the duration of exposure were significant factors determining the extent of tissue injury in the other two patients.