Search

Carpal coalition is a rare condition caused by a failure in the process of apoptosis. It is often incidentally diagnosed and seldomly symptomatic. The lunotriquetral joint is the most commonly affected joint, accounting for 90% of carpal coalitions. Minnaar classified the lunotriquetral coalitions into 4 types based on their type, extent, and associated abnormalities. Accurately classifying the coalition requires advanced imaging, and we show an example that includes 2-dimensional and 4-dimensional computed tomography and magnetic resonance imaging. Management of carpal coalitions include nonoperative and operative management. Splinting, anti-inflammatory drugs, hand therapy, activity modification, and steroid injections are all examples of nonoperative management. Operative management of coalitions in the carpus has historically been an arthrodesis whereas in the tarsal bones the gold standard is resection. Arthrodesis has a high complication rate and reduces wrist range of motion, whereas resection retains range of motion and allows the patient to return to activity sooner. We present 2 techniques of treating symptomatic carpal lunotriquetral coalition with arthroscopic resection.

Identification of intra-articular involvement in proximal humeral fractures is important for operative decision making. The aim of this study was to identify the risk factors associated with intra-articular involvement in proximal humeral fractures.One hundred consecutive three-dimensional computed tomography reconstructions of proximal humeral fractures were identified. The fracture lines were then accurately transcribed onto a two-dimensional superior view of the humeral head and each fracture was assessed for intra-articular involvement. Statistical analyses were undertaken to identify risk factors for intra-articular involvement and extent of involvement. Furthermore, for each risk factor, common fracture patterns were identified and compared to anatomical landmarks.Overall, 58% of the fractures involved the articular surface. High-energy mechanism, female gender, age ≥ 65, and posterior dislocation were risk factors for intra-articular involvement. Low-energy mechanism, female gender, age ≥ 65, varus angulation, and posterior dislocation were risk factors for increased extension of the fracture onto the articular surface.Intra-articular involvement in proximal humeral fractures is influenced by demographics and fracture characteristics (mechanism of injury, angulation, and dislocation). Patients with identified risk factors should be appropriately evaluated for intra-articular fractures during preoperative planning to assist in operative decision making.Basic science; anatomy study.

One of the most popular treatment algorithms for Kienböck disease is based on a progression of successive radiographic changes that was developed in the 1970s. Since then, 2 other important classifications systems have been introduced. One is centered on contrasted magnetic resonance imaging findings and the other, articular cartilage degeneration. All 3 systems have been used, in isolation, to recommend specific treatment modalities. To coordinate all available clinical data and to simplify the treatment selection process, we combined the 3 classification systems into 1 unified classification and treatment algorithm. With the added consideration of some recently introduced surgical options and further knowledge of how Kienböck disease affects children and the elderly, we anticipate that this unified classification system will allow for a more precise and individualized treatment plan.

Objective: Acute and subacute scaphoid fractures were assessed using 3D computer tomography (CT). The aims were to describe fracture morphology, to map fractures onto a 3D scaphoid model and to correlate this to scaphoid anatomy. Materials and methods: A retrospective, multicentre database search was performed to identify CT studies of acute and subacute scaphoid fractures. CT scans of scaphoid fractures less than 6 weeks from time of injury were included in this retrospective, multicentre study. CTs were segmented and converted into three-dimensional models. Following virtual fracture reduction, fractures were mapped onto a three-dimensional scaphoid model. Results: Seventy-five CT scans were included. The median delay from injury to CT was 29 days. Most studies were in male patients (89%). Most fractures were comminuted (52%) or displaced (64%). A total of 73% of displaced fractures had concomitant comminution. Waist fractures had higher rates of comminution and displacement when compared with all other fractures. Comminution was located along the dorsal ridge and the volar scaphoid waist. Conclusion: Our study is the first to describe acute fracture morphology using 3D CT and to correlate comminution and displacement to fracture types. The dorsal ridge and volar waist need prudent assessment, especially in waist fractures.

This dissertation presents a discussion of blocky and randomly functionalized sulfonated syndiotactic polystyrene copolymers. These copolymers have been prepared over a range of functionalization (from 2% to 10%) in order to assess the effect of the incorporation of these polar side groups on both the thermal behavior and morphology of these polymer systems. The two different architectures are achieved by conducting the reaction in both the heterogeneous gel-state to obtain blocky copolymers and in the homogeneous solution state to obtain randomly functionalized copolymers. In order to compare both the thermal properties and morphology of these two systems several sets of samples were prepared at comparable levels of sulfonation. Thermal analysis of these two systems proved that the blocky functionalized copolymers provided superior properties with regard to the speed and total amount of the crystalline component of sulfonated syndiotactic polystyrene. Above 3% functionalizion the randomly functionalized copolymer was no longer able to crystallize, whereas, the blocky functionalized copolymer is able to crystallize even at a functionalization level of 10.5% sulfonate groups. When considering the morphology of these systems even at low percentages of sulfonation it is clear that the distribution of these groups is different based on the amplitude of the signal measured by small angle x-ray scattering. Additionally, methods were developed to describe both the distribution of ionic multiplets, which varies between blocky and randomly functionalized systems, but also the distribution of crystals. At a larger scale ultra-small angle x-ray scattering was employed to attempt to understand the clustering of ionic multiplets in these systems. Randomly functionalized polymers should a peak that is attributed to ion clusters, whereas blocky polymers show no such peak. Additional studies have also been done to look at the analysis of crystallite sizes in these systems when there are multiplet polymorphs present, it was observed the polymorphic composition is drastically different. All of these studies support that these systems bear vastly different thermal behavior and possess significantly different morphologies. This supports the hypothesis that this gel-state heterogeneous functionalization procedure produces a much different chain architecture compared to homogeneous functionalization in the solution-state. Doctor of Philosophy Polymers are a class of chemicals that are defined by having a very large set of molecules that are chemically linked together where each unit (monomer) is repeated within the chemical structure. In particular, this dissertation focuses on the construction what are termed as "blocky" copolymers, which are defined by having two chemically different monomers that are incorporated in the polymer chain. The "blocky" characteristic of these polymers means that these two different monomers are physically segregated from each other on the polymer chain, where long portions of the chain that are of one type, followed by another section of the polymer that has the other type of monomer. The goal of creating this type of structure is to try to take advantage of the properties of both types of monomers, which can create materials with superior synergistic properties. In this case a hydrophobic (water hating) monomer is combined with a hydrophilic (water loving) chain. This hydrophobic component in the polymer is able to crystallize, which provides mechanical and thermal stability in the material by acting as a physical tether to hold neighboring chains together. With the other set of hydrophilic monomers, which in this case have an ionic component incorporated, we can now take advantage of this chemical components ability to aide in the transportation of ions. Transportation of ions is useful in a variety of commercially relevant applications, two of the most important applications of these ionic materials is in membranes that can be used to purify water or membrane materials in fuel cell technologies, specifically for proton exchange membranes. The focus of this research in particular was to create a simple synthesis technique that can create these blocky polymer chain architectures, which is done by performing the reaction while the polymer is made into a gel. The key to this is that the crystals within the gel act as a barrier to chemical reactions, creating conditions where we have substantial portions of the material that are able to be functionalized and the crystals within the material that are protected from being functionalized. By looking at the thermal characteristics, such as melting temperatures and amount of crystals within these systems we have seen that functionalizing these polymers in the heterogeneous gel state gives substantially better properties than functionalizing these materials randomly. Much like oil and water, incompatible polymer chains will phase separate from each other. In this case the hydrophobic and ionic components will phase separate from each other. The shape and distribution of these phase separated structure will dictate many of the material properties, which can be described by modeling the data collected from x-ray scattering experiments. All of this information will tell us based on the initial conditions that these polymers were created in, what properties should be expected based on the morphology and thermal behavior. This gives a better understanding of how to fine tune these properties based on the structure of the gel and chemical reaction conditions.

The management of complex fractures, dislocations, and fracture-dislocations of the elbow can be challenging. External fixation of the elbow, either static or dynamic, has been used as an adjunctive treatment to stabilize the elbow while allowing the ligaments and fractures to heal. Unfortunately, the complication rate of external fixation has been high.

Background The biceps brachii is the main forearm supinator, which is a direct consequence of its anatomic arrangement. The primary aim of distal biceps rupture is to restore supination strength and function. Cadaveric studies demonstrate that anatomic repairs significantly improve the supination moment when compared to more anterior repairs; however, this has not been tested in the clinical setting. The aim of this study was to compare biomechanical and clinical outcomes of an anatomic repair (Footprint), with a widely used transosseous technique (Endobutton). Methods Twenty-two patients were retrospectively identified from a clinical database (11 Footprint versus 11 Endobutton). Biomechanical performance of strength and endurance for flexion and supination was assessed using a validated isokinetic dynamometry protocol and clinical outcome scores (Quick Disabilities of the Arm, Shoulder and Hand Outcome Measure and the Mayo Elbow Performance Score) were collected for all patients. Results For supination, the Footprint group demonstrated a superior trend for all biomechanical parameters tested. This was statistically significant for mean peak torque, total work of maximal repetition and work in the last third of repetitive testing (p = 0.031, p = 0.036 and p = 0.048). For flexion, the Footprint group demonstrated a superior trend for all biomechanical parameters tested but this was only statistically significant for work in the last third of repetitive testing (p = 0.039). The clinical outcomes were good or excellent for all patients in both groups. Conclusion This study is the first to demonstrate that an anatomic Footprint repair restores superior biomechanical supination strength and endurance compared to a conventional Endobutton technique in a clinical setting. Both techniques, however, provide good or excellent clinical outcomes.

The goal of this article is to consolidate the International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine (ISAKOS) Upper Extremity Committee's (UEC's) current knowledge on rotator cuff disease and management, as well as highlight key unresolved issues. The rotator cuff is an anatomically complex structure important for providing glenohumeral function and stability as part of a closed chain system. Current consensus suggests rotator cuff injuries are most accurately diagnosed, at levels similar to diagnosis by magnetic resonance imaging, with a combination of cuff- and impingement-specific clinical tests. Updates in the understanding of acromion morphology, the insertional anatomy of the rotator cuff, and the role of suprascapular nerve release may require changes to current classification systems and surgical strategies. Although initial management focuses on nonoperative protocols, discussion continues on whether surgery for isolated impingement is clinically more beneficial than rehabilitation. However, clear indications have yet to be established for the use of single- versus double-row repair because evidence confirms neither is clinically efficacious than the other. Biceps tenodesis, however, in non-isolated cuff tears has proven more successful in addressing the etiology of shoulder pain and yields improved outcomes over tenotomy. Data reviewing the benefits of tendon transfers, shoulder prostheses, and mechanical scaffolds, as well as new research on the potential benefit of platelet-rich plasma, pluripotential stem cells, and gene therapies, will also be presented.

The purpose of this study was to determine whether a standardized hand activity would produce changes in the cross-sectional diameter of the median nerve. Ultrasound measures of proven reliability of the cross-sectional diameter of the median nerve in the wrist were taken. These measures were taken before activity and immediately after the activity, after 5 minutes, and after 10 minutes. The median nerves of 40 normal subjects showed an increase in cross-sectional diameter immediately after hand activity then returned to a size close to the preactivity size within 10 minutes. The cross-sectional area of the carpal canal did not change significantly after the hand activity was performed. Female gender and body mass index over 25 were associated with significantly larger size increases in the median nerve. This preliminary study suggests that ultrasound is sensitive to the effects of activity upon the hand.

The formation of a painful neuroma after operations on the medial or lateral sides of the elbow is a common problem. Our aim was to determine the relationship of the cutaneous nerves to the three usual skin incisions around the elbow. In 18 freshly frozen cadaver arms we made three standard 16 cm incisions in the skin medially, laterally, and posteriorly and explored them using loupe magnification. The number of nerves crossing each incision was determined by gross observation and their diameter measured by electronic microcallipers. In ten arms, biopsies of the nerves in each incision were sent for histological examination. We found significantly more cutaneous nerves crossing the medial and lateral incisions than the posterior. The diameter of the nerves crossing the posterior incision was significantly smaller than those crossing the lateral incision. Cutaneous nerves are at considerable risk of injury when medial or lateral incisions are used to approach the elbow, but the posterior approach carries less hazard. The routine use of the posterior incision may reduce the incidence of symptomatic paraesthesia and the formation of a painful neuroma after operation.

Radiocarpal fusions are performed for a variety of indications, most commonly for debilitating painful arthritis. The goal of a wrist fusion is to fuse the painful, diseased joints and to preserve motion through the healthy joints. Depending on the extent of the disease process, radiocarpal fusions may take the form of radiolunate, radioscapholunate, or total wrist fusions. Surgical techniques and instrumentation have advanced over the last few decades, and consequently the functional outcomes have improved and complications decreased. Techniques for partial carpal fusions have improved and now include distal scaphoid and triquetrum excision, which improves range of motion and fusion rates. In this article we discuss the various surgical techniques and fixation methods available and review the corresponding evidence in the literature. The authors' preferred surgical technique of radioscapholunate fusion with distal scaphoid and triquetrum excision is outlined. New implants and new concepts are also discussed.

To compare the standard Tajima technique for flexor-tendon repair of the hand with three new techniques with respect to strength and technical ease of the repair and bulk at the repair site.A randomized analysis of human cadaver flexor digitorum superficialis tendon repairs.A musculoskeletal research laboratory at a university-affiliated health centre.Thirty-nine fresh-frozen cadaveric flexor digitorum superficialis tendons from index, long and ring fingers harvested and divided transversely. The tendons were randomly allocated for repair by the current standard technique or one of three new techniques.The standard Tajima (modified Kessler) technique, and the Halsted, Savage or Silfverskiold technique.The time to perform each repair, the cross-sectional dimension and the load to failure of the tendon repairs.The Savage repair tolerated the highest loads, followed by the Halsted, Silfverskiold and Tajima repairs. The Silfverskiold technique was the least time-consuming to perform, followed by the Tajima, Halsted and Savage repairs. All of the techniques increased the cross-sectional dimensions of the tendon: the Silfverskiold repair by at least 50% and the Savage repair by over 100%. Although none of the techniques tested performed ideally, all three new techniques provided greater initial static strength than the standard Tajima method.Further in-vitro and in-vivo studies of these new techniques of flexor-tendon repair of the hand are necessary to optimize the treatment of these injuries.

To investigate outcomes after surgical repair of distal biceps tendon rupture and the influence of arm dominance on isokinetic flexion and supination results.While relatively uncommon, rupture of the distal biceps tendon can result in significant strength deficits, for which surgical repair is recommended. The purpose of this study was to assess patient reported functional outcomes and muscle performance following surgery.A sample of 23 participants (22 males, 1 female), who had previously undergone surgical repair of the distal biceps tendon, were re-examined at a minimum of one year after surgery. Biodex isokinetic elbow flexion and supination testing was performed to assess strength (as measured by peak torque) and endurance (as measured by total work and work fatigue). The Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Mayo Elbow Performance Scale (MEPS) were used to assess participants' subjectively reported functional recovery.At a mean of 7.6 years after surgical repair, there were no differences between the repaired and uninvolved elbows in peak torque (The long-term strength of the repaired elbow was similar to the uninvolved elbow after surgery to the distal biceps tendon. Endurance of the repaired elbow was similar in flexion but greater in supination, probably influenced by arm dominance.Retrospective case series.Level 4.

For those patients with instability of the medial and lateral sided of the elbow, there is a place for a circumferential graft. This has the main advantage of simplifying the bone tunnel creation and graft fixation, compared to having both medial- and lateral-sided reconstructions.