Magnetic resonance imaging of the interosseous membrane of the forearm

BACKGROUND

Diagnosis of damage to the interosseous membrane of the forearm after trauma is difficult. Patients with a proximal radial fracture and associated damage to the interosseous membrane may have wrist pain in association with subluxation or dislocation of the distal radioulnar joint. Accurate identification of injury to the interosseous membrane may allow better planning of surgical treatment.

METHODS

T1 and T2-weighted magnetic resonance images that were made in the axial, sagittal, and coronal planes were used to evaluate the interosseous membrane in the forearms of cadavera, volunteers, and patients. The images were evaluated subjectively by two orthopaedic surgeons and a musculoskeletal radiologist.

RESULTS

The interosseous membrane was most consistently visualized on the axial images. Axial T2-weighted images showed the interosseous membrane clearly. The addition of fat-suppression techniques allowed abnormalities to be identified more accurately. Fast-spin-echo techniques were used to obtain data quickly and accurately.

CONCLUSIONS

The intact and disrupted interosseous membrane can be evaluated with use of magnetic resonance imaging. Axial T2-weighted fast-spin-echo images with fat suppression in the middle one-third of the forearm provide the most accurate information.

Ganglions of the proximal interphalangeal joint

Ganglions of the proximal interphalangeal joint are uncommon. Six patients (nine ganglions) were treated surgically. The lesions presented on the ulnar aspect of the extensor mechanism between the lateral band and the central slip and communicated with the joint by means of a stalk. Mild degenerative joint disease was noted in each case. Surgical excision provided relief of symptoms, and no patient has experienced any recurrence to date.

Tissue expansion prior to revision total knee arthroplasty

The first case of the use of a tissue expander in revision total knee surgery is reported. A 76-year-old woman presented with extremely adherent scare tissue on the anterior proximal tibia that was the result of multiple debridements and skin grafting for an infected primary total knee arthroplasty. The tissue expander was placed prior to subsequent revision total knee arthroplasty to permit complete excision of the scar and to provide tension-free closure with normal skin at the time of revision. Three years after the surgery, the patient is doing well.

Fractures in very low birth weight infants with rickets

A syndrome in very low birth weight premature infants weighing less than 1500 g is evidenced by developmental nutritional rickets and fractures at 75 days of age. In a review conducted over 42 months, 247 very low birth weight cases were identified. Rickets was diagnosed in 96 (39%) infants whose mean age was 50 days and fractures were diagnosed in 26 (10.5%) infants whose mean age was 75 days. These 26 infants experienced 98 fractures: 10 humerus, 13 radius, 8 ulna, 4 metacarpal, 3 clavicle, 54 ribs, 5 femur, and 1 fibula. Risk factors included hepatobiliary disease, total parenteral nutrition, diuretic therapy, physical therapy with passive motion, and chest percussion therapy. With early recognition, metabolic therapy and splinting, not casting, are appropriate treatments.

Femoral osteotomy for secondary arthritis of the hip in young adults

Osteotomy around the hip is a valuable and important treatment option in hip disease. It may be used on either side of the joint or in a combined fashion. The authors review the scientific background to femoral osteotomy and summarize its role in the treatment of developmental dysplasia, nonunion of femoral neck fractures, osteonecrosis, slipped capital femoral epiphysis and Perthes disease. They conclude that it is a most useful tool for the contemporary hip surgeon. The procedure may not be appropriate for elderly patients with arthritic deterioration of the hip, but in carefully selected young adults with clearly defined antecedent developmental conditions, the results can be excellent and long lasting. Careful preoperative planning is emphasized; particular attention must be paid to the possibility of arthroplasty in the future because insertion of the stem of a hip prosthesis can be a problem difficult.

Enhanced spino-pelvic fixation for segmental spinal instrumentation: a preliminary biomechanical evaluation

A new method for spino-pelvic fixation of Luque rods was developed and biomechanically evaluated on cadaveric specimens. The technique is surgically simpler and faster than the Galveston technique because it does not require the complex three-dimensional bending of rods to conform to the medullary cavity of the iliac wings. Spines were tested in axial compression in both bilateral and unilateral ischial weight bearing in the intact condition, instrumented with the new technique, and instrumented with the Galveston technique. Compared to the intact spine, the technique increased bilateral average stiffness by 131% and unilateral average stiffness by 192%. Compared directly to the Galveston technique, the new method exhibited increased average stiffness of 15% in bilateral and 11% in unilateral ischial weight bearing. The new method combines the advantages of a simpler and faster surgical procedure than the Galveston technique with enhanced spino-pelvic fixation with the potential to decrease migration of rods relative to each other and the pelvis.

Interlocking intramedullary fixation of hand fractures

Reduction and stabilization can be especially difficult in treating comminuted hand fractures with bone loss or nonunion. Two cases are presented to illustrate a method of intramedullary fixation using an AO mini fragment reconstruction plate, which allows interlocking fixation proximally and distally. Any defect can be filled with corticocancellous bone graft. When necessary, this graft can be fixed to the metal plate that acts as a strut. The fixation obtained is stable against rotational, angular, and compressive forces, making it a useful adjunct to the hand surgeon's armamentarium.

The small pin circular fixator for distal tibial pilon fractures with soft tissue compromise

A Monticelli-Spinelli small pin circular external fixator was used in combination with closed reduction or a limited open reduction internal fixation in five cases in an attempt to salvage a satisfactory result in distal tibia pilon fractures when associated soft tissue compromise prevented standard fixation with plates and screws. The small pin fixator enhances the ability to perform a closed reduction through a technique that uses distraction with pins in the tibia and calcaneus, combined with correction of angulation by tensioning wires with a stop nut. Small pin stabilization of these comminuted fractures allows early patient mobilization. The small diameter pins support the soft cancellous bone fragments. This technique attempts to combine the benefits of traction, external fixation, and limited internal fixation. We recommend this technique as a salvage procedure when plates and screws are contraindicated because of poor bone and soft tissue conditions.

The small pin circular fixator for proximal tibial fractures with soft tissue compromise

We used a Monticelli-Spinelli small pin circular external fixator in five cases, in combination with closed reduction or limited open reduction internal fixation, to salvage a satisfactory result in juxtaarticular, intraarticular fractures of the proximal tibia, when associated soft tissue compromise prevented standard fixation with plates and screws. The small pin circular fixator allows juxtaarticular placement of the small pins, enhancing stabilization of the comminuted fractures, allowing early range of motion of the joint and early patient mobilization. The small diameter pins support the soft cancellous bone fragments. This technique attempts to combine the benefits of traction, external fixation, and limited internal fixation. We recommend this method as a salvage procedure when plates and screws are contraindicated because of poor bone and soft tissue conditions.

Anatomical demonstration of the nerve-supply to the flexor tendon

A dissection of four unembalmed human fingers demonstrated a branch from the digital nerve which enters the flexor tendon sheath at the same place as the transverse branch of the digital artery. We conclude that this branch supplies the nerve fibres found within the vinculum.

Stabilization of sacroiliac joint disruption with threaded compression rods

Eleven cases of sacroiliac dislocation and/or fracture (Malgaigne pattern) were successfully reduced and stabilized using two threaded compression rods. The mean follow-up period was 26.1 months (range, seven to 45 months). None of the implants failed and there was no subsequent displacement. Two patients had mild residual lower back pain, and one was treated with implant removal without subsequent relief of pain. One patient, in whom the operation was done 110 days after dislocation, had extension of an incomplete preoperative peroneal nerve palsy. After anterior pelvic ring stabilization has been performed, two threaded 3/16-inch diameter rods are driven from the normal posterior iliac wing superficial to the sacrum and through the reduced opposite iliac wing. Compression is obtained with washers and nuts. This procedure can be performed safely and effectively, providing stable fixation and allowing early mobilization to help lessen or prevent the complications associated with prolonged bed rest.

Measurement of effective pedicle diameter in the human spine

Effective pedicle diameter (EPD), the maximal cancellous diameter of the spinal pedicle, demonstrates the maximal diameter available for transpedicular screw placement. The pedicles of 16 spines from T6 to L5 were measured directly with a graduated mean increase in the EPD ranging from 4.8 mm at T6 to 5.9 mm at L5. This direct pedicle measurement was significantly smaller than that of previously reported studies, which directly and radiographically measured pedicle outside width rather than inner diameter. Three specimens had little, if any, pedicular medullary cavity on direct measurement, although radiographic appearance of a medullary cavity existed. If EPD is significantly smaller than radiographic pedicle width measurements, safe transpedicular screw fixation may not be achieved. Preoperative planning must account for this so that transpedicular screws of correct diameter may be used and the complications of pedicular blowout fracture and neurologic impairment may be avoided.

Intracapsular hip fractures: case reports and discussion

Two cases of intracapsular hip fracture illustrate some of the treatment options available for Garden Stage IV fractures. In Case 1, a prosthesis was chosen because of the patient's physiologic age and poor general health. In Case 2, a compression screw augmented with a single-pin fixation to prevent rotation was used. This patient, although only 3 years younger than the first patient, was in good health. Although there was some posterior comminution, an attempt at fixation, allowing time for bone healing, was appropriate. Arthroplasty may be needed in several years if bone healing fails.

Complex femur fractures: treatment with the Wagner external fixation device or the Grosse-Kempf interlocking nail

One hundred complex femur fractures were treated with the Grosse-Kempf interlocking nail and 35 were treated with the Wagner external fixation device. Retrospectively, we analyzed the results in the two groups to determine specific indications for the future use of these nails. The Grosse-Kempf nail, although a technically demanding procedure, achieved excellent overall end results in comminuted closed fractures, and in Type I, Type II, and some Type III open fractures after appropriate wound care. We found that the Wagner apparatus was a simple, easy device for obtaining initial fracture stabilization in contaminated Type III-B and Type III-C open fractures. It does, however, require substantial postoperative care; four cases required secondary intramedullary fixation. We found a high infection rate with secondary reamed intramedullary nailing after initial stabilization with the external fixator.

A case report of malignant mesenchymoma with discussion of musculoskeletal tumor staging: the Enneking system

A 54-year-old black man presented with a soft-tissue sarcoma of the left anterior thigh. Surgical staging studies and initial biopsy results identified the lesion as a grade IIB pleomorphic liposarcoma. After radical hip disarticulation, follow up pathologic studies of the disarticulated limb showed the tumor to be confined to the anterior compartment of the left thigh without extracompartmental extension. The post-excisional surgical pathology report identified at least four different malignant mesenchymal elements: liposarcoma, myosarcoma, chondrosarcoma, and extraosseous osteogenic sarcoma. The sarcoma was therefore reclassified as a malignant mesenchymoma. The fact that the tumor was found to be intracompartmental at the time of surgery changed the staging of the tumor to stage IIA. A radical surgical margin, as recommended by Enneking, remained the treatment of choice. Three months postoperatively, the patient had chest pain and dyspnea. Chest films revealed multiple pulmonary nodules and the patient died of pneumonia 3 months later.

Safety and efficacy of chymopapain (Discase) in the treatment of sciatica due to a herniated nucleus pulposus. Results of a randomized, double-blind study

A prospective, multiinstitutional, double-blind trial comparing the effect of chymopapain (Discase) vs. placebo (cysteine-edetate-iothalamate: CEI) for lumbar intervertebral disc rupture with sciatica was carried out on 173 patients, the largest such study reported to date. Patients were matched with respect to age, sex, physical habitus, and level of injection. The procedure was carried out under local anaesthesia. The success rate was superior in the chymopapain group regardless of the method used to assess outcome or the time over the first 6 months at which the two groups were compared: 71% vs. 45% if code breaks were analyzed at 6 months, and 67% vs. 44% if code breaks were defined as lost to follow-up. A single case of anaphylaxis and one case of septic discitis were the only serious complications noted. This study supports the role of chymopapain in the treatment of lumbar disc rupture with sciatica.

High vacuum as a method of reducing porosity of polymethylmethacrylate

In total hip arthroplasty, fracture and subsequent premature loosening are directly related to the strength of the cement mantle serving as an interface between bone and prosthesis. The cement has been shown to be weakened by its porosity, which enhances the formation of microfractures that contribute to crack propagation. By means of a vacuum mixing method for preparing the cement, nearly all the porosity can be removed and cement strength enhanced by about 17%.

Tibial plateau fractures

Certain factors in tibial plateau fractures that lead to increased disability may be avoided by following the objectives of articular surface restoration, good internal fixation, early knee motion, strengthening exercises, and soft-tissue repair. In some types of fractures, traumatic arthritis may be unavoidable.

Neural anatomy of the human anterior cruciate ligament

The histology of the anterior cruciate ligament was studied by a modified technique of the Gairns gold chloride stain for neural elements. Three morphological types of mechanoreceptors and free nerve-endings were identified: two of the slow-adapting Ruffini type and the third, a rapidly adapting Pacinian corpuscle. Rapidly adapting receptors signal motion and slow-adapting receptors subserve speed and acceleration. Free nerve-endings, which are responsible for pain, were also identified within the ligament. These neural elements comprise 1 per cent of the area of the anterior cruciate ligament.

Chymopapain in perspective

Three hundred fifty-nine patients with herniated nucleus pulposus syndrome were treated by chemonucleolysis with chymopapain. Good to excellent results were achieved in 71% with a minimum of six months follow-up observation. In a group followed for an average of ten years, the result was favorable in 86.6%; 58% of all patients injected had a good to excellent long-term result. Disc space narrowing averaged 2 mm, with no adverse effect on the result. Firm conclusions about the cause of failure of chemonucleolysis could not be drawn. Injection at two levels was recommended when a single offending level could not be identified. There were no cases of anaphylaxis with a premedication regimen of dexamethasone, diphenhydramine, and cimetidine. The procedure was safe and the results were reproducible.

Fixation of metacarpal and phalangeal fractures with miniature plates and screws

Fifty-two unstable metacarpal and phalangeal fractures were treated with miniature plates and screws as internal fixation devices with excellent results based on the criteria of the American Society for Surgery of the Hand (total active range of motion greater than 220 degrees). This technique stabilizes the skeleton, preserves the gliding tissues, and thus allows immediate active range of motion exercises. Transverse, spiral, oblique, and condylar fractures of the metacarpals and phalanges are best suited for this method.

Spinal cord tumor presenting as a herniated lumbar disc

The lesion encountered in this case was that of an intradural-extramedullary tumor. Histologic section showed an organized hematoma, which is a very rare tumor. In a recent review of the literature, only 85 cases have been reported, most in relation to a bleeding intraspinal neoplasm. Our case is especially unusual because there was no clotting abnormality or repeated lumbar punctures or arteriovenous malformation. This case also points out the necessity of a complete physical examination. A CT scan was initially negative because the scan started just below the tumor, hence it was never visualized. Metrizamide myelogram followed by the enhanced CT scan provides a more complete diagnostic study. In this patient's case, the CT scan would have led to inappropriate therapy, whether lumbar laminectomy or chemonucleolysis.

Dural puncture using the lateral approach for chemonucleolysis

The lateral approach for chemonucleolysis was developed to avoid dural puncture, which occurs with midline and posterolateral approaches. It is important to check for dural punctures during the procedure. If the dura is penetrated, a potential pathway is created for chymopapain to enter the subarachnoid space. Large doses of intrathecal chymopapain are highly toxic and small doses show a variable response. Because of the potential disastrous complications associated with intrathecal chymopapain, the chymopapain injection is contraindicated in the presence of a dural leak.

Fractures of the femoral shaft treated by external fixation with the Wagner device

The Wagner external skeletal-fixation system was used to treat twenty complex fractures involving the femur, and nineteen of the fractures healed. Chronic osteomyelitis did not develop in any of the patients.

Treatment of the multiply injured patient: plans for treatment and problems of major trauma

Certain principles involved in the treatment of fractures have stood the test of time. The thrust of modern orthopaedics has been to decrease morbidity by combining these principles with developments in physiology, bioengineering, radiology, and antibiotics. The goal remains anatomic bone union without infection and normal joint and muscle function. The surgeon's mission is to achieve this goal. For the multiply injured patient, survival depends on the quality of care. Surgical orientation permits one to stabilize the fractures and restore the patient to activities of daily living. Multiple fractures set the stage for multiple organ failure, and, as we have discussed, stabilization reduces the incidence of these problems. Basically, open fractures must be stabilized with plaster, traction, or surgery. Multiple fractures need rigid stabilization, which can be achieved with various techniques without jeopardizing limb or life. A simple, comprehensive plan should be implemented when the patient arrives in the emergency room. Treatment requires an interdisciplinary approach, with the surgeon heading a team of physicians, nurses, and technicians capable of handling the complications of each organ system. Teamwork and dedication to excellence by all involved will decrease mortality and morbidity. Survival is to be anticipated. If we have restored the anatomy early, before any organ failure, we are then ready to begin rehabilitation and achieve a much finer and enduring end result for the injured patient.

Biochemical features of pseudomembrane at the bone-cement interface of loosened total hip prostheses

Biochemical features of pseudomembrane formed at the bone-cement interface of 13 failed total hip replacements were studied and histological examination of the pseudomembrane was conducted. The results of biochemical analyses revealed on average hydroxyproline, 86 micrograms/mg; water content, 57%; hexosamine, 12 micrograms/mg; glucosamine/galactosamine, 1.4%; and calcium, 2.1%. Approximately 78% of collagen was extracted with pepsin, whereas only 8 and 0.3% collagen were extracted with acetic acid and neutral salt, respectively. On further differential salting out of the extracted collagen, about 77% was type I collagen, 19% type III, and 2.6% type V. Unlike pseudoarthrosis of fracture, no type II collagen was identified. Overall biochemical features in the light of the histological appearance suggested that pseudomembrane resembles granulation tissue. Bone healing mechanisms at the bone-cement interface appear to differ from that of fracture healing.

Intravenous reserpine for treatment of reflex sympathetic dystrophy

The efficacy of reserpine in relieving the pain of reflex sympathetic dystrophy was tested in 25 patients--21 with upper extremity and four with lower extremity involvement. Injection of the drug relieved the acute signs and symptoms in the upper extremity in 12 of 17 patients. Four patients with quiescent reflex sympathetic dystrophy of upper extremities had prophylactic injection at the time of reconstructive surgery; they had no flare of symptoms. Relief was obtained in the four cases of lower extremity dystrophy. Our patients had no significant side effects. The drug is confined to the extremity by a pneumatic tourniquet as used for intravenous regional anesthesia. After the extremity is exsanguinated and the cuff is inflated, 1 mg of reserpine diluted to 50 ml with normal saline is injected intravenously into the upper extremity. In the lower extremity, 2 mg of reserpine diluted to 100 ml is injected. The tourniquet is removed after 15 minutes. The procedure is safe and can be done in an office setting.