Metacarpal Arc Motion: Comparison of Different Measurement Methods

Introduction The range of motion of the carpometacarpal (CMC) joints is difficult to assess in clinical practice.

Materials and Methods The purpose of this study was to measure a precise range of motion measurement of the metacarpal arc during maximum palmar flexion of the fifth CMC joint in healthy persons with three different methods: optical, electrogoniometrical, and sonographical.

Results The metacarpal arc motion measured with the optical technique was 24.9 degrees (standard deviation [SD]: 6.2 degrees), with the electrogoniometric technique was 24.3 degrees (SD: 3.6 degrees) and with sonography was 25.1 degrees (SD: 3.5 degrees), with no differences between left and right hand for all methods.

Conclusion This study shows that different techniques can be used for the measurement of the metacarpal arc motion. With these techniques, it is possible to assess the metacarpal arc in patients with fractures to the CMC joints to evaluate posttraumatic function und rehabilitation progress. This study shows level of evidence as III.

Quantifying the Center of Elbow Rotation: Implications for Medial Collateral Ligament Reconstruction

BACKGROUND

Medial collateral ligament (MCL) reconstruction of the elbow mandates precise characterization of where the centerline of elbow rotation projects onto the medial epicondyle (ME). A muscle-splitting approach allows the flexor-pronator muscles to remain attached to the ME and facilitates visualization of the MCL remnant, the sublime tubercle, and the ulnohumeral joint line. Knowledge of where the centerline of rotation intersects the ME relative to the ulnohumeral joint line may assist the surgeon during placement of the proximal drill hole.

METHODS

Models were created from the computed tomography scans of 29 normal elbows. The centerline of rotation, center of the trochlea, sublime tubercle, and ulnohumeral joint line were identified. Measurements were taken from the ulnohumeral joint line to the center of the trochlea and to the centerline of rotation in the sagittal view and along the course of the MCL.

RESULTS

The centerline of rotation intersected the ME in a consistent location. With the elbow flexed 90°, the trochlea center and the centerline of rotation are essentially in line with each other. There are significant differences between the distances from the ulnohumeral joint line to the center of the trochlea and to the centerline of rotation in both the sagittal view and along the course of the MCL.

CONCLUSIONS

The centerline of rotation is located 14.31 mm (1.70) from the ulnohumeral joint line in the sagittal view and 16.54 mm (2.09) from the ulnohumeral joint line along the course of the MCL.

[Correlation of Estimated and Factual Operation Time in Frequent Interventions in Traumatolgy]

BACKGROUND

The Surgical Safety Checklist (SSC) was introduced by the World Health Organization (WHO) in 2008 in order to analyse and reduce perioperative surgical morbidity. Preoperative estimation of the expected surgery time (EST) by the surgeon is an integral part of the SSC.

OBJECTIVE

The aim of the present study was to correlate EST and factual surgery time (FST), to identify factors influencing the correlation between the two parameters and to collect more information about planning surgical capacity.

MATERIAL AND METHODS

A retrospective analysis researched the EST and FST for plate osteosynthesis in distal radius fractures, intramedullary femur nailing or the implantation of duo head prosthesis in proximal femur fractures in our department between 06/2012 and 12/2013.

RESULTS

220 patients fulfilled the inclusion criteria and underwent further analysis (palmar plate osteosynthesis: n = 89, intramedullary femur nailing with joint involvement: n = 70, duo head prothesis: n = 61). Mean EST and FST exhibited no significant difference in any of the analysed surgical procedures. However, the correlation coefficients were comparatively low for individual surgical procedures (ρ = 0.60). The surgeon's experience had no influence on the correlation between EST and FST.

CONCLUSIONS

In this study, the FST for palmar plate osteosynthesis, proximal intramedullary femur nailing and implantation of duo head prosthesis agreed well with the national average. Unexpected intraoperative complications may cause above average FST. In this case, the surgical team and coordinator must identify rapid individual solutions.

[Direct Screw Osteosynthesis of a Bennett's Fracture by Radiopalmar Incision after Gedda and Moberg]

BACKGROUND

Bennett's fracture is a partial intra-articular fracture, with two main fragments of the first metacarpal bone. Treatment should aim to rebuild the articular surface and to achieve early mobilisation of the thumb saddle joint.

OBJECTIVE

To demonstrate the operation of direct screw osteosynthesis of a Bennet's fracture by a Gedda/Moberg radiopalmar incision in a video.

PATIENT

During distortion of the thumb, a 31-year old patient suffered a Bennets's fracture, which was operated by direct screw osteosynthesis.

CONCLUSION

Direct screw osteosynthesis is the method of choice to restore the articular surface and early mobilisation of the thumb saddle joint after Bennett's fracture.

Fracture-dislocations of the carpometacarpal joints of the ring and little finger

We report the functional and radiographic results of 16 patients with fracture-dislocations of the ring and little finger carpometacarpal joints and 23 cases with fracture-dislocations of only the little finger carpometacarpal joint treated between 2006 and 2012. The above two cohort populations of patients were treated with either open reduction and pin fixation or closed reduction and pin fixation. These patients were followed for a mean of 13 months (range 9 to 48). The DASH scores for patients with fracture-dislocations of the ring and little finger carpometacarpal joints were 6.0 and of the little finger carpometacarpal joint 7.2. We found no functional differences in term of DASH scores after treatment between patients with fracture-dislocations of only the little finger carpometacarpal joint and both the ring and little finger carpometacarpal joints.

The treatment of the acute Essex-Lopresti injury

The Essex-Lopresti injury (ELI) of the forearm is a rare and serious condition which is often overlooked, leading to a poor outcome. The purpose of this retrospective case study was to establish whether early surgery can give good medium-term results. From a group of 295 patients with a fracture of the radial head, 12 patients were diagnosed with ELI on MRI which confirmed injury to the interosseous membrane (IOM) and ligament (IOL). They were treated by reduction and temporary Kirschner (K)-wire stabilisation of the distal radioulnar joint (DRUJ). In addition, eight patients had a radial head replacement, and two a radial head reconstruction. All patients were examined clinically and radiologically 59 months (25 to 90) after surgery when the mean Mayo Modified Wrist Score (MMWS) was 88.4 (78 to 94), the mean Mayo Elbow Performance Scores (MEPS) 86.7 (77 to 95) and the mean disabilities of arm, shoulder and hand (DASH) score 20.5 (16 to 31): all of these indicate a good outcome. In case of a high index of suspicion for ELI in patients with a radial head fracture, we recommend the following: confirmation of IOM and IOL injury with an early MRI scan; early surgery with reduction and temporary K-wire stabilisation of the DRUJ; preservation of the radial head if at all possible or replacement if not, and functional bracing in supination. This will increase the prospect of a good result, and avoid the complications of a missed diagnosis and the difficulties of late treatment.

Treatment of scaphoid waist fractures with the HCS screw

The aim of the study was to evaluate the clinical results of the Headless Compression Screw (HCS, Synthes) when used for treatment of acute scaphoid waist fractures. The new screw design generates interfragmentary compression with use of a compression sleeve. Twenty-one patients were treated for acute scaphoid waist fractures type B2 with HCS screws. The average time to the final follow-up examination was 12.8 months. All 21 fractures united after a mean time of 7.2 weeks. The mean DASH score was 7.1. The average motion of the wrist in extension was 61°, flexion was 46°, radial abduction reached 25° and the ulnar abduction was 31°. The maximally achieved grip strength was 86% compared to the uninjured side. Treatment of type B2 scaphoid fractures with the Headless Compression Screw showed good functional and radiographic results. The results are similar to those identified using other screw fixation systems.

[Early corrective osteotomy after secondary displaced distal radius fractures in children]

Secondary fracture displacement before osseous consolidation of distal radius fractures in children occasionally leads to restricted forearm rotation. So far, there is no consistent treatment recommendation to correct this complication. We report on 5 children with an age of 8-13 years (mean age 12.3 years, 4 boys, 1 girl) with secondary displaced distal radius fractures and high functional deficits in forearm rotation (mean ROM for pro-/supination 70-0-30°) after osseous consolidation. We performed corrective osteotomies of the distal radius using a palmar approach after a mean of 38 days. Stabilisation was achieved with a fixed-angle plate system. At the final follow-up examination (mean 9 months) the forearm rotation was normal. No complications were observed. We consider corrective osteotomies of the distal radius in children with deficits of forearm rotation to be a possible strategy. Early corrective osteotomies can lead to a predictable increase of function through reestablishing normal articulation.

[Treatment strategy for carpometacarpal fracture dislocation]

Carpometacarpal (CMC) fracture dislocations of the 2nd through 5th ray are rare injuries whose extent is regularly underestimated in the initial radiographic evaluation of the hand. Obtaining a computed tomography scan is imperative due to the radiographic underrepresentation of the full bone and joint injury. Restoration of bone and joint anatomy of the affected region is of paramount import to prevent joint deterioration and loss of hand durability and dexterity. Early surgical intervention can lead to good functional results. Different operative treatment strategies exist with a common approach being Kirschner wire, screw or plate fixation after closed or open fracture reduction and joint relocation.

Motion deficit of the thumb in CMC joint arthritis

PURPOSE

Idiopathic osteoarthritis (OA) of the thumb carpometacarpal (CMC) joint is a common disabling disease that often causes pain and motion loss. The aims of this study were to characterize the multidimensional motion capability of the thumb CMC joint in a group with severe CMC OA and to compare it with a control group.

METHODS

We included 15 subjects with stage III/IV CMC OA according to the Eaton/Littler classification, and 15 control subjects. A motion analysis system using surface markers was employed to quantify the maximum boundary of the thumb circumduction envelope during repetitive thumb movements. We measured the area enclosed by the angular circumduction envelope and the ranges of motion (ROM) in multiple directions for the thumb CMC joint.

RESULTS

Thumb osteoarthritis of the CMC joint stage III/IV resulted in a significantly smaller ROM in flexion/extension (45 degrees +/- 11 degrees for the CMC OA group, 59 degrees +/- 10 degrees for the controls), abduction-adduction (37 degrees +/- 6 degrees for the CMC OA group, 63 degrees +/- 13 degrees for the controls), and pronation-supination (49 degrees +/- 10 degrees for the CMC OA group, 62 degrees +/- 11 degrees for the controls) (p < .01). When analyzing the motion directions in flexion-extension and abduction-adduction separately, there was only a loss of extension and adduction (p < .01).

CONCLUSIONS

Severe stages of thumb CMC OA cause an asymmetrical motion deficit with decreased ROM in extension and adduction, leading to decreased capability of counteropposition.

[Radial nerve palsy associated with humeral shaft fractures - early exploration or expectant procedure? An analysis concerning current strategies of treatment]

BACKGROUND

With a prevalence from 11.8 to 18% no fracture is as often associated with nerve damage as the humeral shaft fracture. Whether the radial nerve should be surgically explored in association with a palsy in humeral shaft fractures in order to exclude an interposition or discontinuity is being discussed controversially. The aim of this study was to assess the strategies for primary care of radial nerve palsies associated with humeral shaft fractures in Germany.

MATERIAL AND METHODS

In a standardised survey 495 traumatological and 134 neurosurgical clinics were interviewed regarding the treatment of primary radial nerve palsies after humeral shaft fractures. The distribution of the survey included all level-one trauma centres. Statistics were based on the supply strategies, the number of observed contusions, discontinuities and inter-position of the N. radialis in the fracture gap. Moreover, the results were recorded after primary neurorrhaphy.

RESULTS

The evaluable response rate to the questionnaire was 56% (university hospitals 77%, level-one trauma centres 63%, level-two trauma centres 70%, level-three trauma centres 44%). 6097 humeral shaft fractures have been treated per year, the incidence of primary radial nerve palsy was 8.6%. Regarding the management strategies, 59% of the hospitals advocated exploration of the nerve, while 25% reported that the decision depends on the individual case. 16% reject the exploration in case of a primary nerve palsy. In the case of an exploration, contusions (74%) of the nerve were largely seen, followed by nerve interpositions in the fracture gap (19%) and discontinuity (7%). In the case of neurorrhaphy, a partial or complete remission was found in 87% of cases.

DISCUSSION

Although a primary expectant procedure is recommended in the literature due to the high spontaneous remission rate of 90%, an early exploration of the nerve is often preferred in clinical practice. In these cases, the use of an interlocking intramedullary nail as a minimally invasive treatment option does not appear useful due to the direct exposure of the fracture zone and the radial nerve. Interestingly, the feared discontinuity occurs rarely. The impact of nerve interposition in the fracture gap without surgical exploration remains unclear due to the lack of visibility.

CONCLUSION

There is no consensus concerning the treatment of radial nerve palsies after humeral shaft fractures in Germany. Discontinuities are rare, the rate of spontaneous recoveries is high. Whether and when an exploration of the radial nerve is obligatory in primary radial palsy remains unclear and should be clarified by prospective randomised trials.

[The operative treatment of the degenerative rupture of the anterior tibialis tendon]

AIM

A degenerative tear of the anterior tibial tendon is a rare event compared to other tendons. The purpose of this study was to evaluate the functional results after surgical refixation.

METHOD

In a retrospective study, we report the functional outcome of five consecutive operatively treated patients suffering from a tear close to the insertion site of the anterior tibial tendon. All patients were assessed postoperatively, the AOFAS and Richter scores were obtained and the range of motion in the ankle joint was evaluated.

RESULTS

Preoperatively all patients presented with a significant walking impairment due to a reduced active dorsiflexion, so the decision for surgical refixation was made. In all cases an MRI scan was performed preoperatively. Postoperative immobilisation without weight-bearing was done for six weeks. All patients returned to their former activity level, were satisfied with the postoperative result and had a normal gait in the follow-up examination. The range of motion was equal on both sides, the median AOFAS score was 86 and the median Richter score was 90 out of 100. There were no postoperative complications.

DISCUSSION

Untreated tears of the anterior tibial tendon lead to significant impairment of the ankle joint and deformities of the foot. There is no consensus about the treatment with recommendations for operative and non-operative treatment. Various surgical procedures have been described. The surgical reconstruction of the tendon leads to a restored function of the ankle joint and allows a normal gait and is therefore desirable. Due to the loss of function and the good results after surgical treatment in our study, the non-operative treatment is not advisable.

CONCLUSION

Surgical repair of degenerative tears of the anterior tibial tendon leads to very good functional results and high patient satisfaction.

[Isolated fractures of the capitate: treatment of delayed union]

Delayed and non-union of isolated fractures of the capitate are rare injuries. Initial plain radiographs do not always show the fractures. Especially fractures through the neck of the capitate can lead to delayed union. We report on a patient with persistent localised pain over the capitate 5 months after a fall on the hand. The CT examination showed a delayed union of the capitate, which was treated with an iliac cancellous bone graft and screw osteosynthesis. Bone healing was verified 3 months after operation. Operative therapy is recommended in cases of delayed union or non-union of the capitate.

Wrist circumduction reduced by finger constraints

PURPOSE

Assessment of wrist motion is important in diagnosing and treating motion impairment after injuries to the wrist. Little is known of how finger posture influences the movement of the wrist. The aim of this study was to investigate the effect of finger constraints on the maximum circumduction movement of the wrist.

METHODS

Fifteen male right-handed subjects performed maximal circumferential wrist movements under 4 finger conditions: unconstrained fingers, holding a large cylinder (50 mm diameter), holding a small cylinder (25 mm diameter), and closed fist position. The wrist motion was captured by a surface marker-based motion analysis system. To quantify wrist motion capability, we constructed the maximal boundaries of wrist motion (circumduction envelope) from angular plots in flexion-extension (FE) and radial-ulnar deviation (RUD). The ranges of motion in FE and RUD and the envelope area were calculated.

RESULTS

Finger constraints significantly reduced motion ranges in flexion and ulnar deviation, but not in extension and radial deviation. In comparison to the unconstrained finger condition, the motion ranges in flexion decreased by 13%, 16%, and 27% for the large cylinder, small cylinder, and fist conditions, respectively. The range of ulnar deviation was reduced by 10% for the large and small cylinder conditions and by 11% for the fist condition. The overall mobility in FE and RUD, as quantified by the area of circumduction envelope, decreased by 15%, 15%, and 23% for the large cylinder, small cylinder, and fist conditions, respectively.

CONCLUSIONS

Wrist mobility is facilitated by the synergistic motion of finger joints. Constraining fingers in static flexion posture reduces wrist flexion and ulnar deviation without decreasing extension and radial deviation. A clinical implication is that wrist motion should be assessed under standardized finger joint configuration.