Synovial sarcoma of the neck

Although the zygomatic arch can be employed as a key landmark to the accurate alignment of a displaced malar fracture, it has been traditionally avoided because of the need for a bicoronal incision. Exposure of the zygomatic arch by means of the conventional bicoronal incision has several possible disadvantages, including an increased risk of blood loss, alopecia, loss of sensation posterior to the incision, and traction palsy of the facial nerve. Endoscopic-assisted exposure of a zygomatic arch can largely obviate the disadvantages of a bicoronal incision and yield this site accessible to reduction and fixation in the routine treatment of displaced malar fractures. A case of endoscopic-assisted open reduction and internal fixation of a moderately displaced malar fracture is presented. In particular, exposure and fracture fixation of the zygomatic arch were performed without the need for a bicoronal incision.     

Spatial learning and hippocampal volume in male deer mice: relations to age, testosterone and adrenal gland weight

Endoscopic carpal tunnel release is a controversial procedure used in the treatment of carpal tunnel syndrome. Although endoscopic carpal tunnel release is associated with less incisional pain and faster recovery time than the open carpal tunnel release, opponents of endoscopic carpal tunnel release suggest that its benefits are outweighed by its higher complication rates from median nerve transection and transient numbness of the fingers. Because of the huge economic and social impact of carpal tunnel syndrome in this country, we performed a cost-effectiveness analysis comparing endoscopic carpal tunnel release and open carpal tunnel release using guidelines established by the Panel on Cost-Effectiveness in Health and Medicine of the U.S. Public Health Service. A decision analytic model was used to measure differences in cost and effectiveness--expressed as quality-adjusted life-years (QALYs)--between endoscopic carpal tunnel release and open carpal tunnel release. The societal perspective was chosen, and probabilities for various outcomes for the two procedures were obtained from published randomized-controlled trials. Cost data were derived from the Medicare Resource-Based Relative Value Units published in the Federal Register. QALYs were obtained from two groups of health care providers using a utility-assessment questionnaire. Using probabilities for various outcomes from the two published randomized-controlled trials comparing endoscopic carpal tunnel release and open carpal tunnel release, we constructed a decision tree to derive both the cost and the QALYs for the two procedures. The incremental cost difference between endoscopic carpal tunnel release and open carpal tunnel release was $46, using Medicare cost and probabilities of various outcomes derived from a study by Brown et al. in 1993. We calculated QALYs for five age groups--25, 35, 45, 55, 65--assuming a life expectancy of 75 years. The marginal effectiveness (QALY of endoscopic carpal tunnel release minus QALY of open carpal tunnel release) ranged from 0.235 QALY for the 25-year-old age group to 0.066 QALY for the 65-year-old age group, giving a cost-effectiveness ratio of $195/QALY and $693/QALY, respectively. When compared with other accepted medical interventions such as breast cancer screening ($4836/QALY) and exercise to prevent coronary heart disease ($13,508/QALY), endoscopic carpal tunnel release seems to be cost-effective. However, our sensitivity analysis indicated that the cost-effectiveness ratio was very sensitive to a major complication such as median nerve injury. For endoscopic carpal tunnel release to be a cost-effective procedure, the incidence of median nerve injury must be one percentage point less for endoscopic carpal tunnel release than for open carpal tunnel release. Based on the data from the randomized-controlled trials, endoscopic carpal tunnel release seems to be a cost-effective procedure; however, before it can be recommended, greater emphasis must be given to the training of surgeons in this new technique, so that major complications such as median nerve injuries can be avoided. In addition, future studies must better define the actual incidence of nerve injuries for both endoscopic carpal tunnel release and open carpal tunnel release in the community setting.     

Operative treatment of fractures of the tibial plafond. A randomized, prospective study

We performed a randomized, prospective study to compare the results of two methods for the operative fixation of fractures of the tibial plafond. Surgeons were assigned to a group on the basis of the operation that they preferred (randomized-surgeon design). In the first group, which consisted of eighteen patients, open reduction and internal fixation of both the tibia and the fibula was performed through two separate incisions. An additional patient, who had an intact fibula, had fixation of the tibia only through an anteromedial incision. The second group consisted of twenty patients who were managed with external fixation with or without limited internal fixation (a fibular plate or tibial interfragmentary screws). Ten (26 per cent) of the thirty-nine fractures were open, and seventeen (44 per cent) were type III according to the classification of Rüedi and Allg?wer. There were fifteen operative complications in seven patients who had been managed with open reduction and internal fixation and four complications in four patients who had been managed with external fixation. All but four of the complications were infection or dehiscence of the wound that had developed within four months after the initial operation. The complications after open reduction and internal fixation tended to be more severe, and amputation was eventually done in three patients in this group. At a minimum of two years postoperatively (average, thirty-nine months; range, twenty-five to fifty-one months), the average clinical score was lower for the patients who had had a type-II or III fracture, regardless of the type of treatment. With the numbers available, no significant difference was found between the average clinical scores for the two groups. All of the patients, in both groups, who had had a type-II or III fracture had some degree of osteoarthrosis on plain radiographs at the time of the latest follow-up. With the numbers available, there was no significant difference between the two groups with regard to the osteoarthrotic changes. We concluded that external fixation is a satisfactory method of treatment for fractures of the tibial plafond and is associated with fewer complications than internal fixation.     

The cutaneous innervation of the palm: an anatomic study of the ulnar and median nerves

Twenty-five fresh-frozen cadaveric hands without obvious deformity were dissected using 3.5x loupe magnification. Median and ulnar nerves were identified in the proximal forearm and dissected distally to the midpalm. Cutaneous branches of median and ulnar nerves were described relative to an incision for carpal tunnel release. The palmar cutaneous branch of the median nerve was present in all 25 specimens. In a single specimen, the palmar cutaneous branch of the median nerve was isolated as it crossed the incision, and in another two specimens, the terminal branches of the nerve were identified at the margin of the incision. In 4 hands, a classic palmar cutaneous branch of the ulnar nerve was found an average of 4.9 cm proximal to the pisiform. In 10 specimens, a nerve of Henle arose an average of 14.0 cm proximal to the pisiform and traveled with the ulnar neurovascular bundle to the wrist flexion crease. In 24 specimens, at least one-usually multiple-transverse palmar cutaneous branch was identified originating an average of 3 mm distal to the pisiform within Guyon's canal. The origin and destination of these nerves was highly variable. In 16 specimens, an incision in the axis of the ring finger would likely have encountered at least one branch of the ulnar-based cutaneous innervation to the palm. Cutaneous branches of the ulnar nerve would be expected to cross the line of dissection frequently during open carpal tunnel release. Decreased levels of discomfort in patients undergoing endoscopic and subcutaneous types of carpal tunnel release may be in part due to the preservation of the crossing cutaneous nerves with these procedures.     

Carpal tunnel release with a small palmar incision

The use of carpal tunnel tome with a small palmar incision to release the transverse carpal ligament is discussed. The technique is fully illustrated, and the authors early clinical experience is reviewed.     

Division of the transverse carpal ligament and flexor tendon excursion: open and endoscopic carpal tunnel release

Ten fresh cadaver upper extremities from 10 different subjects were used in this study of the effect of both open and endoscopic carpal tunnel release on flexor tendon excursion. The amount of excursion necessary to bring each finger from the fully extended to the fully flexed position with the fingertip just touching the palm was measured with the extremity mounted in a device that moved the wrist from extension through flexion. Endoscopic carpal tunnel release, open release, and transverse carpal ligament reconstruction were performed with tendon excursion measurements made in each of four wrist positions after each procedure. Fingertip to palm distance was also measured. The measurements of flexor tendon excursion in neutral wrist position with intact transverse carpal ligament served as the norm for each finger and as the denominator in the ratio of postoperative to preoperative excursion distances. The study confirmed the importance of the transverse carpal ligament as a flexor pulley; transection of the ligament increased the amount of flexor tendon excursion necessary to achieve finger flexion and fingertip-to-palm contact. Tendon excursion/digital flexion improved after transposition flap repair. Neither open nor endoscopic carpal tunnel release conferred any particular benefit to flexor tendon excursion postoperatively. The proximal palmar aponeurosis does not seem to have the same pulley effect as the transverse fibers of the distal palm.     

Myofascial manipulative release of carpal tunnel syndrome: documentation with magnetic resonance imaging

Four patients with carpal tunnel syndrome, unresponsive to routine conservative care, underwent treatment with myofascial release manipulation and self-stretching. Magnetic resonance imaging analysis of the cross-sectional area of the carpal tunnel and electrodiagnosis were performed before and after treatment. The patients improved clinically. The nerve conduction studies showed concomitant reduction in distal latencies or increase in motor response amplitudes. Magnetic resonance imaging demonstrated that the anteroposterior and transverse dimensions of the carpal canal significantly increased after treatment. This study demonstrates that the carpal canal is a distensible structure with the potential to yield to a relatively simple, aggressive, nonsurgical treatment for carpal tunnel syndrome.     

Acute carpal tunnel syndrome

Although the carpal tunnel is open at both ends, it has the physiologic properties of a closed compartment bounded by synovium proximally and distally. When the intracarpal canal interstitial pressure rises above a critical threshold pressure, capillary blood flow is reduced below the level required for median nerve viability. Acute carpal tunnel syndrome is recognized frequently as occurring secondary to wrist trauma and infrequently due to a variety of infectious, rheumatologic, and hematologic disorders. This condition warrants prompt recognition and the treatment is early carpal tunnel release.     

Pet ownership and future health

It is difficult to treat the intra-articular fracture of distal tibia or Pilion's fracture. From 1987 to 1995, 43 cases of Pilon's fracture were admitted and treated with different methods. After treatment, they had been followed up for 1 to 8 years. According to Riiedi's Classification, there were type I 12 cases, type II 21 cases and type III 10 cases. The methods used on these patients included manual reduction and plaster of paris immobilization, calcaneous tubercle traction and plaster of paris immobilization, open reduction and internal fixation with Kirschner wires, and open reduction and internal fixation with AO plate. The outcome was evaluated according to Ovadia's criteria, for type I fracture, 8 cases were treated with conservative method with a satisfactory rate of 79.17% and 4 cases were treated with operation with a satisfactory rate of 91.67%; for type II, conservative method for 12 cases and the satisfactory rate was 33.33%, and operation for 9 cases with a satisfactory rate of 70.37%; for type III, conservative method for 2 cases, with poor result, and operation for 8 cases with satisfactory rate of 79.17%. The indication for conservative treatment was type I fracture. It showed that for Pilon's fracture, the outcome of open reduction and internal fixation was superior to that of the conservative treatment, especially in those having internal fixation with AO plate.     

The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome

The hypothenar fat pad flap interposes adipose tissue from the hypothenar eminence between the median nerve and overlying transverse carpal ligament and surgical scar. This retrospective study reviews 62 hands in 58 patients (46 non-workers' compensation and 16 workers' compensation) with recurrent symptoms after failed open carpal tunnel release who underwent revision carpal tunnel decompression and in whom a hypothenar fat pad flap was used. The follow-up period averaged 33 months. Patient satisfaction was 6 in the non-workers' compensation group and 4 in the workers' compensation group. Average time to return to work for the non-workers' compensation group was 12 weeks, compared to 37 weeks for the workers' compensation group. Study results indicate that the hypothenar fat pad flap produces excellent results in procedures designed to alleviate recalcitrant idiopathic carpal tunnel syndrome.     

Treatment of tibial plateau fractures by limited internal fixation

Seventy-five adults who sustained 76 tibial plateau fractures were treated according to a prospective protocol using instability in extension as the principal indication for operative fixation. Patients showing instability underwent closed manipulative reduction under fluoroscopic guidance. If significant joint depression persisted after reduction, elevation of the fracture was performed either from below using bone punches through a cortical window or via limited arthrotomy. Iliac crest bone graft was used to buttress depressed fractures. Fixation was then secured using 7-mm cannulated screws with washers or buttress plates and screws. Postoperatively, 58 of 76 knees were managed in a hinged knee brace, allowing the patient early range of motion and protected weightbearing for 8 weeks. Patients who were found to have a stable knee were treated with Bledsoe braces according to the postoperative protocol. In the 75 patients, 18 of the 76 knees were unsuitable for percutaneous screw fixation because of fracture complexity requiring plates, severe open injuries, or inadequate reductions with limited fixation had been done. A minimum followup of 12 months was obtained in 55 patients (range, 12-59 months). All fractures had healed at the time of followup. Eighty-seven percent of the patients at followup had a successful outcome using Rasmussen's criteria. Fourteen of these patients had arthroscopic assisted reduction or evaluation. All seven patients who had poor outcomes had AO Type C3 fracture patterns. Severely depressed or comminuted fractures or fractures with significant metaphyseal diaphyseal extension may not be suitable for this technique and require the addition of an external fixation device or buttress plate to maintain the reduction and allow for early range of motion.     

Management of acute perilunate dislocations without fracture of the scaphoid

A retrospective review of 14 cases of acute perilunate dislocations without fracture of the scaphoid managed by three different forms of treatment was conducted at an average follow-up of 29 months. Treatment included closed or open reduction with cast immobilization only (n=2), closed reduction followed by percutaneous K-wire fixation of the carpus (n=4), and open reduction with repair of the torn scapholunate ligaments and K-wire fixation of the carpus (n=8). Based on Cooney's clinical scoring system, there were five excellent, five good, two fair and two poor results. The patients without ligamentous repair did as well as those with ligamentous repair when the scaphoid was reduced anatomically and stabilized with K-wires. In the latter, however, the scapholounate relationship was maintained more consistently. We believe that open reduction through a dorsal approach, direct repair of the scapholunate ligaments, and K-wire fixation of the carpus is a reliable method for obtaining satisfactory clinical and radiographic results in the management of acute perilunate dislocations without fracture of the scaphoid.     

Open medial subtalar dislocation associated with fracture of the posterior process of the talus

A case of medial subtalar dislocation associated with fracture of the posterior process of the talus is described. Although this injury pattern is uncommon, it is important to recognize the associated fracture, as it involves a weightbearing articular surface. In this case, the flexor hallucis longus also prevented anatomic closed reduction necessitating open reduction and internal fixation.     

In favor of annual screening for cancer of the cervix uteri

A case of polymyalgia rheumatica with atypical manifestations, including carpal tunnel syndrome, distal myalgias and a low eritro sedimentation is reported. The association of polymyalgia rheumatica and carpal tunnel syndrome is controversial. Although it has been reported previously in a recent and large review of carpal tunnel syndrome in Rochester, USA, there was not any more cases of polymyalgia rheumatica associated with carpal tunnel syndrome than in the general population. In our patient, the symptoms of polymyalgia rheumatica and of carpal tunnel syndrome were present at the beginning, and both responded satisfactorally to the treatment with methylprednisone. This form of presentation and its response to treatment suggest that the symptoms of carpal tunnel syndrome are caused by the inflammation of the carpal synovial, which is an unfrequent manifestation of polymyalgia rheumatica. We report this case for the purpose of altering to an unusual form of presentation of polymyalgia rheumatica in order to avoid unnecessary surgery for the carpal tunnel syndrome.     

Posterolateral dislocation of the elbow with concomitant fracture of the lateral humeral condyle: case report

We describe a case of a 6-year-old girl with a posterolateral elbow dislocation and a concomitant fracture of the lateral humeral condyle. After reduction of the dislocation, the fracture was diagnosed and treated by open reduction and fixation, with a good functional result. In doubtful cases, oblique, heterolateral, and varus stress films, or even arthrography may be necessary.     

Operative treatment of displaced proximal humeral fractures: two-year results in 99 cases

The operative treatment of comminuted and displaced fractures of the proximal humerus has been evolving in recent years. Classical open reduction and internal fixation techniques have an increased risk of avascular necrosis. Minimal osteosynthesis procedures often result in a suboptimal fracture reduction and require postoperative immobilization of the arm in some cases. This study reviewed ninety-nine out of 142 patients (70%), an average of 30 months (range 12 to 72 months) after indirect reduction and internal fixation of two-, three- or four-part fractures of the proximal humerus. The surgical procedure includes indirect fracture reduction with no manipulation of the different fracture fragments and subsequent buttress-plate fixation, using a limited deltopectoral approach. Mean age of patients was 63 years (range 17 to 85 years). Twenty percent of patients had associated lesions. Five patients presented with fracture-dislocations. Results were, according to the UCLA- and the Constant-rating system good to excellent in 76 and 69% of cases. Twelve patients had a poor functional outcome. The indirect reduction technique reduces the opening of the fracture site to minimum and thereby limits the risk of iatrogenic damage to local vascularity and the rotator cuff. Complete and partial humeral head necrosis developed in 3% and 1% of cases respectively. Non-union occurred in one case. Plate fixation is an adequate procedure for treating unstable and displaced two- to four-part fractures of the proximal humerus. The incidence of avascular necrosis and non-union are low, when fracture reduction is performed indirectly. Plate fixation enables an early functional treatment, with no need for postoperative immobilization.     

Prenatal ultrasound diagnosis of massive subchorionic thrombohematoma

We present a case report of a variation of a Bosworth fracture, which is a posterior dislocation of the proximal fragment of a distal fibula fracture. Our patient had a distal fibula dislocation without fracture. He was treated with an open reduction and internal fixation using syndesmotic screws. At his most recent follow-up, he was ambulating without pain.     

Vertical fracture dislocation of the tarsal navicular

An isolated vertical fracture dislocation of the left tarsal navicular with some comminution was successfully treated with open reduction and internal fixation with a screw. The surgical treatment is described, and early mobilization strongly recommended.     

Isolated volar displaced fracture of the ulnar condyle at the base of the index metacarpal: a case report

A case involving a displaced fracture of the ulnar condyle at the base of the second metacarpal without concomitant dislocation of the second carpometacarpal joint is described. It seems probable that the fracture was produced by simultaneous volar subluxation of the base of the third metacarpal that reduced spontaneously. Open reduction and internal fixation of the fracture with Kirschner wires achieved satisfactory results.     

Intraoperative radiographic assessment of ankle fractures

This retrospective study was performed to determine whether three or two radiographic views are necessary for intraoperative evaluation of low energy, rotational ankle fracture reduction and fixation. Four orthopaedic surgeons independently reviewed two sets of radiographs of 93 low energy, rotational ankle fractures treated by open reduction and internal fixation. The reviewers judged reduction and fixation, without measurement, as if they had been the operating surgeons. Set 1 consisted of mortise and lateral views and Set 2 consisted of anteroposterior, mortise, and lateral views. There was a 2-month interval between the review of Set 1 and Set 2. Intraobserver consistency for Sets 1 and 2 for reduction ranged from 92% to 98% and consistency for fixation ranged from 85% to 94%. These results underwent statistical testing by calculation of the kappa value. With a 95% confidence interval, the kappa value for reduction ranged from 0.376 to 0.701; the kappa value for fixation ranged from 0.598 to 0.781. The interobserver consistency for Sets 1 and 2 also was calculated. The authors conclude that fracture reduction and fixation can be assessed adequately with lateral and mortise views. The anteroposterior view can be eliminated from the standard radiographic protocol, potentially resulting in cost savings.