Extension Block Research Articles

Intra-articular pseudorheumatoid nodule with an extension block of knee: A rare case report

Subcutaneous nodules characterized by central fibrinoid necrosis, surrounded by histiocytes and fibroblasts, are suggestive of rheumatoid arthritis or rheumatic fever. These nodules, when observed in otherwise healthy individuals, are termed as pseudorheumatoid nodules. These are seen in the scalp, ulnar aspect of the forearm, palm, orbit and dorsum of the foot, with no manifestations of rheumatic disease. These represent an unusual reaction to trauma. Rheumatoid nodules are the extra-articular manifestations of rheumatoid arthritis and it will mimic pseudorheumatoid nodule clinically and on histopathology. Intra-articular pseudorheumatoid nodules, however, are rare. Our case was a 37-year-old female who presented with difficulty in walking and coming down the stairs. The MR evaluation showed a cyst-like lesion in the intercondylar notch of the knee and arthroscopic evaluation and excision determined it to be a rheumatoid nodule. In the absence of any other significant features of rheumatoid arthritis, it is reckoned to be a case of unusual presentation and location of pseudorheumatoid nodule.

Tension wire fixation for mallet fracture after extension block pinning failed

Various surgical treatments such as extension block pinning have been proposed for acute bony mallet finger. We evaluated the clinical results of tension wire fixation technique for the treatment of nonunion of mallet fracture after failed mallet finger surgery. Nine male patients were treated with open tension wire fixation for chronic nonunion of mallet fracture after extension block pinning surgery failed. The mean age was 29.3years (range 18-47). We assessed bone union in simple radiographs. Crawford's and Bischoff functional score was used to assess the functional outcome. The mean follow-up period was 45.8months (range 18-74). Clinical and radiographic bone unions were achieved in eight of nine patients with average time of 31days (range 23-41). Mean extension lag at final follow-up was 7° (range 0-25). Four patients showed excellent, three patients showed good and two patients showed fair results on the Crawford's score scale. With Bischoff functional score, all patients were categorized as excellent. Tension wire fixation can be a good second-line reconstructive surgery for the treatment of mallet fracture after extension block failed, so that patients can avoid arthrodesis or complex tendon transfer as a salvage procedure.

A novel closed reduction with extension block and flexion block using Kirschner wires and microscrew fixation for mallet fractures

BackgroundSome patients with mallet fractures who undergo extension block pinning complain of exposed wires, which delay their return to sports and causes inconvenience while performing tasks that require the use of hands during the early postoperative period. The purpose of this retrospective study was to present and evaluate a novel surgical procedure for mallet fractures. MethodsWe treated 20 patients (14 males and six females; mean age, 38.4 years; range 17-68 years) with displaced mallet fractures involving >30 % of the articular surface using the closed reduction and microscrew fixation between January 2009 and January 2012. The distal interphalangeal joint (DIP) joint was immobilized with a splint for 1-3 weeks on an individual case basis. According to Wehbe and Schneider’s classification, there were 12 type IB, six type IIB, and two type IA fractures. The mean follow-up duration was 12.6 months (range 6-31 months). ResultsBone union was achieved in all patients within a mean period of 6.8 weeks, with no incidence of infection, skin necrosis, permanent nail deformity, or secondary osteoarthritis. Only two complications—temporary nail ridging in one patient and a dorsal bump caused by the screw in one patient—were observed. Minimum postoperative displacement was observed in one patient, for whom immobilization with a splint was continued for 4 weeks. Articular incongruity was <1.0 mm in four patients and 1.0-2.0 mm in two patients. Mean DIP joint extension loss was 6.5° and mean flexion was 67.8°. The surgical outcomes were excellent in seven patients, good in nine, and fair in four according to Crawford’s evaluation criteria. ConclusionOur novel surgical procedure combining closed reduction with extension block and flexion block using Kirschner wires and microscrew fixation produces good clinical results with relatively few complications.

Closed Extension Block Technique for Treatment of Osseous Mallet Injury

Objectives: We analyzed the clinical and radiological outcomes of percutaneos extension block technique for treatment of osseous mallet injury. Methods: We included 36 patients who had osseous mallet finger ≥ 20% articular surface involvement. We controlled 29 men, 7 women followed mean 18,5 ( Range 8 – 24) months.Radiologic evaluation was made according to the Doyle classification and 25 injuries were classified type IVb, 11 injuries were classified type IVc. Final evaluation were made according to Crawford evaluation criteria and distal interphalangeal joint motion.Results: The preoperative avarage articular surface involvement was 39,7% ( Range 20 – 60 ). The DIP joint subluxation was seen in 6 patients who had ≥50% articular surface involvement. Clinical results, according to the Crawford criteria, were excellent in 30 ( 83,3% ) patients, good in 4 patients ( 11,1% ), moderate in 2 patients ( 5,5% ). The average extension lag was 3,1° (0°to 17°), and the average final active flexion of DIP joint was 75,1° (50° to 80°). Bone union was showed in all cases radiographically at the final control. Conclusion: The extension block technique is a minimal invasive treatment technique. This technique has decreased the complications of the open surgical treatments. This technique when properly applied has been given functionally satisfactory results. The experience of the surgeon is very effective over the result of the patients.

Transtensional rifting in the proto-Gulf of California near Bahia Kino, Sonora, Mexico

Continental rifts require focused strain to rupture and form an ocean basin. In oblique rifts, such as the Gulf of California, focused transtensional strain associated with strike-slip faulting may serve as a catalyst for rupture. To test this hypothesis, we analyzed structural mapping, geochronology, paleomagnetism, and fault kinematics of pre- and synrift rocks exposed in an ∼200 km 2 coastal mountain belt flanking the eastern rift margin of the northern Gulf of California. This coastal Sonora region hosts the onshore portion of the transform boundary between the Upper Tiburon and Adair-Tepoca marine basins—two early-formed oblique rift segments. Extension commenced here between 11.5 Ma and 7 Ma, resulting in 25°–40° of E-NE tilting, initiation of clockwise vertical-axis rotation of fault-bounded blocks, and minor basin sedimentation. Rates of deformation prior to 7 Ma are unconstrained due to a lack of exposed syntectonic deposits. Deformation after 7 Ma was associated with rapid tilting and the majority of observed clockwise vertical-axis rotation and strike-slip faulting. Nonmarine sedimentary basins accumulated coarse sediments above an unconformity eroded across older, tilted strata. By 5–6 Ma, deformation in coastal Sonora must have largely ceased and migrated westward into the Upper Tiburon marine basin. We document up to 120% total extension and total clockwise block rotations up to 53°. In portions of the study area, extension and rotation were supplanted by strike-slip faulting as deformation proceeded. We develop a tectonic model for this Coastal Sonora fault zone, which is bounded by major NW-striking transform faults with >10 km of displacement. Internal to the Coastal Sonora fault zone, the majority of an estimated 6.2 ± 1.1 km of dextral deformation, associated with up to 5.7 km of WNW-directed extension, occurred over the final 1–2 m.y. of its life span, at a strain rate approaching 10 –14 s –1 . This activity occurred as the plate boundary localized along nascent pull-apart basins in the northern Gulf of California, consistent with the hypothesis that late proto–Gulf of California dextral shear zones, such as the Coastal Sonora fault zone, acted to focus lithospheric-scale strain and promoted continental rupture in the wide-rift setting of the Mexican Basin and Range.

Extension Block Pinning Using a Small External Fixator for Mallet Finger Fractures

To describe surgical outcomes of a series of patients with bony mallet fingers treated by a modified extension blocking technique with external fixation. We developed an external fixator that was attached to the extension block pin. Dorsal rotation of the dorsal fragment during reduction was prevented with 1 or 2 additional pins abutted on the fragment through the fixator. We reviewed 12 consecutive patients with mallet finger fractures who were treated surgically with the external fixator. The mean age of the patients was 33 years (range, 15-60 y). Rotation of the fragment during reduction was well controlled in all patients. All fractures united at an average of 5 weeks after surgery. Average extension lag was 2° and active flexion was 74°. No patient reported pain at a final follow-up of 4 months (range, 3-8 mo). According to the Crawford rating scale, 10 patients were classified as excellent and 2 were good. Our modification of the extension block method prevented dorsal rotation of the fragment during reduction and resulted in early union. Therapeutic IV.

Open Reduction of Proximal Interphalangeal Fracture-Dislocation through a Midlateral Incision Using Absorbable Suture Materials

BackgroundFracture-dislocation of the proximal interphalangeal (PIP) joint is a relatively common injury. Various treatments for fracture-dislocation of the PIP joint have been reported. In the present study, we performed open reduction through a midlateral incision using absorbable sutures to reduce the small bone fragments and performed volar plate repair.MethodsWe treated nine patients with fracture-dislocation of the PIP joint with small fractured bone fragments too small for pinning or screw fixation. Patients with volar plate injury were treated with open reduction and volar plate repair at the periosteum of the middle phalangeal bone base by the modified Kessler method using absorbable sutures. All patients were placed in a dorsal aluminum extension block splint, which maintained the PIP joint in approximately 30 degrees of flexion to avoid excessive tension on the sutured volar plate.ResultsAt a mean final follow-up of postoperative 9 months, all patients were evaluated radiographically and had adequate alignment of the PIP joint and reduction of the displaced bone fragments. Range of motion was improved and there were no complications.ConclusionsThis technique is an excellent alternative to the current method of treating patients with fracture-dislocations that include small fragments that are too small for pinning or screw fixation. It is a less invasive surgical method and enables stable reduction and early exercise without noticeable complications.

Hemi-hamate Autograft Arthroplasty for Acute and Chronic PIP Joint Fracture Dislocations

Treatment of fracture dislocations of the PIP joint represents a hand surgical challenge. In hemi-hamate arthroplasty, the palmar joint surface is reconstructed using an osteochondral graft from the hamate and the immediate stability permits early movement. We performed hemi-hamate reconstructions in 10 patients (mean age 34.9 years), who sustained fractures of the base of the middle phalanx of ≥50% surface and dorsal PIP dislocations. Outcomes were assessed by clinical exam and X-ray. Evaluation criteria were range of motion of PIP and DIP joints, grip strength, joint alignment, complications and donor site morbidity. Mean follow-up was 8.6 months (range 3-14). Fractures mostly involved the 4th and 5th fingers, all patients were male. Indications were subluxation and comminuition in acute cases of <6 weeks (5 patients) and chronic pain and morning stiffness in chronic cases (5 patients). Operative treatment was performed in average after 93 days (range 0-371 days) after injury. Average PIP motion was 71° (range 0-90); DIP motion was 54° (range 10-90) with a mean PIP flexion contracture of 6.5° (range 0-20). Grip strength averaged 95% of the opposite hand. 4 patients had revision surgery (2× arthrolysis PIP joint, 2× screw shortening, 1× neurolysis R. dorsalis N. ulnaris). Hemi-hamate autograft arthroplasty represents an effective procedure to address severe PIP joint fracture dislocations. It restores the comminuted articular surface in chronic injuries and in the acute injury it is a challenging but valuable alternative to extension block splinting. However, donor site morbidity and revision surgery have to be taken into account.

Role of Mass Media in Agricultural Productivity in Adamawa State, Nigeria

The study examined the role of mass media in agriculture in Adamawa State. Specifically, it focused on the extent to which mass media have been used to communicate agricultural information dissemination, farmers’ media preference, challenges experienced in accessing information through the media and the need to establish community based media. A multistage random sampling technique was adopted in selecting respondents for the study. This involved the random selection of one extension block each, from the four Agricultural Development Programme (ADP) extension zones in the state viz: Gombi, Guyuk, Mayo-belwa and Mubi. Two agricultural extension cells were then selected from each of the extension blocks and 10 farmers in each cell were randomly selected. In all 240 farmers were selected for the study. An interview schedule was used to solicit for data from the respondents. Results indicate that, majority of the farmers (69.17%) affirmed radio as the only means through which they access production information. Also, 50% of the respondents preferred television to other media available for communicating agricultural information. All the variables related to the challenges experienced by farmers in accessing information through the mass media and the perception of the community based media were significant at 5% level, attesting a strong relationship. Pest and disease control had 41.7%, improved crop varieties had 25% and weed control had 16%, these were prominent amongst agricultural information disseminated through mass media to farmers. The study suggested the establishment of a community based television stations targeted on agricultural programmes to farmer as this will go a long way in improving not only the quality of information but also its access.KEY WORDS: Extension, Productivity, Access, Information

Dupuytren Contracture - How Fibromatosis Remodels the Palmar Subcutaneous Tissue and Its Fibrous Environment

Our understanding of the process of contracture of the fingers is based on extrinsic and intrinsic theories. Yet there has always been an inherent contradiction in these concepts. Additionally, nearly all of these theories proceed from the assumption of a contractio digitorum and this assumption is reflected in basic research as well. The author presents a concept, which describes the finger contracture more accurately as retention in the flexed position. This contraction-free concept, deduced from the function and structure of the palmar subcutaneous tissue, combines the different pathogenic aspects. Palmar fibromatosis primarily manifests itself in the palmar subcutaneous tissue. The function of this tissue was studied in the living hand; the anatomic structure of the subcutaneous fibrofatty tissue was studied for the first time in slice plastinates of adult hands. The palmar tissue exhibits varying tissue consistencies. It is compressed and expanded as the fingers move. In fibromatosis, fibrous nodules infiltrate the finger tissue in its shortened flexion configuration, which predominates both by day and by night. In the normal hand, the anchoring fibers allow nearly tension-free deformation of the skin tissue. In fibromatosis, this tissue loses its extensibility. Motion in the finger subjects the new formed tissue to tensile stress. This in turn provides the decisive stimulus for adaptive tissue transformation. This process does not require any active contraction. It plausibly explains the finger contracture as an extension block. In the contraction-free concept, the myofibroblast is understood to be a form of fibroblast that resists the tension arising in the tissue by isometric contraction. The contraction-free concept can explain all clinical pictures of fibromatosis as reactive remodeling of the specific local host tissue. It can also provide basic research with a conclusive anatomic pattern. Moreover, it implies a specific therapeutic paradigm: Treatment options that influence the formation of pathologic tissue and address the characteristic tensile stress will be able to control the root causes of the deformity.

BONY MALLET THUMB

Unlike mallet finger, mallet thumb is rare. We treated a case of mallet thumb with avulsion fracture using extension block Kirchner wire technique, and achieved excellent results.

Mucoid hypertrophic mass of the anterior cruciate ligament causing knee extension block

We report on the case of a patient with a knee extension block caused by a mucoid hypertrophic mass on the anterior cruciate ligament (ACL). Magnetic resonance imaging showed diffuse thickening of the ACL with a mass-like lesion anterior to the tibial attachment. Arthroscopy revealed a huge amorphous mass arising from ACL fibers at the tibial attachment that impinged on the femoral intercondylar notch on knee extension. The treatment included excision of the mass and accompanying abnormal ACL fibers and notchplasty, and resulted in complete recovery of knee motion and symptom relief without instability. This case shows that a degenerative mass in the form of a mucoid hypertrophied ACL can cause a knee extension block.

Open accurate reduction for irreducible mallet fractures through a new pulp traction technique with primary tendon repair

Sixteen patients with bony mallet fingers were treated by a new technique of open reduction through a T-shaped dorsal incision and oblique wire fixation via pulp traction with additional primary extensor repair. Surgical indications included fractures with intra-articular involvement over 1/3 of the articular surface, distal phalanx subluxation, and displacement greater than 3 mm irreducible by extension block pinning. The cases were analysed prospectively for a mean follow-up period of 12 months. The results were evaluated using Crawford's criteria. Eleven cases were evaluated as excellent, three cases as good, and two cases as fair. Complications included three cases with transient nail deformity, two cases with flexion limitation of 5° and 10°, and three cases with extension lag between 5°–10°. This new method of accurate reduction achieves good clinical outcomes, with comparatively less complications in mallet fractures irreducible to closed extension block reduction.

Flexor Tendon Rehabilitation

A 36-year-old physical therapist cut her nondominant ring and small fingers slicing a bagel and could not bend the digits at the proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints. She had repairs of complete lacerations of both the flexor digitorum superficialis (FDS) and the flexor digitorum profundus in zone II within 48 hours of injury using a 4-strand repair with nonabsorbable braided suture and a running 6-0 nonabsorbable monofilament epitendinous repair. She was splinted postoperatively in a dorsal extension block splint.

“Dynamic External Fixation for Proximal Interphalangeal Fracture-Dislocations”

Proximal interphalangeal fracture-dislocations and pilon fractures of the middle phalanx represent a conundrum for hand surgeons. Goals of treatment are to: (1) maintain a stable congruent joint, (2) reduce intra-articular step-offs, and (3) prevent stiffness. Because the fragments of the middle phalanx are small, internal fixation is difficult and often impossible. Options other than internal fixation include hemi-hamate arthroplasty, volar plate arthroplasty, extension block pinning, and dynamic external fixation. Techniques for dynamic external fixation of the digit for the treatment of proximal interphalangeal fracture-dislocations and pilon fractures have evolved since first reported in 1946 by Robertson et al. In 1989, Slade et al developed a fixator that uses 3 Kirschner wires and dental rubber bands. Several groups have since published favorable outcomes using this technique. We have used this technique for the past 10 years at our institution and have had similar encouraging results. The present article describes the indications, operative technique, and postoperative protocol used by the authors. A brief review of results and complications are presented, and 2 illustrative case examples are provided.

Do Large-Diameter Hamstring Grafts in Young Patients Prevent Knee Osteoarthritis After ACL Reconstruction?

Do Large-Diameter Hamstring Grafts in Young Patients Prevent Knee Osteoarthritis After ACL Reconstruction?

Evaluation and Treatment of Disorders of the Infrapatellar Fat Pad

The infrapatellar fat pad (IFP), also known as Hoffa's fat pad, is an intracapsular, extrasynovial structure that fills the anterior knee compartment, and is richly vascularized and innervated. Its degree of innervation, the proportion of substance-P-containing fibres and close relationship to its posterior synovial lining implicates IFP pathologies as a source of infrapatellar knee pain. Though the precise function of the IFP is unknown, studies have shown that it may play a role in the biomechanics of the knee or act as a store for reparative cells after injury. Inflammation and fibrosis within the IFP, caused by trauma and/or surgery can lead to a variety of arthrofibrotic lesions including Hoffa's disease, anterior interval scarring and infrapatellar contracture syndrome. Lesions or mass-like abnormalities rarely occur within the IFP, but their classification can be narrowed down by radiographical appearance. Clinically, patients with IFP pathology present with burning or aching infrapatellar anterior knee pain that can often be reproduced on physical exam with manoeuvres designed to produce impingement. Sagittal MRI is the most common imaging technique used to assess IFP pathology including fibrosis, inflammation, oedema, and mass-like lesions. IFP pathology is often successfully managed with physical therapy. Passive taping is used to unload or shorten an inflamed IFP, and closed chain quadriceps exercises can improve lower limb control and patellar congruence. Training of the gluteus medius and stretching the anterior hip may help to decrease internal rotation of the hip and valgus force at the knee. Gait training and avoiding hyperextension can also be used for long-term management. Injections within the IFP of local anaesthetic plus corticosteroids and IFP ablation with ultrasound guided alcohol injections have been successfully explored as treatments for IFP pain. IFP pathology refractory to physical therapy can be approached through a variety of operative treatments. Arthroscopic partial resection for IFP impingement and Hoffa's disease has showed favourable results; however, total excision of the IFP performed concomitantly with total knee arthroplasty (TKA) resulted in worse results when compared with TKA alone. Arthroscopic debridement of IFP fibrosis has been successfully used to treat extension block following anterior cruciate ligament reconstruction, and arthroscopic anterior interval release has been an effective treatment for pain associated with anterior interval scarring. Arthroscopic resection of infrapatellar plicae and denervation of the inferior pole of the patella have also been shown to be effective treatments for refractory infrapatellar pain.

Anatomic Reduction of Mallet Fractures Using Extension Block and Additional Intrafocal Pinning Techniques

BackgroundThe purpose of this article is to report the efficacy of the extension block pinning and additional intrafocal pinning technique applied to cases whose mallet fractures were not reduced with extension block pinning alone.MethodsWe retrospectively reviewed 14 digits with 14 patients who were treated with the extension block pinning and additional intrafocal pinning technique. There were eight men and six women with an average age of 34 years. The average articular surface involvement was 52%. The average follow-up was 16 months and the mean time from injury to operation was 23 days.ResultsAll the cases achieved anatomic reduction of fractures. By Crawford's classification, 9 were excellent and 5 were good. The average active flexion of the distal interphalangeal joint was 78 degrees and the average extension loss was 1.8 degrees. Bone union was observed in all cases after a postoperative mean of 38.4 days. Complications such as skin necrosis, fracture of bony fragments, and nail-plate deformity were not found.ConclusionsAdditional intrafocal pinning technique is considered a simple and useful method to obtain anatomic reduction of mallet fractures in cases where extension block pinning alone is insufficient to restore the anatomic configuration of the articular surface.

Surgical Treatment of Mallet Toe of the Hallux with the Extension Block Method: A Case Report

Level of Evidence: V, Expert Opinion

Outcome of closed proximal phalangeal fractures of the hand

Background:The proximal phalanx (PP) of the fingers is fractured more frequently than the middle or even distal phalanges. The problems of malunion, stiffness and sometimes loss of skin or other soft tissues associated with PP fracture increases the disability. The optimum treatment depends on fracture location, fracture geometry and fracture stability. The objective of the study was to analyse the treatment outcome in a series of closed proximal phalangeal fractures of the hand.Materials and Methods:Eighty-four proximal phalangeal fractures in 68 patients were enrolled from 2007 to 2009. The treatment modalities were broadly categorised into two groups, Group A consisted of conservative treatment, and Group B consisted of surgical treatment. Group A included 47 digits treated with closed reduction (CR) with immobilization (n=43), extension block cast and dynamic traction (n=4), while 37 digits were treated in Group B, which included closed or open reduction (OR) and internal fixation (IF) with K-wires (n=31), OR and IF with stainless-steel wiring (n=2), and mini external-fixator (n=4). Belsky's criteria and Gingrass’ criteria were used for assessment of finger injuries and to assess the efficacy of conservative and surgical modalities for closed proximal phalangeal fractures of the hand.Results:Average period of follow-up was 1 year (range 10-14 months). The excellent to good results seen in Groups A and B were 89% and 92%, respectively. Six complications were seen in Group A, which included four cases with malunion and two cases with digital stiffness. Three complications were seen in Group B, which included one each of malunion, digital stiffness and extensor lag. Overall, maximum poor results (n=4) were seen with CR and buddy strapping.Conclusion:Conservative treatment is an inexpensive method, particularly suitable for stable fractures, and in patients who are poor candidates for surgery, Surgical modalities have distinct advantage of stable fixation, but with added risk of digital stiffness. Percutaneous pinning is a reliable, most commonly used surgical modality and technically easier. Both conservative and surgical modalities have good efficacy when used judiciously