Tendon Dislocation Research Articles

The versatility of the immediate controlled active motion yoke (ICAM)

Purpose: To demonstrate alternative clinical applications for the immediate active controlled motion (ICAM) yoke. Methods: Eight patients from two hand centers with various neurological and/or orthopedic problems affecting metacarpophalangeal (MCP) joint alignment, balance, or range of motion were fitted with variations of the ICAM yoke. Patients were photographed with and without the ICAM yoke to document improved alignment, balance, and function. In the two cases where increased range of motion (ROM) of the metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint was the purpose of incorporating the yoke into the patient's program, ROM measurements were documented on the day the yoke was applied and after it was discontinued. Diagnoses for which the ICAM yoke has been utilized: 1) C5-6 discectomy with extensor lag of the middle and ring digits; 2) metacarpal fracture with extensor lag; 3) ulnar nerve palsy with resultant MCP hyperextension; 4) rheumatoid arthritis (post-MCP arthroplasty); 5) Parkinson's disease with ulnar deviation and dislocation of the extensor tendon of the middle digit; 6) metacarpal head fracture with malalignment and ulnar deviation deformity; 7) PIP joint stiffness (to limit MCP hyperflexion while exercising); 8) decreased MCP joint flexion, status/post gunshot wound to the metacarpal. Results: In all patients, there was a high compliance rate with wearing the yoke. We believe the patients fitted to improve alignment or balance complied because the yoke is small and comfortable and their function improved. In fact, three of the patients discharged from therapy have subsequently returned for fabrication of a replacement of their “permanent adaptive splint.” The two patients who wore the splint to assist in increasing ROM gained flexion of the MCP or PIP joints being addressed. Their ROM charts will be presented. Conclusion: The ICAM yoke is well tolerated and effective in balancing or aligning many hand problems affecting the biomechanics of the MCP joint. The improved function experienced by some of the patients fitted is demonstrated by their desire to have replacements or “back-up yokes” fabricated. The ICAM yoke is also an effective splint to position one or more finger MCP joints in relative extension or flexion to gain motion at the MCP or PIP joints.

Case report of peroneal tendon dislocation evaluated using pre-operative 3D-CT

Case report of peroneal tendon dislocation evaluated using pre-operative 3D-CT

Subluxating Peroneal Tendon: Repair of Superior Peroneal Retinaculum Using a Retrofibular Periosteal Flap

This modification of a soft tissue reconstruction procedure for the treatment of peroneal tendon subluxation and dislocation consists of creating an anterior-based periosteal flap in the peroneal groove from the fibula. This flap is used to augment the superior peroneal retinaculum and prevent the anterior displacement of the peroneal tendons. Its multiple benefits include the augmentation of the anterior aspect of the superior peroneal retinaculum (which may be deficient) and the recreation of the normal anatomy with little disturbance of the surrounding tissue. This simple procedure, with its relative ease of reconstruction, can be performed quickly for patients with acute or chronic peroneal tendon subluxation.

The peroneus quartus muscle. Anatomy and clinical relevance.

Whilst a few studies have associated various symptoms with the presence of a peroneus quartus muscle in the peroneal compartment of the leg, little is known of the clinical relevance of this muscle. We dissected 102 cadaver legs and reviewed the magnetic resonance images of 80 patients with symptoms from the ankle. The peroneus quartus, with a number of different attachments, was present in 6.6% of the legs. It most commonly arose from the peroneus brevis muscle and inserted into the retrotrochlear eminence of the calcaneum. Associated pathology included a longitudinal tear in the tendon of peroneus brevis, possible peroneal tendon subluxation or dislocation, and a prominent retrotrochlear eminence. On the MR scans its presence was associated with pain and weakness of the ankle. Orthopaedic surgeons and radiologists should be aware of the possible presence of the peroneus quartus muscle, not only because of possible associated pathology, but also for its potential use for surgical reconstruction.

Failure of active extension after traumatic cubitus varus

In children cubitus varus is common after malunion of a supracondylar fracture of the humerus. Later problems such as tardy ulnar nerve palsy, snapping of the lateral triceps tendon or ulnar nerve and posterolateral rotatory instability are well documented. We present a case of anteromedial dislocation of the entire triceps tendon with loss of extensor power and describe the method of treatment.

Traumatic soft tissue injuries of the shoulder girdle

As the major hinge of motion of the upper extremity, the shoulder girdle is prone to soft tissue injuries associated with trauma or overuse. Most soft tissue injuries are tendon injuries, joint sprains or dislocations. The trauma mechanism, position of the arm, the anatomic location of pain and presence of referred pain should be investigated. A detailed history and careful physical examination will lead to the diagnosis of specific disorders in most cases. A wide selection of imaging studies is available for shoulder problems. The imaging of choice should be chosen based on the working diagnosis and cost. This review focuses on the diagnosis and management of acute and chronic soft tissue injuries and pathologies involving the adult shoulder.

TREATMENT OF SOFT TISSUE INJURIES TO THE DORSUM OF THE METACARPOPHALANGEAL JOINT (BOXER'S KNUCKLE)

We retrospectively reviewed the surgical treatment for 16 cases of traumatic soft tissue injury to the metacarpophalangeal joint (Boxer's knuckle). A history of trauma was present in all cases and there was an associated extensor tendon dislocation in seven cases. Eight cases were initially treated conservatively, but their symptoms persisted. Intraoperative findings included rupture of the extensor hood or joint capsule in all cases. Surgical closure of the rupture of the joint capsule resulted in a successful outcome in all cases. We consider that conservative treatment of this injury may not be effective when the joint capsule of the metacarpophalangeal joint is ruptured. We recommend arthrography of the metacarpophalangeal joint to assist in the decision as to whether to proceed with surgical or conservative treatment.

Surgical aspects of the hindfoot MR anatomy

The extent of soft tissue trauma in hindfoot injury (calcaneus fracture, talus fracture) is currently being underestimated. A standardization of magnetic resonance (MR) imaging of the hindfoot is necessary for better definition of pathological changes. Standardized MR imaging projections of the hindfoot were illustrated by anatomic analysis of specimen sections using the same sectional plane as in MR imaging. The plastinated sections were obtained from the same specimen that had been scanned previously. MR imaging of the hindfoot enables the assessment of the calcaneocuboid ligament, the interosseous talocalcaneal ligament, trauma of the foot sole, intraosseous and extraosseous vascularization, muscle compartments in the evaluation of compartment syndrome, chondrai flake fractures, tendon dislocation, as well as tendon degeneration, and plantar fasciitis. These anatomical structures, which must be evaluated for preoperative planning, can be identified clearly by MR imaging.

The Skier's Thumb: Ulnar Displacement of the Extensor Pollicis Longus Tendon – a New Type?

The incidence of disruption of the ulnar collateral ligament of the thumb's metacarpophalangeal joint (skier's thumb, gamekeeper's thumb) has increased over the past 20 years. Six different types of injury could be defined. Soft tissue interposition in the joint as well as radial dislocation of the extensor pollicis tendon have been described. We present the case of a skier's thumb with ulnar dislocation of the extensor pollicis longus tendon and tendon interposition in the joint provoking subluxation. The question arises if it possibly constitutes a new, seventh type of this injury.

SURGICAL TREATMENT FOR RECURRENT DISLOCATION OF THE EXTENSOR CARPI ULNARIS TENDON

Twelve patients with recurrent dislocation of the extensor carpi ulnaris tendon were treated with repair or reconstruction of its tendon sheath, and each had a satisfactory result. We found three types of disruption of the fibro-osseous sheath. Type A: the fibro-osseous sheath ruptured ulnarly and the torn sheath lay superficial to the tendon (n=5). These were treated by reconstruction of the sheath using a piece of the extensor retinaculum. Type B: the fibro-osseous sheath ruptured radially and the torn sheath lay in the ulnar groove beneath the tendon (n=3). These were treated by direct suture of the sheath over the tendon. Type C: detachment of the periosteum from the ulnar side of the ulna in continuity with the fibro-osseous sheath formed a false pouch into which the tendon easily dislocated (n=4). These were treated by reattachment of the periosteum.

Arthroscopic Biceps Tenodesis: A New Technique Using Bioabsorbable Interference Screw Fixation

Summary: Interference screw fixation has been used with success for hamstring anterior cruciate ligament reconstruction of the knee. We propose the same fixation principle for arthroscopic tenodesis of a pathologic long head of the biceps (LHB) using bioabsorbable interference screws. Forty-three patients underwent tenodesis of the LHB for a pathologic tendon (tenosynovitis, pre-rupture, subluxation, or dislocation) encountered in three clinical situations: 1) with arthroscopic or mini-open rotator cuff repair (n = 3); 2) with intact cuffs (n = 6); or 3) with massive, irreparable cuff tears (n = 34). Mean age was 63 years. Minimum clinical and radiographic follow-up was 2 years. Six steps were required: 1) glenohumeral exploration and tenotomy of LHB; 2) anterior bursectomy and opening of bicipital groove; 3) LHB exteriorization and preparation; 4) humeral socket preparation; 5) trans-humeral Beath pin “pull-through” technique; and 6) bioabsorbable interference screw fixation. Constant score averaged 43 points before surgery and 79 points at review (p < 0.05). No deficit in elbow flexion-extension was observed. Spring-balance strength of the tenodesed biceps averaged 90% of the contralateral side (range, 80%–100%). Two early patients demonstrated distal biceps retraction and failure of the tenodesis within 3 months. Magnetic resonance imaging at final review revealed tight fixation of the LHB in the humeral socket and no adverse tissue reaction to the screw. These short-term results compare favorably with both open and previously described arthroscopic tenodeses using sutures. This technique is advantageous for pathologic LHB with intact cuffs, associated arthroscopic cuff repairs, and irreparable cuff tears instead of simple tenotomy.

Foot and ankle injuries occurring in inflatable rescue boats (IRB) during surf lifesaving activities.

Inflatable Rescue Boats (IRBs) are utilised by the Surf Life Saving Association (SLSA) in Australia to perform rescue operations and in regional competitions between surf clubs. These activities have resulted in a number of serious foot and ankle injuries which reflect the high impact of this activity in heavy and unpredictable surf. We have retrospectively reviewed 12 significant injuries relating to IRB usage presented to our regional hospital emergency department over a 3-year period. These include 6 Lisfranc fracture dislocations of the midfoot, 4 ankle fracture variants, one tibial shaft fracture, and one traumatic rupture of the peroneal retinaculum leading to peroneal tendon dislocation. Analysis of IRB footstraps in current usage shows they are directly related to the patterns of injury seen. We have recommended modifications to footstraps and handgrips currently in use with the aim of minimising or preventing these injuries.

Subscapularis Tendon Tear: Primary and Associated Signs on MRI

The purpose of this work was to investigate signs of subscapularis tendon tear on MRI. Preoperative written interpretations of high field (n = 9) and low field (n = 7) MRI of 16 patients with tears confirmed at surgery or arthroscopy were reviewed, followed by retrospective review of these studies. A preoperative diagnosis of subscapularis tear was made in five (31%) cases. On retrospective review, primary signs of tear were present in 15 (94%) cases and in two-thirds were limited to the cranial third of the tendon. Supraspinatus tears were present in 69% of cases. Associated findings included medial dislocation (n = 4) or subluxation (n = 3) of biceps tendon, biceps tendinopathy (n = 2), superior labral tear (n = 5), and effusions of superior subscapularis recess (n = 6), subcoracoid bursa (n = 2), or both (n = 5). One or more associated signs were present in 94% of cases. Subscapularis tear is frequently missed on MRI. Recognizing that primary signs of tear may be limited to the cranial third of the subscapularis tendon and identifying associated signs should facilitate diagnosis.

The sagittal band: anatomic and biomechanical study.

Forty-eight digits from 12 human adult fresh-frozen and formalin-preserved cadaveric hands were used to study the anatomy and biomechanics of the sagittal band (SB) and to investigate the mechanism of its injury. The SB was observed to be part of a complex retinacular system in proximity to the metacarpophalangeal (MCP) joint collateral ligaments and the palmar plate. Dynamic changes in SB fiber orientation were observed with different positions of the MCP and wrist joints. The fibers were perpendicular (0 degrees ) to the extensor tendon in neutral position, distally angulated 25 degrees at 45 degrees of MCP flexion, and 55 degrees with full flexion. Swan-Ganz catheter measurements were obtained deep to the SB in varying positions of the MCP joint. The average pressure generation was greatest (50 mm Hg) during full MCP joint flexion and least (30 mm Hg) during 45 degrees flexion. When MCP joint radial or ulnar deviation was added the average measurement was greatest (57) in neutral MCP position and least (35 mm Hg) in 45 degrees flexion. Serial sectioning of the ulnar SB produced no extensor tendon instability. Partial proximal but not distal sectioning of the radial SB produced tendon subluxation. Complete sectioning of the radial SB produced tendon dislocation. Wrist flexion increased tendon instability after radial SB sectioning. We conclude that (1) extensor tendon instability following SB disruption is most common in the long finger and least common in the small finger; (2) ulnar instability of the extensor tendon is due to partial or complete radial SB disruption, (3) the degree of extensor tendon instability is determined by the extent of SB disruption, (4) proximal rather than distal SB compromise contributes to extensor tendon instability, (5) great forces are inflicted on the SB while the MCP joint is in full extension or less frequently in full flexion, which may be the mechanism of its injury, and (6) wrist flexion contributes to extensor tendon instability after SB disruption and may exacerbate the severity of its injury.

Ultrasonography of the Rotator Cuff

There has been limited acceptance of shoulder ultrasonography by orthopaedic surgeons in the United States. The purpose of this retrospective study was to determine the diagnostic performance of high-resolution ultrasonography compared with arthroscopic examination for the detection and characterization of rotator cuff tears. One hundred consecutive shoulders in ninety-eight patients with shoulder pain who had undergone preoperative ultrasonography and subsequent arthroscopy were identified. The arthroscopic diagnosis was a full-thickness rotator cuff tear in sixty-five shoulders, a partial-thickness tear in fifteen, rotator cuff tendinitis in twelve, frozen shoulder in four, arthrosis of the acromioclavicular joint in two, and a superior labral tear and calcific bursitis in one shoulder each. All ultrasonographic reports were reviewed for the presence or absence of a rotator cuff tear and a biceps tendon rupture or dislocation. All arthroscopic examinations were performed according to a standardized operative procedure. The size and extent of the tear and the status of the biceps tendon were recorded for all shoulders. The findings on ultrasonography and arthroscopy then were compared for each parameter. Ultrasonography correctly identified all sixty-five full-thickness rotator cuff tears (a sensitivity of 100 percent). There were seventeen true-negative and three false-positive ultrasonograms (a specificity of 85 percent). The overall accuracy was 96 percent. The size of the tear on transverse measurement was correctly predicted in 86 percent of the shoulders with a full-thickness tear. Ultrasonography detected a tear in ten of fifteen shoulders with a partial-thickness tear that was diagnosed on arthroscopy. Five of six dislocations and seven of eleven ruptures of the biceps tendon were identified correctly. Ultrasonography was highly accurate for detecting full-thickness rotator cuff tears, characterizing their extent, and visualizing dislocations of the biceps tendon. It was less sensitive for detecting partial-thickness rotator cuff tears and ruptures of the biceps tendon.

Intraosseous capture of the long bicipital tendon after fracture-dislocation of the shoulder: A spontaneous Nicola procedure

A case of recurrent traumatic anterior dislocation of the shoulder occurring 12 years after an initial fracture-dislocation is presented. Both dislocations were difficult to reduce. Radiographic abnormalities indicated that at the time of the primary injury, the long bicipital tendon had been captured between the fractured greater tuberosity and the humeral head, creating a spontaneous lesion mimicking a Nicola procedure. The patient did not notice any impaired function or instability after rehabilitation of the first injury. Entrapment of the tendon in the fracture could have contributed to stability during the intervening 12 years. Together with scar tissue formation from the healing of the anterior soft tissues, it also gives a stabilizing effect by a loss in external rotation, limiting the risk of redislocation by preventing the large Hill-Sachs defect from reaching the anterior margin of the glenoid in external rotation. We discuss the role of the long bicipital tendon and other causes for irreducibility associated with fractures of the greater tuberosity. Traumatic anterior shoulder dislocations are sometimes complicated by fracture of the greater tuberosity. If the tuberosity fragment remains in contact with the humeral shaft by periosteum, a closed reduction of the glenohumeral dislocation usually will result in an anatomic repositioning of the greater tuberosity as well. This is due to the balance of the periosteum and the supraspinatus and infraspinatus tendons. The fractured cases are even considered to have a better prognosis 15 concerning the risk of recurrent instability, perhaps attributable to the greater age of these patients. The anterior stabilizing structures might also be less damaged and, if they are not disrupted, instead could act as a hinge during the dislocation. 11 On the other hand, if the fracture involves the bottom of the intertubercular groove, a fracture-dislocation could result in a concomitant dislocation of the long bicipital tendon (LBT) through the fracture to a posterior intra-articular position, rendering the dislocation impossible to amend by closed reduction.7,11

Traumatic dislocation of the extensor tendon at the metacarpophalangeal joint

Traumatic dislocation of the extensor tendon at the metacarpophalangeal joint

TENDON AND NERVE SONOGRAPHY

The refinement of high frequency transducers has improved the ability of ultrasound (US) to detect fine textural abnormalities of tendons and nerves and to identify a variety of pathologic conditions. Characteristic echotextural patterns, closely resembling the histologic ones, are typically depicted in these structures using high US frequencies. In tendon imaging, US can identify tendon dislocations, degenerative changes, differentiate partial from complete tears and determine whether the patient has to be treated surgically or conservatively. A spectrum of findings in inflammatory conditions, including paratendonitis and tenosynovitis, and tendon tumors also can be detected. In nerve imaging, US can support clinical and electrophysiologic testing for detection of compressing lesions caused by nerve entrapment in a variety of osteofibrous tunnels of the limbs and extremities. Nerve tears and tumors also can be diagnosed. Overall, US is an effective technique for imaging tendons and nerves.

EXTENSOR TENDON DISLOCATION IN CEREBRAL PALSY

An 18-year-old man with cerebral palsy presented with a flexion deformity of the middle finger particularly at the metacarpophalangeal joint and ulnar dislocation of the extensor tendon. Releasing the tight ulnar sagittal band and imbricating the attenuated radial sagittal band allowed centralization of the extensor tendon. For complete correction of other deformities intrinsic release and extrinsic flexor muscle lengthening were done. Extensor tendon instability in this case was due to the combined forces of the extrinsic and intrinsic muscles on the retinacular system of the extensor mechanism.

Subluxation and dislocation of the peroneal tendons

Peroneal tendon dislocation resutls from a forced dorsiflexion-eversion injury of the ankle joint. It occurs most frequently as a result of a snow- or water-skiing injury. The patient will often hear a loud “pop” when the injury occurs and experience pain about the distal fibula. As a rule, the tendons spontaneously reduce, but the dislocation may recur. Initial treatment is with a short leg walking cast for 4 to 6 weeks. If the tendons do not stay reduced in the cast, early surgery is indicated to reapproximate the torn retinaculum. If conservative treatment fails and the tendons continue to dislocate, a surgical repair may be performed.