Faculty Bibliography

Injury to the spinal accessory nerve in the posterior triangle of the neck results in trapezius paralysis and shoulder dysfunction. The most common etiology is iatrogenic and has been reported extensively in adults. We report 3 cases of spinal accessory nerve injury recognized postoperatively in children and discuss the microsurgical treatment, results, and simple strategies to avoid this complication.

Locked plate technology has evolved in an effort to overcome the limitations associated with conventional plating methods, primarily for improving fixation in osteopenic bone. The development of screw torque and plate-bone interface friction is unnecessary with locked plate designs, significantly decreasing the amount of soft tissue dissection required for implantation, preserving the periosteal blood supply, and facilitating the use of minimally invasive percutaneous bridging fixation techniques. The locked plate is a fixed-angle device because angular motion does not occur at the plate screw interface. The use of locked plate technology allows the orthopaedic surgeon to manage fractures with indirect reduction techniques while providing stable fracture fixation. The secure 'feel' of locked plates, ease of application, and the low incidence of complications noted in early clinical reports have contributed to the proliferation of this technology. Along with reports of clinical successes, as the use of fixed angle/locked plates has increased, clinical failures are being noticed. This review will focus on the biomechanics of locked plate technology, appropriate indications for its use, laboratory and clinical comparisons to conventional plating techniques, and potential mechanisms of locked plate failure that have been observed

Tennis elbow typically presents as pain and localized tenderness at the lateral aspect of the elbow. It is the most common diagnosis related to the elbow. Microtrauma at the vicinity of the Extensor Carpi Radialis Brevis muscle is postulated to be the cause of this clinical entity. Initial treatment should be conservative and is successful in up to 90% of cases. Modalities such as patient education, physiotherapy, use of splints, anti-inflammatory medication, complementary medicine and eventually local injections are all acceptable treatment methods. Surgical treatment of tennis elbow should be used only as a last resort. Both open and arthroscopic methods are acceptable and their results are considered to be excellent.

Shoulder pain is a common complaint seen at the primary physician's clinic, and it is the third most common musculoskeletal complaint after back and neck pain. Shoulder pain can have a wide range of etiologies: trauma caused from a sprain or a simple muscle strain to a large tear of one of the shoulder stabilizer muscles. Some shoulder pathologies can cause chronic pain and limitation in shoulder range of motion such as impingement syndrome, adhesive capsulitis, calcified tendonitis, cervical radiculopathy, glenohumeral osteoarthritis, and biceps tendonitis. The physician who attempts to diagnose the cause for his patient's shoulder pain faces a great challenge due to the large number of etiologies that can lead to such a complaint. The physician has a large number of tools at his disposal starting from a thorough history emphasizing the time and character of the shoulder pain, range of motion and the ability to do everyday activities, to a wide range of imaging modalities such as X-ray, ultrasound and magnetic resonance imaging. Most of the causes of shoulder pain are adequately treated non-surgically with treatments such as physiotherapy, antiinflammatory medication and local corticosteroid injections. However, some situations necessitate surgical intervention in order to correct and restore the patient's prior level of shoulder function. The physician's ability to correctly diagnose and recommend appropriate lines of treatment, taking into consideration the patient's problem, age, medical condition and prior level of function is the secret to successful treatment, recovery of the patient's shoulder function and most important, patient satisfaction.

Acute distal clavicular osteolysis was first described in 1936. Since then, distal clavicular osteolysis (DCO) has been separated into traumatic and atraumatic pathogeneses. In 1982 the first series of male weight trainers who developed ADCO was reported. The association of weightlifting and ADCO is especially important considering how routine a component weights are to the male athlete's training. The pathogenesis of DCO has often been debated. The most widely accepted etiology involves a connection between microfractures of the subchondral bone and subsequent attempts at repair, which is consistent with repetitive microtrauma. Symptoms usually begin with an insidious aching pain in the AC region that is exacerbated by weight training. On examination, patients have point tenderness over the affected AC joint and pain with a cross-body adduction maneuver. Although DCO may seem like an easy and quick diagnosis, one must rule out other possibilities. Avoidance of provocative maneuvers, modification of weight training techniques, ice massage, and nonsteroidal anti-inflammatory drugs (NSAID) constitute the basis of initial treatment. Much of the literature supports the same general indications for surgery. These include point tenderness of the AC joint, evident abnormal signs with AC joint scintigraphy and AC radiographs, lack of response to conservative treatment, and an unwillingness to give up or modify weight training or manual labor. Distal clavicle resection has provided good results. Distal clavicle osteolysis is a unique disease most likely due to an overuse phenomenon

A case of severe hip pain and limb shortening due to intrapelvic migration of the acetabular cup and protrusion of the femur component is reported in a 55-year-old female [New York, USA]. She presented to the clinic with a complaint of right hip pain which started intermittently a few months before visiting the clinic, but has increased and become debilitating in the past three weeks. The pain was accompanied by lateral thigh paresthesia and weakness. On examination, the right lower extremity appears shorter with decreased light touch sensation on posterolateral aspect of thigh. The patient was unable to raise leg and the range of motion of the hip was limited due to pain. X-ray of the right hip and femur presented a comminuted fracture of the acetabulum and iliac bone with central dislocation of the femoral head into the hemipelvis and migration of the acetabular cup into the pelvis, with breakage and displacement of proximal cerclage wires. Computed tomography angiog! raphy/pyelography, arteriogram and intravenous pyelogram showed the above findings without any internal haemorrhage or further pathology. A two-stage revision repair was planned. At the time of reimplantation, continuity of the acetabulum was verified. And a large uncontained acetabular defect was noted including the entire anterior wall, anterior column, and medial wall. A large superior defect was noted as well. Wire mesh was used to contain the defect which was filled with morselized allograft. A Burch-Schneider cage was placed over the graft. And a constrained polyethylene liner was cemented into the cage. The proximal femur had a small greater trochanteric fragment that was not united. The top three inches of the proximal femur had a defect involving over a third of its circumference, extending below the isthmus, with poor bone quality. This bone was resected and modular Mega-Prosthesis was cemented into the remaining femur. The trochanteric fragment was reattached to ! the prosthesis. At follow-up, the patient was doing well, scar was wel l healed and patient was able to ambulate with a walker

The diagnosis and treatment of injuries involving rupture of the interosseous ligament remain challenging. Few studies have considered the effects of rupture of the interosseous ligament on deep forearm muscle function. The objective of this study was to quantify the attachment areas of the deep forearm muscles on the interosseous ligament. The origins of the extensor indicis, extensor pollicis longus, extensor pollicis brevis, abductor pollicis longus, lexor pollicis longus, and lexor digitorum profundus were digitized from 11 cadavers. Three-dimensional modeling techniques were used to quantify the origin area on bone and the interosse- ous ligament. The extensor pollicis longus and the abductor pollicis longus attached primarily to the interosseous liga- ment (81% and 62%, respectively). Although the other deep forearm muscles had larger origins on bone, relatively large areas on the interosseous ligament were observed, ranging from 31% to 47%. The muscle origins on the interosseous ligament were veriied histologically, where striated muscle originated directly from the dense connective tissue of the interosseous ligament. Due to their relatively large attach- ment areas on the interosseous ligament, the function of the deep forearm muscles might be altered after an interos- seous ligament rupture. Therefore, symptoms such as pain and weakness of the deep forearm muscles could serve as a basis for screening patients with injuries of the interosse- ous ligament. Furthermore, the data may help to elucidate factors limiting the healing of the interosseous ligament. Future studies should focus on quantifying the effect of an interosseous ligament rupture on the function of the deep forearm muscles and developing reconstructions that con- sider this function.