Co-Director, University of Utah School of Medicine
Fractures of the glenoid fossa occur when the humeral head is driven into the center of the concavity skin care korean brand cheap roaccutan express. The fracture then promulgates in a number of different directions skin care zarraz paramedical discount roaccutan express, depending on the characteristics of the humeral head force skin care 2 in 1 4d motion buy cheap roaccutan 5 mg on line. Significantly displaced glenoid fossa and glenoid rim fractures require operative management. Significant displacement can result in posttraumatic degenerative joint disease, glenohumeral instability, and even nonunion. The superior approach is used, in conjunction with a posterior approach, for fractures of the glenoid fossa with a difficultto-control superior fragment. The anterior approach is used for fractures of the anterior glenoid rim and some fractures involving the superior aspect of the glenoid fossa. Subperiosteal mobilization of the teres minor muscle allows access to the lateral scapular border. The posterior and posteromedial heads of the deltoid are detached from the scapular spine and acromial process. The infraspinatus tendon and underlying posterior glenohumeral capsule are incised 2 cm from insertion on the greater tuberosity to allow access to the glenohumeral joint. The trapezius and underlying supraspinatus muscles are split in line with their fibers. The deltoid muscle is split in the line of its fibers over the palpable coracoid process and retracted medially and laterally. Incise the anterior glenohumeral capsule in the same fashion, tag its corners, and turn it back medially to gain access to the glenohumeral joint. Incise the subscapularis tendon 2 cm from its insertion on the lesser tuberosity, dissect it off the glenohumeral capsule, incise the capsule similarly, and turn both of them back medially to gain access to the glenohumeral joint. All soft tissues divided to gain access to the fracture site must be meticulously repaired. With posterior approaches, the deltoid must be securely reattached to the acromion and scapular spine with permanent sutures through drill holes. Axillary radiograph showing the glenoid cavity fragments secured together with cannulated screws and the glenoid unit secured to the scapular body with a malleable reconstruction plate (the acromial fracture was reduced and stabilized with a tension band construct). If severe comminution is present, an iliac crest tricortical bone graft is an option. During the posterior approach, develop the internervous plane in between the infraspinatus (a bipennate muscle) superiorly and the teres minor inferiorly. They also can be driven across the fracture site to provide temporary or permanent fixation. Reconstruction plates may be pre-contoured using a scapula model and flash-sterilized. Cannulated interfragmentary screws can be inserted using previously placed K-wires as guidewires.
An increase in the claw deformity as the patient tries to extend the fingers by flexing the wrist indicates a poor prognosis for tendon transfer surgery acne youtube cheap roaccutan online visa. If the fixed flexion contracture does not respond to therapy acne 2008 cheap 30mg roaccutan with amex, preliminary surgical joint release is necessary before tendon transfers skin care food buy discount roaccutan 5 mg online. Alternatively, the extensor indicis proprius or abductor pollicis longus can be used. For transfers coming from the dorsum of the hand, the pulley is either the index or middle finger metacarpal. Passing the transfer through the third web space, using the middle metacarpal as the pulley, allows the transferred tendon to lie palmar to the adductor pollicis but dorsal to the flexor tendons and neurovascular bundles. The transfer can be inserted directly into the thumb metacarpal, into the adductor pollicis tendon, or into the abductor pollicis brevis tendon. This last technique, favored by Omer, allows the tendon to be sewn to the strong fascia abductor pollicis longus tendon and improves pronation of the thumb to aid in pinch. Preoperative Planning Tendon transfers are indicated when no further nerve recovery is anticipated. In evaluating a patient for tendon transfer procedures, the examiner assesses the number of functions lost, determines the number of muscles available for transfer, and assesses the strength and excursion of each of the donor and recipient muscles. When there are insufficient donor muscles to substitute for all functions that are lost, tenodesis and arthrodesis procedures may partially substitute for the lost function. There should be no fixed flexion contractures of the joints affected by the transfers. The principle of "one muscle and one function" should apply to each tendon transfer. The insertion site of the tendon transfer determines which joints are affected by the transfer. Dissect free of fascia the brachioradialis tendon and its muscle 7 to 10 cm proximal to the musculotendinous junction. Sew a tendon graft, using one slip of the abductor pollicis longus tendon, in a three-pass Pulvertaft fashion into the abductor pollicis brevis tendon. The tendon is lengthened with a palmaris longus graft via a three-pass Pulvertaft method. Tendon graft taken from a slip of the abductor pollicis longus is sewn into the insertion of the abductor pollicis brevis tendon. The tendon is shown through the palmar incision before being passed dorsally through the third web space. Abductor pollicis longus tendon graft passed dorsally through the third web space. With the wrist in neutral and no tension on the graft, the thumb should fully extend. With the wrist in neutral and moderate tension on the tendon, the thumb strongly adducts to the index finger. Set tension to allow the thumb to rest palmar to the index finger when the wrist is in neutral. Take care to weave the tendons proximally enough on the hand such that the weave does not enter the third web space. Split Flexor Pollicis Longus to Extensor Pollicis Longus Tenodesis Make an incision along the radial proximal phalanx of the thumb. Make a transverse midpalm incision, retrieve the tendon, and split it into four tails.
The cut exits superiorly 2 to 3 mm medial to the cuff reflection and inferiorly through the native head acne marks discount roaccutan amex. This will leave a small portion of the native head in place acne on arms buy on line roaccutan, even after the inferior osteophyte is removed skin care knowledge cheap roaccutan 10 mg without prescription. The cut exits inferiorly at the native articular margin and superiorly through the native head. The size of the humeral head is estimated by placing trial humeral heads on the cut surface of the osteotomy. After removal of all osteophytes, the location of the anatomic neck is marked with an electrocautery. The humerus is cut in native retroversion, leaving 2 to 3 mm of bone medial to the supraspinatus insertion. With the humeral head resected, a Fukuda ring retractor is placed within the joint and the humerus is retracted posteriorly. A reverse, double-pronged Bankart retractor is placed on the scapular neck anteriorly, between the anterior capsule and the subscapularis. A blunt Hohmann retractor is placed along the anteroinferior portion of the scapular neck to retract and protect the axillary nerve, and the anterior and inferior capsule is excised. The labrum is excised circumferentially to expose the entire periphery of the glenoid. If greater than 25% posterior humeral subluxation was present preoperatively, care is taken to preserve the posterior capsular attachment to the glenoid. The previously estimated humeral head size may give some idea of the glenoid size. The center of the glenoid is marked and a centering drill hole for the glenoid reamer is drilled. The orientation of this drill hole should be perpendicular to the estimated reamed surface. A nonabsorbable suture is passed around the neck of the prosthesis and the prosthesis is impacted into the humerus with the two ends of the suture protruding anteriorly. Lesser Tuberosity Repair Humeral Preparation and Component Placement the humerus is redelivered into the wound and the humeral canal is reamed with sequentially larger reamers until light purchase is obtained within the intramedullary canal. A box osteotome that corresponds to the final reamer size is passed into the humerus to cut the footprint of the humeral implant. A broach that corresponds to the size of the box osteotome and final canal reamer is placed to the appropriate depth.
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The association of concomitant radial head fractures and ligamentous injuries with capitellar fractures is high acne 2015 purchase on line roaccutan. We do not advocate nonoperative management for any other type of capitellum fracture acne natural remedies generic 30 mg roaccutan with visa. Closed reduction techniques acne 39 weeks pregnant purchase roaccutan 40mg on line, which have been described in the literature, should be performed with caution, and only complete anatomic reduction should be accepted. Lateral radiographs are best for obtaining an initial evaluation of capitellar fractures. Anteroposterior views do not reliably show the fracture, because the outline of the distal humerus is not consistently affected. This view is a lateral oblique projection taken with the x-ray beam pointing 45 degrees dorsoventrally, thereby eliminating the ulno- and radiohumeral articulation shadows. Type 2 fractures are more difficult to diagnose, depending on the amount of subchondral bone accompanying the articular fragment. Capitellar fractures are uncommon, and the wide array of treatment options presented in the literature is based on relatively small series. In elderly patients, we do consider total elbow arthroplasty for complex intra-articular distal humerus fractures. Characteristic "double arc" sign on lateral radiographs of coronal shear fractures. Fractures preferably should be approached within 2 weeks, before osseous healing sets in, but after swelling has gone down. An image intensifier should be used during surgery to confirm reduction of the fracture and proper positioning of implanted hardware. Approach Either a lateral or posterior midline incision should be used, depending on the nature of the fracture, followed by a lateral approach into the elbow joint. This can be exploited and used as the interval to expose the fracture, thereby avoiding the need to cause an additional soft tissue defect. The patient usually is positioned supine on the operating table, with a radiolucent hand table. Alternatively, a lateral or prone position can be considered, with the anterior surface of the elbow supported by a padded bolster to use the universal posterior approach. The common extensor origin is sharply raised off the lateral epicondyle and reflected anteriorly to expose the lateral elbow joint. Care must be taken to avoid damage to the radial nerve traveling between the brachialis and brachioradialis. Often the lateral ligamentous complex will be avulsed from the distal aspect of the humerus, with or without some aspect of the lateral epicondyle. This ligamentous violation can be exploited to improve exposure by hinging open the joint on the medial collateral ligament with a varus stress. The capitellar fracture usually is displaced proximally and rotated and has no soft tissue attachments. Reduction and Fixation the fragment is reduced under direct visualization, held with reduction tenaculums, and provisionally fixed with 0. Cancellous screws are best for fracture fragments with a large subchondral component, as in type 1 fracture fragments. Excision of fracture fragments is recommended in type 2 fractures with small, thin articular pieces and type 3 comminuted fractures where the fragments are not amenable to internal fixation.
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