The Journal of hand surgery
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Randomized Controlled Trial Clinical Trial
Identification of low-effort patients through dynamometry.
In recent years researchers have devised a number of methods to detect patients who purposely exert low effort during grip evaluations. This study further defines the five-rung grip test introduced by Stokes and subsequently challenged by Niebuhr and Marion. New data are presented on the rapid exchange grip test. ⋯ No statistical difference between peak scores on five-rung and rapid exchange grip tests in sincere subjects was found. A statistical difference between peak scores in the low-effort groups was shown. A model has been developed that can be used to categorize patients into low effort or sincere groups.
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A biomechanical cadaver study was performed to determine the roles of the stabilizing structures of the distal radioulnar joint during pronation and supination. Subluxation and dislocation of the radius with respect to the ulna were evaluated in seven cadaver forearms placed in supination, pronation, and neutral forearm rotation. The amount of subluxation was measured with all structures intact, and after sectioning in various sequences the dorsal and palmar radioulnar ligaments, the distal portion of the interosseous membrane including the pronator quadratus, and the entire interosseous membrane. ⋯ When the interosseous membrane was disrupted first, the dorsal radioulnar ligament was found to be more important than the palmar radioulnar ligament in stabilizing the distal radioulnar joint in pronation, and conversely the palmar radioulnar ligament was more important than the dorsal radioulnar ligament in supination. Dislocation, and frequently diastasis, occurred only with sectioning of all four structures. This suggests that all four structures contribute to stability of the distal radioulnar joint.
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Comparative Study
Treatment of trigger finger in patients with diabetes mellitus.
We present a retrospective study of 54 diabetic patients with 121 trigger digits treated over a 3-year period by one to three injections of corticosteroid mixed with local anesthetic. As a group, diabetic patients responded less favorably to treatment by steroid injection (50% symptom resolution) when compared to reported outcomes of steroid injection treatment for stenosing tenosynovitis in the general population. Insulin-dependent diabetic patients have a higher incidence of multiple digit involvement (59% of patients) and of requiring surgical release for relief of symptoms (56% of digits) when compared to non-insulin-dependent diabetic patients (28% of patients with multiple digit involvement; 28% of digits requiring surgery).
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A retrospective review of 25 consecutive patients with 28 proximal phalangeal fractures was performed. Fractures of the thumb were excluded. Twenty-five fractures were closed and three were open. ⋯ One fracture showed appreciable malrotation of 10 degrees. Flexible intramedullary rodding of specific proximal phalangeal fractures provides excellent results with a low complication rate. Proper selection of fractures and good surgical technique are necessary to avoid complications.
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Between 1989 and 1991, 137 nonunions of the scaphoid were treated by the senior author, who noted that 26 of these nonunions had an avascular proximal pole (no punctate bleeding from the bone at the time of surgery). All 26 nonunions were treated with iliac crest bone grafting and Herbert screw fixation. Of these 26 patients, 17 were followed for more than 1 year after their surgery (average follow-up period, 31 months). ⋯ No patient has required either a proximal row carpectomy or wrist arthrodesis. Previously published results of avascular proximal pole scaphoid nonunions suggest that union cannot be obtained and functional results are uniformly poor. In contrast, the functional and x-ray results of our patients are markedly improved over these previous studies--emphasizing the importance of iliac crest bone grafting, rigid internal fixation, and appropriate postoperative immobilization.