Herpetic whitlow occurs from the herpes simplex virus. It is
a self-limited disease, and it often involves the tip of the fingers. It occurs
due to contact with oral or tracheal secretions and from self-inoculation.
Herpetic whitlow is seen in dentists, respiratory therapists,
anesthesiologists, and toddlers (children who suck their thumb). The symptoms
of herpetic whitlow include, burning, inflammation, and a clear fluid (not
purulent). Vesicles on the finger which can be grouped together with inflammation
and redness at the base. The gram stain will usually be negative. Diagnosis can
be done with the Tzanck test. Giant cells can be seen. Treatment is acyclovir,
no surgery. Surgery can make the situation worse.
Galeazzi fracture is a fracture of the distal 1/3 of the
radius with disruption of the distal radioulnar joint (DRUJ). The fracture is
always located above the proximal border of the pronator quadratus. The
pronator quadratus rotates the distal fragment towards the ulna and pulls it
proximally. We usually fix the fractured radius, and we then evaluate DRUF for
instability after we fix the distal radius. If you have instability, make sure
that the joint is reduced, then you will do percutaneous fixation of that
joint. If you don’t have instability, you will do nothing or maybe give a long
arm splint in supination if you think the patient needs the splint.
Basically,
you will need intraoperative evaluation of the DRUJ. Not all distal radial
fractures will be associated with distal radioulnar joint instability. They
found that if the radius fracture is less than 7.5 cm from the join, then the
distal radioulnar joint can be unstable. If the fracture radius is more than
7.5cm from the joint, then the distal radioulnar joint will be rarely unstable.
So the closer the fracture of the radius is to the joint, the more likely that
the distal radioulnar joint is involved, and we need to work diligently to find
the problem and address it. The problem can be instability of the DRUJ. You may
find an ulnar styloid fracture or you find that the radius is short (about 5 mm
or more). In the AP view of the wrist, you may find widening of the joint or in
the lateral view, you find that the ulna goes dorsally or volarly. The distal
radioulnar joint has ligaments, volar and dorsal, that stabilize the joint, and
that joint is usually stable in supination. Sometimes in old, complicated or
difficult cases, you can’t really evaluate the distal radioulnar joint without
getting a CT scan of both wrists (make sure that you position the wrist in the
same position. Anatomic reduction and fixation of the radius with a volar
plate. Then you assess the stability of the distal radioulnar joint. If the
distal radial ulnar joint remains unstable, supination of the wrist may reduce
that joint. If not, either a closed reduction or open reduction with pinning of
the joint is done. If after anatomic restoration and plate fixation of the
radius, the distal radioulnar joint remains irreducible, then the structure
that is most likely obstructing the reduction is the extensor carpi ulnaris. It
is imperative to recognize the problem of Galeazzi fracture, which is the
distal radioulnar joint injury. The treatment of the problem acutely is better
than late reconstruction. When you fix the radius, make sure that the radial
bow is restored. The reduction of the joint is done by supination of the
forearm, and you do immobilization in supination if the distal radioulnar joint
is stable following open reduction of the distal radius. So there is an obvious
injury that you will see, and you will test that injury and see if the joint is
stable in supination. If it is, keep the forearm in supination. You will do pin
fixation if the joint is reducible, but is unstable. The pin fixation will be
done by cross pinning from the ulna to the radius and leave the pins for about
4 weeks. You can do open reduction of the joint if the joint is not reduced and
something is blocking the reduction, such as the extensor carpi ulnaris tendon.
If there is a large ulnar styloid process fracture, you probably need to open
that fracture after you fix the radius, and then do open reduction and internal
fixation of the large ulnar styloid fragment and immobilize the forearm in
supination. It might be difficult to evaluate the stability of the distal
radial ulnar joint. In general, the DRUJ is stable in most cases after anatomic
reconstruction of the radius.
Mycobacterium marinum is the most common atypical
mycobacterium that can cause infection in humans. It is found in salt and fresh
water. It is an acid-fast bacilli. The wrist and the hand are affected in about
50% of the cases. It may cause skin and soft tissue infections after skin
abrasion. The patients are exposed to aquatic environments such as aquariums
and swimming pools. The disease often occurs following the cleaning of fish
tanks. The bacilli enter the body through scratches and abrasions, causing
lesions in the tissue. The diagnosis is usually delayed because the condition
is rare, and the history of aquatic exposure is usually not obtained. The hand
and wrist are commonly involved. There will be painful swelling of the hand.
Subcutaneous granules, masses, nodules, ulcers, and noncaseating granulomas are
present. It may present as chronic tenosynovitis of the hand. It affects the
extensors more than the flexors. It can cause a TB like disease in fish. The
chronic skin lesion is sometimes called a “swimming pool granuloma” or “fish
tank granuloma” in humans. The bacteria grows in a low temperature culture at
30o centigrade. The bacteria grows on Lowenstein-Jensen medium. It
requires lower temperature and a longer period of the incubation (up to 6 weeks
or more). It can be treated with oral antibiotics antimicrobial therapy.
Ethambutol and Rifampin if diagnosed early. Minocycline and Clarithromycin has
been described. Surgery is done in late stages and in deep infection. Surgery
entails synovectomy and debridement in addition to oral antibiotics for
approximately 3 months. Mycobacterium avium-intracellulare occurs in terminal
AIDS patients, or it also can occur in a non HIV patient.
Monteggia fracture is a fracture of the proximal ulna and
radial head subluxation. It is imperative that you restore the length and the
proper alignment of the ulna so that the radial head can be reduced. If we
malalign the ulna, then the radial head will remain subluxed. There are some
cases where the fracture of the ulna is so comminuted that we will be unable to
restore the length of the ulna. We will not even know if we restored the length
of the ulna.
There is a technique that I use in the reconstruction of the ulna
in cases where the ulna is too comminuted. I will open the fracture ulna, and I
will approach the radial head. I will reduce the radial head to the capitellum
and reduce the ulna to the radius and make sure that the proximal radioulnar
joint is anatomic. Once that joint is anatomic, I will pin it with either one
or two K wires. I transfix the ulna to the radial head. We know that the radial
head is reduced, now the ulna will be reduced because the radioulnar joint is
reduced. We are temporarily transfixing the ulna to the radial head, and that
will help to restore the proper length of the ulna. Once the proper length of
the ulna is defined, then reconstruction of the ulna is simplified utilizing a
dorsal ulnar plate. Next, the K wires are removed and the radioulnar joint is
tested for stability. Occasionally, the K wires may be left in place for a few
weeks if needed to provide additional stability, then removed later on.
Monteggia fracture is not a simple fracture. It is a
fracture of the proximal ulna with dislocation of the radial head. Monteggia
fracture can happen in children and in adults. It is one of the most common
injuries that is missed in the emergency room in children. The radial head may
be dislocated or subluxed, and this problem may not be clear on x-rays. If this
injury is missed, then the child will probably need a big surgery to deal with
this big problem. Treatment of this fracture depends on the age of the patient.
In general, in pediatric patients, you will do closed reduction of the ulna and
closed reduction of the radial head. In adult patients, you will do open
reduction with internal fixation of the ulna with dorsal plate and closed
reduction of the radial head. A line drawn from the proximal radius should
bisect the capitellum in all x-ray views. If you are in doubt and not sure, get
x-rays of the other side and compare. Always examine the patient for posterior
interosseous nerve injury.
The most common type is anterior Monteggia. That
means that the apex of the fracture is anteriorly and the radial head goes
anteriorly. Just make it a practice, when you have a fracture of the proximal
ulna, look at the radius and the radial head, and see the position of the
radial head in relationship to the capitellum. Anterior Monteggia is more
common in children. Posterior Monteggia constitutes 70-80% of Monteggia
fractures in adults. There are four types of Monteggia: Type I, Type II, Type
III, and Type IV. Monteggia fracture is classified according to the direction
of displacement of the radial head. The radial head has two relations: relation
with the capitellum and relation with the proximal radioulnar joint. When the
radial head subluxes or dislocates, it subluxes or dislocates from these two
joints. The radial head becomes free. This means that the radius is not
connected to the capitellum or to the superior radioulnar joint. A Type I
fracture is of the middle or the proximal third of the ulna with anterior
dislocation of the radial head, and it has the characteristic that the apex of
the ulnar fracture is anteriorly. Type I fracture is the most common of all
types (especially in children). Type I occurs in about 60% of fractures. In
children, reduce the fractured ulna and reduce the dislocation of the radial
head and immobilize the elbow in flexion and supination. When you flex the
elbow, especially more than 90 degrees, you will relax the biceps (watch the
circulation). A Type II fracture is a posterior type fracture. Posterior
Monteggia is the most common type in adults. It is associated with a higher
complication rate and carries the worst prognosis. 15% of Monteggia fractures
are Type II. It is a fracture of the middle or proximal third of the ulna with
posterior dislocation of the radial head. You should immobilize the elbow in
extension. Type III is a lateral Monteggia. About 20% of Monteggia fractures
are Type III. It is a fracture of the proximal ulna with lateral dislocation of
the radial head. 5% of Monteggia fractures are Type IV; it is very rare. It is
a fracture of the proximal ulna with anterior dislocation of the radial head
and fracture of the proximal third of the radius below the bicipital
tuberosity. The patient will need surgery, even in children. In this case, the
radial head is dislocated, and you also have fractures of the radius and the
ulna. The posterior interosseous nerve is adjacent to the radial neck, placing it
at risk for a traction injury with dislocation of the proximal radius.
You
should do a neurovascular examination. A nerve injury which involves the
posterior interosseous nerve is not uncommon. Ask the patient to “hitchhike”
and extend their fingers. Make sure the wrist is in dorsiflexion when you ask
the patient to extend the fingers. In posterior interosseous nerve injury, the
finger extensors will not be working. If the posterior interosseous nerve is
injured, observe the patient. In case of posterior interosseous nerve injury in
Monteggia fracture, you will reduce and stabilize the fracture and reduce the
radial head dislocation. Observe the nerve; do not explore the nerve. Typically
the nerve injury is a neuropraxia. It can be expected to resolve itself with
observation in 6-12 weeks. If it does not resolve, you will do EMG and nerve
studies after that period of observation. Any time that you have an ulnar shaft
fracture or any fracture of the proximal ulna, check the radial head position.
Make sure that the radial head is reduced to the capitellum (be aware that the
subluxation may be subtle). Recognition of Monteggia fracture in children is
important. Early appropriate treatment is much easier than treating a missed
radial head dislocation. To treat a Monteggia fracture in adult patients, do
open reduction internal fixation (ORIF) of the ulna. When the ulna is properly
aligned and fixed, the radial head will reduce by itself. After fixation of the
ulnar fracture, if the radial head is still not reduced, then assess the ulnar
reduction. Check for malalignment or malreduction of the ulna. It is imperative
that you restore the length and the proper alignment of the ulna, so that the
radial head can be reduced. If we malalign the ulna, then the radial head will
remain subluxed. Radial head instability may be caused by nonanatomic reduction
of the ulna or by interposition of the annular ligament. Fracture of the ulna
may be too comminuted, and it may not be reduced properly. The fracture may
also need bone graft later on for healing. A Monteggia variant associated with
radial head fracture, in addition to dislocation of the radial head fracture,
in addition to dislocation of the radial head and fracture of the ulna can be a
problem. The radial head fracture is usually fixed or replaced, a prosthesis is
used to replace the radial head in the elderly, especially if the fracture is
comminuted. The subluxation of the radial head is reduced, and the fractured
ulna is fixed as usual. Treatment is different in pediatric patients. The
radial head ossifies around four years of age. In Type I, Type II, and in Type
III Monteggia fractures, you will do closed reduction of the ulna to restore
the length of the ulna, and you will do closed reduction of the radial head.
Closed reduction is much more successful in young children. In anterior
Monteggia, you will immobilize the elbow in flexion and supination. In
posterior Monteggia, you will immobilize the elbow in extension. Ulnar fixation
with a rod or a plate is needed in older patients with unstable fractures. Type
IV fractures require surgery. Surgery is also done in cases where we are unable
to restore the proper length of the ulna, we are unable to reduce the ulna, and
we are unable to reduce the radial head. In this situation, we can use IM rod
or a plate. Dislocation of the radial head with fracture of both the radius and
ulnar shaft. Do closed reduction of the radial head with intramedullary pin
fixation of the radius and the ulnar shaft fractures. The radius and ulnar
shaft fractures are stabilized surgically to give a lever arm for reduction of
the radial head. In this type of fracture, the radial head subluxation may be
missed or unappreciated, because the focus is usually on the forearm fractures.
To treat a missed or neglected Monteggia fracture in children, do osteotomy of the
ulna and lengthening with correction of the angulation, and reduction of the
radial head in addition to plating of the ulna. The patient may need open
reduction of the radial head.
