Diego L. Fernandez

Fractures of the distal radius

Fractures of the distal radius , Fractures of the distal radius , کتابخانه دیجیتال جندی شاپور اهواز

Treatment of displaced articular fractures of the radius

Forty patients with articular fractures of the distal radius in which anatomic reduction of the joint surface could not be obtained by closed manipulation or by ligamentotaxis with external fixators had a combination of percutaneous and/or open reduction techniques to restore articular congruity. X-ray films taken after treatment with an average follow-up of 4 years showed satisfactory extraarticular alignment in 85% of the cases, and 37 (92.5%) patients demonstrated an articular step-off of 1 mm or less at late follow-up examination. Radiographic evidence of radiocarpal arthritis was present in 5% of the cases at follow-up examination.

A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability

This article presents a brief description of the following modifications of the original Fisk procedure for navicular nonunions with carpal instability: (1) preoperative calculation of exact scaphoid length and form based on comparative roentgenograms of the opposite wrist, (2) the use of a palmar approach, (3) the insertion of a wedge-shaped corticocancellous graft from the iliac crest after resection of the pseudarthrosis, and (4) the use of internal fixation. Preoperative planning is considered essential to restore the anatomic length, analyze the angular deformity, evaluate the pathologic scapholunate angle, and calculate the resection and size of the graft needed. The palmar approach reduces the danger of iatrogenic damage of the vascular supply of the scaphoid and accidental lesions of the superficial branches of the radial nerve. Furthermore it provides a better exposure of the scapholunate joint to correct lunate rotation. Iliac bone is preferred to the radial styloid graft, as proposed by Fisk, because of its better ability to resist compression forces. Internal fixation adds rotational stability so that continued postoperative plaster immobilization can be reduced to a minimum of 8 weeks.

Distal radioulnar joint injuries associated with fractures of the distal radius.

The most common cause of residual wrist disability after fractures of the distal radius is the distal radioulnar joint. The 3 basic conditions that produce radioulnar pain and limitation of forearm rotation are instability, joint incongruency, and ulnocarpal abutment. The last 2 entities initiate irreversible cartilage damage that eventually leads to degenerative joint disease. Early recognition and management in the acute stage aim at the anatomic reconstruction of the distal radioulnar joint including bone, joint surfaces, and ligaments in an effort to reduce the incidence of painful sequelae and functional deficit. This article provides a description and the treatment options of the distal radioulnar joint lesions that occur in association with fractures of the distal radius, and the results obtained with open and arthroscopic techniques. Both acute and chronic disorders are analyzed, and a prognostic and treatment oriented classification is presented. Furthermore, the pathoanatomy and management of chronic distal radioulnar joint derangement after fracture of the distal radius are reviewed briefly.

Anterior bone grafting and conventional lag screw fixation to treat scaphoid nonunions

The results of 20 established nonunions of the scaphoid treated with resection of the pseudoarthrosis, anterior cortic-cancellous iliac bone grafting, and conventional lag screw fixation with the ASIF 2.7 mm cortical screw are presented. Union rate was 95% and the average time off work was 8.9 weeks. Review of the relevant literature uniformly shows that the most common reasons for failure are improper internal fixation techniques and/or the absence of bone grafting. Successful treatment of scaphoid nonunions with screw fixation and cast-free after-treatment does not depend on the implant used but rather on careful case selection and precise surgical technique.

Non-union of the Scaphoid. Revascularization of the Proximal Pole With Implantation of a Vascular Bundle and Bone-grafting

Eleven patients who had an ununited fracture of the scaphoid associated with loss of the blood supply to the proximal fragment were managed operatively with a combination of an inlay corticocancellous bone graft from the iliac crest and implantation of the second dorsal intermetacarpal artery, its accompanying venae comitantes, and a thin cuff of perivascular tissue. The absence of the blood supply to the proximal pole was evidenced both by radiographic changes--which included increased bone density, absence of normal trabeculae, and cystic changes--and by failure to observe bleeding bone during the operation. There were ten men and one woman. The average duration of non-union was fourteen months (range, six to thirty-three months). Six patients had had previous unsuccessful operative attempts to obtain union. Eight non-unions were in the proximal one-third and three, at the waist of the scaphoid. Union was achieved in ten patients at an average of ten weeks postoperatively. According to the wrist-scoring system of the Mayo Clinic, at an average of five years (range, 2.5 to eleven years), three patients had a grade of excellent; three, good; three, fair; and two, poor. Four patients had subsequent reconstructive procedures; radial styloidectomy, styloidectomy and resection of osteophytes, radioscapholunate arthrodesis, and total wrist arthrodesis were performed in one patient each.

The Extended Flexor Carpi Radialis Approach: A New Perspective for the Distal Radius Fracture

Volar fixation of dorsally unstable distal radius fractures is a new method of treatment that provides the benefits of stable internal fixation without the complications of the dorsal approach. A new, fixed-angle fixation device, the distal volar radius (DVR) plate, (Fig. 1) has been introduced for this purpose. Experience gained by applying this technique to clinically complex cases led us to the realization that more exposure, especially in a dorsal direction, was necessary than that provided by the traditional volar approaches. The need to reduce fractures with significant articular displacement (Fig. 2) and the need to release dorsal callus in inveterate fractures or nascent malunions led us to use an extended form of the flexor carpi radialis (FCR) approach. Volar displaced distal radius fractures are commonly managed with volar buttress plates through the FCR approach. This approach goes deep to the forearm fascia through the FCR tendon sheath and is continuous with the distal part of the Henry approach. The traditional FCR approach provides access to the volar aspect of the distal radius, the volar wrist capsule, and the scaphoid. In comparison with dorsal approaches, which present a high incidence of extensor tendon problems, the FCR approach is relatively free of complications. We extend the FCR approach by releasing the radial septum, by mobilizing the proximal radial fragment, and by using the fracture plane for exposure or what is known as intrafocal technique. Therefore, understanding the anatomy of the radial septum is important. On its proximal aspect, it is a simple fascial wall separating the flexor and extensor compartments of the forearm. At the level of the radial metaphysis, the radial septum is a complex fascial structure that includes the first extensor compartment and the insertion of the brachioradialis. More distally, the radial septum forms the radial insertion of the carpal ligament and ends as the FCR tendon sheath approaches the tuberosity of the scaphoid. The proximal radial fragment has a dependable endosteal blood supply that permits its subperiosteal release and subsequent mobilization. Pronating this fragment out of the way provides wide exposure of the fracture surfaces. This allows the volar reduction and fixation of even the most complex dorsally displaced distal radius fractures. Address correspondence and reprint requests to Dr. Jorge L. Orbay, Miami Hand Center, 8905 SW 87 Ave., Suite 100, Miami, Florida 33176; e-mail: MIAHANDS@ix.netcom.com Techniques in Hand and Upper Extremity Surgery 5(4):204–211, 2001

Loss Of Fixation Of The Volar Lunate Facet Fragment In Fractures Of The Distal Part Of The Radius

BACKGROUND The purpose of the present study is to report on a cohort of patients with a volar shearing fracture of the distal end of the radius in whom the unique anatomy of the distal cortical rim of the radius led to failure of support of a volar ulnar lunate facet fracture fragment. METHODS Seven patients with a volar shearing fracture of the distal part of the radius who lost fixation of a volar lunate facet fragment with subsequent carpal displacement after open reduction and internal fixation were evaluated at an average of twenty-four months after surgery. One fracture was classified as B3.2 and six were classified as B3.3 according to the AO comprehensive classification system. All seven fractures initially were deemed to have an adequate reduction and internal fixation. Four patients required repeat open reduction and internal fixation, and one underwent a radiocarpal arthrodesis. At the time of the final follow-up, all patients were assessed with regard to their self-reported level of functioning and with use of Sarmientos modification of the system of Gartland and Werley. RESULTS At a mean of two years after the injury, six patients had returned to their previous level of function. The result was considered to be excellent for one patient, good for four, and fair for two. The average wrist extension was 48 degrees, or 75% of that of the uninjured extremity. The average wrist flexion was 37 degrees, or 64% of that of the uninjured extremity. The one patient who underwent radiocarpal arthrodesis had achievement of a solid union. The four patients who underwent repeat internal fixation had maintenance of reduction of the lunate facet fragment. The two patients who declined additional operative intervention had persistent dislocation of the carpus with the volar lunate facet fragment. CONCLUSIONS The stability of comminuted fractures of the distal part of the radius with volar fragmentation is determined not only by the reduction of the major fragments but also by the reduction of the small volar lunate fragment. The unique anatomy of this region may prevent standard fixation devices for distal radial fractures from supporting the entire volar surface effectively. It is preferable to recognize the complexity of the injury prior to the initial surgical intervention and to plan accordingly.

Comparative classification for fractures of the distal end of the radius

As suggested by Muller, a useful classification system for distal radius fractures must consider the severity of the bone lesion and serve as a basis for treatment and for evaluation of outcome. Although these fractures have long been considered to be Colles or Smiths fractures, they have been subjected to extensive scrutiny in order to define fracture morphology and treatment considerations. This review highlights a number of contemporary classification systems for distal radius fractures, including the systems of Older et al., the Comprehensive Classification of fractures, the Melone intra-articular classification system, and that of Fernandez.

Results of the modified Sauvé-Kapandji procedure in the treatment of chronic posttraumatic derangement of the distal radioulnar joint.

We reviewed the results of a modified Sauvé-Kapandji procedure with tenodesis of the flexor carpi ulnaris to the carpus in eighteen patients who had chronic derangement of the distal radioulnar joint. There were fourteen men and four women. The mean supination of the forearm had improved from 16 degrees (range, 0 to 75 degrees) preoperatively to 76 degrees (range, 40 to 90 degrees) at the time of the latest follow-up, and the mean pronation had improved from 42 degrees (range, 0 to 80 degrees) preoperatively to 81 degrees (range, 60 to 90 degrees) at the time of follow-up. Pain relief was satisfactory, and the mean grip strength had improved from 36 percent of that on the unaffected side preoperatively to 73 percent at the time of follow-up. One patient had moderate pain over the ulnar stump associated with residual volar instability of the proximal ulnar segment, and he had a tenodesis of the extensor carpi ulnaris as a second procedure. Another patient had mild instability of the stump only after he had a second operation, which was an excision of a bone mass (ossification) in the resected area. The ulnar stump was stable in sixteen patients. Eight of the eleven patients who had performed heavy manual labor before the injury were able to return to work full-time without restrictions. According to a modification of the wrist-scoring system of the Mayo Clinic, at a mean of four years and two months (range, two years to eight years and four months), six patients had an excellent result; seven, a good result; four, a fair result; and one, a poor result. On the basis of our findings, we believe that the index operation is an excellent salvage procedure for the treatment of chronic posttraumatic derangement of the distal radioulnar joint, especially when nonoperative treatment has been unsuccessful and rotation of the forearm is severely limited.