Dominic Power

Four corner fusion using a multidirectional angular stable locking plate.

AIM To review the results of our experience with the Medartis Aptus plating system for four corner arthrodesis of the wrist, which uses a combination of compression screws and variable angle locking screws. METHODS We reviewed the results of 17 procedures in 16 patients that underwent scaphoid excision and four corner fusion using the Medartis Aptus system between May 2010 and June 2014. The primary outcome measure was radiographic and clinical union. RESULTS The mean clinical follow up time was 20.6 mo. The mean union time was 6 mo. Two non-unions required revision procedures. The mean disabilities of the arm, shoulder and hand score taken after union was 36. The mean final grip strength was 27 kg. The mean final range of movement was 30° flexion and 31° of extension. All patients had a restored scapholunate angle on postoperative radiographs. There were no incidences of dorsal impingement. CONCLUSION Overall our experience with the Aptus plating system shows comparable results to other methods of fixation for four corner fusion, in the short to medium term.

Perilunate dislocation in an asymptomatic SNAC wrist: an uncommon presentation requiring a scaphoidectomy and four corner fusion

This report describes a 53-year-old man who presented, following a motocross injury, with a Mayfield stage 1 perilunate dislocation through a pre-existing asymptomatic scaphoid non-union with a degenerative midcarpal joint. A salvage reconstruction with scaphoid excision and four corner midcarpal arthrodesis resulted in a satisfactory outcome. Follow-up at 6 years demonstrated no instability and no further progression of the osteoarthritis.

Distal radius fractures – A volar plate is not just a volar plate

Introduction Increasingly complex distal radius plate designs are available for treating distal radius fractures. As a result, many fractures are being ‘over-treated’ with more complex volar plate designs than necessary. We hypothesise that significant cost savings could be made by rationalising the use of complex locking plate designs. Methods Over a two-year period, radiographs of 250 consecutive distal radius fractures fixed with volar locking plates were reviewed and the type of plate, and type and number of screws used for fixation were noted. Preoperative radiographs were independently reviewed to ascertain if it would have been possible to stabilise the fracture with a simpler, extra-articular plate design. Potential cost savings were then calculated. Results It was deemed that 89 (36.5%) of the 250 cases originally treated with a more complex 2 column variable angle plate could have been treated with an extra-articular construct, leading to potential savings of £19,224. Conclusion It is clear from our data that many distal radius fracture patterns are being ‘over-treated’ with complex locking plate designs with multiple rows of screws and that substantial cost savings could be made by selecting an appropriate construct to suit the fracture pattern.

Salvage of cervical motor radiculopathy using peripheral nerve transfer reconstruction

Abstract Purpose: Motor nerve transfer surgery involves re-innervation of important distal muscles using either an expendable motor branch or a fascicle from an adjacent functioning nerve. This technique is established as part of the reconstructive algorithm for traumatic brachial plexus injuries. The reproducible outcomes of motor nerve transfer surgery have resulted in exploration of the application of this technique to other paralysing conditions. The objective of this study is to report feasibility and increase awareness about nerve transfer as a method of improving upper limb function in patients with cervical motor radiculopathy of different aetiology. Results: In this case series we report 3 cases with different modes of injury to the spinal nerve roots with significant and residual motor radiculopathy that have been successfully treated with nerve transfer surgery with good functional outcomes. The cases involved iatrogenic nerve root injury, tumour related root compression and degenerative root compression. Conclusion: Nerve transfer surgery may offer reliable reconstruction for paralysis when there has been no recovery following a period of conservative management. However the optimum timing of nerve transfer intervention is not yet identified for patients with motor radiculopathy.

Distal radius volar rim plate: Technical and radiographic considerations

AIM To determine technical considerations and radiographic outcomes of the Synthes volar rim distal radius plate to treat complex intra-articular fractures. METHODS This review highlights technical considerations learnt using this implant since it was introduced in a major trauma unit in November 2011, including anatomical reduction and whether this was maintained radiographically. RESULTS Twenty-six of the 382 internally fixed distal radial fractures at our unit (6.8%) were deemed to require this plate in order to achieve optimal fracture fixation between November 2011 and May 2014. A further dorsal and/or radial plate was necessary in 35% and variable angle screws were used in 54% of cases. Post-operatively, mean radial height, inclination, volar tilt and ulnar variance restored were 11.7 mm, 21º, 4.3º and -1.2 mm respectively. There were no cases of non-union or flexor/extensor tendon rupture; one case of loss of fracture reduction. Overall incidence of plate removal was 15% with one plate removed for flexor and one for extensor tendon irritation CONCLUSION The use of a rim plate enables control of challenging far distal fracture patterns. However, additional plates were required to improve and maintain reduction. Variable angle screws were necessary in half the cases to avoid intra-articular screw penetration. If used judiciously, this implant can achieve stable fixation despite the complexity of the fracture pattern.

A review of 10 years of scapula injuries sustained by UK military personnel on operations

Background Scapula fractures are relatively uncommon injuries, mostly occurring due to the effects of high-energy trauma. Rates of scapula fractures are unknown in the military setting. The aim of this study is to analyse the incidence, aetiology, associated injuries, treatment and complications of these fractures occurring in deployed military personnel. Methods All UK military personnel returning with upper limb injuries from Afghanistan and Iraq were retrospectively reviewed using the Royal Centre for Defence Medicine database and case notes (2004–2014). Results Forty-four scapula fractures out of 572 upper limb fractures (7.7%) were sustained over 10 years. Blast and gunshot wounds (GSW) were leading causative factors in 85%. Over half were open fractures (54%), with open blast fractures often having significant bone and soft tissue loss requiring extensive reconstruction. Multiple injuries were noted including lung, head, vascular and nerve injuries. Injury Severity Scores (ISS) were significantly higher than the average upper limb injury without a scapula fracture (p<0.0001). Brachial plexus injuries occurred in 17%. While military personnel with GSW have a favourable chance of nerve recovery, 75% of brachial plexus injuries that are associated with blast have poorer outcomes. Fixation occurred with either glenoid fractures or floating shoulders (10%); these were as a result of high velocity GSW or mounted blast ejections. There were no cases of deep soft tissue infection or osteomyelitis and all scapula fractures united. Conclusion Scapula fractures have a 20 times higher incidence in military personnel compared with the civilian population, occurring predominantly as a result of blast and GSW, and a higher than average ISS. These fractures are often associated with multiple injuries, including brachial plexus injuries, where those sustained from blast have less favourable outcome. High rates of union following fixation and low rates of infection are expected despite significant contamination and soft tissue loss.

Functional Outcome of Fixation of Complex Intra-articular Distal Radius Fractures with a Variable-Angle Distal Radius Volar Rim Plate

Aim To evaluate the outcome of these complex fractures using a volar approach and the DePuy Synthes variable-angle 2.4-mm distal radius rim plate. This plate is precontoured to the volar rim for placement distal to the watershed line allowing purchase of the rim fragment of the lunate facet. Its low profile and smooth edges are designed to minimize flexor tendon irritation. Method We report on a consecutive series of far distal AO-23B3 and AO-23C3 fractures treated using this plate in a tertiary hand center between November 2011 and May 2014. Range of motion, grip strength, and complications were assessed at the final clinical review. Disabilities of the arm, shoulder, and hand (DASH) and patient evaluation measure (PEM) scores were assessed at 12 months after surgery. Results Twenty-six patients were included in this review. Six patients were lost to follow-up at 3 months. This plate was used in isolation in 17 cases, and in combination with a dorsal plate, in cases of dorsal instability after volar plating, in 10 patients. DASH and PEM scores 1 year after surgery were 17.6 and 27%, respectively. Visual analog scores for patient treatment satisfaction and severity of pain showed good satisfaction with treatment and mild intermittent pain on activity. Postoperative range of motion was variable and grip strength was of 71% of the uninjured contralateral side. There were no cases of flexor or extensor tendon rupture. Tendon irritation was noted in two patients. Removal of metal was performed in four patients. Loss of reduction occurred in one case and neurologic complications in two cases. Conclusion This implant is specifically designed for the management of far distal complex intra-articular fractures of the distal radius. Despite the complexity of these fracture patterns and the challenge they pose to accurate reduction and stable fixation, outcomes were satisfactory in this small series. There were no cases of tendon rupture. Removal of metal is not necessary in all cases, but prompt removal should be performed in cases of tendon irritation in view of the risk of tendon rupture.

Psychological consequences of traumatic upper limb peripheral nerve injury: A systematic review:

Introduction Traumatic upper limb peripheral nerve injuries significantly impact individuals’ function and ability to return to work. Patients with peripheral nerve injury experience ongoing psychological impairments for which they are not routinely treated. The aim of this review was to investigate the psychological consequences of traumatic upper limb peripheral nerve injury. Methods A systematic review of MEDLINE, Embase, PsycINFO, CINAHL, AMED, BNI, the Cochrane libraries and grey literature up to October 2015 was undertaken. Two reviewers independently assessed methodological quality in accordance with Cochrane Collaboration recommendations. Eligibility criteria comprised: adults or adolescents with traumatic upper limb peripheral nerve injury using any measurement of psychological well-being. Results Six studies (n = 245) met the inclusion criteria. Methodological quality varied widely. Evidence of post-traumatic stress disorder at one month, which decreased over time, was reported in three studies. Two studies found a statistically significant correlation between the early presence of post-traumatic stress disorder and reduction in function at 12 or more months. Limited information was available on anxiety, depression and mental quality of life. Combined nerve injuries (in two studies) had significantly higher levels of post-traumatic stress disorder, at one month, compared to those with an isolated nerve injury. Conclusion There is some evidence of early post-traumatic stress disorder following traumatic upper limb peripheral nerve injury, which may have an impact on functional outcome. However, high-quality studies using prospective cohorts are required to further evaluate the psychological aspects associated with this traumatic injury.

Adipofascial radial artery perforator flap interposition to treat post-traumatic radioulnar synostosis in a patient with head injury

We report this 47-year-old man who presented with polytrauma following a fall from a roof in March 2011. He sustained a head injury and a complex, comminuted forearm fracture. He underwent an open reduction and internal fixation of the fracture at the time of injury, but later developed a rigid type 2 diaphyseal radioulnar synostosis, with loss of forearm rotation. Synostosis excision and a radial artery perforator-based adipofascial interposition flap to prevent recurrence has resulted in a good functional outcome and no recurrence at 2.5 years follow-up.

Acute scaphoidectomy and four-corner fusion for the surgical treatment of trans-scaphoid perilunate fracture dislocation with pre-existing scaphoid non-union

This paper presents a rare case of trans-scaphoid perilunate fracture dislocation with concurrent scaphoid non-union of the left wrist following a motorcycle accident. Emergent CT identified scaphoid non-union advanced collapse and an acute scaphoidectomy, four-corner fusion, denervation and radiocarpal ligament repair was performed.