Dominique Della Santa

Complications of plate fixation in metacarpal fractures

BACKGROUND The objective of this study is to assess the complications after open reduction and plate fixation of extra-articular metacarpal fractures. METHODS We retrospectively reviewed the clinical and radiologic records of 129 consecutive patients with 157 metacarpal fractures treated by open reduction and internal fixation with plates between 1993 and 1999. Intra-articular fractures and fractures of the thumb metacarpal were excluded. Eighty-one patients (64 men and 17 women) with 104 fractures were available for review, at an average follow-up of 13.6 months (range, 6-27 months). RESULTS Twenty-eight patients (35%) and 33 fractures (32%) had one or more complications, including difficulty with fracture healing (12 patients [15%]), stiffness (eight patients [10%]), plate loosening or breakage (seven patients [8%]), complex regional pain syndrome (two patients), and one patient who developed a deep infection. CONCLUSION Despite technical advances in implant material, design, and instrumentation, plate fixation of metacarpal fractures remains fraught with complications and unsatisfactory results.

Screw Impingement on the Extensor Tendons in Distal Radius Fractures Treated by Volar Plating: Sonographic Appearance

OBJECTIVE The objective of our study was to analyze the sonography examinations of nine consecutive patients with a history of distal radius fracture treated by open reduction and internal fixation of the volar plate who were referred by hand surgeons for sonography of the dorsal aspect of the wrist. CONCLUSION We postulate that impingement of the extensor tendons in patients with distal radius fracture treated by volar plating starts with local hyperemia and is followed by tenosynovitis and, finally, by partial and complete tendon tears. Sonography is an effective, dynamic, and noninvasive technique with which to diagnose and evaluate damage to the extensor tendons and their synovial sheaths.

Sonography of Masses of the Wrist and Hand

OBJECTIVE The aim of this article is to present the sonographic appearance of the most common masses of the wrist and hand and to discuss the role of sonography in their diagnosis. CONCLUSION Sonography is a readily available imaging technique that can detect and assess masses of the wrist and hand. Together with standard radiography, sonography can be used as a first-line radiologic technique in this field.

Trans-trapezium carpo-metacarpal dislocation of the thumb

We report a case of carpo-metacarpal dislocation associated with an isolated horizontal fracture of the trapezium. It is a rare lesion which is difficult to diagnose by standard radiography, and CT may be necessary for the diagnosis and correct treatment. In our case, stable osteosynthesis was achieved by internal screw fixation, and at follow-up there was an unrestricted, painless range of motion of the thumb.

Bone-tendon ligamentoplasty for chronic ulnar instability of the thumb metacarpophalangeal joint: an anatomic reconstruction of the ulnar collateral ligament.

The metacarpophalangeal joint (MCP) of the thumb allows movement in two planes of motion: flexion/ extension and pronation/supination. In extension, the MCP joint is stabilized mainly by the palmar plate, from 15° onward by the collateral ligaments, with some degree of mediolateral shift with further flexion, until they are completely taut in full flexion. The ulnar collateral ligament (UCL) consists of two portions: the main portion of the UCL has its origin on the dorsal third of the metacarpal head and inserts distal and volar at the base of the proximal phalanx, whereas the smaller portion has its insertion in the palmar plate. The main portion of the UCL is taut in flexion, whereas the accessory portion is taut in extension. The UCL is essential to achieve a useful pinch grip. If the UCL is insufficient, contraction of the flexor pollicis longus muscle causes a lateral shift of the proximal phalanx instead of flexion. If one portion of the ligament is torn and the other is intact, flexion leads to thumb supination. In cases of chronic ulnar instability of the MCP joint, anatomic reconstruction of the UCL is the prerequisite for achieving stability while maintaining mobility. To gain these ends, we believe that both portions of the UCL should be reconstructed individually. HISTORICAL PERSPECTIVE

A comparison of diaphyseal and metaphyseal techniques of ulna shortening

The aim of this retrospective study was to compare two techniques of ulna shortening for ulnocarpal abutment. The technique performed initially was diaphyseal osteotomy. Subsequently, a metaphyseal osteotomy was performed to avoid the drawbacks related to the plate. The study group consisted of 29 patients: 13 with diaphyseal and 16 with metaphyseal osteotomies. The pre-operative diagnosis was ulnocarpal abutment in all cases. The results were graded according to the scoring system of Chun and Palmer and patients’ self-assessment. Both rankings were related to indications, age, gender, occupation, and surgery. Final follow-up occurred at a median of 54 (range 15–144) months after surgery. There was no delayed union or non-union, necrosis of the ulnar head, or infection. Pain relief was the main benefit. Both techniques gave similar outcomes for pain relief, satisfaction, and objective results. The shortening was significantly greater in the metaphyseal group without any apparent consequence on function or pain. No screw removal was needed after metaphyseal osteotomy; in contrast, plate removal was required in all patients. We conclude that both techniques are valuable alternatives for treating ulnocarpal abutment.

De l'utilité des substituts osseux : à propos de 101 fractures du radius distal

The aim of the present retrospective study was to evaluate the performance of bone graft substitutes currently in use. After exclusion of those with inadequate data for comparison, 70 out of the 101 operated fractures remained available for statistical analysis. Grafts were used in 38 cases: 23 were bone substitutes and 15 autogenous grafts. Distal radial inclination and lateral angles showed no significant difference. Analysis of ulnar variance showed the relative inability of intramedullary pinning to maintain radial length in the absence of graft. In contrast external fixators preserved radial length both with and without bone grafts, and with all types of graft material. TCH (hydroxyapatite and calcium phosphate) or autogenous bone grafts allowed intramedullary pinning to maintain radial length; whereas collagen matrix material was ineffective. We conclude that TCH and autogenous bone grafts have equivalent effectiveness despite potential bias in this study.

Proximal fractures of the fifth metacarpal: a retrospective analysis of 25 operated cases

The clinical and radiological outcomes of 25 surgically treated fractures of the proximal third of the fifth metacarpal were retrospectively analysed. Many different methods of osteosynthesis were used. At follow-up after a mean of 3.3 years, 15 of 25 patients had no pain. Most patients regained a nearly full range of motion in the adjacent joints and more than 90% of the contralateral grip strength. X-ray signs of degenerative arthritis in the metacarpohamate joint were observed in 10 of 25 patients. Pain was found to be directly correlated with the presence of degenerative changes.

Treatment of Fractures of the Fingers. What’s New?

These are questions that a hand surgeon should consider when faced with acute injuries such as finger fractures which represent about half of all hand trauma. In this editorial, I will comment upon four articles on hand fractures. Avulsion fractures from the base of the proximal phalanges of the fingers by Shewring and Thomas is a prospective study. It compares surgical fixation of these fractures with conservative treatment and highlights the advantages of the palmar approach over the dorsal one. The results are clear-cut, with 24 of 25 patients treated by primary internal fixation achieving a full range of movement within 10–24 days, and all fractures uniting within 3 months without any post-operative complications. On the contrary, eight patients treated by immobilization for 6 weeks had persistent pain and no signs of bone union. Seven of these eight subsequently had a successful outcome after secondary surgery. Only one patient who had declined surgery had persistent pain and a nonunion at 1 year follow-up. Zemel (1992) described three degrees of metacarpophalangeal joint ligament sprains, with the third degree being a complete tear with major instability for which surgical repair is indicated. An X-ray may or may not show an avulsed fragment from the base of the proximal phalanx. Zemel preferred a dorsal approach and reattached the ligament using a pull-out technique. Bone fragments, when present, were fixed by K-wires and the metacarpophalangeal joint was pinned in flexion for 3 weeks to prevent loss of finger flexion. Kuhn et al. (2001) used a palmar A1 pulley approach in ten patients with avulsion-fractures of the base of the proximal phalanx, which he stabilized with internal fixation. I congratulate Shewring and Thomas for achieving union in all cases and restoring full finger mobility and hand strength and wish that I could achieve such good results. I personally hesitate to operate upon such injuries because of the potential for post-operative loss of finger flexion. In my earliest cases, this probably occurred as I used the dorsal approach suggested by Hastings and Carroll (1988). More recently, I have used a palmar approach for my more recent cases and have obtained better functional results.

A case of Maffucci syndrome.

The Maffucci syndrome consists of a combination of multiple enchondromas and haemangiomas. It appears in the first two decades of life, with no family history. In this case we are reporting about a 26-year-old female who had suffered from multiple enchondromas since the age of two. At the age of nine, the patient presented with additional haemangiomas, which facilitated making proper diagnosis. She now presents with a massive lesion of her left upper extremity. The patient had initially rejected operative treatment when the disease was at early stages. At later stages, a more complex reconstruction of the hand would have been necessary to secure hand function. This procedure that sometimes induces a risk related to potential necessity of blood transfusion was rejected by the patient for religious reasons. Amputation of the extremity was therefore the last resort procedure.