Gerardo Gallucci

Evaluation of simplified Frykman and AO classifications of fractures of the distal radius. Assessment of interobserver and intraobserver agreement.

Summary. In order to evaluate interobserver and intraobserver agreement of the Frykman and AO classifications and their variations between assessors with different levels of experience, three hand specialists, a fellow and two senior residents classified radiographs of 200 fractures of the distal radius in anteroposterior and lateral views. Reproducibility was assessed by the use of the proportion of agreement and kappa coefficient between pairs of observers. The Frykman classification showed moderate interobserver reproducibility (kappa = 0.43) and good intraobserver reproducibility (kappa = 0.61). The experience of the reviewers did not significantly affect either of these. The AO system showed regular interobserver reproducibility (kappa = 0.37) and moderate intraobserver reproducibility (kappa = 0.57). The younger group obtained higher intraobserver agreement than the senior. Possible causes for the low reproducibility of both classifications are discussed together with a review of the literature. We do not recommend the Frykman or AO classifications for clinical application because of their questionable reproducibility.Résumé. Les classification des fractures de l’ extremité distal du radius est un thème de controverse. Les objectifes du travail sont de déterminer la reproductivité intra et interpersonnelle des classifications de Frykman et AO et évaluer ses variation avec l’expérience des observateurs. Trois spécialistes en chirurgie de la main et trois chirurgiens orthopédiques en formation ont evalué deux cents paires radiographiques en face et en profil. La reproductivité a été calculé en utilisant la proportion d’accord et le coefficient “kappa”. La classification de Frykman a obtenu une reproductivité interpersonnelle modéré (kappa = 0.43) et une bonne reproductivité intrapersonnelle (kappa = 0.61). L’experience des évaluateurs n’intervient pas. La classification AO a montré une reproductivité interpersonnelle régulière (kappa = 0.37) et une reproductivité intrapersonnelle modéré (kappa = 0.57). Ce sont les non spécialistes qui ont obtenu les meilleurs valeurs de reproductivité intrapersonnelle. Cette différence a été statistiquement significative. On discute les possibles causes de la baisse de reproductivité dans ce groupe d’observateurs avec la litterature. Nous ne recommandons pas l’usage de ces classifications dans la pratique quotidienne.

Proximal radio-ulnar synostosis and nonunion after olecranon fracture tension-band wiring: A case report

Fractures of the olecranon are the most common type of elbow fracture. Displaced fractures usually require operative treatment with open reduction and internal fixation to allow early motion in order to avoid significant stiffness of the elbow joint. Two parallel Kirschner wires inserted across the fracture into the medullary canal of the proximal ulna combined with a tension band wiring is a recognized and frequently performed method of fixation for noncomminuted fractures. Although isolated closed fractures of the olecranon in adults have a favorable long-term outcome, a few complications with this technique have been reported. The most common complication is migration of the K wires proximally leading to pain and local skin complications, with a high incidence (80%) of reoperation for the removal of symptomatic hardware. Therefore, this method has been modified so that the distal end of the Kirschner wires are inserted through the anterior cortex of the proximal ulna to prevent proximal wire migration postoperatively and to increase the stability of the tension band unit. The authors present a case of a patient with an isolated fracture of the olecranon that developed a proximal radioulnar synostosis and an olecranon nonunion associated with the use of the transcortical tension-band wiring technique. The possible mechanism for the synostosis formation, different from others described previously in accordance with the literature reviewed, will also be discussed herein below.

Arthroscopic treatment of synovial chondromatosis of the shoulder: Report of three patients

Synovial chondromatosis (SC) is a rare arthropathy that affects diarthrodial joints. It is 3 times more common in men than in women, and it is most commonly diagnosed between ages 30 and 50. The disorder is characterized by multiple nodules of metaplastic cartilage cells that suffer endochondral ossification. The process follows 3 stages: (1) active intrasynovial disease without loose bodies, (2) transitional lesions with synovial proliferation and free loose bodies, and (3) loose bodies without synovial disease. Patients with SC often report a history of pain, swelling, and decreased range of motion (ROM); the symptoms may be present for several years. Although spontaneous regression has been recorded, the treatment of choice is the surgical removal of the loose bodies and synovectomy. The arthroscopic approach has been proposed as an attractive alternative with many advantages over open surgery. We report 3 patients with SC of the shoulder who were treated arthroscopically. Two of these patients also required capsular release for restriction of their ROM. We also discuss the correct time to perform the procedure.

Non-surgical functional treatment for displaced olecranon fractures in the elderly

We retrospectively evaluated the clinical and radiological outcomes of a consecutive cohort of patients aged > 70 years with a displaced fracture of the olecranon, which was treated non-operatively with early mobilisation. We identified 28 such patients (27 women) with a mean age of 82 years (71 to 91). The elbow was initially immobilised in an above elbow cast in 90° of flexion of the elbow for a mean of five days. The cast was then replaced by a sling. Active mobilisation was encouraged as tolerated. No formal rehabilitation was undertaken. At a mean follow-up of 16 months (12 to 26), the mean ranges of flexion and extension were 140° and 15° respectively. On a visual analogue scale of 1 (no pain) to 10, the mean pain score was 1 (0 to 8). Of the original 28 patients 22 developed nonunion, but no patients required surgical treatment. We conclude that non-operative functional treatment of displaced olecranon fractures in the elderly gives good results and a high rate of satisfaction.

Comparative clinical study of locking screws versus smooth locking pegs in volar plating of distal radius fractures

The present study was performed to test the null hypothesis on no difference in stability of fixation after volar plating of intra-articular distal radius fractures (AO C2-C3) with either locking smooth pegs or locking screws in a clinical setting. A retrospective evaluation included adult patients with C2-C3 AO fractures treated with a volar plate with locking smooth pegs or locking screws. Radiographic assessment was performed to evaluate extra- and intra-articular parameters in the early postoperative period and after bone union. Twenty-seven consecutive patients were included. Thirteen cases had fixation with locking screws and 14 had fixation with locking smooth pegs. Both groups had bone fragment displacement after fixation. However, there were no significant differences between the groups either in extra- or intra-articular parameters defined by Kreder et al. (1996). Our study shows that, in a clinical setting, there is no difference in stability fixation between locking screws or smooth locking pegs in C2-C3 distal radius fractures.

Chronic scapholunate dissociation: ligament reconstruction combining a new extensor carpi radialis longus tenodesis and a dorsal intercarpal ligament capsulodesis.

Scapholunate dissociation (SLD) is the commonest cause of carpal instability and wrist osteoarthrosis. The value of early diagnosis and treatment of this injury is well established in the literature. When a partial or total rupture of the scapholunate ligament is treated with early anatomic reduction and repair, functional results may be good to excellent. However, if this ligament is not addressed acutely then an overall carpal malalignment may seem progressively as a result of failure of the secondary scaphoid stabilizers. Chronic SLD will lead to scapholunate advanced collapse and progressive painful arthritis of the wrist. Although most surgeons agree that operative intervention is indicated, no clear consensus exists on the best treatment for patients with chronic SLD. Several procedures have been described that include some sort of partial fusion, capsulodesis, tenodesis, or bone-ligament-bone graft. If there is no evidence for arthrosis, soft-tissue procedures using either capsulodesis or tenodesis may be carried out in an attempt to preserve radiocarpal and intercarpal motion whereas avoiding fusion. This article describes a scapholunate ligament reconstruction combining a new dorsal extensor carpi radialis longus tenodesis and a dorsal capsulodesis for the treatment of chronic SLD.

Dynamic splint for the treatment of stiff elbow

Background The purpose of this paper is to retrospectively evaluate the results of the treatment of elbow stiffness with the use of dynamic splints. Methods We included 17 patients with stable and congruent joints, with a range of motion of 100 degrees or less who had not responded to the rehabilitation program. Average previous mobility was 108–42 degrees, with a total arc of 66 degrees. The splints consist of an articulated brace with springs. On average their use began 94 days after surgery or trauma and continued for 86 days. Statistical analysis was performed. Average follow-up was 18 months. Results Postoperative mobility was 126–19 degrees, with a total arc of 107 degrees. Motion increased an average of 41 degrees. Six patients failed to recover a functional arc of motion. Conclusion Our results suggest that dynamic splints are useful in the treatment of elbow stiffness. We achieved an average improvement of 41° in the arc of motion, which in many cases has rendered arthrolysis unnecessary. Tailoring the splint to the individual patient is very important since its usage must be prolonged in order to achieve plastic deformity through the principle of progressive stretching.

Desmoid tumor of the forearm. Reconstructive surgery and functional result

Functional results after resection-reconstruction operated at the same time. Desmoid tumors, also known as aggressive fibromatosis, are benign locally aggressive tumors with a high rate of recurrence. Most authors recommend surgical treatment with wide-free margin. Achieving margins of normal tissue around an upper extremity lesion without creating significant functional compromise is frequently difficult. Therefore, functional reconstructive surgery is important, considering that for most patients treated for these tumors, the life expectancy is high and considering also that wide resection can affect the function and the aesthetics as well. We present a case of aggressive fibromatosis in the proximal third of the forearm treated by wide resection and reconstructive surgery in one single procedure, with an acceptable functional result with no evidence of recurrence at 3 years of follow-up.

A Prospective Clinical Study of the A1 Pulley in Trigger Thumbs

A prospective study was performed in 19 patients with trigger thumbs to define the anatomy of the A1 pulley of the thumb in this condition and to evaluate biomechanical parameters of the thumb after complete division of the A1 pulley. Pre- and postoperatively, flexion of the interphalangeal and metacarpophalangeal joints, key pinch strength and tip pinch strength were measured and compared with these measurements on the contralateral thumb. We identified three types of A1 pulley. The clinical data showed that there is no deficit with respect to motion and strength of the thumb after completely sectioning any of the three types of A1 pulley.

Les fractures intraarticulaires du radius distal à déplacement postérieur traitées par plaque palmaire à stabilité angulaire. Technique et résultats

OBJECTIVES The purpose of this study was to evaluate the results and complications of locked palmar plating in patients with articular fracture of the distal radius. METHODS Twenty-two patients were reviewed retrospectively. The average age was 68 years. All fractures were classified as Type C according to the AO classification. Clinical and functional examination including range of motion, grip strength, pain and return to previous activities were assessed. Loss of radial height, radial inclination, palmar tilt and ulnar variance were evaluated with preoperative and postoperative radiographs. RESULTS At an average follow-up of 10 months, the range of motion was 124 degrees in flexion and extension and 178 degrees in pronation and supination. Grip strength was 80% of the opposite side. Fifteen patients were free of pain. Three patients suffered tenosynovitis of the extensor tendons. Radiographic measurements averaged 11 mm radial height, 21 degrees radial inclination, 4 degrees palmar tilt and 1 mm ulnar variance. CONCLUSIONS The result of this study showed that locked palmar plating of articular distal radius fractures is effective even in cases of metaphyseal comminution with a low rate of complications.