Jörg van Schoonhoven

Malunion of the distal radius

Fractures of the distal radius are extremely common injuries, which are steadily becoming a public health issue. One of the most common complications following distal radius fractures is still malunion of the distal radius. This review of the literature surrounding distal radius malunion covers the biomechanics of distal radial malunion, treatment options, indications for surgery, surgical techniques, and results.

Die primäre Naht der Fingerbeugesehnen

ZusammenfassungOperationszielWiederherstellung der Beugesehnenkontinuität und -mechanik durch direkte Naht. Aktive Nachbehandlung für Streckung und Beugung.IndikationenDurchtrennung der tiefen und der oberflächlichen Beugesehne in allen Zonen, auch in Kombination mit Begleitverletzungen, wenn eine primäre Heilung und ein gutes funktionelles Ergebnis zu erwarten sind.KontraindikationenAkute und chronische Infektion.Fehlende personelle, instrumentelle oder organisatorische Voraussetzungen.Keine spannungsfreie Naht möglich.Stark infektionsgefährdete oder verschmutzte Wunden und ausgedehnte Quetschverletzungen.Begleitverletzungen, die eine postoperative Mobilisation verhindern.Eine Gefäßverletzung verbietet eine Naht nach Mantero.OperationstechnikSchnittführung nach handchirurgischen Gesichtspunkten unter Einbeziehung der Wunde. Eröffnung der Sehnenscheide im Kreuzbandbereich. Vierstrangnaht, bestehend aus zwei versetzten geblockten Zweistrangnähten und einer epitendinösen fortlaufenden Kreuzstichnaht. Ist der Sehnenstumpf in Zone I kürzer als 1 cm, Naht nach Mantero. Bei einer ansatznahen knöchernen Abscherung transossäre Ausziehnaht.WeiterbehandlungAktive Beugung und Streckung in einer dorsalen Handgelenkschiene.ErgebnisseDie in der Literatur beschriebenen Nachuntersuchungsergebnisse von Kernnähten mit mehr als zwei Strängen erbringen in 69–96% sehr gute und gute Ergebnisse.AbstractObjectiveFlexor tendon repair by direct suture, providing tendon function and mechanical properties and allowing postoperative active extension and flexion.IndicationsFlexor tendon laceration in all zones, when primary healing and a good functional outcome can be expected.ContraindicationsFlorid and chronic infection.Lack of skill, instruments, or manpower.Tension-free suture is not feasible.Severe soft-tissue problems.Mantero suture in case of coexistent artery injury.Surgical TechniqueHand surgical incisions and approach to the tendon. Opening of the tendon sheath in the region of oblique pulley. A four-strand core suture consisting of two locked two-strand sutures and a circumferential epitendon cross-stitch suture are performed. Lacerations in zone I with a tendon stump shorter than 1 cm require a Mantero suture and avulsions require a pull-out suture technique.Postoperative ManagementActive flexion and active extension in a dorsal wrist cast.ResultsThe clinical outcome studies after repair of zone II flexor tendon injuries using a multiple-strand suture technique describe 69–96% excellent and good results.OBJECTIVE Flexor tendon repair by direct suture, providing tendon function and mechanical properties and allowing postoperative active extension and flexion. INDICATIONS Flexor tendon laceration in all zones, when primary healing and a good functional outcome can be expected. CONTRAINDICATIONS Florid and chronic infection. Lack of skill, instruments, or manpower. Tension-free suture is not feasible. Severe soft-tissue problems. Mantero suture in case of coexistent artery injury. SURGICAL TECHNIQUE Hand surgical incisions and approach to the tendon. Opening of the tendon sheath in the region of oblique pulley. A four-strand core suture consisting of two locked two-strand sutures and a circumferential epitendon cross-stitch suture are performed. Lacerations in zone I with a tendon stump shorter than 1 cm require a Mantero suture and avulsions require a pull-out suture technique. POSTOPERATIVE MANAGEMENT Active flexion and active extension in a dorsal wrist cast. RESULTS The clinical outcome studies after repair of zone II flexor tendon injuries using a multiple-strand suture technique describe 69-96% excellent and good results.

Long-Term Results after Midcarpal Arthrodesis

Background and Purpose Midcarpal arthrodesis is a well-accepted treatment option for advanced carpal collapse. In this study, we retrospectively assessed survival, analyzed complications and reviewed the long-term follow-up after midcarpal fusion. Materials and Methods The computerized medical records of 572 patients who had undergone 594 four-corner fusions between 1992 and 2001 were explored. Furthermore 56 patients with 60 midcarpal fusions were randomized for clinical and radiological follow-up at a mean of 14.7 years. Results Forty midcarpal fusions (6.7%) had to be converted into complete wrist arthrodesis. The reasons were ongoing pain in spite of a well-healed midcarpal fusion (31) or nonunion (9). Sixty-three patients (11%) required revision surgery because of nonunion (22), hematoma (8), wound infection (3) or persisting pain (31). In clinical follow-up the mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 20.4. Pain at rest was infrequent, a mild increase with daily activity was complained of (mean visual analog scale [VAS] 3.3). The mean active range of wrist motion for extension and flexion, ulnar and radial deviation and supination and pronation reached 62.5%, 68.4%, 94.7%, and mean grip strength 84.9% of the unaffected side. All patients had radiographic abnormalities, with frequent evidence of osteoarthritis of the lunate fossa. Patients with preserved carpal height appeared to have less pain, better DASH scores and a better range of motion. Conclusions The midcarpal arthrodesis is a long-lasting treatment option for advanced carpal collapse and has good long-term results. Level of Evidence Level IV, Therapeutic study.

Ulnar shortening osteotomy for malunited distal radius fractures: results of a 7-year follow-up with special regard to the grade of radial displacement and post-operative ulnar variance

IntroductionThe treatment of ulnar-sided wrist pain after malunited distal radius fractures remains controversial. Radial corrective osteotomy can restore congruity in the distal radioulnar joint (DRUJ) as well as adequate length of the radius. Ulnar shortening osteotomies leave the radius’ angular deformities unchanged, risking secondary DRUJ osteoarthritis. We supposed that, even within the widely accepted limit of 20°, a greater angulation of the radius in the sagittal plane correlates with a higher rate of DRUJ osteoarthritis. Furthermore, we suspected worse results from an ulna shortened to a negative rather than a neutral or positive ulnar variance.Materials and methodsFor this retrospective study, we reviewed 23 patients a mean 7.2 (range 5.6–8.5) years after ulnar shortening osteotomy for malunion of distal radius fractures. We compared 14 patients with up to 10° dorsal or palmar displacement from the normal palmar tilt of 10° to 9 patients with more than 10° displacement, and 15 patients whose post-operative ulnar variance was neutral or positive to 8 who had a negative one.ResultsUlnar-sided wrist pain decreased enough to satisfy 21 of the 23 patients. Clinical results tended to be better when radial displacement was minor and when post-operative ulnar variance was positive or neutral. A shorter ulna significantly increased the rate of DRUJ osteoarthritis, whereas a greater degree of radial displacement only increased the rate slightly.ConclusionsRadial corrective osteotomy should be discussed as alternative when displacement of the radius in the sagittal plane exceeds 10°. The ulna should be shortened moderately to reduce the risk of osteoarthritis in the distal radioulnar joint.

Die Hemiresektions-Interpositionsarthroplastik des distalen Radioulnargelenks nach Bowers

ZusammenfassungOperationszielWiederherstellung der Unterarmdrehung und Schmerzreduktion am distalen Radioulnargelenk durch Resektion der Gelenkflächen des Ulnakopfes unter Erhalt oder Refixation des ulnokarpalen Komplexes und Interposition eines Kapsel-Retinakulum-Lappens zwischen Incisura ulnaris des Radius und distaler Ulna.IndikationenSchmerzhafte Arthrosen des distalen Radioulnargelenks.KontraindikationenLongitudinale Instabilitäten des Unterarms, z.B. bei Essex- Lopresti-Läsionen oder nach Radiuskopfresektionen. Posttraumatische ulnare Translokation des Carpus.OperationstechnikEröffnung des distalen Radioulnargelenks durch den Boden des fünften Strecksehnenfachs unter Bildung eines ulnar gestielten Kapsel-Retinakulum-Lappens. Erhalt des vierten und sechsten Strecksehnenfachs. Resektion der gelenktragenden Teile des Ellenkopfes unter Erhalt des Processus styloideus ulnae und des Ansatzes des ulnokarpalen Bandkomplexes (TFCC [„triangular fibrocartilage complex“]). Gegebenenfalls Refixation oder Rekonstruktion des ulnokarpalen Bandkomplexes. Interposition des Kapsel-Retinakulum-Lappens zwischen Radius und Ulna. Stabilisation der distalen Ulna durch Naht der dorsalen Anteile des Interponats an die dorsale Lippe der Incisura ulnaris des Radius.WeiterbehandlungRuhigstellung in einer Oberarmgipsschiene in 45° Supinationsstellung des Unterarms für 4 Wochen. Anschließend werden Pronation und Supination mit einer thermoplastischen, Ulna und Radius ulnar umgreifenden Schiene unter Freilassung des Radio- und Ulnokarpalgelenks für weitere 4 Wochen begrenzt. Danach Steigerung des Bewegungsumfangs und der Belastung bis zur Vollbelastung.ErgebnisseDie Hemiresektions-Interpositionsarthroplastik des distalen Radioulnargelenks reduziert den Schmerz signifikant und erhöht die Grobkraft. Bei präoperativer Einschränkung der Umwendbewegung kann der Bewegungsumfang durch die Operation deutlich gesteigert werden. Eine Instabilität des Ulnaendes kann verbleiben bzw. resultieren, was aber nur bei einem Teil der Patienten leichte Beschwerden verursacht. Die Patientenzufriedenheit ist hoch bei gutem funktionellem Ergebnis.AbstractObjectiveRestoration of forearm rotation and pain relief at the distal radioulnar joint by resection of the joint surfaces of the ulnar head, interposition of a capsular-retinacular flap, and preservation or reconstruction of the ulnocarpal complex.IndicationsPainful osteoarthritis of the distal radioulnar joint.ContraindicationsLongitudinal instability in the forearm, e.g., Essex-Lopresti lesions or after radial head resection. Posttraumatic ulnar subluxation of the carpus.Surgical TechniqueExposition of the distal radioulnar joint via the floor of the fifth extensor compartment and preparation of an ulnarbased capsular-retinacular flap. Preservation of the fourth and sixth extensor compartment. Resection of the jointbearing areas of the ulnar head preserving the ulnar styloid and the triangular fibrocartilage complex (TFCC). If necessary, refixation or reconstruction of the TFCC. Interposition of the capsular-retinacular flap between the distal radius and ulna. Stabilization of the distal ulna by suture fixation of the dorsal part of the flap to the dorsal rim of the sigmoid notch.Postoperative ManagementImmobilization in a long arm cast with 45° forearm supination for 4 weeks. Afterwards, forearm pronation and supination are further limited for 4 weeks by a splint. Following that period, the range of motion and the load are raised to normal levels.ResultsThe hemiresection-interposition arthroplasty of the distal radioulnar joint improves the range of forearm rotation. Pain is significantly reduced and grip strength increased. Instability of the distal ulna may persist or result; however, this gives rise to moderate complaints only in some patients. Patients’ satisfaction is high and the functional results are good.

Die Fesselung des Kahnbeins nach Brunelli in der Modifikation nach Garcia-Elias, Lluch und Stanley zur Behandlung der veralteten skapholunären Dissoziation

OBJECTIVE Stabilization of the scaphoid correcting rotary subluxation and replacement of the biomechanically essential dorsal part of the scapholunate ligament for prevention of osteoarthritis. INDICATIONS Scapholunate dissociation without useful remnants of the ligament and reducible malalignment of the scaphoid. CONTRAINDICATIONS Fixed scaphoid malalignment. Osteoarthritis (SLAC [scapholunate advanced collapse] wrist). SURGICAL TECHNIQUE Dorsal approach to the wrist using the flap described by Berger. Correction of rotary subluxation and stabilization of the scaphoid using a distally based strip of flexor carpi radialis tendon, which is created through a separate palmar incision, and fixed to a bone anchor in the lunate through a tunnel from the palmar side of the distal pole of the scaphoid to the origin of the dorsal part of the scapholunate ligament from the scaphoid combined with transfixation of the scaphoid to the capitate and the lunate bone in corrected position using two Kirschner wires (1.6 mm). Additionally, the flexor carpi radialis strip is looped through a split in the dorsal radiotriquetral ligament and fixed to itself. POSTOPERATIVE MANAGEMENT Immobilization using a below-elbow cast including the metacarpophalangeal joint of the thumb for 6 weeks. Removal of the Kirschner wires 8 weeks postoperatively, followed by physiotherapy to improve wrist motion. RESULTS 14 out of 17 patients were available for a clinical and radiologic examination after a mean follow-up time of 10.5 months (minimum 6, maximum 15 months). Two of these patients had to undergo another operative procedure in the meantime, one partial and the other total wrist fusion. The remaining twelve patients had a mean DASH Score (Disabilities of the Arm, Shoulder and Hand) of 25 (minimum 0, maximum 59 points) and a mean modified Mayo Wrist Score of 80 points (minimum 60, maximum 97 points). Contrary to the good clinical results, the final radiologic examination demonstrated a tendency toward loss of correction compared to the postoperative X-rays.

Corrective Osteotomy for Malunited, Palmarly Displaced Fractures of the Distal Radius

Background: In spite of the considerable information regarding the indications for, and the techniques and results of, corrective osteotomy of malunited, dorsally displaced fractures of the distal radius, there have been few reports concerning osteotomy of palmarly angulated malunions of the distal radius. The purpose of the current study was to evaluate our experience with this condition. Patients and Methods: We retrospectively reviewed 20 patients, which were operated on for a malunited, palmarly tilted fracture of the distal radius between 1993 and 1998. The investigated criteria included range of motion, grip strength, pain relief, and X-ray findings. Wilcoxons sign-rank test was used to evaluate the extent of improvement concerning these criteria. Results: At an average of 18 months after osteotomy, radiographs revealed a statistically highly significant improvement in all radiologic parameters. The increase in ulnar and radial deviation of the wrist, and forearm supination, as well as the decrease of pain were statistically highly siginificant. The resultant improvement in grip strength in the current series was significant. Conclusion: Corrective osteotomy of palmarly displaced malunions of the distal end of the radius just as in the case of their dorsal counterparts is of great benefit and leads to improved hand and wrist function as well as diminished pain.

Gipsverbände in der Handchirurgie

ZusammenfassungImmobilisierende Verbände sind wesentlicher Bestandteil der konservativen und perioperativen Behandlung in der Handchirurgie. Der einfache Gipsverband zeichnet sich durch niedrige Kosten und hervorragende Modellierbarkeit aus. Dieser Beitrag gibt eine Übersicht über häufig angewandte Gipsverbände in der Handchirurgie.AbstractImmobilization is as essential to conservative treatment of the hand as it is perioperatively in surgical treatment. Low cost and outstanding moldability distinguish plaster of Paris. This paper surveys frequently used applications of plaster of Paris in hand surgery.Immobilization is as essential to conservative treatment of the hand as it is perioperatively in surgical treatment. Low cost and outstanding moldability distinguish plaster of Paris. This paper surveys frequently used applications of plaster of Paris in hand surgery.

Preventable Repeat Wrist Arthroscopies: Analysis of the Indications for 133 Cases

Background Frequently, patients undergo repeated wrist arthroscopies for single wrist problems. Purpose The purposes of this study were to assess the indications for repeat wrist arthroscopies and to identify potentially preventable procedures. Methods For this retrospective, two‐center study, the electronic patient records were examined for patients, who underwent repeat wrist arthroscopy in a 5‐year period. The cases were sorted by the underlying pathologies and the causes that necessitated repeat arthroscopies. Results Ulnar‐sided wrist pain accounted for 100 (77%) of all 133 revision arthroscopies: 67 of which due to suspected ulnar triangular fibrocartilage complex (TFCC) avulsions, 33 due to ulnar impaction syndromes. Cartilage was reassessed in 22 (17%) wrists. Thereby, insufficient preoperative diagnostics necessitated pure diagnostic before therapeutic arthroscopy in 49 (37%) wrists: 48 of which for TFCC pathologies, one for a scapholunate (SL) ligament lesion. The uncertainty of diagnosis despite previous arthroscopy necessitated 18 (14%) revision arthroscopies: 15 for ulnar TFCC avulsions, 1 for a central TFCC lesion, 2 to reevaluate the SL ligament. Inadequate photo or video documentation of the cartilage necessitated arthroscopic reassessment in 16 (12%) wrists. Conclusion In this series, two out of three revision arthroscopies could potentially have been prevented. Inadequate preoperative diagnostics with the lack of reliable preoperative diagnoses necessitated pure diagnostic arthroscopies for ulnar‐sided wrist pain. However, even arthroscopically, the diagnosis of ulnar TFCC avulsions or SL ligament lesions is not trivial. Surgical skills and experience are necessary to detect such lesions. Finally, adequate photo or video documentation may prevent repeated arthroscopic diagnostic procedures. Level of Evidence Level IV.

Die dorsale Kapsulodese zur Behandlung der skapholunären Instabilität

ZusammenfassungOperationszielStabilisierung der proximalen Handwurzelreihe bei skapholunärer Bandruptur zur Verhinderung eines karpalen Kollapses.IndikationenAls zusätzliche Maßnahme zur Naht des komplett rupturierten skapholunären Bandes insbesondere bei statischer, aber nicht fixierter skapholunärer Fehlstellung.KontraindikationenFixierte Fehlstellung des Skaphoids und/oder Lunatums. Radiokarpale oder mediokarpale Arthrose.OperationstechnikDorsaler Zugang zum Handgelenk unter Eröffnung des zweiten, dritten und vierten Strecksehnenfachs und Resektion des schmerzleitenden Nervus interosseus posterior. Eröffnen der Gelenkkapsel über dem Radiokarpalgelenk sowie Inspektion der Knorpelflächen und des skapholunären Bandes auf nahtfähige Bandanteile. Erforder lichenfalls Reposition von Skaphoid und Lunatum. Naht des skapholunären Bandes. Sofern eine Reposition von Skaphoid und Lunatum erforderlich ist, temporäre Kirschner-Draht-Transfixation des Skaphoids zum Kapitatum und Lunatum. Darstellen des Ligamentum intercarpale dorsale. Heben des mittleren Drittels des Bandes, am distalen Skaphoidpol gestielt. Durchziehen des ulnaren Endes durch einen Schlitz im Ligamentum radiotriquetrum dorsale. Umschlagen des überstehenden Bandanteils und Vernähen mit sich selbst. Raffung des verbliebenen proximalen Drittels an das distale Drittel des Ligamentum intercarpale dorsale.WeiterbehandlungRuhigstellung im Unterarmgipsverband unter Einschluss des Daumengrundglieds für 6 Wochen. Erforderlichenfalls Entfernung der Kirschner-Drähte nach 8 Wochen. Anschließend Physiotherapie zur Verbesserung der Handgelenkbeweglichkeit.ErgebnisseDie Untersuchungsergebnisse in der Literatur zeigen überwiegend eine Verbesserung der Schmerzsymptomatik. Die Ergebnisse der radiologischen Parameter und die Arthrosevermeidung lassen keine einheitliche Erfolgsbewertung zu.AbstractObjectiveTo regain stability of the proximal carpal row after scapholunate ligament rupture in order to avoid osteoarthritis and carpal collapse.IndicationsAs additional therapy in scapholunate ligament repair especially in patients with static, but reducible scapholunate malalignment.ContraindicationsFixed scapholunate malalignment. Osteoarthritis of the radiocarpal or the midcarpal joint.Surgical TechniqueDorsal approach to the carpal joint with release of the second, third and fourth extensor compartment and resection of the dorsal interosseous nerve. Opening of the radiocarpal joint for inspection of the chondral surfaces and the scapholunate ligament for possible repair. If needed, reduction of scaphoid and lunate. Repair of the scapholunate ligament. If a reduction of scaphoid and lunate is necessary, temporary Kirschner wire fixation of the scaphoid to the capitate and the lunate. The dorsal intercarpal ligament is identified and its middle third is dissected and elevated from the triquetrum remaining attached to the distal scaphoid pole. The ulnar end of the elevated part of the dorsal intercarpal ligament is pulled through a split in the dorsal radiotriquetral ligament and fixed to itself. Closure of the proximal and distal third of the dorsal intercarpal ligament.Postoperative ManagementManagement Immobilization in a below-elbow cast including the metacarpophalangeal joint of the thumb for 6 weeks. Removal of the Kirschner wires, if used, 8 weeks postoperatively. Physiotherapy to improve wrist motion.ResultsMost of the reports in the literature show an improvement of pain. The effect on radiologic parameters and the development of osteoarthritis remains uncertain.OBJECTIVE To regain stability of the proximal carpal row after scapholunate ligament rupture in order to avoid osteoarthritis and carpal collapse. INDICATIONS As additional therapy in scapholunate ligament repair especially in patients with static, but reducible scapholunate malalignment. CONTRAINDICATIONS Fixed scapholunate malalignment. Osteoarthritis of the radiocarpal or the midcarpal joint. SURGICAL TECHNIQUE Dorsal approach to the carpal joint with release of the second, third and fourth extensor compartment and resection of the dorsal interosseous nerve. Opening of the radiocarpal joint for inspection of the chondral surfaces and the scapholunate ligament for possible repair. If needed, reduction of scaphoid and lunate. Repair of the scapholunate ligament. If a reduction of scaphoid and lunate is necessary, temporary Kirschner wire fixation of the scaphoid to the capitate and the lunate. The dorsal intercarpal ligament is identified and its middle third is dissected and elevated from the triquetrum remaining attached to the distal scaphoid pole. The ulnar end of the elevated part of the dorsal intercarpal ligament is pulled through a split in the dorsal radiotriquetral ligament and fixed to itself. Closure of the proximal and distal third of the dorsal intercarpal ligament. POSTOPERATIVE MANAGEMENT Management Immobilization in a below-elbow cast including the metacarpophalangeal joint of the thumb for 6 weeks. Removal of the Kirschner wires, if used, 8 weeks postoperatively. Physiotherapy to improve wrist motion. RESULTS Most of the reports in the literature show an improvement of pain. The effect on radiologic parameters and the development of osteoarthritis remains uncertain.