Marcos V. Masson

Volar approach to dorsal displaced fractures of the distal radius.

This method was originally designed for comminuted intra-articular distal radius fractures (AO type C/ Fernandez type III and V fractures) (Table 1) and later expanded to include all unstable distal radius fractures. AO type C or complete articular fractures of the distal radius have traditionally been considered the most difficult of all radius fractures. The issues of achieving adequate intra-articular and extra-articular parameters of reduction, providing sufficient stability, not disturbing the adjacent soft tissues, and assessing associated injuries have often confounded each other. Nearly all the methods of fixation as well as operative approaches that are used in the treatment of radius fractures have been suggested for use in type C fractures. Closed reduction and internal fixation alone can seldom provide sufficient stability. External fixation introduces the complications of pin tract infection, radial neuralgia, extrinsic extensor tightness, and wrist capsular stiffness, while often not assuring an adequate intra-articular reduction. Dorsal plating has risen in prominence recently but requires a significant exposure through the specialized structure of the dorsal extensor tendon retinacular mechanism (DEM). A review of the literature for radius fracture treatments and outcomes favors a method developed in China. Support for the articular surface is provided largely by bone grafting with temporary interim stabilization provided by a load sharing external fixator (one not placed under excessive traction or wrist flexion). After 4 weeks of early healing, the fixator is removed, and rehabilitation begins. We were initially pleased with the results of this method but found it inadequate for the typical high-energy complex fracture patterns characteristic for our institution. Geissler and others have shown that despite radiographs that show an anatomic reduction of the articular surface, arthroscopy of the radiocarpal joint showed significant articular step-off. They also showed a high incidence of treatable associated injuries to the interosseous carpal ligaments and triangular fibrocartilage complex. The role of direct and indirect nerve injury associated with high-energy radius fractures has been manifested both in the final outcome and in the variable incidence of reflex sympathetic dystrophy (RSD) reported in many series. Reviewing the current information regarding the treatment of high-energy distal radius fractures and being faced weekly with the challenge of treating these injuries, we sought to devise a unified method of treatment to meet the following goals:

Management of the stiff proximal interphalangeal joint

Abstract The stiff digit occurs most frequently after posttraumatic injuries and as a postsurgical complication. The identification and precise participation of the structures involved may be difficult. A step-wise algorithmic approach trying to minimize morbidity may help to obtain the best results. A review of the literature reveals that a midaxial approach is versatile, can accommodate skin deficiencies, and offers appropriate volar and dorsal exposure. Sequential joint release is achieved by complete capsular incision, collateral ligament excision, and volar plate release or partial excision. Tenolysis also may be required for full passive range of motion. Neuroleptoanalgesia is important in proving reconciliation of active and passive discrepancies. Severe cases may require staged reconstructive efforts and represent a higher risk for neurovascular complications. A ray resection may be an appropriate alternative in these individuals. Dedicated rehabilitation including a tendon acceleration program should maintain the motion accomplished during surgery.