Mark Henry

Volar fixed-angle plating of the distal radius.

Abstract The treatment of unstable distal radius fractures continues to improve as better methods of skeletal fixation and soft‐tissue management are developed. Apart from closed reduction and percutaneous pinning of simpler fracture patterns, the three main methods of management are external fixation, dorsal plating, and volar fixed‐angle plating. Specific advantages of volar fixed‐angle plating include stable fixed‐angle support that permits early active wrist rehabilitation, direct fracture reduction, and fewer soft‐tissue and tendon problems. Volar fixed‐angle plating also avoids the complications often associated with external fixation and dorsal plating. Biomechanical data indicate that, when loaded to failure, volar fixed‐angle plates have significant strength advantages over dorsal plating. Volar fixed‐angle plating is advantageous in elderly osteopenic patients and for high‐energy comminuted fractures and malunions requiring osteotomy.

Fractures of the proximal phalanx and metacarpals in the hand: preferred methods of stabilization.

&NA; Treatment of fractures of the proximal phalanx and metacarpals is based on the presentation of the fracture, degree of displacement, and difficulty in maintaining fracture reduction. A wide array of treatment options exists for the variation in fracture patterns observed. Inherently stable fractures do not require surgical treatment; all other fractures should be considered for additional stabilization. In general, of the many combinations of internal fixation possible, Kirschner wires and screw‐and‐plate fixation predominate. Early closed reduction typically is successful for unicondylar fractures of the head of the proximal phalanx. Bicondylar proximal phalanx fractures usually are treated with plate fixation. Transverse and short oblique proximal phalanx fractures generally are treated with Kirschner wires, although a stable short oblique transverse shaft fracture can be managed with an intrinsic plus splint. Plate fixation is used in comminuted proximal phalanx as well as comminuted metacarpal fractures, and lag screws in spiral long oblique phalanx shaft fractures and metacarpal head fractures. Kirschner wire fixation is successful in metacarpal neck fractures as well as both short and long transverse oblique shaft fractures.

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:

Distal Radius Fractures: Current Concepts

Despite the frequency of distal radius fractures, studies in the existing literature have not been able to determine the optimal surgical strategies for various fracture patterns. Numerous clinical articles have been written, but most are level IV case series or expert opinion reviews. Good biomechanics studies have been published that suggest advantages of certain fixation methods over others. Transference of these expectations to clinical reality, however, requires well-controlled patient trials. In large part, this has not happened. This article reviews the theoretical pros and cons of different surgical strategies used for adult distal radius fractures, and then looks at randomized controlled trials that have been published in the last 5 years.

Dupuytren's disease: current state of the art

BackgroundThis review article critically examines the current literature for Dupuytrens disease.MethodsFive procedures are considered: dermofasciectomy, limited fasciectomy, segmental aponeurectomy, needle aponeurotomy, and collagenase injection. Studies regarding the efficacy of these treatments focus primarily on the initial degree of correction, rate of recurrence, and complications.ResultsNo one treatment has been declared superior and substantial controversy exists. Comparison between studies has been hampered by the absence of uniform definitions for clinical success and measurable disease progression. Traditional post-operative care includes formal therapy and night splinting, but recent studies have questioned the value of these adjuncts.ConclusionThe extent of involvement at which the surgeon should intervene was previously well accepted by convention, but as the paradigm shifts towards less invasive procedures, treatment may be offered at an earlier stage. Future research should be structured to recognize the value-based decision making used by patients when selecting treatment.

Management of acute triangular fibrocartilage complex injury of the wrist.

Abstract Acute trauma to the triangular fibrocartilage complex includes tears of the fibrocartilage articular disk substance and meniscal homolog as well as radioulnar ligament avulsions, with or without an associated fracture. Patient evaluation includes clinical examination, imaging studies, and wrist arthroscopy (diagnostic). The Palmer classification is typically used to define injuries to the triangular fibrocartilage complex. The critical distinction is in differentiating injuries that produce instability of the distal radioulnar joint from those that do not. Also important is the recognition of acute injuries in the context of an ongoing degenerative pattern (ie, Palmer class 2 lesions). Nonsurgical management includes temporary splint immobilization of the wrist and forearm, oral nonsteroidal anti‐inflammatory medication, corticosteroid joint injection, and physical therapy. Surgical strategies include débridement, acute repair, and subacute repair. Most surgical procedures can be performed arthroscopically. However, open ligament repair may be needed in the setting of distal radioulnar joint instability.

A Unified Approach to Radial Tunnel Syndrome and Lateral Tendinosis

Two of the most common diagnoses assigned to patients presenting with lateral elbow and proximal forearm pain are lateral tendinosis and radial tunnel syndrome. Traditionally, these 2 conditions have been treated as distinct and separate entities with most patients being diagnosed with either one or the other, but not both. The extensor carpi radialis brevis (ECRB) and, to a lesser the degree, a portion of the extensor digitorum communis that form the conjoined lateral extensor tendon are thought to be primarily responsible for the excessive traction that induces lateral tendinosis (a degenerative process of microtears in the tendon with impaired healing), but the supinator blends with these same fibers and shares a role in the pathology. The supinator, primarily the arcade of Frohse, has been thought to play the majority role in compressing the posterior interosseous nerve in radial tunnel syndrome, but the undersurface thick tendon of the ECRB may also cause substantial nerve compression. Reduction of the linear tension transmitted by the ECRB is the common element in the various surgical treatments for lateral tendinosis, performed anywhere from directly at the lateral epicondyle to the distal myotendinous junction. Nerve decompression by division of fascial bands is the goal in surgery for radial tunnel syndrome. These 2 surgical approaches need not be mutually exclusive. In fact, this separation of the 2 clinical entities may play a role in the unpredictable results reported in the literature. This article presents a unified approach to treating both pathologies simultaneously including short-term clinical results.

Reconstruction of Both Volar and Dorsal Limbs of the Scapholunate Interosseous Ligament

Complete scapholunate interosseous ligament deficiency can lead to pain, reduced functional performance, and scapholunate advanced collapse arthritis. Efforts to restore carpal stability began with procedures to tether scaphoid motion. Techniques evolved to include multiple differing strategies of linking the scaphoid to the lunate dorsally in the transverse plane. Actually restoring stability has proven elusive owing to the impossibility of truly replicating the original anatomy and the multidirectional forces to which the scapholunate interface is subjected. The described surgical technique differs from others by reconstructing both the volar and dorsal limbs of the scapholunate ligament and accounting for the multiple force vectors involved in scapholunate instability.

GENICULAR CORTICOPERIOSTEAL FLAP SALVAGE OF RESISTANT ATROPHIC NON-UNION OF THE DISTAL RADIUS METAPHYSIS

Non-union at the metaphyseal level is rare following a fracture of the distal radius. When a non-union does occur, it is usually easily treated with cancellous bone graft from the iliac crest. Resistant and multiply operated atrophic non-unions more frequently occur at the diaphyseal level of long bones. A corticoperiosteal free flap based on the articular branch of the descending genicular artery has previously been described to treat such difficult non-union cases in various sites, but not at the distal radius. At the distal radius metaphysis, the close relationship with the extensor tendons raises concern regarding the ability to fit this free flap to the non-union site without significant interference with tendon function. By careful technique of crumbling the cortex of the flap without tearing the periosteal continuity, the flap can be contoured and snugly fit to this particular site while preserving tendon function. A unique case is presented of a multiply operated resistant atrophic non-union of the distal radius metaphysis in a heavy smoker that was rapidly healed using the genicular corticoperiosteal free flap.

A PROSPECTIVE PLAN TO MINIMISE MEDIAN NERVE RELATED COMPLICATIONS ASSOCIATED WITH OPERATIVELY TREATED DISTAL RADIUS FRACTURES

Loss of median nerve function or a neuropathic pain syndrome may occur in around 20% of distal radius fractures if post-traumatic oedema in the carpal canal generates excessive pressure on the median nerve. No method currently exists to reliably distinguish which patients may benefit from a concomitant carpal tunnel release. This case series details the results of following a prospective plan designed to minimise median nerve related complications associated with distal radius fractures by measuring Semmes-Weinstein monofilament scores in 374 radius fracture patients who underwent surgical stabilisation. One hundred and sixty-nine patients with the clinical symptoms of median nerve compression, a decrement in monofilament score of grade 1 (out of 5) compared to the contralateral side or at least 4.31 g underwent concomitant carpal tunnel release. The remaining 205 patients did not have carpal tunnel release. There were no cases of neuropathic pain or loss of median nerve function.