Maximillian Soong

Volar Locking Plate Implant Prominence and Flexor Tendon Rupture

BACKGROUND Flexor tendon injury is a recognized complication of volar plate fixation of distal radial fractures. A suspected contributing factor is implant prominence at the watershed line, where the flexor tendons lie closest to the plate. METHODS Two parallel series of patients who underwent volar locked plating of distal radial fractures from 2005 to 2008 and with at least six months of follow-up were retrospectively reviewed. Group 1 included seventy-three distal radial fractures that were treated by three orthopaedic hand surgeons with use of a single plate design at one institution, and Group 2 included ninety-five distal radial fractures that were treated by four orthopaedic hand surgeons with use of a different plate design at another institution. On the postoperative lateral radiographs, a line was drawn tangential to the most volar extent of the volar rim, parallel to the volar cortical bone of the radial shaft. Plates that did not extend volar to this line were recorded as Grade 0. Plates volar to the line, but proximal to the volar rim, were recorded as Grade 1. Plates directly on or distal to the volar rim were recorded as Grade 2. RESULTS In Group 1, the average duration of follow-up was thirteen months (range, six to forty-nine months). Three cases of flexor tendon rupture were identified among seventy-three plated radii (prevalence, 4%). Grade-2 plate prominence was found in two of the three cases with rupture and in forty-six cases (63%) overall. In Group 2, the average duration of follow-up was fifteen months (range, six to fifty-six months). There were no cases of flexor tendon rupture and no plates with Grade-2 prominence among ninety-five plated radii. CONCLUSIONS Flexor tendon rupture after volar plating of the distal part of the radius is an infrequent but serious complication. The plate used in Group 1 is prominent at the watershed line of the distal part of the radius, which may increase the risk of tendon injury. We found no ruptures in Group 2, perhaps as a result of the lower profile of the plate. Further studies are needed before recommending one plate over another. Regardless of plate selection, surgeons should avoid implant prominence in this area.

Fluoroscopic Evaluation of Intra-Articular Screw Placement During Locked Volar Plating of the Distal Radius: A Cadaveric Study

PURPOSE To evaluate specific fluoroscopic views for assessment of intra-articular screw placement during locked volar plating of the distal radius. METHODS The distal radius of a cadaver forearm was plated with a fixed-angle volar plate according to the surgical technique guide of the manufacturer. A goniometer was used to place the specimen at various described angles in the fluoroscope including standard posteroanterior (PA), tilt PA (11 degrees ), standard lateral, and tilt lateral (15 degrees , 23 degrees , 30 degrees ) views. Radiographic images of each screw individually and in various combinations were digitally captured. RESULTS Only the tilt PA view correctly showed all 4 screws to be extra-articular. On the standard PA view, the 2 ulnar screws appeared intra-articular. Lower angle tilt lateral views (15 degrees and 23 degrees ) correctly visualized the ulnar screws but not the styloid screw. The highest angle lateral view (30 degrees ) correctly visualized the radial screws but not the sigmoid (most ulnar) screw. The styloid screw appeared to be intra-articular on every lateral view except at 30 degrees and was correctly visualized on both the PA and tilt PA views. CONCLUSIONS Multiple oblique views are required for evaluation of intra-articular screw placement during locked volar plating of the distal radius. Lower angle tilt lateral views are more specific for the ulnar screws, and higher angle views are more specific for the radial screws. We suggest first placing the ulnar screws whenever possible, using lower angle tilt lateral views (15 degrees to 23 degrees ) to evaluate for intra-articular placement. The styloid screw may be placed last and can then be evaluated on the PA and tilt PA views.

Long-Term Results of Bone-Retinaculum-Bone Autograft for Scapholunate Instability

PURPOSE To report long-term follow-up of scapholunate interosseous ligament reconstruction with bone-retinaculum-bone autograft in patients with dynamic scapholunate instability. METHODS Of the 14 patients from the previously reported cohort who had bone-retinaculum-bone autograft for dynamic instability, 6 returned for clinical examination and radiographs, 3 were reached by telephone, and 2 were lost to follow-up. The remaining 3 had salvage procedures (2 total wrist arthrodeses and 1 proximal row carpectomy) between the prior report and the current study and thus reached an endpoint, at 2 to 4 years. For the 6 who returned, outcome measurements included scapholunate angle and gap, radiographic evidence of secondary arthritis, wrist extension and flexion, grip strength, and Mayo wrist score. RESULTS Follow-up averaged 11.9 years (range, 10.7-14.1 y). Clinical and radiographic outcomes deteriorated moderately from the prior report. Mayo wrist score averaged 83. There were 3 failures, resulting in 1 proximal row carpectomy and 2 total wrist arthrodeses. Findings at repeat surgery in the failed group included an intact graft without any apparent abnormalities, a partially ruptured graft (after a subsequent re-injury), and a completely resorbed graft. CONCLUSIONS Bone-retinaculum-bone autograft reconstruction is a viable treatment option for dynamic scapholunate instability in which the scaphoid and lunate can be reduced. Results may deteriorate but are similar to those reported previously from other techniques. Problems with graft strength or stiffness may necessitate further surgery.

Ring and Little Finger Metacarpal Fractures: Mechanisms, Locations, and Radiographic Parameters

PURPOSE To describe a series of ring and little finger metacarpal fractures with regard to mechanism, location, midshaft diameter, and isthmus diameter, to better define injury patterns and assist the surgeon in selection of appropriately sized implants. METHODS We reviewed all metacarpal fractures in skeletally mature patients who presented to a single surgeon over a 2-year period. Fractures of the ring and little finger metacarpals were analyzed with regard to mechanism and fracture location. Metacarpal midshaft and minimum isthmus diameters were measured on posteroanterior radiographs. RESULTS A total of 101 fractures involved the ring and little finger metacarpals. Punching-type injuries accounted for most fractures in the little finger metacarpal (49 of 67) and ring finger metacarpal (26 of 34). Among these punching-related ring and little finger metacarpal fractures, the most common fracture location was the little finger metacarpal neck (34 of 75), followed by the ring finger metacarpal shaft (21 of 75). Among men in this series, the metacarpal midshaft and minimum isthmus diameters were significantly narrower in the ring finger metacarpal than in the little finger (7.4 vs 8.7 mm, p < .001; and 2.2 vs 3.8 mm, p < .001). CONCLUSIONS Whereas punching injuries tended to cause neck fractures in little finger metacarpals in this series, they caused shaft fractures in ring finger metacarpals, which may thus be considered a variant boxers fracture. Furthermore, in men with fractures, the ring finger metacarpal is significantly narrower than the little finger, both in midshaft diameter and isthmus diameter, which surgeons should consider when planning internal fixation. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.

Ulnar nerve palsy associated with fracture of the distal radius

Objective: To describe the clinical features and outcome of a series of patients with complete motor and sensory ulnar nerve palsy associated with a fracture of the distal radius. Design: Retrospective case series. Setting: Level 1 trauma center. Patients/Participants: Five adults with acute complete motor and sensory ulnar nerve palsy associated with fracture of the distal radius were treated during a 2 year period. There were 3 men and 2 women, with an average age of 42 years (range, 33 to 56 years). All 5 distal radius fractures were high energy and widely displaced. Three patients had an associated ulna fracture (2 styloid, 1 styloid and distal diaphysis), and 1 had a complete triangular fibrocartilage complex (TFCC) avulsion from the distal ulna (associated with an open wound). Two patients had open fractures. Intervention: Open reduction and internal fixation of the distal radius fracture in 4 patients and external fixation in 1 patient. Three patients had exploration and release of the ulnar nerve because it was associated with an acute carpal tunnel syndrome. Main Outcome Measurements: Recovery of ulnar nerve function. Results: At an average follow-up of 17 months, 4 patients had complete or near-complete recovery of ulnar nerve function. One patient had moderate motor and mild sensory dysfunction. Conclusions: Acute ulnar nerve palsy may occur in association with high-energy, widely displaced fractures of the distal radius. These are usually neurapraxic injuries that recover to normal or near-normal strength and sensation. We recommend exploration and release of a complete ulnar nerve palsy associated with a fracture of the distal radius fracture when there is an open wound or an acute carpal tunnel syndrome, and observation without exploration otherwise.

Prospective Evaluation of an Opioid Reduction Protocol in Hand Surgery

PURPOSE We investigated whether written guidelines for surgeons and educational handouts for patients regarding safe and effective opioid use after hand surgery could reduce prescription sizes while achieving high patient satisfaction and a low refill rate. METHODS All patients undergoing isolated carpal tunnel release or distal radius volar locked plating in a hand surgery group practice during a 6-month period were prospectively enrolled. Surgeons prescribed analgesics at their own discretion based on written guidelines. Patients received an educational handout regarding safe opioid use and disposal, a diary to record daily pain visual analog scale score and consumption of opioid and over-the-counter (OTC) analgesics, and a pain catastrophizing scale questionnaire. Collected data were compared with a retrospective cohort of the same surgeons, procedures, and period 1 year earlier. RESULTS In the carpal tunnel release group (121 patients), average prescription size was 10 opioid pills, compared with 22 in the prior year. Average consumption was 3 opioid pills, supplemented with 11 OTC pills. In the volar locked plating group (24 patients), average prescription size was 25 opioid pills, compared with 39 in the prior year. Average consumption was 16 opioid pills, supplemented with 20 OTC pills. Patient satisfaction was comparably high in both groups. Eight patients required opioid refills overall. Patients with pain catastrophizing scale greater than 10 used more than twice as many opioid pills. Of 109 patients with leftover opioids, 10 reported proper disposal. CONCLUSIONS Written guidelines and educational handouts significantly reduced the number of prescribed opioid pills by 35% to 55% while achieving high patient satisfaction and a low refill rate. We recommend 5 to 10 opioid pills for carpal tunnel release and 20 to 30 for distal radius volar plating. Pain catastrophizing is associated with greater opioid consumption and may help target patients for additional support. Potential for opioid abuse and diversion may persist despite these interventions. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.

Acute contaminated open forearm fractures treated with VersaJet Hydrosurgical Débridement.

The ideal method of irrigation and débridement for severe extremity wounds has yet to be determined. This report demonstrates the use of hydrosurgical débridement in the treatment of highly contaminated acute forearm fractures in a 22-year-old man ejected during a motor vehicle crash in a farm area. The result was rapid, selective, and effective débridement of deeply embedded material, which allowed for expeditious reconstruction with internal fixation, tendon transfers, and groin flap coverage while avoiding infection and injury to vital structures. The technique is described in detail and the current literature is reviewed.

Acute Forearm Compartment Syndrome Secondary to Digit Avulsion Injury: A Case Report

Patients with mutilating hand and finger injuries often present first to orthopaedic, plastic, or general surgeons covering emergency room call and sometimes present only by telephone consultation. The present report describes a patient who presented with a severe finger avulsion in whom the most urgent issue was an ipsilateral forearm compartment syndrome secondary to the avulsion. The patient was informed that data concerning the case would be submitted for publication, and he consented. A fifty-five-year-old man was using a high-speed rotary tool, which caught a nylon cord that became wrapped around the right, dominant index finger. He presented to the emergency room with an open dislocation of the proximal interphalangeal joint. The soft tissues were nearly circumferentially avulsed (Fig. 1). Distally, the finger was dusky and insensate. The remaining fingers had normal color and capillary refill. The patient was otherwise healthy and denied taking any regular medications, including Coumadin (warfarin) and anti-inflammatory medications. Fig. 1 Near circumferential degloving injury of the index finger. The patient complained of severe and worsening pain in the forearm and required 8 mg of intravenous hydromorphone in one hour. Physical examination revealed tense swelling and tenderness, which was greatest at the volar aspect of the middle part of the forearm and was worse with passive extension of the uninjured digits. He also complained of numbness in the median and ulnar nerve distributions, where he had corresponding decreased sensibility on examination. Radial and ulnar pulses were palpable at the wrist. Radiographs of the hand reflected dislocation of the proximal interphalangeal joint of the …

Metacarpal fractures in the athlete

Purpose of reviewTo describe current evaluation and treatment of metacarpal fractures in athletesRecent findingsBiomechanical and clinical studies involving lower-profile, locking, shorter length, and double-row or separate-dual plate configurations, as well as intramedullary screw fixation, have demonstrated the potential benefits of internal fixation with promising results.SummaryTreatment should be customized to the specific athlete and injury, and is often successful without surgery, or with percutaneous pin fixation. Internal fixation of metacarpal fractures has improved with new hardware and new techniques, and may expedite return to play, although further clinical studies are needed.

Kienbock's Disease and Scapholunate Dissociation after Acute Wrist Trauma

Scapholunate dissociation is well-known to result from acute wrist trauma [9], or in some cases from chronic crystalline synovitis [1, 6]. The etiology of Kienbock’s disease, or osteonecrosis of the lunate bone, remains unclear, and is likely multifactorial. Trauma may be contributory, although variations in lunate and radial morphology, ulnar-negative variance, lunate vascular pattern, disruption of venous outflow, and systemic conditions such as autoimmune disease and sickle cell anemia have all been associated [5, 12]. Both conditions have been studied extensively as independent pathologies, without any defined relationship. We present a case of Kienbock’s disease accompanied by scapholunate dissociation precipitated by a single traumatic event and followed by simultaneous progression. Both conditions have a variety of treatment options and remain controversial, reflecting a lack of prevailing reliably effective and durable surgical procedures, a lack of high-level evidence, and an uncertain natural history [5, 7, 8, 12]. The combination of these conditions presented unique concerns and was ultimately treated successfully with proximal row carpectomy.