P.-B. Rey

Technical note: How to spare the pronator quadratus during MIPO of distal radius fractures by using a mini-volar plate.

Few surgical approaches have been described that spare the pronator quadratus (PQ) during the treatment of distal radius fractures. The PQ supplies blood to the distal radial epiphysis, helps stabilize the distal radio-ulnar joint, and contributes 21% of pronation strength. Sparing the PQ should result in faster bone union and shorter recovery time. To achieve these goals, we currently use a minimally-invasive volar procedure using a specially-designed short plate (APTUS Wrist 2.5 XS, Medartis(©)). A 20mm incision is made over the fracture line as described by Henry. The PQ is dissected and then detached from the volar side of the radius. Forceps are used to slide the plate under the muscle. The screws are locked after carefully elevating the distal edge of the PQ. A preliminary study of distal radius fracture fixation by this technique was performed in 31 patients. The scar was 26mm in length and the duration of surgery was 34minutes on average. Patients wore a removable brace for 15 days, and passive wrist motion without loading was allowed during the first week. Functional recovery was faster than seen in previously published series. An average Quick DASH score of 10 was achieved by the 10th post-operative week. Although there are no contraindications to this technique, the quality of the reduction is more important than the scar size and desire to spare the PQ. Never hesitate to convert the incision to a classical Henry approach if technical difficulties arise. Our technique seems best suited to patients with high functional demands. It is currently being evaluated in a prospective series.

Article originalAspects anatomiques et biomécaniques des fractures du radius distal de l’adulte : revue de la littératureAnatomy and biomechanics of distal radius fractures: A literature review

Distal radius fractures remain the most frequent fractures in the adult. Associated osteoporosis increases morbidity risk (secondary displacement is the most frequent) and mortality risk (in women older than 60). Severity of the fracture and functional results are related to the bone mineral density. Anatomy has been recently revisited with better description of palmar and dorsal aspects in order to avoid material-related complications. Standard postero-anterior, lateral and oblique radiographs of the wrist show the fracture and the displacement. CT scan is warranted if conventional X-rays are insufficient to show the articular surface. The involvement of the metaphysis (comminution), the epiphysis (articular fracture) and the ulna is different in each case and each fracture is an association of these three components. The MEU classification describes the fracture with sufficient inter-observer reliability and intra-observer reproducibility to be a useful tool for treatment and prognosis. The PAF system is used to propose the most appropriate treatment for each patient. Anatomical reduction and stable fixation are associated with good functional results but in high demanding patients.

Anatomical and computed tomography study of the eighth costochondral junction: topography for costochondral graft harvesting

IntroductionCostochondral grafts have long been used in maxillofacial reconstruction, but have been little used in trauma and orthopedic cases. This surgical technique requires that a graft be harvested from the thorax in the area of the eighth rib. Pleuropulmonary complications are very rare. Although the harvesting technique is simple, it needs to be demystified.Goal of studyThis study was performed to define anatomical relationships in the eighth costochondral junction and identify topographical and anatomical landmarks that will make it easier to harvest this structure.MethodThis was a two-part study. First, an anatomical study was carried out on human cadaver thoraxes to define topographical landmarks and study the anatomical surroundings of the eighth costochondral junction. Second, an imaging study was performed using a database of existing patient computed tomography (CT) scans of the chest and abdomen to confirm the topographical landmarks defined in the first part of the study. The spine was used as a reference for both studies. The location of the eighth costochondral junction was defined relative to the spinal processes along with its location on the lower rib cage hemiperimeter in the transverse plane starting at the corresponding spinous process.ResultsThe eighth costochondral junction was in line with the spinal process of the twelfth thoracic vertebra in the vast majority of cases and located at two-thirds of the lower rib cage hemiperimeter from the posterior median sulcus, regardless of the patient’s chest shape, age and gender. This junction was always located under a single muscle (external oblique) and protected by a thick perichondrium layer, which separates it from the intercostal pedicles, endothoracic fascia and parietal pleura.DiscussionThis two-part study has identified reliable landmarks for harvesting of an osteochondral graft at the eighth costochondral junction and, by describing its anatomical surroundings, helps take the mystery out of its harvesting. These landmarks were identified in supine cadavers and in free-breathing patients lying in supine for the CT portion. This position must be used when identifying these landmarks in a patient undergoing costochondral autograft harvesting for cartilage reconstruction.

Functional treatment of metacarpal diaphyseal fractures by buddy taping: A prospective single-center study

Metacarpal diaphyseal fractures are classically treated using a non-removable glove for 4 to 6 weeks. Here, we report the results of treatment by immediate active protected mobilization (buddy taping for four weeks) of minimally displaced M2 to M5 fractures. Fifty-four fractures (15 transverse or short oblique and 39 spiral or long oblique) in 51 patients were included during a one-year period; the average age of patients was 31 years. Clinical and radiographic assessments were carried out at day 15 and then months 1, 2 and 6 post-fracture. Thirty-one cases were reviewed at day 15, 27 at 1 month, and 22 at 2 months. The initial volar tilt was 26° on average for the short oblique or transverse fractures, and 11.5° for the long oblique or spiral fractures. Six fractures (11%) experienced 16.6° of secondary displacement on average. The fracture was healed in 37% of cases at 1 month, and in 100% of cases at 2 months in the patients who were reviewed clinically. Reduction in the QuickDASH and VAS for pain was evidence of fast functional recovery. The range of motion was comparable to that of the contralateral side in 90% cases after 2 months. Grip and pinch strength was 33% less than the contralateral side at 2 months. Although secondary displacement occurs in some cases, the functional results of this simple and practical treatment method are good after 2 months, as there is little pain, stiffness, strength loss and no cases of nonunion.

Snowblower injuries to the hand.

The aim of this study was to describe the nature and incidence of hand injuries caused by snowblowers, as well as the accident conditions and accident prevention. We conducted a retrospective evaluation over ten consecutive winters. Nine patients were included. All were men with an average age of 49.7 years (17-71). The accidents occurred at home in seven out of nine patients. The machine was running in 50% of the injury events. In most cases, the injuries occurred when the patient tried to unclog snow from the lateral discharge chute. Only four out of the nine patients had read the instructions or received instructions from the salesperson. The dominant hand was injured in 7 out of 9 patients. An average of 2.7 fingers were injured. The longest fingers were most commonly injured: 8 middle fingers, 7 ring fingers, 4 little fingers, 2 indexes and 1 thumb. All the fractures were open. Three patients were operated on several times. In 7 out of 9 cases, the patients had sequelae such as amputation. The mean time off work was 11.4 weeks (3-24). All the patients were experienced snowblower users (9 years and 57th use on average). Snowblower accidents are very mutilating. Prevention must include protected access to blades and better verbal and written safety warnings.