Seung-Han Shin

Open reduction and internal fixation for Mason type III radial head fractures: Is it different from that for Mason type II fractures?

Purpose: The objective of this study was to investigate whether the outcomes of Mason type III radial head fractures (RHFs) treated by open reduction and internal fixation (ORIF) were comparable to those of Mason type II RHFs treated by ORIF. Methods: A total of 87 surgically treated RHF patients were reviewed. Their fractures were Mason type II in 39 patients (all treated by ORIF) and Mason type III in 48 patients (40 treated by ORIF, 7 by radial head arthroplasty, and 1 by resection). Although ORIF was preferred for Mason type III RHFs in our series, an arthroplasty was performed when the fracture accompanied severe associated injuries or multiple traumas. Radiological and functional outcomes were evaluated and complications were reviewed. Results: When Mason type II and Mason type III in general were compared, QuickDASH score, a shortened version of the Disabilities of the Arm, Shoulder and Hand (DASH) score, and forearm rotation were significantly worse in Mason type III. However, when comparing Mason type II and Mason type III treated by ORIF in which the proportion of associated injuries were not significantly different, there was no significant difference in QuickDASH score, range of extension/flexion, or complication rate. Forearm rotations were significantly more limited in Mason type III treated by ORIF (7° for pronation and 7° for supination), and Mason type had an independent effect on forearm rotations in multivariate analysis. Conclusion: ORIF for Mason type III fractures with low level of associated injury can be as good as that for Mason type II fractures, except for less forearm rotation.

During forearm rotation the three-dimensional ulnolunate distance is affected more by translation of the ulnar head than change in ulnar variance

Ulnolunate abutment has been thought to be aggravated by pronation because of an increase in ulnar variance. We hypothesized that the ulnolunate distance might be greater in pronation because the ulnar head is dorsally translated. Twenty-one three-dimensional reconstructions of computed tomographic scans of wrists taken in supination and pronation were investigated. The ulnolunate distance was measured in each position, and the change in ulnolunate distance from supination to pronation was calculated. The changes in ulnar variance from supination to pronation and the amount of translation of the ulnar head were measured directly by superimposing three-dimensional reconstructions. The mean ulnolunate distance in pronation was significantly greater than in supination. There was no significant correlation between the changes in ulnolunate distance and in the ulnar variance. The change in ulnolunate distance had a significant positive linear relationship with the amount of translation of the ulnar head. The change in ulnolunate distance during forearm rotation is determined by the amount of translation of the ulnar head rather than by change in ulnar variance. Level of evidence: IV

Where Is the Ulnar Styloid Process? Identification of the Absolute Location of the Ulnar Styloid Process Based on CT and Verification of Neutral Forearm Rotation on Lateral Radiographs of the Wrist

Background The location of the ulnar styloid process can be confusing because the radius and the hand rotate around the ulna. The purpose of this study was to identify the absolute location of the ulnar styloid process, which is independent of forearm pronation or supination, to use it as a reference for neutral forearm rotation on lateral radiographs of the wrist. Methods Computed tomography (CT) images of 23 forearms taken with elbow flexion of 70° to 90° were analyzed. The axial CT images were reconstructed to be perpendicular to the distal ulnar shaft. The absolute location of the ulnar styloid process in this study was defined as the position of the ulnar styloid process on the axial plane of the ulnar head relative to the long axis of the humeral shaft with the elbow set in the position for standard lateral radiographs of the wrist. To identify in which direction the ulnar styloid is located on the axial plane of the ulnar head, the angle between “the line of humeral long axis projected on the axial plane of the ulna” and “the line passing the center of the ulnar head and the center of the ulnar styloid” was measured (ulnar styloid direction angle). To identify how volarly or dorsally the ulnar styloid should appear on the true lateral view of the wrist, the ratio of “the volar-dorsal diameter of the ulnar head” and “the distance between the volar-most aspect of the ulnar head and the center of the ulnar styloid” was calculated (ulnar styloid location ratio). Results The mean ulnar styloid direction angle was 12° dorsally. The mean ulnar styloid location ratio was 1:0.55. Conclusions The ulnar styloid is located at nearly the ulnar-most (the opposite side of the humerus with the elbow flexed) and slightly dorsal aspects of the ulnar head on the axial plane. It should appear almost midway (55% dorsally) from the ulnar head on the standard lateral view of the wrist in neutral forearm rotation. These location references could help clinicians determine whether the forearm is in neutral or rotated position on an axial CT/magnetic resonance imaging scan or a lateral radiograph of the wrist.

Feasibility and Advantages of Full Thickness Skin Graft from the Anterolateral Thigh

BACKGROUND Full thickness skin graft (FTSG) gives better outcomes than split thickness skin graft (STSG), but it has the drawback of limited donor sites. Anterolateral thigh (ALT), a popular donor site of STSG, is also a popular donor site of perforator flaps. This area has the advantage of large flap size available with primary closure. Based on this we harvested FTSG instead of STSG from the ALT. METHODS We retrospectively reviewed 10 cases of FTSG from the ALT, with the recipient site of foot in 3, ankle in 2, lower leg in 2, forearm in 2, and wrist in 1 patient. In all cases elliptical full thickness skin was harvested from the ALT, and the donor site was closed primarily. The skin was defatted and placed onto the defect with vacuum-assisted closure (VAC). The skin size ranged 7-30 cm in length and 3-12 cm in width. Mean follow up period was 7 months (range, 3-13). RESULTS FTSG from the ALT provided durable wound coverage, with excellent color and texture matching. Partial (< 20%) graft failure was observed in 1 case, but no additional surgery was necessary. No patient reported donor site pain at postoperative 2 weeks. No donor site complications were encountered. No patient complained a feeling of tension in the thigh at final follow-up. CONCLUSIONS FTSG from the ALT is feasible with the aid of VAC. Considering the skin quality, large skin size available, early pain relief, and little donor site morbidity, the ALT should be revisited as a donor site of FTSG.

Sauve-Kapandji Procedure in Patients With Advanced Distal Radioulnar Joint Arthritis

Purpose: We evaluated the clinical and radiographic outcome of the Sauve-Kapandji procedure for the treatment of advanced distal radioulnar joint arthritis. Materials and Methods: Between January 2001 and July 2013, 26 patients, 31 wrists were treated for advanced distal radioulnar joint arthritis with Sauve-Kapandji procedure. Twenty-two patients (27 wrists) had rheumatoid arthritis and the remaining 4 patients (4 wrists) had osteoarthritis. The average age of patients was 50 years (range, 25-74 years). Twenty-one patients were women and 5 were men. Patients were evaluated in terms of wrist pain, bony union, instability of the ulnar proximal stump, ulnar stump pain, range of motion, and other complications. Pain was evaluated using a visual analogue scale (VAS). Radiographic evaluation included calculation of the carpal translation index to assess the extent of ulnar translation of the carpus. The average follow-up period after surgeries was 36.8 months (range, 6-152 months). Results: Pain was resolved in 24 patients with 29 wrists, but mild pain was remained in 2 patients (2 wrists). The average VAS score improved from 4 ± 1.88 preoperatively to 0.71 ± 0.9 at the last follow-up (P = .001). Bone unions in distal radioulnar joint were obtained in all 26 patients, 31 wrists at mean 10.7 (range, 6-28) weeks after operation. The supination/pronation range of motion was changed from 55/50° preoperatively to 79/71° at postoperative 6 months follow-up (P = .31). The mean carpal translation index did not change after the operation. Conclusion: The Sauve-Kapandji procedure is a reliable method of relieving pain, preserving range of motion (supination/pronation) and preventing ulnar translation of the carpus in managements of the severely destroyed distal radioulnar joints.

Accuracy of Radiographic Evaluation of Ulnar Styloid Base Fracture by Simple Radiogram

Purpose: There remains uncertain whether to fix an ulnar styloid fracture accompanied by distal radius fracture. Fixation should be required in cases of the fracture involving a fovea of ulnar head, an attachment site of deep portion of triangular fibrocartilage. We analyzed the patients with ulnar styloid fracture accompanied by distal radius fracture using simple radiograph and 3D computed tomography (3D CT) scan images, respectively, and compared accuracy of evaluation for the types of ulnar styloid fractures, which might designate the treatment methods. Materials and Methods: We retrospectively reviewed 168 patients who underwent surgery for distal radius fracture in our hospital from January 2005 to March 2015, and evaluated whether ulnar styloid base was involved using simple radiographs and 3D CT scan images. The accuracy of evaluation by simple radiographs was compared with the findings of 3D CT scan images. To avoid the effect of memory, evaluation using 3D CT scan images was performed in a randomized order 2 weeks after initial evaluation for simple radiograph. Results: On simple radiographs, 64 patients (38%) had ulnar styloid base fractures; however, 21 cases of these revealed nonbase fractures by 3D CT scan images. And 7 out of 104 cases, on simple radiographs, determined as nonbase fracture by simple radiographs, were diagnosed as base fractures by 3D CT scans. Based on the findings of 3D CT scan images, the accuracy of simple radiographic evaluation for types of ulnar styloid fractures was 83%, with 86% sensitivity and 82% specificity. The positive predictive value was 67% and the negative predictive value was 93%. Conclusion: Accuracy of radiographic evaluation of ulnar styloid base fracture accompanied by distal radius fracture, when compared with 3D CT, was 83%. Therefore, we recommend that 3D CT scan image–based evaluation should be performed in case of unclear involvement sites so as to determine whether to fix it or not.