Xavier Mir

Monteggia fractures in adults. Review of 54 cases

INTRODUCTION We present a review of Monteggia fractures treated in our hospital between 1992 and 1998. PATIENTS AND METHODS Fifty four patients with a Monteggia fracture were treated in our hospital with an average follow-up of 24 months (12-48 months). The average age was 41 years (18-81 years). According to the classification of Bado, there were 24 type I, 20 type II, 6 type III and 4 type IV. The etiology was in 27 cases a motor-vehicle and motorcycle accident, five a pedestrian struck by a car, 21 by a causal fall and only one by a direct hit by an iron bar in an assault. In 56% of the patients, the lesions were associated with polytrauma. In all the cases, treatment consisted of open reduction and internal fixation of the ulnar fracture using different methods of osteosynthesis (3.5 mm DCP, 3.5 mm reconstruction plates, 6.5 mm cancellous screw, tension band technique with Kirschner wires, and one-third tubular plates). Initial treatment of the radial head dislocation was attempted by closed reduction and verification under fluoroscopy. Subsequent open reduction and osteosynthesis were performed in 10 cases, and resection of radial head was necessary in three cases as the initial treatment. There were six open fractures with one case developing chronic infection. RESULTS Results were evaluated according to the criteria of Anderson (union fracture, elbow and wrist flexion/extension). The results were excellent in nine patients (17%), satisfactory in 33 (61%), unsatisfactory in nine (17%) and failure in three (5%). Complications could be attributed to the severity of injury, type of fixation and errors in technique (four non-union, three failure of one-third tubular plates, one distal radioulnar instability) and to some features peculiar to this lesion (five nerve injuries, three redislocations of the radial head and four radioulnar synostosis). We needed to perform 14 reoperations to resolve some of the above mentioned complications.

New surgical approach to advanced Kienböck disease: lunate replacement with pedicled vascularized scaphoid graft and radioscaphoidal partial arthrodesis.

Reconstructive procedures such as proximal row carpectomy or partial arthrodesis have been commonly proposed for advanced Kienböck disease (Lichtmann IIIB to IV). The purpose of this study is to evaluate an alternative surgical technique to advanced Kienböck disease: lunate excision and replacement with pedicled vascularized scaphoid graft and partial radioscaphoidal arthrodesis. The main advantage of the proposed intervention is to preserve mobility while not jeopardizing prime clinical outcomes such as pain. By replacing the devitalized lunate we aim at maintaining midcarpal range of motion, and preventing disease progression with carpal collapse and osteoarthritis of the wrist. Between 2002 and 2008, 13 patients of mean age 41 years (range, 25 to 57 y) were operated using this technique. The surgical act included 3 key steps. First, we excised the lunate, then, filled the generated gap with the rotated scaphoid, using it as a pedicled vascularized autograft. Finally, we performed a partial radioscaphoid arthrodesis. At the final follow-up, none of the intervened patients had pain at rest, and 6 patients could perform nonrestricted daily activities. The average postoperative range of motion in flexion/extension was 70 degrees (range, 55 to 90 degrees), 44% (range, 38% to 54%) of what could be achieved by the contralateral arm, and only 16% (range, 14% to 19%) or 25 degrees (range, 18 to 30 degrees) less than the preoperative range of motion of the same wrist. Grip strength improved by more than 30% (range, 24% to 36%). At an average follow-up of 4 years after surgery, 12 of 13 patients had no radiographic evidence of osteoarthritis or collapse of subchondral bone at the level of the new scaphocapitate joint. At follow-up evaluation, the average DASH score was 14 points (range, 6 to 20). The patients experienced a significant improvement in their functional abilities, achieving good results compared with the conventional techniques. The absence of carpal collapse and good functional results are encouraging.

Simultaneou Triple Dislocation of the Small Finger

To the Editor: Simultaneous dislocation of all phalangeal joints of a triphalangeal digit is extraordinary. The literature documents just one such a case in an index finger in 1989. We present a patient with a triple dislocation of the small finger. A 34-year-old, right-handed man experienced a direct impact to the tip of his right little finger and forced hyperextension while practicing karate. He presented to our emergency department with a grossly deformed and painful finger. There were no neurovascular or skin lesions. Radiology showed simultaneous dorsal dislocation of both interphalangeal joints and a dorsal dislocation of the metacarpophalangeal joint without any avulsion fractures (Fig. 1). Under regional anesthesia, closed reduction of the triple dislocation was achieved by longitudinal traction. The reduction was performed progressing

Periprosthetic Proximal Fracture in Total Wrist Arthroplasty

To the Editor: A periprosthetic fracture in total wrist arthroplasty (TWA) is rare. The literature documents 1 case in 1996 after revision of the distal component of a TWA for bone loosening. A 54-year-old, right-handed man fell on the right wrist, causing forced hyperextension. He had undergone right TWA (Universal Total Wrist; KMI, San Diego, CA) 9 years previously for rheumatoid arthritis. Radiographs showed periprosthetic fracture at the tip of the radial component. Computed tomography showed no signs of subsidence or loosening of radial component (Fig. 1). Fracture reduction and internal fixation were achieved with the assistance of fluoroscopic guidance. A locking compression plate using 4 distal unicortical screws and 5 proximal bicortical screws secured fixation. The fracture site was grafted by autologous cancellous bone from the patient’s olecranon. At the 12-month follow-up, the patient had recovered painless range of motion. X-rays showed bone healing and good alignment without signs of loosening. Total wrist arthroplasty is associated with complications such as joint imbalance, dislocations, and loosening of the components. Although fixation of the proximal component usually has not been a problem because the implant rests against cortical

Volar Locking Plate Breakage after Nonunion of a Distal Radius Osteotomy

We report a 38-year-old male with a nonunion followed by plate breakage after volar plating of a distal radius osteotomy. Volar locking plates have added a new approach to the treatment of distal radius malunions, due to a lower morbidity of the surgical approach and the strength of the final construction, allowing early mobilization and return to function. Conclusion. Plate breakage is an uncommon complication of volar locking plate fixation. To our knowledge, few cases have been described after a distal radius fracture and no case has been described after a distal radius corrective osteotomy. In the present case, plate breakage appears to have occurred as a result of a combination of multiple factors as the large corrective lengthening osteotomy, the use of demineralized bone matrix instead of bone graft, and the inappropriate fixation technique as an unfilled screw on the osteotomy site, rather than the choice of plate.