桡骨远端C型骨折掌侧锁定钢板与外固定架的疗效比较

目的比较掌侧锁定钢板与外固定架治疗桡骨远端C型骨折的疗效。方法采用随机对照法,纳入2014年10月到2017年10月收治的桡骨远端C型骨折患者,随机分为两组,分别采用外固定架或者掌侧锁定钢板治疗。比较两组患者手术时间、术中出血量、骨折愈合时间、术后并发症发生率;比较末次随访时患者腕关节活动度、桡骨掌倾角、尺偏角;比较健、患侧握力比值和患侧腕关节Gartland-Werley评分。结果共纳入30例患者,其中外固定架组14例,掌侧锁定钢板组16例。两组患者术后均随访1年。结果显示,掌侧锁定钢板组手术时间长于外固定架组,术中出血量多于外固定架组,但末次随访时桡骨掌倾角、尺偏角恢复水平优于外固定架组(P<0.05);两组骨折愈合时间,末次随访时腕关节屈伸、旋转活动度,健、患侧握力比,患侧腕关节Gartland-Werley评分等,均未见明显统计学差异(P>0.05);两组患者均未发生术后并发症。结论对于桡骨远端C型骨折,外固定架治疗的手术风险小于掌侧锁定钢板,但会造成术后一定程度的复位丢失,然而这种复位丢失并不影响患者的腕关节功能恢复。     

微型骨锚治疗手指近侧指间关节慢性掌板撕脱性损伤

目的介绍应用微型骨锚治疗手指近侧指间关节慢性掌板撕脱性损伤的手术治疗方法。方法对8例慢性掌板损伤病例,采用手术切开,掌板松解,Mitek微型骨锚重建撕脱掌板止点,术后早期进行屈伸功能锻炼。术后1年随访,随访内容包括手指近侧指间关节(proximal interphalangeal point,PIP)活动范围,关节疼痛,工作能力和患者主观满意度。结果本组患者术前PIP活动度为55.3°±27.8°,术后12个月为80.6°±17.6°(P<0.01)。3例优;3例良;2例一般;优良率达到75%。结论应用微型骨锚重建PIP关节撕脱掌板止点,恢复撕脱掌板正常的解剖学关系,能有效治疗慢性掌板撕脱伤;显著改善患指屈伸功能;缓解疼痛。     

Locking of a metacarpo-phalangeal joint caused by a haemangioma of the volar plate

A case of locking of a metacarpo-phalangeal joint in a 47-year-old woman is reported. Full movement of the joint was restored after excision of a haemangioma which had arisen from the volar plate. Other causes of locking are described and recommendations for treatment are made.     

Volar plate arthroplasty for osteoarthritis of the proximal interphalangeal joint: a preliminary report

Osteoarthritis of the hand, including involvement of the proximal interphalangeal joint, is common in the aging population. The purpose of this study is to provide a preliminary retrospective report on 12 volar plate arthroplasties in 9 patients who had volar plate advancement arthroplasty for osteoarthritis of the proximal interphalangeal joint. The average age of the patients was 67.6 years. All of the patients' data were obtained from office notes and hand therapy assessment sheets. The average time from surgery to follow-up evaluation was 36.5 months. All patients had significant pain relief. Range of motion was maintained; there was no significant difference between preoperative and final arc of motion values. Preoperative pinch and grip strengths did not differ significantly from the final values. Postoperative position was similar to preoperative angulation, with recognized lateral stability. Our results suggest that volar plate advancement arthroplasty represents a good primary surgical therapeutic option for the osteoarthritic proximal interphalangeal joint, providing pain relief while preserving motion, strength, and stability.     

Volar plate arthroplasty of the distal interphalangeal joint

Ten patients with chronic dorsal fracture subluxation of the distal interphalangeal joint were managed over 5 years with volar plate advancement arthroplasty. The mean time from injury to definitive surgical treatment was 8 weeks (range, 2 weeks to 4 months). All injuries were characterized by volar comminution and impaction of the distal phalanx, with associated dorsal subluxation. Surgical treatment included volar plate advancement arthroplasty and K-wire fixation of the reduced joint for 4 weeks. All patients were evaluated at an average postoperative duration of 25 months (range, 10-60 months). The average arc of motion of the distal interphalangeal joint of the 4 fingers (6) was 42 degrees and of the interphalangeal joint of the thumb (4) was 51 degrees. All patients had a residual flexion contracture averaging 12 degrees (range, 6 degrees to 25 degrees ). Volar plate advancement arthroplasty is an effective treatment for chronic distal interphalangeal joint dorsal fracture subluxation.     

掌板关节囊松解术治疗压砸伤术后掌指关节屈曲障碍

目的 探讨应用掌板关节囊松解术治疗手掌严重压砸伤造成的掌指关节屈曲障碍.方法 2005年9月-2008年6月,应用掌板关节囊松解术治疗8例严重压砸伤术后掌指关节被动屈曲障碍的患者,并进行随访,结合蜡疗及功能锻炼观察掌指关节屈曲功能的恢复情况.结果 8例患者均为第3掌指关节被动屈曲障碍,术后关节屈曲功能均获明显改善.屈曲失能角度(F)减小,达到0°～30°;失能值降低,达到0%～18%.结论 应用掌板关节囊松解术治疗手掌严重压砸伤造成的掌指关节屈曲障碍,是一种操作简便、疗效可靠的良好方法.     

An irreducible dislocation of the great toe. Report of two cases and review of the literature

Irreducible dislocation of an interphalangeal (IP) joint of the great toe is a rare condition. Twenty-two cases including the present two cases are reported in available literature. Two different types are identifiable. In one type, where the ruptured volar plate is displaced into the joint space between two phalanges, the toe is slightly elongated, but the deformity of the toe is not so marked. In the other type, where the volar plate is completely displaced over the proximal phalangeal neck, the deformity of the toe is extreme as the IP joint is locked in hyperextension. In the former type, the dislocation is often misinterpreted to have been repositioned manually because of relatively slight deformity. In either type of dislocation, the volar plate is detached from both the distal and proximal phalanges, and so displaced into the joint, as to form a barrier to manual repositioning. Open reduction is mandatory.     

Proximal interphalangeal joint fracture dislocations

Proximal interphalangeal joint fracture dislocations are complex, potentially disabling injuries for any patient, especially the competitive athlete. Dorsal fracture dislocations are fairly common and volar fracture dislocations are rare. Stable injuries often heal with minimal functional deficit, whereas unstable injuries can result in limitation in range of motion, joint incongruity, and degenerative joint disease. A number of surgical procedures have been described to treat the unstable dorsal fracture dislocation, including ORIF, extension block pinning, external fixation, dynamic traction, and volar plate arthroplasty. Volar fracture dislocations are usually amenable to closed or open reduction and internal fixation. The results of treatment of both volar and dorsal fracture dislocations can be unpredictable.     

Transverse volar skin laceration of the finger: Sign of volar plate injury.

Transverse tears of the volar skin of a finger with a hyper-extension injury is associated with frequent volar plate tears or avulsions. Recognition is essential for surgical exploration of the volar plate and supporting joint structures and, if injured, surgical repair should be carried out at the time of skin suturing.     

A simplified technique for treating the complex dislocation of the index metacarpophalangeal joint.

The volar approach to open reduction of the complex dislocation of the index metacarpophalangeal joint as described by Kaplan proved to have certain disadvantages. Digital nerves are easily damaged during exposure and there is a limited view of the entrapped fibrocartilaginous volar plate dorsal to the metarcarpal head. A direct dorsal longitudinal incision through the skin and extensor tendon gives full exposure. The volar plate attached to the proximal phalanx and trapped over the dorsal aspect of the metacarpal head is in full view. The volar plate is split longitudinally and the dislocation reduces spontaneously as the flexor tendons and lumbrical muscle slip by the metacarpal head. The advantages of this approach as compared with the volar approach are: (1) there is full exposure of the fibrocartilaginous volar plate, the main structure blocking reduction; (2) digital nerves are not as apt to be damaged; and (3) accurate reduction and fixation of the osteochondral fracture of the metacarpal head, frequently seen with this dislocation, is possible.     

Treatment of hyperextension deformity of the thumb metacarpophalangeal joint in basal joint arthritis: a novel technique based on an anatomic study

Advanced stages of basal joint arthritis are sometimes characterized by an adduction deformity of the first metacarpal and a hyperextension deformity of the unstable metacarpophalangeal (MCP) joint. Stabilizing the MCP joint in these patients is critical to ensure a pain-free repair and efficient pinch mechanism. This study presents the anatomic basis for a novel capsulodesis technique using the volar plate that can be incorporated into any reconstructive basal joint procedure when clinically indicated. Eleven normal cadavers were dissected to expose the volar plate. The dimensions of the volar plate, relationship of the sesamoid bones to the oblique pulley, and the distance from the sesamoids to the base of the proximal phalanx were compared between specimens. The radial border of the volar plate measured 8.5 ± 1.3 mm, ulnar border 8.8 ± 1.0 mm, proximal border 7.5 ± 1.0 mm, and distal border 7.8 ± 0.6 mm. The distance between the ulnar sesamoid bone and the oblique pulley measured 12.1 ± 1.1 mm and from the radial sesamoid to the oblique pulley measured 16.6 ± 0.2 mm. The distance between the sesamoids and the base of the phalanx measured 2.2 ± 0.2 mm. The anatomic studies provide a foundation on which the surgeon can understand the complex nature of the MCP joint. This study describes a novel technique for MCP capsulodesis of the thumb in which volar plate flaps are imbricated to provide stability to the MCP joint, obviating the need for suture anchors and tendon grafts.     

Reconstruction of the unstable proximal interphalangeal joint: The double superficialis tenodesis

A technique is described for reconstructing the unstable proximal interphalangeal joint where there has been a break in continuity of both the volar plate and the collateral ligament. Both slips of the superficialis are used. They are divided proximally and tenodesed in appropriate positions on the proximal phalanx.     

Ulnar deviation after volar subluxation of the proximal interphalangeal joint

A rare case of irreducible and progressive ulnar deviation after volar subluxation of the proximal interphalangeal joint is presented. An immobilized proximal interphalangeal joint with remaining volar subluxation after improper reduction showed ulnar deviation at 3 weeks after injury. During surgery, the radial collateral ligament was found to be ruptured at its origin, with formation of concomitant scar tissues. There were no apparent lesions at the central slip, lateral band, and volar plate. Interposition of the ruptured ligament and infiltration of the surrounding scar tissues into the proximal interphalangeal joint were identified. Surgical incision of the capsule along the dorsal margin of the radial collateral ligament readily produced successful reduction. The irreducible and progressive ulnar deviation of the proximal interphalangeal joint seemed to result from gradual infiltration of the scar tissues, subsequent to remaining volar subluxation because of interposition of the ruptured collateral ligament.     

Metacarpophalangeal arthroscopy.

Although small joint arthroscopy has become commonplace over the past decade, relatively little attention has been paid to the investigation and clinical utility of metacarpophalangeal (MP) joint arthroscopy. The literature is scant in this area and consists of only a handful of case reports. In addition, the arthroscopic anatomy of the MP joint has not as yet been reported. Six cadaveric hands (24 joints) were rigorously studied in the laboratory using standard 2.5-mm small joint arthroscopic instrumentation and 5 lb of overhead traction. Radial and ulnar portals were used with care not to injure the extensor tendons. Arthroscopic anatomic landmarks include: (1) A consistent tripartite configuration of the main radial and ulnar collateral ligaments with characteristic changes in relative fiber orientation as the digit goes from extension to flexion, (2) nonvisualization of the accessory collateral ligament from inside the joint, (3) transitional amorphous capsular fibers connecting the collateral ligaments to the volar plate and dorsal capsule, (4) four synovial recesses (radial, ulnar, volar, and dorsal-proximal), (5) metacarpal head and proximal phalanx, (6) a consistent circumferential meniscal equivalent around the margin of the proximal phalanx articular surface, and (7) the sesamoid-metacarpal articulation in the thumb MPjoint. There are published case reports on the utility of MP joint arthroscopy for synovectomy in rheumatoid arthritis and hemachromatosis and realigning Stener lesions in gamekeepers' thumbs. The current clinical series reveals preliminary experience with the technique. MP joint arthroscopy was useful in relieving a locked MP joint from a loose osteochondral body and sagittal tear in the volar plate that enfolded into the joint surface. Intra-articular release of post-traumatic volar plate and dorsal capsular contracture were readily accomplished using this technique. Juxta-articular bone lesions such as osteoid osteomas can be removed with careful preoperative planning. Gamekeeper's thumbs that are unstable on stress radiographs can undergo arthroscopy with excellent sensitivity to determine the presence of a Stener lesion before an open or arthroscopic repair. The advantages of arthroscopic versus open techniques are similar to those experienced in larger joints. With time, more indications will emerge.     

The 45 degrees pronated oblique view for volar fixed-angle plating of distal radius fractures

Distinctive to volar fixed-angle plating of the distal radius, the optimal position of the distal fixed-angle support is in the subchondral bone immediately proximal to the articular surface. Standard intraoperative radiographic imaging of the distal radius during placement of a volar fixed-angle plate does not provide adequate visualization of the subchondral bone-distal support interface. A 45 degrees pronated oblique view is described to address this specific issue of whether volar hardware placed at the immediate subchondral bone level has effectively avoided the radiocarpal joint. This is a quite important radiographic consideration when pursuing the strategy of volar fixed-angle plating of distal radius fractures.     

Distal radioulnar joint volar instability after ligament reconstruction failure treated with sigmoid notch osteotomy

Because osseous abnormalities result in distal radioulnar joint instability, a sigmoid notch osteotomy is used to restore stability. This article describes a case of distal radioulnar joint volar instability treated with sigmoid notch osteotomy of the volar rim.A 22-year-old man presented with a 9-month history of right wrist pain with volar instability after a fall, which was treated conservatively. He reported a history of remote trauma when he was 7 years old but had been asymptomatic since then. Four months later, he underwent anatomical distal radioulnar joint ligament reconstruction at another hospital after a diagnosis of distal radioulnar joint instability, but the instability had persisted.Computed tomography revealed dynamic volar subluxation of the ulnar head with hypoplasia and a flattened volar lip of the sigmoid notch. Therefore, a sigmoid notch osteotomy of the volar rim was performed. Postoperatively, an above-elbow cast was applied with forearm pronation for 6 weeks. Six months later, the patient had regained 60° of supination and 70° of pronation. He reported minor pain and no instability. Computed tomography scan at 6 months postoperatively revealed union of the osteotomy site and confirmed the maintenance of reduction. The patient returned to work.     

Late presentation of a complete complex thumb metacarpophalangeal joint dislocation: A case report

Metacarpophalangeal (MP) joint injuries and dislocations of the fingers and thumb are not uncommon. They can be classified directionally as either being volar or dorsal, and are further categorized as incomplete, simple complete or complex complete. Complex dislocations are described as dislocations that are irreducible and often require surgical intervention. This is often because tissue has become entrapped within the MP joint, precluding its anatomical reduction. For the thumb MP joint, anatomical structures that may become trapped include the volar plate, sesamoid bones, bony fracture fragments or the flexor pollicis longus tendon. Both dorsal and volar surgical approaches have been described, and their relative merits will be discussed. The unusual case of a late presentation (two months postinjury) of a complex complete dorsal dislocation of the thumb MP joint approached from a dorsal incision is presented.     

Irreducible dislocation of the thumb interphalangeal joint due to displaced flexor pollicis longus tendon: case report and new reduction technique

Dislocation of the thumb interphalangeal (IP) joint is uncommon because of the inherent stability of the joint. Cases in which reduction was blocked by the volar plate, the flexor pollicis longus (FPL) tendon, the sesamoid bone, and an osteochondral fragment have been described in the literature. This article reports a case of closed thumb IP joint dislocation caused by the displacement of the FPL tendon. A new percutaneous reduction technique for this injury will also be presented. A 63-year-old woman presented to the emergency room with an obvious thumb deformity. Radiographs confirmed dorsal dislocation of the thumb IP joint without associated fracture. Closed reduction was not successful. Percutaneous reduction was performed under locoregional anesthesia, because the dislocation was due to an FPL tendon that had displaced dorsally and radially to the proximal phalanx. After reduction, Kirschner wire fixation was not needed, but IP joint immobilization with a splint was required for 3 weeks. Postoperatively, there were no complications in soft tissues and the operative scar was almost unrecognizable. This technique enables a mini-invasive reduction by operating percutaneously on the FPL. In addition, unlike with a volar zigzag approach, it is possible to suppress the occurrence of postoperative adhesion of the flexor tendon. This new minimally invasive reduction technique is useful for irreducible dislocation of the thumb IP joint due to a displaced FPL tendon.     

Préservation du muscle carré pronateur dans les ostéosynthèses des fractures de l’extrémité distale du radius par plaque palmaire verrouillée. Technique chirurgicale

IntroductionA surgical technique is described to preserve the pronator quadratus muscle when fixing distal radius fractures with volar locking palmar plates.TechniqueUsing a classic volar Henry approach to the wrist, the fibrous distal attachments of the pronator quadratus muscle are released. The locking palmar plate is passed under the pronator quadratus muscle and its correct placement is checked by fluoroscopy. Locking screws are inserted through mini-incisions in pronator quadratus.DiscussionThe pronator quadratus muscle plays an important role in wrist function, both in forearm pronation and as a stabilizer of the distal radioulnar joint. Mechanical impingement between the volar plate and the flexor tendons can cause adherences, ruptures and tenosynovitis. These should be reduced if pronator quadratus were intact.ConclusionPreservation of the pronator quadratus muscle is possible for the majority of the fractures of the distal radius treated with locking volar plate osteosynthesis.     

The role of post-operative radiographs in predicting risk of flexor pollicis longus tendon rupture after volar plate fixation of distal radius fractures – A case control study

Background and aimVolar plating of distal radius fractures is one of the common procedures performed in trauma surgery. Flexor pollicis longus (FPL) rupture has been described as complication following volar plating of distal radius fractures.The aim of our study was to investigate the possible relation between parameters measured on post-operative radiographs and the occurrence of FPL ruptures.Materials and methodsThis was a case control study. The post-operative radiographs of 11 FPL rupture, and 22 non-FPL rupture patients were reviewed with respect to fracture reduction and plate position and the various parameters were calculated by five independent people.Logistic regression was used to examine the importance of the variables.ResultsWe identified two significant factors to predict FPL rupture after volar plating of distal radial fractures. These were radial tilt and plate distance from the joint line. The odds ratio of ruptures was 0.74 (95% CI 0.57–0.95) for every degree of radial tilt <25° and 0.50 (95% CI 0.28–0.88) for every millimetre that the distal end of the plate was away from the volar lip of the distal radius at the wrist joint.ConclusionPost-operative radiographs could help us predict FPL rupture after distal radius volar plating. The findings also highlight the need for good fracture reduction and thoughtful placement of the volar plate intraoperatively to minimise the risk of FPL tendon rupture.