Mini-open versus extended open release for severe carpal tunnel syndrome

Background

This study aims to compare surgical outcomes of severe carpal tunnel syndrome (CTS) treated with mini-incision versus extensile release.

Methods

The method employed in this study was a retrospective review of patients with severe CTS, defined by electrophysiologic studies showing non-recordable distal sensory latency of the median nerve. Patients underwent either a mini-incision (2 cm) release of the transverse carpal ligament (group 1) or extensile release proximal to the wrist flexion crease (group 2). Exclusion criteria included prior carpal tunnel release, use of muscle flap, multiple concurrent procedures, or a prior diagnosis of peripheral neuropathy. Group 1 included 70 wrists (40 females, 30 males). Group 2 included 64 wrists (35 females, 29 males). Reported outcomes included pre- and post-operative grip strength as well as Boston Carpal Tunnel Questionnaires (BCTQ).

Results

Patients in group 1 had a 22.6 % increase in grip strength postoperatively (4.5 months ± 5.0), while patients in group 2 had a 59.3 % increase (10.0 months ± 6.9). BCTQ surveys from group 1 (n = 46) demonstrated a symptom severity score of 12.93 and functional status score of 9.39 at an average follow-up of 41.9 ± 10.6 months. Group 2 (n = 42) surveys demonstrated averages of 12.88 and 9.10 at 43.1 ± 11.6 months. One patient in the mini-incision cohort required revision surgery after 2 years, while no patient in the extended release cohort underwent revision.

Conclusion

No significant differences between the two procedures with regard to patient-rated symptom severity or functional status outcomes were found. Both techniques were demonstrated to be effective treatment options for severe CTS.     

Intramedullary repair device against volar plating in the reconstruction of extra-articular and simple articular distal radius fractures; a randomized pilot study

Purpose

This prospective randomized pilot study reports our institutional experience and early results using Sonoma Wrx (Sonoma Orthopedic Products, Santa Rosa, CA) in the treatment of extra-articular and simple intra-articular distal radius fractures.

Material and methods

A total of 64 patients, were enrolled in the study. They were considered eligible if they had; unstable extra-articular distal radius fractures and simple intra-articular distal radius fractures suitable for closed reduction (AO types; A2.2, A2.3, A3.1 C2.1, C2.2). Patients in group I received intramedullary fixation using the Sonoma Wrx® device and patients in group II received standard volar locking plate fixation. Radiographic criteria of acceptable healing were used for evaluation.

Results

Two groups were similar in terms of baseline characteristics. Mean time of operation was significantly shorter in Group 1 vs. in group 2 (36.81 ± 7.11 vs. 48.97 ± 5.9 minutes, p = 0.001). Time to healing of the fracture was not different between two groups (5.45 ± 1.09 vs. 5.70 ± 1.04 weeks for Group 1 vs. 2, respectively p = 0.36). Overall complications occurred in 9 patients in group 1 and in 15 patients in group 2 (p = 0.17). Follow-up was completed in all patients with a median time of 12 months and 13 months in group 1 and 2, respectively. On radiographic evaluation radial inclination, radial height and volar tilt were not significantly different between group 1 and 2, respectively. There were no significant differences between two groups in regard to wrist rotational degrees measured in last follow-up visit.

Conclusion

Sonoma Wrx Device is reliable and effective in terms of achieving satisfactory outcomes in treatment of distal radius fractures. It may be reasonable to use this device to prevent complications that are related to extensive soft tissue dissection.     

Determinants of distal radius fracture management in polytrauma patients

Background

Over 640,000 distal radius fractures occur annually in the United States. No studies have been performed looking specifically at polytrauma patients who sustain distal radius fractures. We sought to determine variables affecting management of distal radius fractures in polytrauma patients.

Methods

An IRB-approved review of trauma patients from 2008–2011 was performed. Records for patients with distal radius fractures were examined, assessing age, gender, Glascow Coma Score, Injury Severity Score, mechanism, type, and characteristics of injury, as well as operative repair. A logistic regression was performed using SPSS 15.0.

Results

The database identified 12,054 patients, 434 sustaining a distal radius fracture. No statistically significant difference in operative repair based on mechanism of injury (p = 0.465) was identified. A total of 285 patients (65.7 %) underwent surgery for distal radius fractures. In univariate analysis, younger age was the only statistically significant demographic predictor of surgical intervention (p = 0.003). In both univariate analysis and logistic regression, open, intra-articular, displaced, and comminuted fractures, as well as those with concomitant ulna fractures were statistically significantly associated with operative repair. Fracture displacement was the most likely variable to be associated with surgical intervention (OR = 12.761, 95 % CI[7.219, 22.556]) (p < 0.001).

Conclusions

In polytrauma patients, surgery for distal radius fractures is associated with younger age, open, intra-articular, displaced, and comminuted fractures, as well as concomitant ulna fractures. Displaced fractures were almost 13 times more likely to undergo surgical intervention than non-displaced fractures. Gender and mechanism of injury are not predictive of surgical intervention.     

Radiographic interpretation of distal radius fractures: visual estimations versus digital measuring techniques

Purpose

Distal radius fractures are a common injury. In the emergency room, trainees regularly assess these fractures using visual estimation. Our hypothesis is that assessment of radiographic parameters has sufficient accuracy for rendering treatment consistent with formal measurements.

Methods

This study compared visual measurements made by 25 orthopaedic residents and attending physicians to formal measurements made by a single fellowship trained musculoskeletal radiologist in a series of patients with distal radius fractures. A search was performed utilizing the ICD-9 code for distal radius fracture in all patients presenting to a single institution emergency department. Participants used visual estimation to rate 25 radiographs. Parameters estimated included radial inclination, radial height, volar tilt, and the presence of intra-articular displacement. Analysis using Lin concordance coefficients, Bland Altman plots, and the Kappa statistic evaluated the agreement between visual estimation and formal measurements. The proportion of raters whose estimates would have resulted in a course of treatment that conflicted with the formal reading quantified the potential impact of visual estimation on treatment.

Results

Concordance coefficients were poor for radial inclination (ρc = 0.13), radial height (ρc = 0.24), and volar tilt (ρc = 0.46). The Kappa statistic for intra-articular displacement was 0.4. Analysis performed according to level of training did not result in substantial improvements in these statistics. Treatment based on visual estimates conflicted with formal readings 34 % of the time for radial inclination, 38 % of the time for radial height, 27 % of the time for volar tilt, and 31 % of the time for intra-articular displacement.

Discussion

Visual estimation is not an adequate form of measurement for evaluation of patients with distal radius fractures. Physicians should be mindful of these results when developing treatment plans based solely upon visual estimation.     

A cohort study of one-year functional and radiographic outcomes following intra-articular distal radius fractures

Background

The purpose of this study was to describe the outcomes of a series of patients followed prospectively after intra-articular distal radius fractures.

Methods

One hundred forty-eight patients with intra-articular fractures (mean age, 47 years; age range, 44–54 years; gender distribution, 60 males and 88 females) were treated with cast only, arthroscopy/closed reduction plus pins, arthroscopy/closed reduction with external fixation, open reduction and internal fixation (ORIF) alone, and ORIF with external fixation according to surgeon preference and fracture characteristics. The 1-year outcomes across the groups were measured radiographically (n = 148) and functionally (n = 113; 1-year Wrist Outcome Measure score, Grip Strength, SF-36, and PRWE scores).

Results

Radiographically, the groups had statistically significant differences in radial inclination, volar tilt, intra-articular step-off, and radial shortening in the pre-treatment X-rays. However, following treatment, treatment groups demonstrated no difference statistically in their follow-up radiographic measures. One-year PRWE scores were found to be statistically different across groups. Across groups, the ORIF-alone treatment group had the highest PRWE score reflecting greatest amount of pain and disability. One-year wrist outcome measure scores and grip strength scores were also found to be significantly different across treatment groups. The general health status as measured by the SF-36 was not found to be different across treatment groups.

Conclusions

These findings are consistent with treatment by indication; suboptimal ORIF outcomes may reflect older practice patterns with dorsal plating. A randomized control trial that compares treatments controlling for fracture severity and studies that develop formal clinical prediction rules for treatment assignment are needed.     

Postsurgical complications following distal radius volar plating in a diabetic population at short-term follow-up

Background

Diabetes mellitus increases the risk of complications following operative treatment of lower extremity fractures. There is little published data establishing the impact of diabetes following surgical treatment of upper extremity fractures. This investigation aimed to compare the incidence of short-term postsurgical complications following volar locked plating of distal radius fractures in patients with and without diabetes.

Methods

A retrospective matched cohort investigation of 33 diabetics matched 1:2 to 66 non-diabetics was performed, accounting for age, gender, fracture type, and smoking status. Electronic medical records and radiographs were reviewed for all major and minor postsurgical complications. Demographic characteristics, postoperative radiographic parameters, and final range of motion were also compared. Mean follow-up was 5.3 ± 8.2 and 5.5 ± 7.8 months for diabetics and non-diabetics, respectively.

Results

The diabetic cohort had a significantly higher overall complication rate with 24 postsurgical complications affecting 12 patients (36 %) compared to 16 complications affecting 12 patients (18 %) in the non-diabetic cohort. There was no difference in the incidence of major complications requiring operative intervention. Minor complications were significantly more common in the diabetic group and were largely accounted for by peripheral neuritis with an incidence of 30 %. Final radiographic outcomes and range of motion were similar.

Conclusions

Diabetics experienced a greater incidence of minor postsurgical complications following volar locked plating of distal radius fractures when compared to a matched, control population. The difference in outcomes is largely accounted for by the increased incidence of peripheral neuritis among diabetics. Diabetic patients should be counseled pre-operatively regarding their elevated risk profile.     

Routine use of locking shaft screws is not necessary in volar plate fixation of distal radius fractures

Hypothesis

Volar locking plate fixation is a common treatment method for distal radius fractures. Recently, implants have been designed with an option to use locking screws in the shaft portion of the plate. While there is a high incidence of low bone mineral density in patients who sustain fragility fractures of the distal radius, the need for locking shaft screws is not well defined. Our hypothesis is that the routine use of locking screws in the shaft portion of volar plates is not required to maintain reduction or to prevent hardware failure.

Methods

A retrospective review was performed in all patients over age 50 years who underwent volar plate fixation using an implant with non-locking shaft screws for a distal radius fracture during a 2-year period. Patients were permitted to perform early range of motion exercises. Radiographs were examined and measurements were obtained to assess maintenance of reduction and incidence of hardware failure. Patients were followed at least until fracture healing. Patients were excluded from analysis if locking shaft screws were utilized or if follow-up was inadequate.

Results

Forty-one patients met the inclusion criteria. The average age was 62 years (range 50–79). There were 12 men and 29 women. The implant used incorporated 3.5-mm shaft screws in 26 patients and 2.4-mm shaft screws in 15 patients. All patients healed within acceptable radiographic parameters (mean volar tilt = 4.9°, mean radial inclination = 21.7°, mean radial height = 11.6 mm). There were not any instances of hardware failure.

Discussion

Distal radius fractures frequently occur in patients with low bone mineral density. Non-locking, bicortically placed shaft screws provide adequate stability to allow for early range of motion without loss of reduction or hardware failure. The routine use of locking screws in the shaft portion of volar plates does not appear justified.     

The use of a single volar locking plate for AO C3-type distal radius fractures

Background

A single volar locking plate (VLP) is now frequently used for open reduction and internal fixation (ORIF) of many types of distal radius fractures. Comminuted intra-articular distal radius fractures (AO C3-type) are typically the most challenging to surgically treat. No studies directly address the adequacy of a VLP alone for maintaining reduction of AO C-type fractures. We hypothesized that a single VLP provides an effective method for maintaining reduction for these fractures.

Methods

We retrospectively evaluated radiographs of a series of AO C-type fractures. Seventy-seven patients with 77 AO C3-type fractures were identified from billing records and were eligible for the study. All patients were treated by fellowship-trained hand surgeons. Radiographs at the time of union were compared to those from immediately postoperatively.

Results

Sixty-nine of 77 (89.6 %) fractures treated with VLP fixation alone for AO C3-type distal radius fractures united without loss of reduction. Eight of 77 (10.4 %) patients treated with VLP for AO C3 fractures lost reduction. The most common fracture fragment to lose reduction was the lunate fossa (5 of 8); loss of reduction of the scaphoid fossa die-punch fragment (2 of 8) and the radial styloid (1 of 8) were also seen.

Conclusions

The majority (89.6 %) of AO C3-type fractures treated with a single volar locking plate come to union without loss of reduction.Level of evidence: Level IV.     

Association between individual DASH tasks and restricted wrist flexion and extension after volar plate fixation of a fracture of the distal radius

Background

Symptoms and psychosocial factors are suggested to account for more of the variation in disability than physical impairment, but perhaps less so at the level of specific tasks. This study assessed the influence of impaired wrist motion on specific tasks on the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

Methods

Sixty-three patients with an operatively treated fracture of the distal radius completed the Pain Catastrophizing Scale (PCS), Pain Anxiety Symptoms Scale, and Center for Epidemiologic Studies Depression Scale (CES-D) just before surgery and the DASH questionnaire 3 months after surgery. Nine questions on the DASH were selected as potentially sensitive to changes in wrist motion and evaluated in bivariate and multivariable analyses.

Results

In multivariable models of factors associated with specific tasks, only “Open a tight or new jar” was affected by wrist flexion and PCS accounting for 33 % of the variation. Motion, pain, and PCS were significant predictors of the DASH score. Among the eight tasks not related to wrist motion, 33 % of the variation in disability with writing was accounted for by PCS and limb dominance; 20 % of disability preparing a meal by pain, CES-D, and PCS; 14 % of disability with making a bed by pain and CES-D; and 23 % of changing a light bulb overhead by age, pain, and fracture type.

Conclusions

After volar plate fixation of a fracture of the distal radius, upper extremity disability based on select items from the DASH questionnaire correlated minimally with impairment of wrist motion, even at the level of specific tasks.

Level of Evidence

Prognostic Level II.     

Complication rates and reduction potential of palmar versus dorsal locking plate osteosynthesis for the treatment of distal radius fractures

Background

The aim of this study was to evaluate the complication rates of volar versus dorsal locking plates and postoperative reduction potential after distal radius fractures.

Materials and methods

For this study 285 distal radius fractures (280 patients/59.4 % female) treated with locked plating were retrospectively evaluated. The mean age of the patients was 54.6 years (SD 17.4) and the mean follow-up was 33.2 months (SD 17.2). The palmar approach was used in 225 cases and the dorsal approach in 60 cases (95 % type C fractures).

Results

Adequate reduction was achieved with both approaches, regardless of fracture severity. In the dorsal group, the complications and implant removal rates were significantly higher and the operative time was also longer.

Conclusions

Based on these facts, we advocate the palmar locking plate for the vast majority of fractures. In cases of complex multifragmentary articular fractures where no compromise in reduction is acceptable, and with the biomechanical equality of palmar and dorsal plating remaining unproven, dorsal plating may still be considered.

Level of evidence

Therapeutic level IV.     

Ulnar Styloid Fracture in Distal Radius Fractures Managed with Volar Locking Plates: To Fix or Not?

Distal radius fracture is usually associated with ulnar styloid fracture. Whether to fix the ulnar styloid or not remains a surgical dilemma as some surgeons believe that their repair is imperative while others feel that they should be managed conservatively. This prospective study involved 47 patients with unilateral fracture of the distal radius who met the inclusion criterion and underwent open reduction and internal fixation with volar locking plates; 28 patients (12 males and females = 16) had an associated ulnar styloid fracture (Group A) while 19 (7 males; 12 females) did not have any ulnar styloid fracture (Group B). At the time of final evaluation both the groups were compared clinically by measuring the grip strength and range of motion around the wrist and the radiologically by measuring radial angle, radial length, volar angle and ulnar variance. Subjective assessment was done using DASH score and final assessment using Demerit point system of Saito. In Group A, average time for consolidation was 9.4 weeks, 17 patients developed non-union of the ulnar styloid, average DASH scores was 4.4 and according to Demerit point system of Saito, there were 78.5 % excellent, 17.9 % good and 3.6 % fair results; there were 2 cases of loss of reduction out of which one had persistent ulnar sided wrist pain. In Group B the average time for consolidation was 10.2 weeks, average DASH score was 3.8.and Demerit point system of Saito yielded 78.9 % excellent, 15.8 % good and 5.3 % fair results. There was one case of loss of reduction and one case of carpal tunnel syndrome which was managed conservatively. Both groups attained excellent range of motion, grip strength and well maintained the post operative radiological parameters. The comparison of clinico-radiological parameters in both groups was found to be statistically insignificant. To conclude, ulnar styloid fracture or its non union does not affect the outcome of an adequately fixed distal end radius fracture. We urge caution in electing operative treatment of non-united fracture of the ulnar styloid until better scientific report for treatment of pain associated with these fracture is available.     

The functional outcome of forty-nine single-incision suture anchor repairs for distal biceps tendon ruptures at the elbow

Purpose

The objective of this retrospective study was to evaluate the functional results of distal biceps tendon repair using suture anchors via a single-incision approach.

Methods

Forty-nine patients were re-examined at a mean follow-up of 44.2 ± 32.1 months (range, 12–119 months). Subjective and objective criteria included patient’s satisfaction, active range of motion (ROM), maximum isometric strength in flexion (at 45° and 90°), and supination of both arms. Functional scoring included the Morrey elbow score (MES) and the QuickDASH. Furthermore, follow-up radiographs were performed.

Results

Eighty-six percent of patients were highly satisfied or satisfied with their outcome. Compared to contralateral, the active ROM of elbow flexion, extension, and pronation was not affected; however, supination was decreased by 3° (P < 0.001). The isometric maximum strengths showed significant deficits in all tested scenarios (at 45°, P = 0.002; at 90°, P < 0.001; for supination, P < 0.001). The MES and the QuickDASH were 97.2 ± 4.9 and 7.9 ± 13.9, respectively. Heterotopic ossifications (HO) were found in 39 % of patients; however, with respect to scores and strength, no significant differences were seen compared to patients without HO. Moreover, four anchor failures were detected.

Conclusions

Single-incision suture anchor repair provides high patient’s satisfaction and good results with respect to ROM and functional scoring. Nevertheless, based on presented data, the patient has to be informed of postoperative HO and especially for supination strength weakness after surgery. Distal biceps tendon repair should be reserved for experienced upper extremity surgeons to avoid procedure-related complications.     

Evaluation of the Sigmoid Notch Involvement in the Intra-Articular Distal Radius Fractures: The Efficacy of Computed Tomography Compared with Plain X-ray

Background

The purpose of this study is to evaluate the efficacy of computed tomography (CT) scans compared with plain radiographs on detecting the involvement of the sigmoid notch.

Methods

This study involved 121 cases diagnosed as the intra-articular distal radius fracture and performed post-reduction CT scans. We determined the presence of the sigmoid notch involvement with both plain radiographs and CT scans and compared findings of plain radiographs with CT scans about the incidence and the pattern of injuries. And the differences of results between arbeitsgemeinschaft für osteosyntheses (AO) type C2 and C3 were compared.

Results

The incidences of sigmoid notch involvement detected in plain radiographs were 81 cases (66.9%), whereas CT scans were 99 cases (81.9%). The sensitivity of plain radiographs compared with CT scans was 74.7%, the specificity was 68.2%, the positive predictive value was 91.4%, the negative predictive value was 37.5%, the false negative value was 25.3%, and the false positive value was 31.8%. In comparison between AO type C2 and C3, the incidence of sigmoid notch involvement was not a significant difference, but the displacement of fracture fragment showed a significant difference.

Conclusions

The intra-articular distal radius fracture usually accompanies the sigmoid notch involvement. Considering that the evaluation of sigmoid notch involvement by plain radiography often results in misinterpretation or underestimation, performing CT scan in intra-articular distal radius fracture is thought to be beneficial.     

Comparison of the efficacy of a distal clavicular locking plate versus a clavicular hook plate in the treatment of unstable distal clavicle fractures and a systematic literature review

Purpose

The purpose of this study was to retrospectively compare and review the clinical outcomes between the distal clavicular locking plate and clavicular hook plates in the treatment of unstable distal clavicle fractures; moreover, the relevant literature of the two fixation methods was reviewed systematically to identify the non-union, complications, or functional scores, according to the treatment methods and determine which treatment method is better.

Methods

Sixty-six patients with 66 unstable distal clavicle fractures who underwent open reduction and internal fixation with either a distal clavicular locking plate (36 patients) or a clavicular hook plate (30 patients ) were evaluated. The main outcome comparisons included Constant score, rate of non-union, rate of complication, and rate of returning to work three months postoperatively.

Results

No significant difference was found between locking plate and hook plate groups in union rate and Constant score (P > 0.05). However, the results indicated that the distal clavicular locking plate group had a significantly lower rate of complications (P < 0.05) and symptomatic hardware (P < 0.05). In addition, the distal clavicular locking plate facilitated the return to work better than the clavicular hook plate (P < 0.05).

Conclusions

Both distal clavicular locking plate and clavicular hook plate achieved good results in the treatment of unstable distal clavicle fractures; however, internal fixation with a distal clavicular locking plate had greater ability to return to their previous work after surgery in three months and fewer complications than the clavicular hook plate.     

Contralateral electrodiagnosis in patients with abnormal median distal sensory latency

Background

We hypothesized that electrodiagnostic evidence of carpal tunnel syndrome (CTS) on the contralateral, less-severe side correlates with disease severity.

Methods

We retrospectively reviewed 285 adults that had bilateral electrodiagnostic testing and a median distal sensory latency (DSL) greater than 3.6 ms on at least one side. Variables associated with abnormal contralateral median DSL were analyzed in bivariable and multivariable analysis.

Results

Patients with a nonrecordable median DSL on the worst side were significantly more likely to have electrodiagnostic evidence of contralateral CTS compared to patients with a prolonged DSL on the worst side (90 versus 65 %, respectively; p < 0.001). Bilateral symptoms were reported by 75 % of patients. The best logistic regression model for electrodiagnostic evidence of contralateral CTS included nonrecordable median DSL of the worst side and polyneuropathy (p < 0.001 and p = 0.14, respectively).

Conclusions

The finding that disease severity relates to the probability of contralateral abnormalities is consistent with the concept that CTS is typically bilateral. Patients with CTS on one side should be advised of the likelihood that it can be present or may develop on the other side.     

Comparison of low, multidirectional locked nailing and plating in the treatment of distal tibial metadiaphyseal fractures

Purpose

The aim of this study was to compare the results of a new technique for low, multidirectional locked nailing with closed reduction and minimally invasive plating in the treatment of distal tibial metadiaphyseal fractures.

Methods

Forty-six matched patients were divided according to age, gender, Injury Severity Score, and fracture pattern into group A (expert tibial nailing) and group B (minimally invasive plating). Then, the patients were followed up, and the clinical and radiographic results were retrospectively analysed.

Results

The mean followed-up was 24.7 ± 2.7 months in group A and 25.8 ± 2.8 months in group B. No patient had nonunion, shortening, hardware breakdown, or deep-seated infection. Patients in group A had a significantly shorter mean operating time, hospital stay, full weight-bearing time and union time (76 ± 16.6 vs. 90 ± 20.3 minutes, p = 0.000; 5.8 ± 2.1 vs. 8.9 ± 3.1 days, p = 0.000; 9.0 ± 1.4 vs. 11.1 ± 1.7 weeks, p = 0.000; and 21.3 ± 3.5 vs. 23.1 ± 3.6 weeks, p = 0.047, respectively). Three patients in group A and one patient in group B presented with malalignment (p = 0.608). The mean Olerud-Molander Ankle score was 89.0 ± 7.1 in group A and 87.6 ± 8.4 in group B (p = 0.478).

Conclusions

Distal tibia metadiaphyseal fractures may be treated successfully with low, multidirectional locked nails or plates. However, low, multidirectional locked nailing may represent a superior surgical option, since it offers advantages in terms of mean operating time, hospital stay, full weight-bearing time and union time.     

Fatigue performance of angle-stable tibial nail interlocking screws

Purpose

Tibial nail interlocking screw failure often occurs during delayed fracture consolidation or at early weight bearing of nailed unstable fractures, in general when high implant stress could not be reduced by other means. Is there a biomechanical improvement in long-term performance of angle stable locking screws compared to conventional locking screws for distal locking of intramedullary tibial nails?

Methods

Surrogate bones of human tibiae were cut in the distal third and distal locking of the 10 mm intramedullary tibial nail was performed with either two angle stable locking screws or two conventional locking screws in the mediolateral plane. Six specimens per group were mechanically tested under quasi-static and cyclic axial loading with constantly increasing force.

Results

Angle stable locking screw constructs exhibited significantly higher stiffness values (7,809 N/mm ± 647, mean ± SD) than conventional locking screw constructs (6,614 N/mm ± 859, p = 0.025). Angle stable locking screw constructs provided a longer fatigue life, expressed in a significantly higher number of cycles to failure (187,200 ± 18,100) compared to conventional locking screw constructs (128,700 ± 7,000, p = 0.004).

Conclusion

Fatigue performance of locking screws can be ameliorated by the use of angle stable locking screws, being especially important if the nail acts as load carrier and an improved stability during fracture healing is needed.     

Scapholunate instability after distal radius volar plating

Background

Prior to volar locked plating and early motion protocols, ligamentous injuries incidentally associated with distal radius fractures may have been indirectly treated with immobilization. Our goal was to determine the prevalence of scapholunate instability in our population, while identifying those who may have had progression of instability.

Methods

We retrospectively reviewed 221 distal radius fractures treated with a volar locking plate during a 6-year period. Average patient age was 59 years. Standard posteroanterior and lateral radiographs from the first and last postoperative visits were analyzed for scapholunate instability, using the criteria of scapholunate gap ≥3 mm and scapholunate angle ≥60°.

Results

Six patients (3 %) met neither or only one criterion for instability at the first postoperative visit and did not have ligament repair and then went on to meet both criteria at the last postoperative visit after an early motion protocol. Seven patients (3 %) met both criteria at the first and last postoperative visits and did not have ligament repair. Five patients (2 %) underwent primary scapholunate ligament repair at the time of distal radius fixation.

Conclusions

In our representative population, scapholunate instability was uncommon, either from initial injury or possible progression of occult ligament injury, despite early motion without operative treatment of the ligament. Thus, we did not find strong evidence for routinely delaying motion or pursuing further workup. When early radiographs clearly demonstrate acute scapholunate instability, more aggressive treatment may be appropriate for selected patients.     

Endoscopic versus open carpal tunnel release: A short-term comparative study

Objective:

To compare the results of endoscopic carpal tunnel release (CTR) with open CTR in patients with idiopathic Carpal tunnel syndrome (CTS).

Materials and Methods:

Seventy-one patients with CTS were enrolled in a prospective randomized study from May 2003 to December 2005. All patients had clinical signs or symptoms and electro-diagnostic findings consistent with carpal tunnel syndrome and had not responded to nonoperative management. Sixty-one cases were available for follow-up. Endoscopic CTR was performed in 30 CTS patients and open CTR was performed in 31 wrists (30 patients). Various parameters were evaluated, including each patient''s symptom amelioration, complications, operation time, time needed to resume normal lifestyle and the frequency of revision surgery. All the patients were followed up for six months.

Results:

During the initial months after surgery, the patients treated with the endoscopic method were better symptomatically and functionally. Local wound problems in terms of scarring or scar tenderness were significantly more pronounced in patients undergoing open CTR compared to patients undergoing endoscopic CTR. Average delay to return to normal activity was appreciably less in group undergoing endoscopic CTR. No significant difference was observed between the endoscopic CTR group and open CTR group in regard to symptom amelioration, electromyographic testing and complications at the end of six months.

Conclusion:

Short-term results were better with the endoscopic method as there was no scar tenderness. Results at six months were comparable in both groups.     

Irreducible dorsal distal radius fracture-dislocation with accompanying dorsal displacement of flexor tendons and median nerve: A rare type of injury

INTRODUCTION

High energy distal radius fractures may cause significant soft tissue injuries. Dorsal displacement of median nerve and flexor tendons to dorsal compartment between distal radioulnar joint was an unreported type of soft tissue injury.

PRESENTATION OF CASE

35-Year male admitted following fall from height diagnosed as closed distal radius fracture with dorsal displacement. The patient had no flexion and extension of all fingers with loss of sensation. Radial artery pulse was not palpable. Radiography and CT imaging revealed distal radius fracture with dorsal displacement with dorsal carpal dislocation. After failure of closed reduction, operative treatment was performed. At surgery, flexor tendons and median nerve was found to be placed at dorsal compartment. Reduction of the soft tissues was facilitated by distraction of distal radioulnar joint.

DISCUSSION

Dorsal displacement of volar structures as the result of fracture dislocation was found to be an unreported type of injury. Difficulty during reduction of dorsally displaced structures is an important feature of the case.

CONCLUSION

For severely displaced and deformed distal radial fractures and fracture dislocations, threshold for operative treatment should be kept low.