Tension wire fixation for mallet fracture after extension block pinning failed

Introduction

Various surgical treatments such as extension block pinning have been proposed for acute bony mallet finger. We evaluated the clinical results of tension wire fixation technique for the treatment of nonunion of mallet fracture after failed mallet finger surgery.

Materials and methods

Nine male patients were treated with open tension wire fixation for chronic nonunion of mallet fracture after extension block pinning surgery failed. The mean age was 29.3 years (range 18–47). We assessed bone union in simple radiographs. Crawford’s and Bischoff functional score was used to assess the functional outcome.

Results

The mean follow-up period was 45.8 months (range 18–74). Clinical and radiographic bone unions were achieved in eight of nine patients with average time of 31 days (range 23–41). Mean extension lag at final follow-up was 7° (range 0–25). Four patients showed excellent, three patients showed good and two patients showed fair results on the Crawford’s score scale. With Bischoff functional score, all patients were categorized as excellent.

Conclusions

Tension wire fixation can be a good second-line reconstructive surgery for the treatment of mallet fracture after extension block failed, so that patients can avoid arthrodesis or complex tendon transfer as a salvage procedure.     

Outcomes Following Operative Treatment of Adolescent Mallet Fractures

Background

Many surgeons advocate for surgical intervention of adult mallet fractures that involve either subluxation of the distal interphalangeal (DIP) joint or those that involve more than one-third of the articular surface. However, the efficacy of operative treatment and complication rates are unclear regarding the adolescent population.

Questions/Purposes

The goal of this study is to evaluate the clinical outcomes following operative fixation of bony mallet fractures in the adolescent population.

Methods

Seventeen patients with bony mallet fractures treated surgically were retrospectively reviewed. Twelve patients were treated by closed reduction with extension block pinning. The other patients underwent an open reduction and pin fixation. The average age was 15.2 years (13–18). Most injuries were sport related. The average time from injury to presentation was 17 days and from injury to surgery was 24.5 days. Nine patients had subluxation at the DIP joint and all involved at least one-third of the articular surface.

Results

The average time from surgery to pin removal was 28 days (19–46). All distal phalanx physis were closed or nearly closed. One patient reported pain at the final follow-up. Two patients (11.8%) had major complications. One had an extension contracture postoperatively, did not attend therapy, and re-fractured 5 months later requiring reoperation. The second was treated delayed (32 days) and lost fixation, requiring revision surgery and antibiotics for a superficial infection. Two patients with delayed treatment (32 and 44 days) had an extensor lag (11.8%).

Conclusions

Operative treatment of mallet fractures with subluxation or involving more than one-third of the articular surface appears effective. Pin removal 4 weeks postoperatively appears adequate. Complications occurred with delayed presentation and non-compliance.

     

Ergebnisse der konservativen Therapie beim frischen und alten ligamentären Mallet-Finger

Background

In the treatment of the acute ligamentous mallet finger, conservative therapy with a Stack or Winterstein splint is an established approach, though there are many different conservative therapy regimes. There are even more therapy options for the chronic mallet finger (more than 4 weeks old) including different operation techniques.

Material and methods

In a retrospective study, 44 patients with an acute and 33 patients with a chronic ligamentous mallet finger treated with a Stack or Winterstein splint were investigated.

Results

The results in both groups are satisfactory (SD <10°: 70.5% in the acute, 87.9% in the chronic lesions). The subjective satisfaction (scale 1–6) was high in both groups. It was even significantly higher in the group with the chronic lesions (acute: 2.55±1.63, chronic: 1.82±1.38). In both groups there was no correlation between an initially high extension deficit and a bad therapy outcome.

Conclusions

Also in chronic ligamentous mallet finger, conservative therapy should be attempted before an operation, irrespective of the initial extension deficit, especially because the stress and the therapy risk for the patient with this therapy is small.     

Conservative treatment of the distal radius fracture using thermoplastic splint: pilot study results

Introduction

Fractures of the distal radius are common accounting for approximately one-sixth of all fractures treated in the emergency room. This study reviews a series of patients with stable distal radius fractures who have been treated with thermoplastic splint.

Methods

This study was undertaken between November 2009 and May 2010 in a single orthopaedic fracture outpatient clinic. All patients had undisplaced or minimally displaced distal radius fractures. Children and open fractures were excluded. Patients had been reviewed in the outpatients with radiographs on 1, 2, 6 and 12 weeks after injury. Skin condition and satisfaction were assessed on splint removal. Radiological parameters of radial inclination, radial length and palmer tilt were measured.

Results

In total, 26 patients were treated with the splint. The average age of the patients was 45.1 (range, 21–73), and male/female ratio was 12:14. On average, the splint was removed at 5.1 weeks (mode = 6 weeks). The right- to left-side ratio was 11:15. Eleven of those fractures were on the dominant side. There was no significant difference in the radiological outcomes pre- and post-splinting. Nearly all patients had been satisfied with the splint. Two patients had minor cast complications whilst 23 patients were able to shower whilst in splint.

Conclusion

Patients treated with thermoplastic splint showed no deterioration in their radiological outcomes. Nearly all the patients had been satisfied with the splint.     

The Meniscus Arrow® as a fixation device for the treatment of mallet fractures: results of 50 cases

Background

The treatment of mallet fractures is a controversial and challenging problem. Generally, mallet fractures are treated conservatively except those involving more than one third of the base of the distal phalanx. Many different surgical fixation techniques have been published. This paper describes a new fixation procedure using ultimate bioresorbable meniscal fixation nails (Meniscus Arrows®).

Methods

Mallet fractures in 50 digits of 49 patients were fixed with this nail in an outpatient surgical procedure, mostly under local (Oberst-block) anaesthesia. The average operation time was 21 min.

Results

According to the Crawford criteria, patient outcome was graded as excellent in 48 %, good in 22 %, and fair in 28 %. In one patient, the outcome was graded as poor, but the fracture was in a pre-existent arthritic joint. All fractures were consolidated without recurrent dislocation. Complications included one wound infection, which was successfully treated with antibiotics and without further consequences. No nail deformities occurred. Two times, the nail spontaneously and gradually dislocated during intensive use of the hand after, respectively, 3 and 6 months and could easily be removed under local anaesthesia without any functional sequelae.

Conclusion

The bioresorbable meniscal nail fixation technique provides a fast and successful surgical treatment for mallet fractures with a minimum of adverse events.     

Fractures of the sustentaculum tali

Objective

Anatomical reconstruction of displaced sustentaculum tali fractures via a direct medial approach.

Indications

Displaced fractures of the sustentaculum tali with incongruity or depression of the medial facet of the subtalar joint, entrapment of the flexor hallucis longus or flexor digitorum longus tendons, fracture line extending into the posterior facet of the subtalar joint.

Contraindications

Infected or grossly contaminated soft tissue, severely restricted vascular supply to the foot, high perioperative risk.

Surgical technique

Direct medial approach over the sustentaculum tali, retraction of the tendons, joint exploration, fracture reduction using the medial facet and cortical outline as guidelines, fracture fixation with two small fragment screws from medial to lateral directed slightly plantarly and posteriorly. Fractures with depression of the medial facet as a whole can alternatively be reduced and fixed percutaneously.

Postoperative management

Lower leg splint for 5–7 days, partial weight-bearing with 20 kg for 6–8 weeks (until radiographic signs of consolidation) in the patient’s own shoewear, early range of motion exercises of the ankle, subtalar and mid-tarsal joints.

Results

Over a course of 15 years, 31 patients were treated operatively for sustentacular fractures. In all, 27 patients (87?%) had additional fractures to the same foot and ankle. Eighteen patients with a mean age of 41 years treated at our institution with screw fixation for a unilateral fracture of the sustentaculum tali could be followed for a mean of 80 months (range 15–151 months). No wound healing problems or infections were seen with the medial approach. At the time of follow-up, 15 sustentaculum tali fractures had an average Foot Function Index of 21.6 and an average AOFAS Ankle–Hindfoot Score of 83.6. Patients with isolated fractures of the sustentaculum tali had significantly better scores than those with additional injuries. In 1 patient, an additional lateral process fracture of the talus required subtalar fusion due to persistent pain. Care must be taken not to overlook these atypical calcaneal fractures and accompanying injuries to the mid-tarsal joint and the lateral talar process as seen in 45% and 23%, respectively, in the present series.     

Posterior fixation of type IV humeral capitellum fractures with fully threaded screws in adolescents

Purpose

Humeral capitellum fractures comprise approximately 1% of all elbow fractures. In this study, we examined the clinical, radiographic, and functional outcomes following operative stabilization of Bryan and Morrey type IV fractures of the capitellum in adolescents. We applied headless cannulated screws in a posteroanterior direction without damaging the articular cartilage surface of the fractures.

Methods

Eight adolescent patients (six male, two female) with a mean age of 15 ± 2.1 years (range 13–18 years) were treated for type IV (McKee) humerus capitellum fractures. In the preoperative radiological evaluation, anteroposterior and lateral radiographs and computed tomography (CT) images were performed. A lateral surgical approach was used, and cannulated fully threaded headless screws were applied in a posteroanterior direction as fixation materials in the fracture reduction. The Mayo Elbow Performance Score was used in the evaluation of elbow joint functions.

Results

Patients were followed up for a mean of 24.6 months. Fracture union was achieved at a mean of 5 ± 0.92 weeks (range 4–6 weeks). The mean elbow extension flexion arc was 135° ± 13.47° (range 110°–150º) and the mean pronation supination arc was 156° ± 4.43° (150°–160°). In one patient, there was nonconformity in the humerus trochlea and in another patient, there was keloid formation on the surgical scar. All patients attained excellent results according to the Mayo Elbow Performance Score.

Conclusions

In the treatment of type IV capitellum fractures in adolescents, open reduction with a lateral surgical approach and fixation using posteroanterior directed, cannulated, fully threaded, headless screws is a reliable method to achieve a pain-free functional elbow joint.     

A safe and cost-effective method for treatment of angulated fifth metacarpal shaft fractures in the out-patient clinic

Introduction

Surgical treatment is justified in patients with fifth metacarpal shaft fractures with angulation exceeding 30°, as these patients are prone to have shortening, restriction of movements, decreased efficiency of the flexor tendons and poor cosmetic results. The authors describe a new technique where these patients can be treated in the clinic non-surgically.

Material and methods

Twenty-three patients with angulated fractures were prospectively enrolled for the study from Jan 2009 to Dec 2009. After appropriately instructing the patient, an ulnar nerve block was performed at the wrist. Once the nerve block had taken effect, the fracture was manipulated and an ulna gutter 3-point moulded splint was applied in the plaster room. The reduction was then confirmed with an x-ray. The patients were assessed using disability of arm, shoulder and hand (DASH) score and radiographs at follow-up.

Results

At the average follow-up of 12.38 months (range, 9–17), the DASH score was 2.03 (range, 0–6.7). The return to sports/work was at 3.2 weeks (range, 1–6) following the injury. The DASH work and sports score was 3.55 (range, 0–12.5) and 0.89 (range, 0–12.5) respectively. The mean initial fracture angulation of 40.05°, reduced to 15.76°. All the patients had a completely pain-free manipulation with no complications related to the technique and reduction.

Conclusions

In the current economic climate with pressure on time and resources, the authors suggest the treatment described above of these fractures in the clinic. It is a safe, cost-effective and easily learnt technique.     

Die Versorgung der dorsalen Endphalanxbasisfraktur der Langfinger mittels Hakenplatte

Objective

Anatomical reposition and stabilization of dorsal distal phalanx fractures with a hook plate.

Indications

Dislocated mallet fractures type Doyle IVb with dislocation of the fragment by more than 2?mm and/or tilting of the fragment as well as dislocation of the dorsal distal phalanx fractures type Doyle IVc.

Contraindications

Florid inflammation of and injuries to the soft tissues in the operation area.

Surgical technique

Dorsal approach to the distal interphalangeal joint (Y-, S-, H-shaped). Preparation of the fragment, cleaning the fracture gap, repositioning of the fragment, mounting of the plate, placing the screw. Controlling by image converter. Suture of the skin; tape.

Postoperative management

Stack splint for 4?weeks. After week?3, start with exercising of the distal interphalangeal joint within the splint. Physiotherapy is usually not required. Full exertion after 6?C8?weeks is possible. The period of inability to work is dependent on the patient??s occupation. Due to the danger of perforation and infection, it is recommended that the plate be removed after 3?C6?months.

Results

From February?2002 to September?2009, 77?mallet fractures type Doyle IVb and IVc were operatively stabilized with a hook plate. In a retrospective study, 59?patients were followed up at a mean interval of 38.3 (3?C69)?months after the operation. Wound healing problems or inflammation were not observed. Visible disturbances of nail growth were macroscopically seen in 11.9%. Results were very good in 35?patients (59.3%), good in 16?patients (27.1%), sufficient in 5?patients (8.5%), satisfying in 1?patient (1.7%), and insufficient in 2?patients (3.4%).     

Sekundäre Rekonstruktion des digitalen A2-Ringbands

Objective

Secondary reconstruction of A2 flexor pulley for after closed rupture.

Indications

Persisting impairment of finger function and strength after combined injury of A2 and C1 pulley. Passive free movement of all finger joints.

Contraindications

Fixed flexion contractures of interphalangeal joints after complex finger injuries. Degenerative arthrosis of interphalangeal joints.

Surgical technique

A strip of extensor retinaculum approximately 10 mm in width together with the periosteum from the second floor of the extensor tunnel was used for reconstruction of the A2 pulley. After drilling bilateral burr holes in the palmar aspect of the phalanx at the distal and proximal ends of the A2 pulley, the graft was fixed by the periosteum to the bone of the phalanx, placing the synovial layer innermost.

Postoperative management

Postoperatively, patients in both treatment groups wore a palmar splint which extended from the distal interphalangeal joint to the proximal palmar crease for 4 weeks. The metacarpophalangeal joint and the proximal interphalangeal joint were held in full extension. After removing the splint, physiotherapy was started. Full load-bearing, hard manual work and sport activities were not permitted for 3 months.

Results

Fifteen patients were treated using the extensor retinaculum for reconstruction of the A2 flexor pulley. The mean follow-up time was 48 months. The average range of motion of the PIP joint was 97?%, the average power grip strength 96?%, the finger pinch strength 100?%, and the average circumference 95?% of the uninjured contralateral side. The Buck–Gramcko score showed the following results: 10 excellent, 2 good, and 1 fair.     

Die Littler-Tenodese zur Behandlung der rheumatischen Schwanenhalsdeformit?t

Objective

Correction of swan neck deformity at the PIP and DIP joint by reconstruction of the oblique retinacular ligament through palmar transposition of one distally pedicled lateral band (oblique retinacular ligament reconstruction (ORL)?=?Littler?II).

Indications

Rheumatoid swan neck deformity Nalebuff stages?I?CIII (dynamic, partially contracted, contracted). The swan neck deformity should be of articular origin.

Contraindications

Advanced radiologic changes of the PIP joint (Larsen?3?C4) [12]. Extrinsic and intrinsic causes of swan neck deformity. Flexor tendon synovitis.

Surgical technique

Dorsal approach to the PIP joint. One lateral band is sectioned proximally at the level of the musculotendinous junction. It is then isolated from the extensor apparatus and left pedicled distal at the insertion. The isolated lateral band is then passed underneath the Cleland ligament from distal to proximal and is sutured to the distal edge of the A2?pulley. The correct tension of the tenodesis achieves flexion at the PIP joint and extension at the DIP joint. In contracted and partially contracted joints, the PIP joint is temporarily transfixed. Depending on the clinical findings, a synovectomy or dorsal arthrolysis of the PIP joint must be performed.

Postoperative management

Immediate postoperative mobilization of the PIP joint for flexion. A figure-of-eight finger splint has to be worn for 12?weeks. The splint must allow full PIP flexion and limit extension over 20?C30° of flexion. In case of temporary transfixation of the PIP joint, wire removal after 4?C6?weeks and start of mobilization. Passive extension over 20?C30° of flexion only after 12?weeks.

Results

From 2004?C2007, 30?PIP joints in 20?rheumatoid patients were treated for swan neck deformity. In all cases, the original method as described by Littler was used. A change of the procedure due to insufficiency of the Cleland ligament or the A2?pulley was not necessary in any of the cases. After a mean of 22?months, 26?PIP joints in 17?patients could be followed up. In 12?PIP joints, the deformity was partially contracted, in two joints contracted. In 10?joints, a dorsal arthrolysis had to be performed, while a lengthening of the medial band was performed in 1?patient. The swan neck deformity could be compensated in all cases. Preoperative hyperextension of a mean 21° could be reduced to a mean 24° of flexion postoperatively. The ROM did not change much but was shifted from the extension sector to the flexion sector of the PIP joint. In no case were complications or recurrence of the deformity noted. Pain could be reduced in all patients except one. The radiologic joint situation was Larsen stage 2.2 preoperatively and 2.3 postoperatively.     

Anatomic Reduction of Mallet Fractures Using Extension Block and Additional Intrafocal Pinning Techniques

Background

The purpose of this article is to report the efficacy of the extension block pinning and additional intrafocal pinning technique applied to cases whose mallet fractures were not reduced with extension block pinning alone.

Methods

We retrospectively reviewed 14 digits with 14 patients who were treated with the extension block pinning and additional intrafocal pinning technique. There were eight men and six women with an average age of 34 years. The average articular surface involvement was 52%. The average follow-up was 16 months and the mean time from injury to operation was 23 days.

Results

All the cases achieved anatomic reduction of fractures. By Crawford''s classification, 9 were excellent and 5 were good. The average active flexion of the distal interphalangeal joint was 78 degrees and the average extension loss was 1.8 degrees. Bone union was observed in all cases after a postoperative mean of 38.4 days. Complications such as skin necrosis, fracture of bony fragments, and nail-plate deformity were not found.

Conclusions

Additional intrafocal pinning technique is considered a simple and useful method to obtain anatomic reduction of mallet fractures in cases where extension block pinning alone is insufficient to restore the anatomic configuration of the articular surface.     

Arthrodese der Mittel- und Endgelenke der Kleinzehen

Objective

Elimination of the fixed lesser toe deformity by arthrodesis of the proximal or distal interphalangeal joints (PIP and DIP, respectively).

Indications

Painful fixed deformity. PIP joint: fixed hammer toe or clawtoe. DIP joint: fixed mallet toe. Relative indication: flexible hammer toe, clawtoe or mallet toe.

Contraindications

General operative contraindications. Relative contraindications also include severe deformities affecting the metatarsophalangeal (MTP) joint, for which the arthrodesis should combine an operative procedure of the MTP joint.

Surgical techniques

PIP arthrodesis: Dorsal incision centered over the PIP joint, exposure of the PIP joint by transsecting the extensor tendon and joint capsule, release of the collateral ligaments, while carefully protecting the neurovascular bundles, resection of the head of the proximal phalanx and the articular surface of the middle phalanx. The arthrodesis should be stabilised in mild plantar flexion. The tip of the toe should have contact with the surface when the push up test is done. The arthrodesis technique depends on the implant used. The extensor tendon is sutured and the wound is closed. DIP arthrodesis: dorsal incision centered over the DIP joint, exposure of the DIP joint by transsecting the extensor tendon and joint capsule, release of the collateral ligaments, while carefully protecting the neurovascular bundles. Resection of the head of the middle phalanx and the articular surface of the distal phalanx. The arthrodesis should be stabilised in straight position. The arthrodesis technique depends on the implant used. The extensor tendon is sutured and the wound is closed.

Postoperative management

Postoperative full weight bearing for 3–6 weeks, depending on the arthrodesis technique used.

Results

Stabilisation of the toe with adequate alignment is achieved by arthrodesis of the affected joint. In general, digital fusion of the fixed lesser toe pathology shows a high subjective satisfaction rate among the patients, although the rate of pseudarthrosis in attempted PIP or DIP arthrodesis is quite high. Major reasons for postoperative dissatisfaction were swelling, wound necrosis, pin infection, floating toe, shortening and angulation of the toe.     

Management of high-energy tibial plateau fractures by Ilizarov external fixator

Background

Despite the evolution of surgical techniques and implants, high energy tibial plateau fractures remain a challenging problem. The goals of treatment are to obtain a well-aligned stable joint with a painless functional range of motion and prevention of posttraumatic arthritis. Indirect reduction techniques and other soft tissue preservation methods safeguard the vascularity and emphasize restoring both joint congruity and the mechanical axis of the limb. The aim of this study was to evaluate the clinical outcome of using Ilizarov external fixator in the treatment of Schatzker type V–VI tibial plateau fracture.

Methods

This study was done during the period 2009–2011 for the treatment of 30 patients with high energy tibial plateau fractures (Schatzker type V in 17 and type VI in 13 patients) by Ilizarov external fixator. The mean age was 36 years .There were 23 males. The right limb was affected in 17 patients. There were 10 open fractures and other associated injuries in 9 patients.

Results

The mean of follow up period was 18 months. All the fractures were united in an average time of 15 weeks. There were pin track infection in 20 patients and other few complications in 8 patients. According to knee society score, there was an excellent result in 16.7 %, good in 60 %, fair in 20 %, and poor in 3.3 %.

Conclusion

Ilizarov external fixation is a safe and effective treatment option for high energy tibial plateau fractures with good functional results.     

A systematic review of outcomes of revision amputation treatment for fingertip amputations

Purpose

The purpose of this study was to conduct a systematic review of outcomes of fingertip revision amputation for fingertip amputation injuries in the English-language literature to provide best evidence of functional outcomes.

Methods

A MEDLINE literature search was performed to identify studies that met the following criteria: (1) reported primary data; (2) included at least five cases of primary revision amputation treatment following digit amputation injury; (3) reported finger or thumb amputation at or distal to the distal interphalangeal (DIP) joint or interphalangeal (IP) joint, respectively; (4) presented at least one of the following outcomes: static two-point discrimination (2PD), cold intolerance, arc of motion (AOM) of metacarpophalangeal (MCP) joints, proximal interphalangeal joints (PIP), DIP joints, or return-to-work time.

Results

Thirty-eight studies met the inclusion criteria. Twenty-seven studies reported 2PD, 20 studies reported cold intolerance, eight studies reported AOM, and 18 studies reported return-to-work time after revision amputation of fingertip injuries. The mean 2PD was 5.6 mm. On average, 24 % of patients experienced cold intolerance. AOM at the PIP joint was reported in four studies and averaged 94°. DIP joint AOM was presented in four studies and averaged 66°. Thumb MCP and IP joint AOM was presented in three and four studies, respectively. Mean thumb MCP joint AOM was 54° and that of the IP joint was 71°. The mean return-to-work time was 47 days.

Conclusions

On average, fingertip revision amputation can achieve almost normal sensibility and satisfactory motion and patients can expect to return to work on average approximately 7 weeks after surgery.     

Open reduction and bi-columnar internal fixation of intra-articular distal humerus fractures through a combined medial and lateral approach

Purpose

The aim of this retrospective study was to investigate the suitability of bi-columnar internal fixation through a combined medial and lateral approach for the treatment of intra-articular distal humerus fractures.

Methods

Nineteen cases of intra-articular distal humerus fractures were treated with open reduction and bi-columnar internal fixation through a combined medial and lateral approach. The reduction in the articular surface and functional recovery of the affected elbows was assessed at an average follow-up of 15.8 ± 7.9 (7–43) months.

Results

The gap in the main articular fragments was less than 1 mm in 16 cases, while a gap of more than 1 mm and less than 2 mm was identified in 2 cases and of 3.7 mm in one case. All the fractures were united. At the latest follow-up, the mean flexion–extension of the elbows was 113.4° ± 20.7°, while the pronation–supination of the forearms was 158.3° ± 8.5°, and the mean Mayo Elbow Performance Index was 93.7 ± 9.1 points, leading to 13 excellent outcomes, and 6 with good results.

Conclusions

Intra-articular fractures of the distal humerus can be effectively treated by open reduction and internal fixation through a combined medial and lateral approach at the elbow.     

Surgical treatment of vertically unstable lateral clavicle fractures (Neer 2b) with locked plate fixation and coracoclavicular ligament reconstruction

Introduction

The present study evaluates the outcome of patients treated with a combination of locked plate fixation and minimal-invasive coracoclavicular (CC) ligament reconstruction for unstable lateral clavicle fractures type IIb according to Neer.

Patients and methods

Fourteen patients with an unstable lateral clavicle fracture were treated with a combination of locked plate fixation and a minimal-invasive CC ligament reconstruction. At a mean follow-up of 38 months, patients were re-evaluated using the Constant-Murley score, the Acromioclavicular (AC) joint instability score and the TAFT score. Furthermore, anterior–posterior (ap) stress radiographs and axillary views were performed in order to detect any recurrent instability.

Results

Bony union was achieved in all cases within 6–10 weeks. The mean Constant-Murley score of the affected shoulder was 93.5 points compared to 97.2 of the contralateral unaffected shoulder. The mean Taft score was 11.2 points and the mean AC joint instability score was 92 points in comparison to 96 points on the unaffected side. The mean CC distance at the time of the injury was 21 mm compared to 8.5 mm after surgery and 12 mm a the final follow-up examination. The CC distance did not differ between the postoperative X-rays and those at the time of follow-up (p = 0.068). Three plates had to be removed because of implant irritation.

Conclusion

A combination of locked plate fixation and CC ligament augmentation in a minimal-invasive manner can be regarded as suitable for the treatment of vertically unstable lateral clavicle fractures and is associated with excellent clinical and radiological outcomes and a low complication rate.     

Treatment of intraarticular middle phalanx fractures using the Ligamentotaxor®

Background

We evaluated the outcome of intraarticular middle phalanx fractures after dynamic treatment with the Ligamentotaxor® system.

Materials and methods

Ten consecutive patients (seven male, three female; mean age 52 years) with intraarticular middle phalanx fractures were treated with the Ligamentotaxor® between 2009 and 2011. Proximal interphalangeal joint mobility, grip strength and ‘Disabilities of the Arm, Shoulder and Hand’ (DASH) score were evaluated in a 15-month follow-up. The reconstitution of the intraarticular space was measured immediately after trauma, at 6 weeks and at 15 months by radiograph control. The severity of the trauma was classified according to AO.

Results

We found B1 30 %, C1 (Seno I + II) 50 % and C3 (Seno III–V) 20 %. In 60 % of the cases, fractures were localized on the middle base of the fifth digit, in 20 % on the third digit and in 20 % on the index finger. The dynamic treatment lasted 7 weeks; patients were exposed to full workload after 9 weeks. The mean flexion mobility after 15 months reached 73° (range 60–100°), and the extension deficit was 13° (range 0–20°) on average. Grip strength attained 71.3 % (range 60–87 %) of the contralateral side. Initial x-ray after trauma compared to the x-ray after 15 months showed an intraarticular space reconstitution average of 0.5 mm (range 0.1–0.9 mm) anterior–posterior and 0.6 mm (range 0.1–1 mm) lateral. Patients evaluated their outcome with an average of 14.6 points (range 3.3–26.7) using the DASH score.

Conclusion

Good results can be obtained with the Ligamentotaxor®. We recommend it for the dynamic treatment of intraarticular middle phalanx finger fractures. Larger series and long-term results are needed.     

Distal radius fractures and the volar lunate facet fragment: Kirschner wire fixation in addition to volar-locked plating

Background

The volar lunate facet fragment of a distal radius fracture may not be stabilized with volar-locked plating alone due to the small size and distal location of the fragment. Identification and stabilization of this small fragment is critical as unstable fixation may result in radiocarpal and radioulnar joint subluxation. The addition of spring wire fixation with volar plating can provide stable internal fixation of this critical fracture fragment.

Methods

A retrospective review (2006–2011) identified nine patients with distal radius fractures with an associated volar lunate facet fragment that were treated with volar-locked plating and spring wire fixation of the volar lunate facet fragment. Radiographic indices, range of motion, grip strength, and postoperative Patient-related wrist evaluation (PRWE) scores were obtained to assess pain and function.

Results

All distal radius fractures healed, and the volar lunate facet fragment reduction was maintained. The mean follow-up was 54 weeks. Mean active range of motion was 46° wrist flexion, 51° wrist extension, 80° pronation, and 68° supination. The mean grip strength was 21 Kg, achieving 66 % of the uninjured limb. The average PRWE score was 17. No patient required removal of hardware or had evidence of tendon irritation.

Conclusions

The addition of spring wire fixation to volar-locked plating provided stable fixation of the volar lunate facet fragment of distal radius fractures without complication. This technique addresses a limitation of volar-locked plating to control the small volar lunate facet fragment in distal radius fractures otherwise amenable to volar plating.

Level of Evidence

A retrospective case series, Level IV.     

Versorgung von Fingerfrakturen mit der Minihakenplatte

Background

Fixation of the small bony fragments of the phalanges is often difficult. In this study a clinical and radiological evaluation was carried out after operative treatment using the mini-hook plate.

Patients and methods

Between 2003 and 2006 a total of 36 fractures were treated operatively using the mini-hook plate. Of the patients 24 had an basal avulsion fracture of the distal phalanx and 11 patients (12 fractures) had other bony avulsion fractures of the phalanges. The patients were evaluated clinically and radiologically as well as using the disabilities of the arm, shoulder and hand (DASH) questionnaire.

Results

A total of 29 patients with 30 fractures were examined. The mean follow-up was 13.6 months. The mean range of motion in the affected finger joint was 60.3?° and the mean DASH score was 2.8 points. Postoperatively five nail growth defects, one infection and one secondary dislocation of the implant were observed.

Conclusion

Using the mini-hook plate, preservation of the joint and stable internal fixation with no need for temporary arthrodesis is possible; however, prerequisites are experience and skill of the surgeon with a difficult surgical technique.