Outcomes after repair of subacute-to-chronic grade III metacarpophalangeal joint collateral ligament injuries in fingers are suboptimal

Purpose

Although injury to the collateral ligaments of the metacarpophalangeal joint (MPJ) of the fingers is less common than corresponding injuries in the thumb, similar disability may result from chronic untreated injuries. We evaluated injury characteristics and the outcome after primary repair of subacute to chronic grade III collateral ligament injuries of the MPJs of the fingers.

Methods

We retrospectively reviewed all patients who underwent primary repair of a finger MPJ collateral ligament over a 3-year period. Twenty-five digits in 23 patients with subacute to chronic injuries were identified, all of which had complete MPJ collateral ligament tear. Postoperatively, we assessed disability using DASH scores and evaluated joint stability, range of motion, and grip strength. These measures were compared to preoperative data to assess results. Post hoc analysis was used to compare the level of disability between index and small radial collateral ligaments and other finger CL injuries.

Results

Intraoperative findings revealed complete tears in all cases and all ligaments were of sufficient quality to permit primary repair using a suture anchor. The average preoperative DASH score was 40 (range 17–77) in 7 patients (nine fingers) where this was available. Postoperative DASH scores were available in 19 patients (21 fingers). The average postoperative DASH score was 19 (range 0–65). In the subgroup of patients with preoperative and postoperative DASH scores, there was no statistically significant difference after surgery (preop DASH 39.1 vs. postop DASH 23.8, p = 0.17). The average grip strength as a percentage of the contralateral hand was 68 % (range 32–100 %). The average postoperative MPJ arc of motion was 75° (range 50–90°). Post hoc analysis showed statistically significant higher postoperative DASH scores among small finger RCL repairs compared to other finger CL repairs (p = 0.007).

Discussion

Primary repair of complete MPJ collateral ligament injuries of the fingers may be performed in the subacute to chronic setting. Although joint stability was restored, patients continued to have decreased grip strength and residual disability.     

Outcome following distally locked volar plating for distal radius fractures with metadiaphyseal involvement

BackgroundThe surgical treatment of metadiaphyseal distal radius fractures may be difficult due to the associated articular or periarticular extension that limits standard fixation techniques. Longer distal radius volar locking plates allow stable fixation of the distal fragments while providing standard plate fixation in the proximal radius. We hypothesize that this plating technique allows adequate fixation to both the distal radius and metadiaphyseal fragments. The purpose of the study is to describe the outcomes, radiographic parameters, secondary surgeries, and complication rate with this device.MethodsA retrospective chart review was conducted on adult patients with a distal radius fracture and metadiaphyseal involvement treated with a volar, distally locked plate. All patients were followed up for radiographic union, with a mean time of 219 days (range 38–575). Fracture patterns, outcomes of range of motion, grip strength, and complications, as well as injury, post open reduction and internal fixation (ORIF), and finally, healed radiographic parameters were recorded.ResultsTwenty patients with 21 fractures were included. At union, mean radiographic parameters were the following: volar tilt of 8°, radial inclination of 27°, radial height of 14 mm, and ulnar variance of −1 mm. The mean final range of motion was 52° flexion, 50° extension, 68° pronation, and 66° supination. Complications included one infection and one plate removal. Four patients developed a nonunion requiring secondary procedures. There were no incidents of hardware failure or adhesions requiring tenolysis.ConclusionDistally locked long volar plating for metadiaphyseal distal radius fractures is a safe and effective treatment option for these complex fracture patterns allowing anatomic restoration of the radial shaft and distal radius.     

A Comparative Study between Conservative and Surgical Treatments of Triangular Fibrocartilage Complex Injury of the Wrist with Distal Radius Fractures

BackgroundTriangular fibrocartilage complex (TFCC) injury is common in distal radius fractures. The purpose of this study was to compare the conservative and surgical treatments of TFCC injury of the wrist associated with distal radius fractures.MethodsA retrospective study was conducted on 39 patients who received treatment for TFCC injury with distal radius fractures. All patients were treated using a volar locking plate for distal radius fractures. Twenty-six patients who received conservative treatment for TFCC through long arm splinting were classified into group 1, and 13 patients who received surgical treatment for TFCC were classified into group 2. The splint was maintained for 6 weeks in both groups. For clinical evaluation, the range of motion (ROM) of the wrist joint, patient-rated wrist evaluation (PRWE) score, Disabilities of the Arm, Shoulder and Hand (DASH) score, and grip strength were measured. Distal radioulnar joint (DRUJ) stability was evaluated through a stress load test and graded between grade 0 and 3 intraoperatively after fixation and at the final follow-up.ResultsIn group 1, the average DASH score was 11.1 ± 4.4, the average PRWE score was 10.2 ± 4.6, the grip strength was 89.4% relative to the unaffected side, the average ROM of the wrist joint was 65° ± 7.0° for extension, 51.5° ± 8.1° for flexion, 86° ± 5.1° for supination, and 85° ± 5.2° for pronation, and DRUJ stability at the final follow-up was grade 0 in 58.62%, grade 1 in 31.03%, grade 2 in 10.34%, and grade 3 in 0%. In group 2, the average DASH score was 13 ± 5.0, the average PRWE score was 12.4 ± 3.7, the grip strength was 87.3% relative to the unaffected side, and the average ROM of the wrist joint was 60° ± 9.8° for extension, 53.1° ± 7.0° for flexion, 85° ± 5.3° for supination, and 86.8° ± 4.5° for pronation. At the final follow-up, DRUJ stability was grade 0 in 66.67%, grade 1 in 25%, grade 2 in 8.3%, and grade 3 in 0%. The 2 groups showed no statistically significant differences in DASH score, PREW score, grip strength, ROM, and final follow-up DRUJ stability.ConclusionsThere were no statistically significant differences in the clinical outcomes between the surgical and conservative treatment groups. Therefore, when normal radiological indices are achieved after treatment of distal radius fractures, DRUJ stability can be obtained by conservative treatment.     

Are Volar Locking Plates Superior to Percutaneous K-wires for Distal Radius Fractures? A Meta-analysis

Background

Distal radius fractures are common, costly, and increasing in incidence. Percutaneous K-wire fixation and volar locking plates are two of the most commonly used surgical treatments for unstable dorsally displaced distal radius fractures. However, there is uncertainty regarding which of these treatments is superior.

Questions/purposes

We performed a meta-analysis of randomized controlled trials to determine whether patients treated with volar locking plates (1) achieved better function (2) attained better wrist motion, (3) had better radiographic outcomes, and (4) had fewer complications develop than did patients treated with K-wires for dorsally displaced distal radius fractures.

Methods

We performed a comprehensive search of MEDLINE (inception to 2014, October Week 2), EMBASE (inception to 2014, Week 42), and the Cochrane Central Register of Controlled Trials to identify relevant randomized controlled trials; we supplemented these searches with manual searches. We included studies of extraarticular and intraarticular distal radius fractures. Adjunctive external fixation was acceptable as long as the intent was to use only K-wires where possible and external fixation was used in less than 25% of the procedures. We considered a difference in the DASH scores of 10 as the minimal clinically important difference. We performed quality assessment with the Cochrane Risk of Bias tool and evaluated the strength of recommendations using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Seven randomized trials with a total of 875 participants were included in the meta-analysis.

Results

Patients treated with volar locking plates had slightly better function than did patients treated with K-wires as measured by their DASH scores at 3 months (mean difference [MD], 7.5; 95% CI, 4.4–10.6; p < 0.001) and 12 months (MD, 3.8; 95% CI, 1.2–6.3; p = 0.004). Neither of these differences exceeded the a priori-determined threshold for clinical importance (10 points). There was a small early advantage in flexion and supination in the volar locking plate group (3.7° [95% CI, 0.3°–7.1°; p = 0.04] and 4.1° [95% CI, 0.6°–7.6°; p = 0.02] greater, respectively) at 3 months, but not at later followups (6 or 12 months). There were no differences in radiographic outcomes (volar tilt, radial inclination, and radial height) between the two interventions. Superficial wound infection was more common in patients treated with K-wires (8.2% versus 3.2%; RR = 2.6; p = 0.001), but otherwise no difference in complication rates was found.

Conclusions

Despite the small number of studies and the limitations inherent in a meta-analysis, we found that volar locking plates show better DASH scores at 3- and 12-month followups compared with K-wires for displaced distal radius fractures in adults; however, these differences were small and unlikely to be clinically important. Further research is required to better delineate if there are specific radiographic, injury, or patient characteristics that may benefit from volar locking plates in the short term and whether there are any differences in long-term outcomes and complications.

Level of Evidence

Level I, therapeutic study.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-015-4347-1) contains supplementary material, which is available to authorized users.     

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 70° Supinated Oblique View: A Cadaveric Analysis to Determine Ideal Radial Styloid Screw Position in Locked Volar Plating of Distal Radius Fractures

Background: Defining an intraoperative radiographic view to best determine the radial styloid screw position in locked volar plating of distal radius fractures may improve fixation and aid in decreasing cortical penetration and implant complication. We used a cadaveric model to demonstrate a reproducible, oblique radiographic view to identify the radial styloid screw position. Methods: Nine fresh-frozen elbow-to-fingertip cadavers were used for this study. A 2.4-mm variable angle volar distal radius locking plate was applied to the distal radius. A Kirschner wire (K-wire) was inserted into the radial styloid through the plate. Placement of the K-wire through the tip of the styloid at the cortical edge was confirmed through a separate radial incision. A second K-wire was placed through the radius shaft into the ulna to aid in angular measurements. Live fluoroscopic imaging was used as the forearm was brought from full 90° of supination toward neutral. Once the K-wire was abutting the cortical edge, rotation ceased, and a goniometer was used to measure the angle of forearm rotation. This was repeated for a total of 3 repetitions on each specimen. Results: The average angle of supination best depicting the position of the radial styloid screw was 68.5° (range = 64.3°-70.5°). Conclusions: Radial styloid screw fixation in locked volar plating of distal radius fractures increases the ultimate strength to failure, but screw penetration and tendon irritation can occur. The 70° supinated oblique intraoperative view provides the most accurate evaluation of the position of the radial styloid screw.     

Isolated volar surgical approach for the treatment of perilunate and lunate dislocations

Background:

Volar and/or dorsal surgical approaches are used for surgical treatment of perilunate and lunate dislocations. There are no accepted approaches for treatment in the literature. We evaluated the functional results of isolated volar surgical approach for the treatment of perilunate and lunate dislocation injuries.

Materials and Methods:

9 patients (6 male and 3 female patients average age 34.5 ± 3.6 years) diagnosed with perilunate or lunate dislocations between January 2000 and January 2009 were involved in the study. The reduction was performed through isolated volar surgical approach and K-wire fixation, fracture stabilization with volar ligament repair was performed. Range of wrist joint motion, fracture healing, carpal stability, grip strength, return to work were evaluated and also direct radiographs were taken routinely at each control. The scapholunate interval and the scapholunate angle were evaluated radiographically. Evaluations of the clinical results were done using the DASH, VAS and Modified Mayo Wrist Scores.

Results:

The physical rehabilitation was started at 6^th week, after the K-wires were removed. The average followup was 18.2 months (range 12-28 months). At the final followup, the average flexion extension arc was 105.0 ± 9.6° (74.6% of the other side), the average rotation arc was 138.8 ± 7.8° (81.5% of the other side) and the average radioulnar arc was 56.1 ± 9.9° (86.4% of the other side). The grip strength was 0.55 bar; 83.2% that the uninjured arm. According to the Mayo Modified Wrist score, the functional result was excellent in five patients and good in four and the average DASH score was 22.8. The scapholunate interval was 2.1 mm and scapholunate angle was 51°.

Conclusion:

The clinical and radiological results of the isolated volar surgical approach were satisfactory. The dorsal approach was not needed for reduction of dislocations during operations. Our results showed that an isolated volar approach was adequate.     

The Measurement of the Inclination Angle of the Hamate and Analysis of the Inclination Angle for the Rotation Deformity of the Little Finger in the Fixation of the Carpometacarpal Joint

ObjectiveComplex base fractures of the fifth metacarpal bone and dislocation of the fifth carpometacarpal joint are more prone to internal rotation deformity of the little finger sequence after fixation with a transarticular plate. In the past, we have neglected that there is actually a certain angle of external rotation in the hamate surface of transarticular fixation. This study measured the inclination angle of the hamate surface relative to the fifth metacarpal surface for clinical reference.MethodsIn a prospective single‐center study, we investigated the tilt angle of 60 normal hamates. The study included thin‐layer computed tomography (CT) data from 60 patients from the orthopaedic clinic and inpatient unit from January 2017 to March 2020, including 34 men and 26 women who were 15~59 years old, average 35 years old. The CT data of 60 cases in Dicom format of the hand was input into Mimics and 3‐Matics software for three‐dimensional (3D) reconstruction and measuring the angle α between hamate surface and the fifth metacarpal surface. According to the possible placement of the transarticular plate on the fifth metacarpal surface, we measured the angle β between the hamate surface 1 and the fifth metacarpal surface and the angle γ between the hamate surface 2 and the fifth metacarpal surface.ResultsThe average angle between the hamate surface and the fifth metacarpal surface was 11.66°. The hamate surfaces 1 and 2 have an external rotation angle of 7.30° and 7.51° on average with respect to the fifth metacarpal surface, respectively. There is no statistically significant difference in the angles between the two groups (P > 0.05).ConclusionsThe horizontal angle of the dorsal side of the hamate is different from the back of the fifth metacarpal surface, and the hamate has a certain external rotation angle with respect to the fifth metacarpal surface. No matter how the transarticular plate is placed, the plate always has a certain external rotation angle relative to the fifth metacarpal surface. When the fixation is across the fifth carpometacarpal joint, if the plate does not twist and shape, it will inevitably cause internal rotation of the fifth metacarpal, resulting in internal rotation deformity of the little finger sequence.     

Malunited extra-articular distal radius fractures: corrective osteotomies using volar locking plate

Background

Multiple techniques for corrective osteotomy have been developed in recent years with the same aims: to improve the radiographic parameters and improve motion, pain and grip strength. Volar fixed-angle plates have added a new concept to the treatment of distal radius fractures thanks to the low morbidity of the surgical approach and the strength of the final construct, allowing early mobilization and return to function.

Materials and methods

Between 2005 and 2012, 20 patients with symptomatic dorsally malunited extra-articular fractures of the distal radius underwent corrective osteotomy using a volar locking plate without additional bone graft. At a mean follow-up of 50 months, all the patients were clinically and functionally evaluated.

Results

All measurements of pain, final range of motion and grip strength significantly improved compared with preoperative measurements. The mean preoperative DASH score reduced from 54 points preoperatively to 25 postoperatively. Based on the modified Mayo wrist score, we obtained 14 excellent and six good results. Palmar tilt improved from an average of 23° to 11°. Radial inclination improved from an average of 29° to 22°, and ulnar variance decreased from an average of 3.6 mm to 0.9 mm. There were two cases of transient median neuroapraxia that resolved before the 6-week follow-up appointment. No other major complications, including non-union and infection, were observed.

Conclusion

The volar approach and locking plate, without necessarily the use of bone grafting, proved to be an effective approach for addressing symptomatic and even severe deformities of the distal radius.

Type of study/level of evidence

Therapeutic IV     

External fixation versus volar locking plate for displaced intra-articular distal radius fractures: a prospective randomized comparative study of the functional outcomes

Background

The objective of the study was to compare the efficacy of external fixation and volar plating on the functional parameter of displaced intra-articular (Cooney’s type IV) distal end radius fractures using the Green and O’Brien scoring system.

Materials and methods

This prospective randomized study comprised 68 patients treated with external fixation and 42 patients treated with volar locking plates. The patients were followed up at 6 months and 1 year after surgery. The assessment of pain, range of motion, grip strength and activity were assessed at each follow-up visit and scored according to the Green and O’Brien scoring system.

Results

At 1 year after surgery, we observed that external fixation showed significantly better results than volar locking plates using the Green and O’Brien scores for range of motion (22.0 ± 4.77 vs 19.89 ± 5.05), grip strength (19.91 ± 5.4 vs 16.89 ± 4.4) and final outcome (87.36 ± 11.62 vs 81.55 ± 11.32). No difference was found in pain and activity between these two groups of patients. Patients aged <50 years treated with external fixation showed excellent results (final score (91.57 ± 9.01) at 1 year follow-up.

Conclusion

External fixation showed superiority over volar locked plating after 1 year of surgery.

Level of evidence

IV.     

Combined Approach for Intra-articular Distal Radius Fracture: A Case Series and Literature Review

BackgroundThe purpose of this study was to classify the possible indications for a combined approach to distal radius fractures (DRFs) by investigating surgical outcomes of patients treated according to our treatment algorithm.MethodsA combined approach was performed in 32 patients. Patients who were thought to need a combined approach were classified into three types according to the combined injuries associated with loss of volar cortical buttresses in DRFs. The classifications included the following: type 1, free intra-articular fragments; type 2, distally migrated dorsal fragments located beyond the wrist joint; and type 3, centrally impacted articular fragments and displaced dorsal fragments, not reduced by indirect methods.ResultsSeven patients had type 1 fractures treated with volar plates and excision of the intra-articular fragments. Fourteen patients had type 2 fractures: 12 were treated with volar plates and excision of dorsal fragments, and 2 with relatively large unstable dorsal fragments were treated with combined volar and dorsal plates. The remaining 11 patients had type 3 fractures treated with combined volar and dorsal plates. At the latest follow-up, the radiographs revealed an average of 16.9° of radial inclination, an average of 4.2° of volar tilt, and an average of 7.5 mm of radial height. According to the Garland and Werley scores, the functional results were excellent for 3 patients, good for 25, and fair for 4.ConclusionsThe classification system indicated when an additional dorsal approach was needed in unstable DRFs, and it may establish useful guidelines for appropriate surgical decision-making.     

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.     

Dsteosynthesis with long volar locking plates for meta- physeal-diaphyseal fractures of the distal radius

Objective：Metaphyseal-diaphyseal fractures of the distal radius are a major treatment dilemma and orthopaedic surgeons have to pay due consideration to restoration of anatomy of distal radius together with rotation of the radial shaft and maintenance of radial bow and interosseous space.We performed this study to evaluate the clinic-radiological outcome of metaphyseal-diaphyseal fractures of the distal radius treated with long volar locking plates.Methods：This prospective study involved 27 patients （22 males and 5 females） with metaphyseal-diaphyseal fracture of the distal radius.Their mean age was （30.12±11.48） years （range 19-52 years） and the follow-up was 26.8 months （range 22-34 months）.All patients underwent open reduction and internal fixation with a long volar locking plate.According to AO/OTA classification,there were 7 type A3,13 type C2 and 7 type C3 fractures.Subjective assessment was done based on the disabilities of the arm,shoulder and hand （DASH） questionnaire.Functional evaluation was done by measuring grip strength and range of motion around the wrist and the radiological determinants included radial angle,radial length,volar angle and ulnar variance.The final assessment was done according to Gartland and Werley scoring system.Results：Postoperative radiological parameters were well maintained throughout the trial,and there was significant improvement in the functional parameters from 6 weeks to final follow-up.The average DASH scores improved from 37.5 at 6 weeks to 4.2 at final follow-up.Final assessment using Gartland and Werley scoring system revealed 66.67%（n=l8） excellent and 33.33% （n=9） good results.There was one case of superficial infection which responded to antibiotics and another carpel tunnel syndrome which was managed conservatively.Conclusion：Volar locking plate fixation for metaphyseal-diaphyseal fractures of distal radius is associated with excellent to good functional outcome,early rehabilitation and minimal complications.     

Isolated dorsal approach for the treatment of neglected volar metacarpophalangeal joint dislocations

Here, we present the clinical and radiological results of three neglected volar metacarpophalangeal dislocations in 2 patients, which were treated with open reductions 10 and 24 mo after the dislocations. There was a mean of a 20°(range 10°-30°) limitation of extension and a 53.3°(range 30°-70°) limitation of flexion preoperatively. Postoperatively, there was no limitation of extension(at 8 and 12 mo) in any of the fingers. In terms of flexion, one finger had full function, one had a 10° and the last one had a 30° limitation of flexion. Two of the fingers presented anesthesia preoperatively, which improved to hypesthesia postoperatively. One finger had hypesthesia, which improved postoperatively. During surgery, a ruptured dorsal capsule was found to have interposed into the joint, making closed reduction impossible. Our experience with these two patients demonstrated that, even in neglected cases, open reduction using an isolated dorsal approach may result in satisfactory clinical andradiological outcomes.     

拇指籽骨翻转脱位致掌指关节绞锁的诊治

目的:探讨拇指籽骨翻转脱位致掌指关节绞锁的诊断和治疗.方法:对5例掌指关节绞锁患者(男4例,女1例;年龄18～47岁,平均35岁)行闭合手法复位,成功3例,另2例闭合复位失败后行手术切开复位.术中见拇指籽骨翻转脱位,与掌板、拇短屈肌腱一起卡入掌指关节间隙的掌侧,形成绞锁.籽骨复位后,绞锁即得到纠正.结果:5例均获得随访,时间3～34个月,平均15个月.治疗后所有患者局部疼痛症状消失,无红肿,手指感觉正常,掌指关节屈曲35°～60°,平均45°,不影响正常生活及正常工作,治疗后绞锁无复发.结论:拇指籽骨翻转脱位是导致掌指关节绞锁的重要原因之一.     

Comparison of Minimally Invasive Fixation of Mid‐Shaft Clavicular Fractures with Threaded Elastic Intramedullary Nail (TEIN) and Elastic Locking Intramedullary Nail (ELIN)

ObjectiveTo compare the effectiveness of threaded elastic intramedullary nail and elastic locking intradullary nail (ELIN) for mid‐shaft clavicular fractures.MethodsThe clinical data of 47 patients with middle clavicle fracture treated by TEIN and ELIN from August 2017 to March 2019 were analyzed retrospectively. Twenty‐three patients received intramedullary fixation treatment with ELIN, nine males and 14 females, AO/OTA fracture classification type 2A (n = 17) and 2B (n = 6). Twenty‐four patients received intramedullary fixation treatment with TEIN, including nine males and 15 females, AO/OTA classification: type 2A (n = 18) and 2B (n = 6). All patients were anesthetized with ipsilateral cervical plexus block. After internal fixation was removed, the clinical outcomes were assessed and evaluated. The Constant‐Murley score and disabilities of the arm, shoulder and hand questionnaire (DASH) score were compared between the two groups to evaluate the functional status of all patients. The study was done accordingly to the guidelines provided by the ethics committee.ResultsAll patients in the two groups completed the operation successfully and were followed up. In the ELIN group, the operation time was 20.78 ± 7.71 min, intra‐operative blood loss was 13.26 ± 9.72 mL, incision length was 1.60 ± 0.92 cm, internal fixation removal time was 12.86 ± 2.24 weeks, Constant‐Murley score was 99.30 ± 1.36 points and DASH score was 1.43 ± 3.00 points. In the TEIN group, the operation time, intra‐operative blood loss, incision length, internal fixation removal time, Constant‐Murley and DASH scores were 22.83 ± 8.17 min, 22.08 ± 11.22 mL, 2.48 ± 0.84 cm, 15.66 ± 5.58 weeks, 95.79 ± 7.38 point and 6.69 ± 11.55 point respectively. In the ELIN group, four cases developed skin irritation, and the symptoms were relieved after removal of internal fixation. In the TEIN group, one patient''s internal fixation broke and had an obvious scar at the incision, but there was no fracture after replacement of internal fixation; withdrawal of TEIN occurred in four patients, the nail did not shift again until the last follow‐up; skin irritation and temporary bursitis occurred in six patients, and the symptoms were relieved after internal fixation was removed. No other conditions were found in the patients, and bony healing was achieved in all patients.ConclusionELIN prevents shortening and malunion of the clavicle, reduces secondary damage to related tissues, and leads to restoration of clavicle length and faster osseous healing.     

Retrograde Headless Intramedullary Screw Fixation for Displaced Fifth Metacarpal Neck and Shaft Fractures: Short Term Results

BackgroundThis study aimed to evaluate the early clinical outcomes of retrograde headless intramedullary screw fixation for displaced fifth metacarpal neck and shaft fractures.MethodsWe retrospectively reviewed nine patients treated with retrograde intramedullary screw fixation of fifth metacarpal neck and shaft fractures between 2011 and 2013. Patient demographics and outcomes including hand dominance, age, sex, type of injury, injury and postoperative radiographs, return to work, time to fracture union radiographically, complications, visual analog score, disabilities of the arm, shoulder, and hand scores, postoperative metacarpophalangeal joint range of motion, and grip strength were recorded.ResultsNine fractures in nine patients with a mean age of 32 years (19–54) were included. There were seven metacarpal neck and two metacarpal shaft fractures. All patients sustained injury by direct impact of fist against an object. No case involved worker’s compensation. Patients had a mean follow-up of 36 weeks (6–57 weeks) and at the time of latest follow-up had no pain. Mean radiographic healing was 49 days (28–85 days). Mean return to work was 6 weeks (4–10 weeks). Mean metacarpalphalangeal joint motion was 0° extension and 90° flexion. Mean disabilities of the arm, shoulder, and hand scores pre- and postoperatively improved from 43 to 0.7, respectively. The mean postoperative grip strength was measured of the injured hand (40 kg) and un-injured hand (41 kg).ConclusionsRetrograde headless intramedullary screw fixation of fifth metacarpal neck and shaft fractures has overall favorable early outcomes and offers the benefit of stable fixation, early motion without cast immobilization, and the ability for early return to work. This technique is a viable surgical option for these fractures and may be considered in the appropriate patient population.     

Close Reduction Technique for Severely Displaced Radial Neck Fractures in Children

IntroductionRadial neck fractures account for 5–10% of paediatric elbow trauma. Radial neck fractures have been classified by Judet into five types (I–IVb). There is a global agreement to reduce radial neck fractures with angulation more than 30° (Type III, IVa and IVb). Various maneuvers have been described but none of them uniformly achieved complete reduction in severely displaced radial neck fractures (Type IVa and Type IVb Judet). In this case series, we are presenting our experience with close reduction of ten severely displaced paediatric radial neck fractures to achieve complete anatomical reduction.MethodsWe attempted close reduction in ten consecutive children with average age of 8.59 ± 1.68 years (range, 6–12 years) who presented with severely displaced radial neck fracture (Type IVa and IVb Judet). There were five girls. All patients had close injuries and presented to us within 24–48 h. One of the patients had associated undisplaced lateral condyle fracture. We have excluded two patients with associated elbow dislocation. Close reduction was performed within 48 h of initial injury.ResultsWe were able to obtain complete anatomical reduction in all of our patients with this technique. None of the patients required fixation of fracture. At 1 year of follow-up, (12 ± 2.07 months, range 9–16 months) all patients demonstrated almost full range of elbow and forearm motion. Final radiographs revealed complete union without any evidence of avascular necrosis.ConclusionThis technique offers an option of close reduction for the most severely displaced radial neck fractures, which were otherwise being treated by surgical intervention.Electronic Supplementary MaterialThe online version of this article (10.1007/s43465-020-00168-6) contains supplementary material, which is available to authorized users.     

Percutaneous Screw Fixation of Scaphoid Waist Fracture Non-Union Without Bone Grafting

The aim of the study was to evaluate results of volar percutaneous headless compression screw fixation without bone grafting in 21 patients with scaphoid waist nonunion fractures. The inclusion criteria in this series were scaphoid waist fracture nonunion with intact cartilaginous envelope, minimal fracture line at nonunion interface, no cyst or sclerosis, no avascular necrosis and normal scapholunate angle without humpback deformity. There were 17 male and 4 female patients with an average age of 23 years (range 16–45 years). All patients had radiographic examinations that included Posteroanterior, lateral, oblique and scaphoid views. Preoperative MRI to assess the cartilaginous shill and vascularity of scaphoid was done. CT scans were performed postoperatively to confirm scaphoid fracture healing. The average clinical follow-up was at 25 months (range 18–35) postoperatively. All fractures united successfully with no additional procedures. The average DASH score (disabilities of the arm, shoulder, and hand) at final follow-up was 8 (range 0–16). Percutaneous fixation for selected scaphoid nonunion can avoid the morbidity of an open approach and bone grafting.     

Anatomic relationships in distal radius bridge plating: a cadaveric study

Background

Two separate approaches have been described for radiocarpal spanning internal fixation for high-energy distal radius fractures with metaphyseal extension. To our knowledge, relevant anatomic relationships and structures at risk for iatrogenic injury have not been identified in the literature.

Methods

Twelve fresh frozen cadaver arms were randomized to fixation with a dorsal radiocarpal spanning plate using one of two techniques: (1) index finger metacarpal fixation (index group) or (2) middle finger metacarpal fixation (middle group). Cadaveric dissection and relevant anatomic relationships were assessed in relation to the plate.

Results

Superficial branches of the radial sensory nerve were in contact with the index group plate in all specimens, while no contact occurred in the middle group specimens. No extensor digitorum comminus (EDC) middle extensor tendons contacted the plate in the index group; an average of 10 cm of plate contact was seen in the middle group. The extensor pollicis longus (EPL) tendon contacted the plate in both the index and middle groups for an average distance of 12.4 and 25.5 mm, respectively. One complication [EPL and extensor indicis proprius (EIP) entrapment] was observed in the middle finger metacarpal group.

Conclusion

Mounting the dorsal bridge plate to the index finger metacarpal places the superficial branches of the radial sensory nerve at risk during dissection, while mounting the plate to the middle finger metacarpal leads to a greater degree of tendon-plate contact.