Distal Radioulnar oint Prosthesis

The distal radioulnar joint (DRUJ) prostheses have been available for many years and despite their superior outcomes compared to conventional DRUJ reconstructions in both short and long-term follow-ups, they have not become as popular as common hip and knee prostheses. In the current review article, at the first step, we discussed the applied anatomy and biomechanics of the DRUJ, and secondly, we classified DRUJ prostheses according to available literature, and reviewed different types of prostheses with their outcomes. Finally we proposed simple guidelines to help the surgeon to choose the appropriate DRUJ prosthesis.

Factors Associated With Reoperation After Silicone Metacarpophalangeal Joint Arthroplasty in Patients With Inflammatory Arthritis

Background: Silicone metacarpophalangeal (MCP) joint arthroplasty has a high revision rate. It has been suggested that the preoperative degree of ulnar drift and radial wrist deviation influences the durability of MCP silicone arthroplasties. The goal of this study was to evaluate what factors are associated with reoperation after silicone MCP arthroplasty. Materials and Methods: We retrospectively evaluated all adult patients who underwent MCP silicone arthroplasty between 2002 and 2016 at one institutional system for inflammatory arthritis. After manual chart review, we included 73 patients who underwent 252 arthroplasties. Fingers treated included 66 index, 67 long, 60 ring, and 59 small fingers. Results: The overall reoperation rate was 9.1% (N = 23). Indications for reoperation were implant breakage (n = 11), instability (n = 4), soft tissue complications (n = 4), infections (n = 3), and stiffness (n = 1). There was a trend that patients who underwent single-digit arthroplasty had higher rates of revision (19% vs 3.5%, P = .067). Radiographic follow-up demonstrated joint incongruency in 50% of cases, bone erosion in 58% of cases, and implant breakage in 19% of cases. There was a trend toward higher rates of revision in patients without preoperative MCP joint subluxation (19% vs 6.7%, P = .065) The 1-, 5-, and 10-year implant survival rates were 96%, 92%, and 70%, respectively. Revision surgery occurred at <14 months in 15 patients (65%) and after 5 years in 8 (35%) patients. Conclusions: Revision surgery after silicone MCP arthroplasty appears to be bimodal. Patients with greater hand function preoperatively may be at higher risk of revision surgery.

A systematic review and meta-analysis of the pronator quadratus repair following volar plating of distal radius fractures

BACKGROUND

Distal radius fracture (DRF) is the most common upper extremity fracture that requires surgery. Operative treatment with a volar locking plate has proved to be the treatment of choice for unstable fractures. However, no consensus has been reached about the benefits of pronator quadratus (PQ) repair after volar plate fixation of DRF in terms of patient-reported outcome measures, pronation strength, and wrist mobility.

METHODS

We searched the PubMed, Embase, Cochrane Central, and China National Knowledge Infrastructure (CNKI) databases up to March 13, 2020, and included randomized-controlled, non-randomized controlled, or case-control cohort studies that compared cases with and without PQ repair after volar plate fixation of DRF. We used a random-effects model to pool effect sizes, which were expressed as standardized mean differences (SMDs) and 95% confidence intervals. The primary outcomes included Disabilities of the Arm, Shoulder, and Hand scores and pronation strength. The secondary outcomes included the SMDs in pain scale score, wrist mobility, and grip strength. The outcomes measured were assessed for publication bias by using a funnel plot and the Egger regression test.

RESULTS

Five randomized controlled studies and six retrospective case-control studies were included in the meta-analysis. We found no significant difference in primary and secondary outcomes at a minimum of 6-month follow-up. In a subgroup analysis, the pronation strength in the PQ repair group for AO type B DRFs (SMD = - 0.94; 95% CI, - 1.54 to - 0.34; p < 0.01) favored PQ repair, whereas that in the PQ repair group for non-AO type B DRFs (SMD = 0.39; 95% CI, 0.07-0.70; p = 0.02) favored no PQ repair.

DISCUSSION

We found no functional benefit of PQ repair after volar plate fixation of DRF on the basis of the present evidence. However, PQ muscle repair showed different effects on pronation strength in different groups of DRFs. Future studies are needed to confirm the relationship between PQ repair and pronation strength among different patterns of DRF.

REGISTRATION

This study was registered in the PROSPERO registry under registration ID No. CRD42020188343 .

LEVEL OF EVIDENCE

Therapeutic III.

Bone density measurements from CT scans may predict the healing capacity of scaphoid waist fractures

Aims

We quantitatively compared the 3D bone density distributions on CT scans performed on scaphoid waist fractures subacutely that went on to union or nonunion, and assessed whether 2D CT evaluations correlate with 3D bone density evaluations.

Methods

We constructed 3D models from 17 scaphoid waist fracture CTs performed between four to 18 weeks after fracture that did not unite (nonunion group), 17 age-matched scaphoid waist fracture CTs that healed (union group), and 17 age-matched control CTs without injury (control group). We measured the 3D bone density for the distal and proximal fragments relative to the triquetrum bone density and compared findings among the three groups. We then performed bone density measurements using 2D CT and evaluated the correlation with 3D bone densities. We identified the optimal cutoff with diagnostic values of the 2D method to predict nonunion with receiver operating characteristic (ROC) curves.

Results

In the nonunion group, both the distal (100.2%) and proximal (126.6%) fragments had a significantly higher bone density compared to the union (distal: 85.7%; proximal: 108.3%) or control groups (distal: 91.6%; proximal: 109.1%) using the 3D bone density measurement, which were statistically significant for all comparisons. 2D measurements were highly correlated to 3D bone density measurements (Spearman’s correlation coefficient (R) = 0.85 to 0.95). Using 2D measurements, ROC curve analysis revealed the optimal cutoffs of 90.8% and 116.3% for distal and proximal fragments. This led to a sensitivity of 1.00 if either cutoff is met and a specificity of 0.82 when both cutoffs are met.

Conclusion

Using 3D modelling software, nonunions were found to exhibit bone density increases in both the distal and proximal fragments in CTs performed between four to 18 weeks after fracture during the course of treatment. 2D bone density measurements using standard CT scans correlate well with 3D models. In patients with scaphoid fractures, CT bone density measurements may be useful in predicting the likelihood of nonunion. Cite this article: Bone Joint J 2020;102-B(9):1200–1209.

Scapholunate Diastasis in Distal Radius Fractures: Fracture Pattern Analysis on CT Scans

Objectives  Our understanding of distal radius fractures with concomitant scapholunate (SL) diastasis primarily comes from plain radiographs and arthroscopy. The clinical implications of SL diastasis are not clear. The aim of this study is to describe fracture characteristics of distal radius fractures on computed tomography (CT) scans in patients with distal radius fractures and static SL diastasis. Methods  We queried our institutional databases to identify patients who were treated for a distal radius fracture, had a CT scan with a wrist-protocol, and static SL diastasis on their CT scan. Our final cohort consisted of 26 patients. We then collected data on their demographics, injury, treatment, evaluated injury patterns, and measured radiographic SL characteristics. Our study cohort consisted of 11 men (42%) and almost half of our cohort ( n  = 12; 46%) had a high-energy mechanism of injury. The majority of the patients ( n  = 20; 77%) had operative treatment for their distal radius fracture and two patients (7.7%) had operative treatment of their SL injury. Results  The mean SL distance was 3.5 ± 1.1 mm. Twenty patients (77%) had an intra-articular fracture. In these patients, we observed three patterns: (1) scaphoid facet impaction; (2) lunate facet impaction; and (3) no relative impaction. We observed other injury elements including rotation of the radial styloid relative to the lunate facet and partial carpal subluxations. Conclusion  Static SL dissociation in the setting of distal radius fractures may be an indication of a complex injury of the distal radius, which may not be directly apparent on plain radiography. If these radiographs do not demonstrate impaction of the lunate or scaphoid facet, a CT scan may be warranted to have a more detailed view of the articular surface. Level of Evidence  This is a Level III, diagnostic study.

Reevaluation of the Scaphoid Fracture: What Is the Current Best Evidence?

Scaphoid fractures are common and notorious for their troublesome healing. The aim of this review is to reevaluate the current best evidence for the diagnosis, classification, and treatment of scaphoid fractures and nonunions. MRI and CT are used to establish a "definitive diagnosis" with comparable diagnostic accuracy although neither is 100% specific. Current classifications cannot reliably predict union or outcomes; hence, a descriptive analysis of fracture location, type, and extent of displacement remains most useful. Treatment of a nondisplaced scaphoid waist fracture remains an individualized decision based on shared decision-making. Open reduction and internal fixation may be preferred when fracture displacement exceeds 1 mm, and the fracture is irreducible by closed or percutaneous means. For unstable nonunions with carpal instability, either non-vascularized cancellous graft with stable internal fixation or corticocancellous wedge grafts will provide a high rate of union and restoration of carpal alignment. For nonunions characterized with osteonecrosis of the proximal pole, vascularized bone grafting can achieve a higher rate of union.

Dorsal Barton fracture is a variation of dorsal radiocarpal dislocation: a clinical study

Dorsal Barton fractures may be better described as variants of dorsal radiocarpal dislocations. We aimed to better characterize these fractures by reviewing 111 patients in the ICUC® dataset who had a dorsally displaced, intra-articular distal radius fracture. We identified 13 patients with a dorsal Barton fracture on radiographs (dorsal articular margin fracture with radiocarpal subluxation and intact volar cortex). All patients with a dorsal Barton fracture had radial styloid involvement and volar cortical disruption that was subsequently identified on three-dimensional CT. Based on three-dimensional CT and intra-operative findings, none of the patients had classically described dorsal Barton fractures. All patients were treated using a volar exposure. A volar capsular tear was identified intra-operatively in three patients and the volar capsule repaired. This series supports the contention that dorsal Barton fractures are better characterized and treated as a variation of a dorsal radiocarpal dislocation. Level of evidence: IV.

Improvement of Orthopedic Residency Programs and Diversity: Dilemmas and Challenges, an International Perspective

BACKGROUND

To date, little has been published comparing the structure and requirements of orthopedic training programs across multiple countries. The goal of this study was to summarize and compare the characteristics of orthopedic training programs in the U.S.A., U.K., Canada, Australia, Germany, India, China, Saudi Arabia, Russia and Iran.

METHODS

We communicated with responders using a predetermined questionnaire regarding the national orthopedic training program requirements in each respondent's home country. Specific items of interest included the following: the structure of the residency program, the time required to become an orthopedic surgeon, whether there is a log book, whether there is a final examination prior to becoming an orthopedic surgeon, the type and extent of faculty supervision, and the nature of national in-training written exams and assessment methods. Questionnaire data were augmented by reviewing each country's publicly accessible residency training documents that are available on the web and visiting the official website of the main orthopedic association of each country.

RESULTS

The syllabi consist of three elements: clinical knowledge, clinical skills, and professional skills. The skill of today's trainees predicts the quality of future orthopedic surgeons. The European Board of Orthopedics and Traumatology (EBOT) exam throughout the European Union countries should function as the European board examination in orthopedics. We must standardize many educational procedures worldwide in the same way we standardized patient safety.

CONCLUSION

Considering the world's cultural and political diversity, the world is nearly unified in regards to orthopedics. The procedures (structure of the residency programs, duration of the residency programs, selection procedures, using a log book, continuous assessment and final examination) must be standardized worldwide, as implemented for patient safety. To achieve this goal, we must access and evaluate more information on the residency programs in different countries and their needs by questioning them regarding what they need and what we can do for them to make a difference.

Revision Fixation of Distal Humerus Fracture Nonunions in Older Age Patients with Poor Bone Quality or Bone Loss - Is This Viable as a Long-term Treatment Option?

BACKGROUND

The purpose of this retrospective study was to analyze the long-term results of revision ORIF, joint contracture release, and autogenous bone-grafting in the treatment of distal humerus frac-ture nonunions in older aged patients with poor bone quality or bone loss who would have been candidates for total elbow arthroplasty.

METHODS

Seven patients (average age at index procedure: 53.3 years, range: 41-75) with a distal humerus fracture nonunion treated with revision ORIF, joint contracture release and autogenous bone grafting between 1989-2000 were available for follow-up. Radiographic union and arthrosis were assessed using the most recent radiograph. Pain-related outcomes were measured using PROMIS Pain Interference scores. Functional outcomes were evaluated using the Mayo Elbow Perfor-mance Index (MEPI).

RESULTS

After an average follow-up of 22 years (range: 19-27 years), all nonunions were healed after the index procedure and had an average arc of ulnohumeral motion of 80°, flexion of 112°, and flex-ion contracture of 32°. Average arthrosis grade was moderate joint-space narrowing with osteo-phyte formation. One patient had exertional discomfort but none required chronic pain medica-tions. PROMIS-Pain Interference scores were no different than the general population (mean [95%CI] = 49.2 [41.8, 56.6], p =0.83). Per the MEPI, the functional result was excellent in five patients, good in one, and poor in one.

CONCLUSION

Despite older age and worse bone quality, distal humerus fracture nonunions can be treated using revision ORIF, joint contracture release and autogenous bone-grafting with acceptable long-term outcomes.

LEVEL OF EVIDENCE

IV.

Dorsal Lunate Facet Fracture Reduction Using a Bone Reduction Forceps

Background  The dorsal lunate facet fragment represents part of a complex articular injury of the distal radius and is challenging to reduce through a standard volar approach. We propose reduction through a standard volar approach and intraoperative dorsal lunate facet reduction using a bone forceps. To evaluate the postoperative reduction, we used computed tomography (CT) scan. Methods  We retrospectively included 60 patients with a median follow-up of 44 weeks. Fracture reduction was evaluated using pre- and direct postoperative CT scans of the wrist, measuring the articular gap and step of the sigmoid notch. The range of motion was evaluated clinically by the treating physician. Bivariate analysis was performed to compare pre- and postoperative radiographic measurements and to compare wrist range of motion. Results  When comparing the injured with the uninjured wrist, there was a significant difference in flexion, extension, pronation, and supination. In 87% of the patients, there was complete radiographic reduction of the fracture. Conclusion  This study shows that dorsal ulnar lunate facet fracture fragments in distal radius fractures can be reduced through a standard volar approach with the help of an intraoperative bone reduction forceps. Using wrist CT, we showed that 87% of the patients with a dorsal ulnar lunate facet fragment had a postoperative articular step or gap of <1 mm. Level of Evidence : This is a level IV, therapeutic study.

Best Approaches in Distal Radius Fracture Malunions

PURPOSE OF REVIEW

Malunion remains a common complication in the treatment of distal radius fractures. The purpose of this review was to discuss the various approaches in planning and surgical management for extra- and intra-articular distal radius malunions.

RECENT FINDINGS

Several recent studies have reported good results with surgical correction of distal radius malunions utilizing a number of preoperative planning methods and surgical approaches. Three-dimensional models and custom cutting guides have recently become more popular, but their benefit in comparison to other methods remains unclear. Regardless of preoperative planning method or surgical approach, good results can be achieved with correction of distal radius malunion with careful attention to patient selection, indications, and surgical technique.

Distal Radioulnar Joint Replacement in the Scarred Wrist

Background  Radiocarpal or midcarpal arthritis can occur simultaneously with arthritis of the distal radioulnar joint (DRUJ), leading to functional impairment of the wrist. Treatment often involves wrist arthroplasty or arthrodesis, either with simultaneous or secondary procedures, addressing the DRUJ. Successful treatment of solitary DRUJ arthritis with DRUJ replacement has been reported. However, outcomes in patients with multiple prior wrist surgeries are lacking. Surgery in these wrists is challenging because surgical scarring and advanced bone deformities make implant positioning more difficult. Therefore, the aim of this study was to evaluate the outcomes in patients that underwent total wrist arthrodesis and DRUJ replacement after multiple prior wrist surgeries. Methods  We prospectively enrolled patients that underwent total wrist arthrodesis and replacement of the DRUJ, either simultaneously or during separate procedures from 1999 to 2012. We included 14 patients with a median age of 43 years (interquartile range [IQR]: 35-47). As objective outcomes range of motion, weight-bearing ability, grip strength, was measured. For the subjective outcomes, we used an analogue pain score and the disabilities of the arm shoulder and hand (DASH) scores. Results  At a median follow-up of 5.6 years (IQR: 3.2-7.1). The average DRUJ range of motion and weight lifting ability significantly improved. As for the subjective evaluations, postoperative pain scores improved significantly, as did the DASH scores. Four of the patients had a postoperative complication, including infection and heterotopic ossification, of which two required reoperations. Additionally, 5 patients developed pisotriquetral arthritis requiring, pisiform excision, triquetrum excision, or the combination of both. Conclusion  Distal radioulnar joint replacement with a semiconstrained prosthesis was an effective method to restore the function of the wrist and forearm. As the surgical anatomy and soft tissue envelope were compromised in these patients, additional surgical exposure is necessary, adding to the complexity in these patients. No radiographic loosening Level of Evidence  This is a therapeutic level IV study.

Three-Dimensional Compared with Two-Dimensional Preoperative Planning of Corrective Osteotomy for Extra-Articular Distal Radial Malunion: A Multicenter Randomized Controlled Trial

BACKGROUND

Malunion is the most frequent complication seen after a fracture of the distal end of the radius. The primary aim of this study was to compare patient-reported outcome measures (PROMs) after corrective osteotomy for malunited distal radial fractures with and without 3-dimensional (3D) planning and use of patient-specific surgical guides.

METHODS

From September 2010 to May 2015, 40 adult patients with a symptomatic extra-articular malunited distal radial fracture were randomized to 3D computer-assisted planning or conventional 2-dimensional (2D) planning for corrective osteotomy. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score. Secondary outcomes included the Patient-Rated Wrist Evaluation (PRWE) score, pain and satisfaction scores, grip strength, and radiographic measurements at 3, 6, and 12 months postoperatively.

RESULTS

From baseline to 12 months of follow-up, the reduction in the mean DASH score was -30.7 ± 18.7 points for the 3D planning group compared with -20.1 ± 17.8 points for 2D planning (p = 0.103). Secondary functional outcome by means of the PRWE resulted in a similar reduction of -34.4 ± 22.9 points for the 3D planning group compared with -26.6 ± 18.3 points for the 2D planning group (p = 0.226). There were no significant differences in pain, satisfaction, range of motion, and grip strength. Radiographic analysis showed significant differences in the mean residual volar angulation (by 3.3°; p = 0.04) and radial inclination (by 2.7°; p = 0.028) compared with the templated side, in favor of 3D planning and guidance. The duration of preoperative planning and surgery as well as complication rates were comparable.

CONCLUSIONS

Although there was a trend toward a minimal clinically important difference in PROMs in favor of 3D computer-assisted guidance for corrective osteotomy of extra-articular distal radial malunion, it did not attain significance because of (post hoc) insufficient power. Despite the challenge of feasibility, a trial of large magnitude is warranted to draw definitive conclusions regarding clinical advantages of this advanced, more expensive technology.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Predictors of Carpal Tunnel Release After Open Distal Radius Fracture

The purpose of this investigation was to determine the incidence and identify the predictors of carpal tunnel release (CTR) after open fractures of the distal radius (DRF). Patients with clinical symptoms of persistent median nerve neuropathy that required CTR were analyzed for risk factors. One hundred thirty-nine open DRFs (107 grade I, 23 grade II, 9 grade III) met the inclusion criteria. The incidence of CTR was 13.7% in all open DRFs (19 out of 139). Multivariable logistic regression analysis identified four predictors: male sex [odds ratio (OR) = 8.8, p = .001], type III Gustilo and Anderson grade (OR = 6.2, p = .04), OTA fracture type C (OR = 3.8, p = .03), and the application of external fixation (OR = 14.0, p D .02). The probability of CTR, determined by preoperative variables, was 80% with three factors present and 2% with no risk factors. High-risk patients may be identified who may benefit from closer perioperative surveillance and possibly carpal tunnel release. (Journal of Surgical Orthopaedic Advances 26(4):227-232, 2017).

Patient Satisfaction After Bilateral Thumb Carpometacarpal Osteoarthritis Surgery

This study seeks to determine whether patients with bilateral thumb carpometacarpal osteoarthritis were sufficiently satisfied with their surgeries to choose to undergo surgery again. The null hypothesis is that patients are dissatisfied with the results of the first surgery. Out of 46 living patients meeting enrollment criteria, 41 were enrolled and evaluated using the Disabilities of the Arm, Shoulder and Hand (DASH) score and the Enneking musculoskeletal score. The average DASH score was 17.37. The average Enneking musculoskeletal score was 88.21. Of 41 patients, one expressed unwillingness to undergo the next procedure, three indicated that they would reluctantly do surgery again, and four were satisfied. The remaining 33 subjects were enthused with their functional result, expressing willingness to undergo the procedure again. At an average follow-up of 44.9 months, most patients are satisfied with bilateral thumb carpometacarpal surgery for osteoarthritis. Consent for the contralateral surgery implies that the outcome of the first surgery was sufficiently acceptable to seek surgery on the contralateral thumb. (Journal of Surgical Orthopaedic Advances 26(4):250-256, 2017).

Current Perspectives on Complex Wrist Fracture-Dislocations

Although perilunate injuries represent only 5% of all carpal injuries, they compose a spectrum of devastating complex wrist injuries. Perilunate injuries result from high-energy trauma to the wrist and may be associated with multiple fractures, dislocations, and ligament injuries. Although the diagnosis of a perilunate injury is made via radiographic assessment, missed diagnosis occurs in 25% of patients with a perilunate injury. Immediate diagnosis of perilunate injuries is critical to optimize patient outcomes. Closed reduction of perilunate injuries is performed to avoid permanent damage to the median nerve and other compromised structures. As swelling subsides, open reduction is performed to restore anatomic alignment, attain stable fixation, and repair the ligaments. Despite optimal management of perilunate injuries, complications, including median nerve dysfunction, complex regional pain syndrome, carpal instability, and late posttraumatic arthritis, may occur. Satisfactory outcomes can be achieved in patients with a perilunate injury via prompt recognition and timely surgical management. Although radiographic signs of arthritis develop in many patients with a perilunate injury, these radiographic signs do not necessarily correlate with functional outcomes. Some patients with a perilunate injury require salvage procedures for the management of persistent complications. Radiocarpal fracture-dislocations are a complex wrist fracture-dislocation pattern. Radiocarpal fracture-dislocations generally result from high-energy trauma and are characterized by a carpal dislocation, which usually involves a small portion of the rim of the dorsal or volar aspect of the distal radius. Neurologic dysfunction and elevated intracompartment pressure may be present in patients with a radiocarpal fracture-dislocation. Wrist fracture-dislocations are associated with a number of complications, including intercarpal instability, later arthrosis, carpal nonunion, and loss of radiocarpal mobility.

Incidence and Functional Outcomes of Scapholunate Diastases Associated Distal Radius Fractures: A 2-year Follow-Up Scapholunate Dissociation

BACKGROUND

The Scapholunate Interosseous Ligament (SLIL) is the first intrinsic carpal ligament to be injured in wrist trauma, present in up to 64% of the distal radius fractures. However, it remains unclear what patients develop symptoms, making primary treatment of these injuries accompanying distal radius fractures remains questionable.

OBJECTIVE

The aim of this study was to evaluate the functional outcomes of patients with scapholunate diastasis associated with distal radius fractures.

METHODS

We evaluated 391 patients with a distal radius fracture. Using Computer Tomography (CT) scans the scapholunate interval was measured. We identified 14 patients with an SLD (>3mm) of the injured wrist, which underwent a CT-scan of the contralateral wrist. To evaluate the functional outcomes at a mean follow up of 136±90 weeks, we used the Quick Disabilities of the Arm, Shoulder and Hand (qDASH) Score.

RESULTS

There were 8 patients with bilateral SLD and 6 patients with unilateral SLD. Five patients had a qDASH score of 0 and one patient showed a qDASH score of 18.2. The patient with a poor score had bilateral preexisting osteoarthritis of the wrist. No patient had additional surgery of the SLIL.

CONCLUSION

In patients with distal radius fractures, more than half of the 14 patients with an SL gap on CT had widening on the contralateral side. It is therefore worthwhile to image the contralateral wrist before diagnosing a SLD. The patients with unilateral SLD should not be surgically treated at initial presentation because they may have good functional outcomes after a follow up of 2 years.

Nonrheumatoid Arthritis of the Hand

Arthropathy of the hand is commonly encountered. Contributing factors such as aging, trauma, and systemic illness all may have a role in the evolution of this pathology. Besides rheumatoid arthritis, other diseases affect the small joints of the hand. A review of nonrheumatoid hand arthropathies is beneficial for clinicians to recognize these problems.

Abductor Digiti Minimi Flap for Vascularized Coverage in the Surgical Management of Complex Regional Pain Syndrome Following Carpal Tunnel Release

BACKGROUND

The development of Complex Regional Pain Syndrome (CRPS) represents a potentially devastating complication following carpal tunnel release. In the presence of a suspected incomplete release of the transverse carpal ligament or direct injury to the median nerve, neurolysis as well as nerve coverage to prevent recurrent scar has been shown to be effective.

METHODS

Retrospective chart review and telephone interview was conducted for patients who underwent abductor digiti minimi flap coverage and neurolysis of the median nerve for CRPS following carpal tunnel release.

RESULTS

Fourteen wrists in 12 patients were reviewed. Mean patient age was 64 years (range, 49-83 years), and the mean follow-up was 44 months. Carpal tunnel outcome instrument scores were 47.4 ± 6.8 preoperatively and 27.1 ± 10.6 at follow-up ( P < .001). Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores at follow-up were 29.4 ± 26. No significant postoperative complications were identified.

CONCLUSIONS

The abductor digiti minimi flap is a reliable option with minimal donor site morbidity. It provides predictable coverage when treating CRPS following carpal tunnel syndrome.

Open Reduction and Internal Fixation for Lateral Unicondylar Distal Humeral Fractures

Introduction

Unicondylar distal humeral fractures are uncommon, partially intra-articular fractures (OTA/AO type B1) that are among the most complex fractures to treat^1,2; however, most displaced distal humeral fractures, including lateral unicondylar distal humeral fractures^2-5, can be effectively managed with open reduction and internal fixation.

Indications & Contraindications

Step 1 Preparation of the Operating Room and the Patient

Perform sterile preparation, have the patient brought into the operating room, induce anesthesia, and place the patient in the lateral decubitus or supine position before sterile draping.

Step 2 Approach to the Fracture

Make a lateral incision, expose the lateral distal part of the humerus, identify the ulnar nerve if necessary, visualize the fracture fragments, and debride the fracture site.

Step 3 Reduction of the Fracture

Reduce the fracture and fix it temporarily.

Step 4 Plate Fixation of the Fracture

Determine the plate length; position the plate posterolaterally, posteriorly, or laterally; insert screws; remove provisional Kirschner wires; and obtain intraoperative images.

Step 5 Final Radiographic Imaging

Make anteroposterior and lateral radiographic images to confirm reduction and adequate anatomic alignment of the elbow and the position of the hardware.

Step 6 Closure of the Wound

Deflate the tourniquet, irrigate the wound, and apply postoperative dressings.

Results

The detailed outcome for a cohort of 24 patients who underwent this procedure has been reported elsewhere⁶.

Pitfalls & Challenges

Compressive Neuropathy of the Ulnar Nerve: A Perspective on History and Current Controversies

The untoward effects resulting from compression of the ulnar nerve have been recognized for almost 2 centuries. Initial treatment of cubital tunnel syndrome focused on complete transection of the nerve at the level of the elbow, resulting in initial alleviation of pain but significant functional morbidity. A number of subsequent techniques have been described including in situ decompression, subcutaneous transposition, submuscular transposition, and most recently, endoscopic release. This manuscript focuses on the historical aspects of each of these treatments and our current understanding of their efficacy.

Scaphocapitate Syndrome With Associated Trans-Scaphoid, Trans-Hamate Perilunate Dislocation: A Case Report and Description of Surgical Fixation

Background: Perilunate fracture dislocations are often associated with fractures of the distal pole of the scaphoid or the proximal pole of the capitate. However, the combination of perilunate dislocation with multiple carpal fractures and associated scaphocapitate syndrome is very rare. Methods: We report a unique case of scaphocapitate fracture syndrome with perilunate dislocation and fracture of the hamate resulting from a high-energy injury to the wrist during a dirt-bike competition. Results: Open reduction and internal fixation of the scaphoid fracture with a 3.0-mm headless screw, the head of the capitate with a 1.5-mm lag screw, and the hamate fracture with a 1.3-mm lag screw was performed. The lunotriquetral dissociation was reduced, with the ligament repaired and the joint stabilized using a Kirschner wire. All screw heads are carefully buried under the articulate cartilage. Conclusions: Prompt anatomic reduction and stable osteosynthesis of all fractures in this patient resulted in successful healing and return to activity.

Management of Radial Head Fractures: Current Concepts

Radial head fractures are common injuries and are accompanied by clinically relevant associated injuries in over one-third of patients. They are commonly classified by the Mason classification or one of its modifications. Type I fractures are treated conservatively with early mobilization. Type II fractures can be treated conservatively or by open reduction and internal fixation (ORIF), depending on fragment size and dislocation. Bony restriction in forearm rotation is an indication for surgical treatment. Type III fractures are treated surgically, by means of ORIF, prosthetic replacement or excision. Comminuted fractures with more than three fragments are regarded as unsuitable for ORIF. However, optimal treatment of type II and III fractures is still the subject of debate and there is a strong need for randomized clinical trials and uniform fracture classification and outcome measures.

AO Distal Radius Fracture Classification: Global Perspective on Observer Agreement

Background The primary objective of this study was to test interobserver reliability when classifying fractures by consensus by AO types and groups among a large international group of surgeons. Secondarily, we assessed the difference in inter- and intraobserver agreement of the AO classification in relation to geographical location, level of training, and subspecialty. Methods A randomized set of radiographic and computed tomographic images from a consecutive series of 96 distal radius fractures (DRFs), treated between October 2010 and April 2013, was classified using an electronic web-based portal by an invited group of participants on two occasions. Results Interobserver reliability was substantial when classifying AO type A fractures but fair and moderate for type B and C fractures, respectively. No difference was observed by location, except for an apparent difference between participants from India and Australia classifying type B fractures. No statistically significant associations were observed comparing interobserver agreement by level of training and no differences were shown comparing subspecialties. Intra-rater reproducibility was "substantial" for fracture types and "fair" for fracture groups with no difference accounting for location, training level, or specialty. Conclusion Improved definition of reliability and reproducibility of this classification may be achieved using large international groups of raters, empowering decision making on which system to utilize. Level of Evidence Level III.