Intra-articular fractures of the hand

Innovations in Small Joint Arthroscopy

With advancements in surgical instrumentation and techniques, the role of arthroscopic and arthroscopic-assisted surgical procedures is ever-growing. Arthroscopy offers direct, magnified visualization of pathology and reductions and is more accurate than relying on intraoperative fluoroscopy alone. It also minimizes soft tissue stripping, which is of particular importance to smaller fracture fragments whose vascularity is precarious and can be injured through open approaches.

Proximal Interphalangeal Joint Congruity: A Biomechanical Study

BACKGROUND

Surgical approaches to the proximal interphalangeal (PIP) joint often require disruption of soft tissue stabilizers. Additionally, PIP joint injuries frequently result in soft tissue disruption. This study evaluates the necessity of repairing soft tissue stabilizers by assessing their role in maintaining native joint congruity.

METHODS

Eight specimens were used to evaluate congruity at 0° and 30° flexion when loaded with 2 N of valgus force. This was performed in the native joint and after sequential sectioning of the surrounding ligaments in order: volar plate (VP), radial collateral ligament (CL), and ulnar CL. The skin flap was sutured with the ligaments unrepaired and the load was reapplied. Radiographs were taken after each load and used to measure the joint line convergence angle (JLCA).

RESULTS

Mean JLCA increased in both degrees of flexion after ligaments were sectioned but was only significantly different from the native joint after the VP was disrupted along with 1 CL. Joint congruity improved following repair of the skin flap in both degrees of flexion but was not significant. Joints were more congruent in 30° flexion for all subgroups, but none were significantly different compared to 0° flexion.

CONCLUSIONS

Disruption of the VP is insufficient to significantly alter PIP joint congruity. While sectioning of both the VP and CLs resulted in a statistically significant change in joint congruity, mean JLCA demonstrated changes of minor clinical significance. The osseous anatomy of the phalanges imparts inherent stability that maintains a congruent joint despite loss of the soft tissue stabilizers.

Cost-effectiveness of introducing cone-beam computed tomography (CBCT) in the management of complex phalangeal fractures: economic simulation

Purpose

The purpose of this study was to evaluate the cost-effectiveness of introducing cone-beam computed tomography (CBCT) in the management of the complex finger fractures with articular involvement.

Methods

We created a decision tree model simulating the diagnostic pathway of complex finger fractures, suggesting the use of CBCT as alternative to multi-slice computed tomography (MSCT), and we compared their clinical outcomes, costs, and cost-effectiveness for a hypothetical cohort of 10,000 patients. Measures of effectiveness are analysed by using quality-adjusted life years, incremental cost-effectiveness ratio, and net monetary benefit.

Results

Diagnosis of a complex finger fracture performed with CBCT costed 67.33€ per patient, yielded 9.08 quality-adjusted life years, and gained an incremental cost-effectiveness ratio of 29.94€ and a net monetary benefit of 9.07 € at 30,000€ threshold. Using MSCT for diagnosis costed 106.23 €, yielded 8.18 quality-adjusted life years, and gained an incremental cost-effectiveness ratio of 371.15 € and a net monetary benefit of 8.09 €. CBCT strategy dominated the MSCT strategy. The acceptability curve shows that there is 98% probability of CBCT being the optimal strategy at 30,000€ threshold (1 EUR equal to 1.11 USD; updated on 02/02/2020).

Conclusion

CBCT in complex finger fractures management is cost saving compared with MSCT and may be considered a valuable imaging tool in preoperative assessment, allowing early detection and appropriate treatment. It shortens the time to completion of diagnostic work-up, reduces the number of additional diagnostic procedures, improves quality of life, and may reduce costs in a societal perspective.

An investigation of the acute management of closed intra-articular fractures of the proximal interphalangeal joint in Ireland

Purpose

Many treatment methods for intra-articular fractures of the proximal interphalangeal (PIP) joint are described in the literature without a consensus on the most effective approach. The purpose of this study was to investigate the methods of treatment of PIP joint fractures being used by trauma surgeons in the Republic of Ireland currently and the timing of referral to therapy.

Design/methodology/approach

A cross-sectional descriptive study methodology was used to survey trauma surgeons, occupational therapists and physiotherapists in Ireland. An online platform was used. A total of 21 surveys were returned by surgeons and 37 by therapists. Descriptive statistical analysis was used to present the results.

Findings

Buddy strapping was reported as the primary treatment method for stable PIP joint fractures. All levels of fracture severity were reported to be treated using traction constructs, which include static and dynamic fixation and orthoses. Unstable fractures were managed using open reduction with internal fixation by 50 per cent of surgeons. Early timing of referral to therapy is reported by more surgeons than therapists. The majority of therapists indicated that they did not have the resources to see patients at the optimal time.

Originality/value

To the authors’ knowledge, this study provides the first description of the management of PIP joint fractures across the Irish health service. The findings of this study suggest that additional therapy resources are required within the health service executive to facilitate the desired early referral to therapy and to enable service development for this category of hand fractures.

Proposal of a New Dynamic Distraction Device to Treat Complex Periarticular Fractures of the Metacarpophalangeal Joint of Long Finger

Background: Complex periarticular fractures of the metacarpophalangeal joint (MCPJ) are often challenging to treat. Conservative and operative treatments are often burdened with stiffness, loss of function, and poor clinical outcome. These phenomena could be a direct consequence of long period of immobilization. To promote a short time of immobilization and a quick return to daily activities, it is mandatory to stabilize the fracture maintaining the active range of motion (AROM) of the ray. A simple solution is to reduce the fragments by means of dynamic ligamentotaxis. The authors propose a new dynamic distraction device (DDD) for the MCPJ. Methods: The DDD for the MCPJ was made of Kirschner wires bent and connected to counteract dislocation forces and to allow mobilization of the joint. The DDD was tested on a cadaver model under a simulated load in physiological conditions, and also in metacarpal and proximal phalanx (P1) fracture patterns. The effectiveness of the device was evaluated under fluoroscopy. Results: The data showed that DDD is able to achieve fracture reduction through ligamentotaxis and primary fragments stability and to avoid secondary dislocation during AROM of complex periarticular fractures of the MCPJ. Conclusions: The frame could be an alternative option to treat periarticular fractures of the MCPJ. The DDD implant has several advantages: It is time efficient because assembly and application take only few minutes. Furthermore, it is very versatile; indeed, it can be used in all metacarpal and phalanx bones, even in the central rays.

Computed tomographic analysis of the internal structure of the metacarpals and its implications for hand use, pathology, and surgical intervention

The variation of bone structure and biomechanics between the metacarpals is not well characterized. It was hypothesized that their structure would reflect their common patterns of use (i.e., patterns of hand grip), specifically that trabecular bone density would be greater on the volar aspect of all metacarpal bases, that this would be most pronounced in the thumb, and that the thumb diaphysis would have the greatest bending strength. Cross-sections at basal and mid-diaphyseal locations of 50 metacarpals from 10 human hands were obtained by peripheral quantitative computed tomography. The volar and dorsal trabecular densities of each base were measured and characterized using the volar/dorsal density ratio. The polar stress-strain index (SSIp), a surrogate measure of torsional/bending strength, was measured for each diaphysis and standardized for bone length and mass. Comparisons were made using mixed-model analyses of variance (ANOVAs) and post hoc tests. Volar/dorsal trabecular density ratios showed even distribution in all metacarpal bases except for the thumb, which showed greater values on the volar aspect. The thumb, second, and third metacarpals all had high bending strength (SSIp), but the thumb's SSIp relative to its length and trabecular mass was much higher than those of the other metacarpals. Trabecular density of the metacarpal bases was evenly distributed except in the thumb, which also showed higher bending strength relative to its length and mass. Understanding of how these indicators of strength differ across metacarpals may improve both fracture diagnosis and treatment and lays the groundwork for investigating changes with age, hand dominance, and occupation.

Management of Acute Postoperative Pain in Hand Surgery: A Systematic Review

PURPOSE

To conduct a systematic review to guide hand surgeons in an evidenced-based approach in managing postoperative pain.

METHODS

We performed a literature review for primary research articles on management of postoperative pain in hand surgery patients using Medical Literature Analysis and Retrieval System Online (MEDLINE; PubMed), Excerpta Medica database (EMBASE), and the Cochrane Collaboration Library. Inclusion criteria were primary journal articles examining treatment of acute postoperative pain based on any modality. Data related to pain assessment, postoperative recovery, and total postoperative analgesic consumption were extracted.

RESULTS

A total of 903 publications were reviewed; 184 publications underwent abstract review. After applying inclusion and exclusion criteria, 10 primary articles were selected for inclusion in this review. Data were noted to be heterogeneous and findings were compiled. Results were divided into groups evaluating postoperative pain medications or pain infusion catheters.

CONCLUSIONS

Although this review did not demonstrate a best practices model for postoperative pain management, it provides evidence for alternative medications and treatment strategies. The evidence available suggests that postoperative pain control should begin before surgery and that combining multiple strategies for pain treatment is beneficial. Given the increasing attention paid to narcotic prescriptions and the potential for abuse, surgeons should adopt evidence-based pain management practices. We provide an example algorithm for pain treatment in hand surgery based on available data and the authors' experience.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Management of complications with hand fractures

Both operative and nonoperative treatment of hand fractures can result in numerous complications, including stiffness, malunion, nonunion, arthritis, infection, and complex regional pain syndrome. These complications are frequently encountered and are often challenging to treat. This article systematically outlines the diagnosis and treatment of each of these complications to achieve the best possible outcome for the patient's overall hand function.