Single-incision extensile volar approach to the distal radius and concurrent carpal tunnel release: cadaveric study

[Our preferred Approaches to the distal Radius]

This article describes our preferred approaches to the distal radius treating acute fractures and malunion by plating.

Acute Carpal Tunnel Syndrome and Median Nerve Neurapraxia: A Review

Prompt diagnosis and treatment of acute injury to the median nerve after wrist trauma are paramount to a successful outcome. Neuropathy can occur primarily at the time of injury, secondary to unreduced fracture fragments or callus, or from prolonged immobilization in palmar flexion. Acute carpal tunnel syndrome is a surgical emergency that requires decompression. Progressively worsening pain and sensory disturbances in the median nerve distribution are findings that will distinguish an acute carpal tunnel syndrome from the less severe median nerve neurapraxia. This article describes the key differences between neurapraxia and acute compartment syndrome and their respective treatment.

Surgical Technique for Concurrent Endoscopic Carpal Tunnel Release and Distal Radius Fracture Fixation Using the Flexor Carpi Radialis Approach: A Case Series

Purpose

Multiple prior studies have assessed the results of open approaches for concurrent carpal tunnel release with distal radius fracture fixation; however, less is known regarding the feasibility of endoscopic techniques, especially in the setting of high-energy trauma. In this study, we assessed the feasibility and results of concurrent endoscopic carpal tunnel release and distal radius fracture fixation using the flexor carpi radialis approach after high- and low-energy trauma.

Methods

We performed a retrospective, single-surgeon study of 17 consecutive adult patients (aged >18 years) who underwent open reduction internal fixation of an acute distal radius fracture with concurrent endoscopic carpal tunnel release at a level 1 trauma center between April 2017 and October 2020. Recovery from median nerve dysfunction was assessed from patient charts at routinely scheduled postoperative follow-up visits (at 2 weeks, 4 weeks, 6 weeks, and 12 weeks).

Results

The transverse carpal ligament could be visualized and released in all patients. All patients had a return of light touch sensibility with or without intermittent paresthesia by 12 weeks after surgery (the median time from surgery to recovery was 19 days [range, 12–82 days]). There were no patient reports or clinical examination evidence of palmar cutaneous branch, recurrent motor branch, or the third common digital nerve injury. Time to recovery was significantly different in the setting of high- versus low-energy trauma (26 days vs 18 days, respectively; P = .02).

Conclusions

In this study, we demonstrated that concurrent endoscopic carpal tunnel release using the flexor carpi radialis approach for distal radius fracture fixation in the settings of high- and low-energy trauma is safe from major complications and effective at releasing the transverse carpal ligament.

Type of study/level of evidence

Therapeutic IV.

The effects of pistol grip power tools on median nerve pressure and tendon strains

Objectives. Tendonitis and carpal tunnel syndrome are common cumulative trauma disorders that can occur with repetitive usage of pistol grip power tools. The role of reaction torque resulting in a forceful rotary displacement of the tool handle, as well as the role of applied grip force, is not clear in the development of these disorders. This study aimed to quantify the flexor tendon strains and median nerve pressure during a typical power tool operation securing a threaded fastener. Methods. Six fresh-frozen cadaver arms were made to grip a replica pistol grip power tool using static weights to apply muscle forces. A 5-Nm torque was applied to the replica power tool. The median nerve pressure and strains in the flexor digitorum profundus and superficialis tendons were measured using a catheter and strain gauges, at three wrist flexion angles. Results. The peak tendon strains were between 1.5 and 2% and were predominantly due to the grip force more than the transmitted torque. Median nerve pressure significantly increased with the wrist flexed versus extended. Conclusion. The results indicate that the contribution of the grip force to the tendon strain and median nerve pressure was greater than the contribution from the reaction torque.

The Biomechanics of Multiligament Knee Injuries: From Trauma to Treatment

The multiple ligament injured knee is a complex biomechanical environment. When primary stabilizers fail, secondary stabilizers have an increased role. In addition, loss of primary restraints puts undue stress on the remaining intact structures of the knee. Treatment of these injuries requires accurate diagnosis of all injured structures, and careful consideration of repairs and reconstructions that restore the synergistic stability of all ligaments in the knee.

Distal radius fracture fixation with a volar locking plate and endoscopic carpal tunnel release using a single 15mm approach: Feasibility study

Distal radius fractures (DRF) may trigger, reveal or decompensate acute carpal tunnel syndrome (CTS) in 0.5-21% of cases. Internal fixation and median nerve release must then be carried out urgently. Less invasive approaches have been described for both the median nerve release using an endoscopic device and for the DRF fixation using a volar locking plate. We assessed the feasibility of DRF fixation and median nerve release through a single, minimally-invasive 15mm approach on a series of 10 cases. We reviewed retrospectively 10 consecutive cases of DRF associated with symptomatic CTS in 8 women and 2 men, aged 57 years on average. CTS was diagnosed clinically. All patients were treated during outpatient surgery with a volar locking plate and endoscopic carpal tunnel release using a single 15mm minimally-invasive approach. In one case, arthroscopic scapholunate repair was also required. Six months after the procedure, all patients were reviewed with a clinical examination and a radiological evaluation. The average values for the clinical and radiological outcomes were as follows: pain on VAS 1.5/10; QuickDASH 14.3/100; flexion 90%; extension 90.6%; pronation 95.6%; supination 87.9%; grip strength 90.1%; 2PD test 5.2mm (4-8mm). Five complications occurred: two cases of temporary dysesthesia in the territory of the median nerve and one case of temporary hypoesthesia of the palmar branch of the median nerve, which had all completely recovered; two cases of complex regional pain syndrome type I, which were still active at 6 months. Despite its methodological weaknesses, our study is the only one to describe the technical feasibility of a single 15mm minimally-invasive approach for both internal fixation using a volar locking plate and endoscopic nerve release, with no serious complications. This technique should be added to the surgical toolbox of minimally-invasive procedures for the hand and wrist.

Does routine carpal tunnel release during fixation of distal radius fractures improve outcomes?

OBJECTIVE

This case-control study was designed to test the hypothesis whether carpal tunnel release (CTR) during fixation of distal radius 23-C2 AO fractures improves outcomes.

METHODS

Thirty-five consecutive patients who sustained distal radius fractures of the dominant hand participated in this study. Patients were allocated into two groups: (a) The ORIF + CTR (16 patients (11 males and 5 females)); (b) the ORIF and NOT CTR 19 patients (12 males and 7 females). Patient assessment included visual analogic scale of pain (VAS), the subjective Mayo Wrist Score (MWS), electromyograms (EMG) at 3 month and 6 months from the day of injury and complications. All patients had the same physiotherapy treatment algorithm following surgery. Patient follow up took place at 1 month, 3, 6, and 12 months.

RESULTS

A the T12 month follow up point the VAS average was 0.8 (range 0-3) in ORIF + CTR group compared to 1.2 (range 0-3) in the ORIF and NOT CTR. The MWS average was 98.7 (range 95-100) in ORIF + CTR group versus 97.6 (range 95-100) in ORIF no CTR group. There was no statistical significance (p > 0.5) between the two groups during the follow up period. Patients in the sixth month of ORIF + CTR had no suffering of the median nerve, while 31.58% of patients in ORIF and no CTR found to have carpal tunnel syndrome.

CONCLUSIONS

Routine release of the transverse carpal ligament at the time of fracture fixation may reduce the incidence of postoperative median nerve dysfunction.

Iatrogenic Injuries of the Palmar Branch of the Median Nerve Following Volar Plate Fixation of the Distal Radius

Background: Our aims were to identify iatrogenous injuries to the palmar branch of the median nerve sustained during volar plate fixation of the distal radius, make the clinician aware of this relatively uncommon complication of distal radius fixation, to emphasise common threads in symptomatology and to propose an algorithm for evaluation and management.

Methods: Retrospectively interrogating our database over a 5 year period, the case records, neurophysiology records, operative records, therapy records were reviewed. The data was analysed with regard to the grade of surgeon performing the procedure, the site of injury, complexity of the fracture, delay to surgery, implant choice and outcome of the treatment. Variations in nerve anatomy were documented during revision surgery and common themes in symptomatology and clinical presentation were identified.

Results: Seven patients with an iatrogenic injury involving the palmar branch of the median nerve associated with volar plate fixation of the distal radius were assessed. The male: female ratio was 1:6 and the mean age of patients was 47.8 years (33-74 years). The initial operative fixation was undertaken by a consultant orthopaedic surgeon at a mean of 7.8 (1-17) days from injury. The mean time from fracture fixation surgery to referral to the peripheral nerve injury service was 8.9 (2-36) months. Six patients presented with pain on attempted wrist extension. Five patients had parasthesia, hyperaesthesia or dysaesthesia in the distribution of the PCBMN. Anaesthesia or hypoaesthesia was present in three patients. Two patients presented with symptoms of complex regional pain syndrome (CRPS) Type 2.

Conclusions: Revising relevant anatomy and possible variations as well as careful placements of retractors in the region of the median nerve could bring down these injuries. We propose an algorithm for their management.

The EFCR Approach and the Radial Septum-Understanding the Anatomy and Improving Volar Exposure for Distal Radius Fractures: Imagine What You Could Do With an Extra Inch

Locked volar plating is the most common surgical procedure to address distal radius fractures. The extended flexor carpi radialis approach continues to be an excellent method for visualizing distal radius fractures and applying a volar plate. A new understanding of the anatomy allows for better visualization and reduction of the many different distal radius fracture patterns surgeons commonly see. Within the extended flexor carpi radialis approach, we describe the radial septum in further detail including the anatomy which comprises the radial septum triangle. Knowledge of this area allows for better visualization, more anatomic reductions, and fewer complications.

Single-Incision Carpal Tunnel Release and Distal Radius Open Reduction and Internal Fixation: A Cadaveric Study

BACKGROUND

The safety of surgical approaches for single- versus double-incision carpal tunnel release in association with distal radius open reduction and internal fixation remains controversial.

PURPOSE

The purpose of this study was to identify critical structures to determine if a single-incision extension of the standard flexor carpi radialis (FCR) approach can be performed safely.

METHODS

Nine cadaveric arms with were dissected under loupe magnification, utilizing a standard FCR approach. After the distal radius exposure was complete, the distal portion of the FCR incision was extended to allow release of the carpal tunnel. Dissection of critical structures was performed, including the recurrent thenar motor branch of the median nerve, the palmar cutaneous branch of the median nerve (PCBm), the palmar carpal and superficial palmar branches of the radial artery, and proximally the median nerve proper. The anatomic relationship of these structures relative to the surgical approach was recorded.

RESULTS

Extension of the standard FCR approach as described in this study did not damage any critical structure in the specimens dissected. The PCBm was noted to arise from the radial side of the median nerve an average of 6.01cm proximal to the proximal edge of the transverse carpal ligament. The PCBm became enveloped in the layers of the antebrachial fascia and the transverse carpal ligament at the incision site, protecting it from injury. The recurrent motor branch of the median nerve, branches of the radial artery and the median nerve proper were not at risk during extension of the FCR approach to release the carpal tunnel.

CONCLUSIONS

Extension of the standard FCR approach to include carpal tunnel release can be performed with minimal risk to the underlying structures. This exposure may offer benefits in both visualization and extent of carpal tunnel release.

Concurrent Minimally Invasive Carpal Tunnel Release Techniques in Distal Radius Open Reduction Internal Fixation

Carpal tunnel syndrome is a common complication associated with distal radius fractures. Open carpal tunnel release in the same setting as open reduction and internal fixation of distal radius fractures is widely accepted. In this paper, we describe the technical details of a minimally invasive carpal tunnel release in the same setting as the fixation of a distal radius fracture via the same incision. Two options of minimally invasive techniques are described: The Knifelight® (Stryker, Kalamazoo, Michigan, USA) instrument and the single portal carpal tunnel release system (Agee, 3M Healthcare, St Paul, Minnesota, USA). Being well known and accepted techniques of carpal tunnel release, we believe that the techniques described in this paper provide a viable alternative for carpal tunnel release in the setting of distal radius fracture fixation; with the added advantages of the original minimally invasive techniques.

The Extended Flexor Carpi Radialis Approach for Concurrent Carpal Tunnel Release and Volar Plate Osteosynthesis for Distal Radius Fracture

PURPOSE

To determine the relative benefits of an extended flexor carpi radialis (FCR) (eFCR) approach with prophylactic carpal tunnel release at the time of volar plate osteosynthesis for distal radius fracture via a single incision into the traditional volar Henry (VH) approach.

METHODS

This was a prospective cohort comparison of preoperative and postoperative median nerve function of 27 patients (15 eFCR and 12 VH) with unilateral, isolated distal radius fractures requiring open reduction internal fixation without preoperative acute carpal tunnel syndrome. Patients were operated on via either the eFCR or VH approach. The validated Levine-Katz Carpal Tunnel Questionnaire (symptom and functional severity scores) was administered and Semmes-Weinstein monofilament and 2-point discrimination testing were conducted preoperatively and at 6 weeks and 3 months postoperatively. Grip and pinch strength were measured at 6 weeks and 3 months. The groups were comparable in terms of age, sex, and fracture type and displacement.

RESULTS

Comparing across groups, there were no statistically significant differences in any outcome measured preoperatively or postoperatively. The eFCR and VH groups demonstrated significant improvement in functional severity scores, symptom severity, and grip strength. The symptom severity score improved to statistical significance at 6 weeks in the eFCR group and at 3 months in the VH group.

CONCLUSIONS

In this small comparative study, the eFCR approach was found to be safe and efficacious. There was no increased surgical morbidity, which suggests that this technique can be used safely for all patients undergoing volar plating and not just in cases of concurrent carpal tunnel syndrome. It allows easier retraction of carpal tunnel contents; therefore, it is our preferred approach.

Basal Joint Arthroplasty and Radial-sided Carpal Tunnel Release Using a Single Incision

PURPOSE

The purpose of our study was to determine in vivo outcomes and consistency of relief of symptoms attributable to carpal tunnel syndrome in patients who underwent radial-sided carpal tunnel release in conjunction with basal joint arthroplasty through a single incision.

MATERIALS AND METHODS

A retrospective chart review identified all patients who had undergone radial-sided carpal tunnel release in combination with basal joint arthroplasty at 1 institution from February 2011 through April 2014. Both preoperative and postoperative symptoms attributable to carpal tunnel syndrome were documented. Patient outcomes were assessed using the QuickDASH (Disabilities of the Arm, Shoulder, and Hand) questionnaire. The mean length of follow-up was 16 months (range, 2 to 37 mo).

RESULTS

Eight patients (7 women; 10 extremities) were available for follow-up. There was complete resolution of all symptoms attributable to carpal tunnel syndrome in 9 of 10 extremities. There was complete relief of paresthesias in the remaining extremity (and the patient reported complete relief of night waking), as well as improvement but not resolution of hypoesthesia and pain.

CONCLUSIONS

Radial-sided carpal tunnel release performed with basal joint arthroplasty through a single incision provided reliable improvement or resolution of carpal tunnel syndrome symptoms.

Carpal tunnel release using the radial sided approach compared with the two-incision approach

We compared carpal tunnel release using a radial sided approach (RCTR) with a two-incision approach with regards to complications, grip strength, and functional outcomes. Retrospective chart review was done and data was collected pre-operatively, and post-operatively at six weeks and three months. A total of 32 and 26 patients were included in the two-incision and RCTR groups respectively. At six weeks, the RCTR group showed an increased grip strength (+32.24%) while the two-incision group was weaker (-6.75%). Both groups showed an increased strength at three months, RCTR at 98.4% while the two-incision group was significantly lower at 38.6% increase. Both techniques provided improvement in outcome scores, with no statistical difference. RCTR was associated with a significantly earlier return of grip strength and had better grip strength at six weeks and three months post-operatively. Both techniques provided symptom relief and good functional outcome.

Median neuropathy in malunited fractures of the distal radius

PURPOSE

Irritation of the median nerve is a well-characterized complication after acute fractures of the distal radius, but there is limited literature on median neuropathy in malunited fractures. The aims of our prospective study were to estimate the prevalence of the median neuropathy, explore the relationship between radiographic findings and the condition, and investigate whether corrective osteotomy without carpal tunnel release was a sufficient treatment.

METHODS

Thirty consecutive patients, who were referred to us for treatment of symptomatic distal radial malunion, underwent nerve conduction studies of both wrists by one board-certified neurologist under standardized conditions. Test results were correlated with conventional radiographic parameters (radial tilt, radial inclination, palmar shift, ulnar variance, radiolunate and capitolunate angle) and computer tomography (CT) based measurements of the cross-sectional area of the carpal tunnel. After corrective osteotomy without carpal tunnel release, 10 of 13 patients with unilateral preoperative median neuropathy agreed to an electrodiagnostic re-examination by the same neurologist.

RESULTS

Nineteen patients demonstrated abnormal test results, but only seven patients complained about paresthesias of median-innervated fingers. There was no correlation between median neuropathy and conventional radiographic parameters. Surprisingly, the cross-sectional area of the carpal canal was significantly greater for patients with median neuropathy. Symptoms resolved in all patients after corrective osteotomy. Postoperatively, six of ten patients demonstrated improved nerve conduction studies, although only four patients demonstrated normal test results.

DISCUSSION

There is a high rate of subclinical median neuropathy in malunited distal radial fractures that cannot be predicted by conventional radiographic parameters. Corrective osteotomy without carpal tunnel release is a sufficient treatment for neuropathy in malunited distal radius fractures.

Avoiding and treating perioperative complications of distal radius fractures

Numerous methods of treatment are available for the management of distal radius fractures, with modern trends favoring volar fixed-angle distal radius plates. Whatever the method of fixation, recognition, management, and prevention of the known associated complications are essential to achieve a good outcome. This article reviews the common preventable complications that are associated with operative treatment of distal radius fractures, including tendon injuries, inadequate reduction, subsidence or collapse, intra-articular placement of pegs or screws, nerve injuries, complex regional pain syndrome, carpal tunnel syndrome, and compartment syndrome.

Surgical approaches to the distal radius

INTRODUCTION

Fractures of the distal radius are among the most common fractures seen. They encompass a myriad of presentations and fracture patterns that often benefit from various open reduction and internal fixation techniques-including volar plating, dorsal plating, radial plating, intramedullary nailing, and fragment-specific fixation. In order to obtain optimal reduction of these fractures, surgeons require a thorough understanding of the anatomy and various surgical exposures.

ANATOMY

The distal radius is surrounded by a soft tissue envelope rich in vascularity and cutaneous innervation. The osseous surface consists of two articular surfaces and three cortical sides covered almost entirely by soft tissue.

SURGICAL APPROACHES

Approaches to the distal radius can be broadly divided into volar, radial, and dorsal. Visualization of the articular surface can be accomplished best arthroscopically. Arthroscopy can be performed alone or in conjunction with other open approaches to the distal radius.

SUMMARY

This article will review the pertinent anatomy and various surgical approaches in order to facilitate the surgeon's ability to safely expose a distal radius fracture.

Volar plate osteosynthesis of distal radius fractures with concurrent prophylactic carpal tunnel release using a hybrid flexor carpi radialis approach

PURPOSE

To evaluate the safety and efficacy of a hybrid flexor carpi radialis (FCR) approach for volar plate osteosynthesis of displaced distal radius fractures with concurrent prophylactic carpal tunnel release (CTR) in patients without preoperative signs or symptoms of acute carpal tunnel syndrome secondary to the fracture.

METHODS

A total of 68 displaced distal radius fractures in 65 eligible adult patients (35 men, 30 women; mean age, 48.6 +/- 15.4 y) who had volar plate osteosynthesis and concomitant prophylactic CTR through a hybrid FCR approach by a single surgeon were included in this study. A systematic chart review and subsequent telephone questionnaire were performed to identify any postoperative median nerve dysfunction, recurrent motor or palmar cutaneous branch injury, tendon injury, or other complications directly related to the approach.

RESULTS

Reported symptoms consistent with late median nerve dysfunction were identified in 2 cases; however, no patients in this series required additional surgery for early or late median neuropathy. Furthermore, no cases of median nerve sensory or motor branch injury or tendon injury were identified. No other unforeseen complications specifically related to the approach were observed.

CONCLUSIONS

Volar plate osteosynthesis of distal radius fractures with a concurrent prophylactic CTR can be safely performed through the described hybrid FCR approach in patients without signs or symptoms of acute CTS. Routine release of the transverse carpal ligament with the hybrid FCR approach at the time of fracture fixation might reduce the incidence of postoperative median nerve dysfunction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.