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Assiotis A, Rumian A, Uppal HS, Yeoh C. How to Deal With an Unreconstructable Distal Radius Fracture. Cureus 2024; 16:e52487. [PMID: 38371019 PMCID: PMC10874134 DOI: 10.7759/cureus.52487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 02/20/2024] Open
Abstract
The most prevalent long bone fracture is that of the distal radius, and it affects all age groups. These fractures can present after low-energy or high-energy trauma, and their configuration often varies depending on the mechanism of injury. Their management can be operative or non-operative, and the scientific literature is abundant in studies comparing these two treatment modalities. There is also a healthy scientific debate as to the indications that should guide surgery for these injuries. A male patient sustained a high-energy fracture to his distal radius and presented to our unit soon after the injury. His fracture presented significant surgical challenges due to its complexity. It was stabilised surgically, and the patient recovered good function after rehabilitation. This case aims to demonstrate a surgical treatment protocol and the relevant surgical considerations when dealing with significant injuries, such as the one presented in this paper, where traditional fixation techniques may not yield a satisfactory outcome.
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Affiliation(s)
| | - Adam Rumian
- Trauma and Orthopaedics, Lister Hospital, Stevenage, GBR
| | - Harpal S Uppal
- Trauma and Orthopaedics, Lister Hospital, Stevenage, GBR
| | - Clarence Yeoh
- Trauma and Orthopaedics, Lister Hospital, Stevenage, GBR
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2
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Bell JA, James NF, Mauck BM, Calandruccio JH, Weller WJ. The Pitfalls of Difficult Distal Radius Fractures and Provisional Reduction. Orthop Clin North Am 2024; 55:113-122. [PMID: 37980096 DOI: 10.1016/j.ocl.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Distal radius fractures are some of the most common injuries encountered in orthopedics and require careful consideration when determining the appropriate treatment options. These fractures can be difficult injuries to treat surgically based on a large variability of fracture patterns, bone quality, and anatomy. It is important to understand the potential pitfalls associated with the treatment of difficult distal radius fractures to prevent avoidable complications. Some of these pitfalls include but are not limited to appropriate surgical exposure and soft tissue handling, provisional reduction, fixation type, and augmentation of fracture fixation.
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Affiliation(s)
- Jared A Bell
- Department of Orthopedic Surgery, University of Florida Health Jacksonville, 655 8th Street West, Jacksonville, FL 32209, USA
| | - Nicholas F James
- Department of Orthopedic Surgery, University of Florida Health Jacksonville, 655 8th Street West, Jacksonville, FL 32209, USA.
| | - Benjamin M Mauck
- Campbell Clinic Department of Orthopedic Surgery, University of Tennessee Health Science Center, 7887 Wolf River Boulevard, Germantown, TN 38138, USA
| | - James H Calandruccio
- Campbell Clinic Department of Orthopedic Surgery, University of Tennessee Health Science Center, 7887 Wolf River Boulevard, Germantown, TN 38138, USA
| | - William J Weller
- Campbell Clinic Department of Orthopedic Surgery, University of Tennessee Health Science Center, 7887 Wolf River Boulevard, Germantown, TN 38138, USA
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3
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Cha SM, Shin HD, Kim SW. Volar Locking Plate Fixation for Distal Radius Fractures Distal to the Watershed Line with an Intact Lunate Volar Rim. J Hand Surg Asian Pac Vol 2023; 28:708-716. [PMID: 38073409 DOI: 10.1142/s2424835523500753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
Background: We treated distal radius fractures (DRFs) beyond the watershed line without fracture of the lunate volar rim using a volar locking plate (VLP) and report the radiological and clinical outcomes at least 3 years after surgery. Methods: In 41 consecutive patients between January 2012 and August 2017, the fragment was composed of the radial styloid process (distal to the watershed line) and the lunate volar rim was intact. We evaluated demographic factors, radiological features and radiological/clinical outcomes at the final follow-up. Results: Twenty-nine patients were followed and evaluated. The mean follow-up period was 5.7 years. The mean patient age was 52.7 years and 24 patients had intracapsular intra-articular fractures. The fracture line was present in the lunate fossa in all patients. Twenty patients were classified as Soong grade 2, and five and four patients were grades 1 and 0, respectively. No radiological parameter (volar tilt, radial inclination, step-off and ulnar variance) was significantly different between the affected and contralateral normal sides. The mean visual analogue scale pain score and Disabilities of the Arm, Shoulder and Hand score, as well as the range of movement of the wrist, were not different between the affected and contralateral normal wrists. Finally, the grip strength on the affected side was 92% of the contralateral value. Major complications, such as nonunion, malunion and tendon rupture, were absent. Conclusions: DRFs distal to the watershed line with an intact lunate volar rim are rare and easy to miss. Careful inspection of 3D-CT images is necessary to determine these injuries, and the optimal choice for proper fixation of the fragment amongst the commercial VLPs would result in satisfactory radiological and clinical outcomes. Level of Evidence: Level IV (Therapeutic).
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Affiliation(s)
- Soo Min Cha
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hyun Dae Shin
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Seung Won Kim
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
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Lari A, Nouri A, Alherz M, Prada C. Operative treatment of distal radius fractures involving the volar rim-A systematic review of outcomes and complications. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3419-3428. [PMID: 37148390 DOI: 10.1007/s00590-023-03558-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 04/23/2023] [Indexed: 05/08/2023]
Abstract
PURPOSE Distal radius fractures involving the volar rim are a subset of unstable and extremely distal fractures involving the volar lunate and/or scaphoid facets. Volar rim fractures (VRF) are challenging to manage and different treatment options have been described. This study aimed to compare outcomes and assess the rates of complications and implant removal for different treatment methods of wrist fractures involving VRF. METHODS A systematic review of studies published in MEDLINE, EMBASE, Web of Science and Cumulative Index to Nursing and Allied Health literature (CINAHL) was conducted to assess the operative outcomes of VRF. Data on patient demographics, implant usage, postoperative outcomes, complications, and implant removal were compiled. RESULTS Twenty-six studies met the inclusion criteria with a total of 617 wrists. The most commonly used implants were 2.4 mm variable-angle volar rim plate (DePuy Synthes) (17.5%), Acu-Loc II (Acumed) (14%) and standalone hook plates (13%). The average outcome measures were Q-DASH (10.9 ± 7), MWS (85.8 ± 7.5), PRWE (15.9 ± 12.1), and DASH (14 ± 8.5). The overall complication rate was 14% (n = 87), with 44% (n = 38) involving flexor tendon problems. The implant removal rate was 22%, with routine removal being performed in 54% and non-routine removal in 46% of cases. CONCLUSION The current treatment of VRF yields favorable functional outcomes across different treatment options. However, these fractures have a high rate of complications and re-interventions, particularly for symptomatic implants. LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Ali Lari
- Department of Orthopedic Surgery, AlRazi National Orthopedic Hospital, Kuwait City, Kuwait.
| | - Abdullah Nouri
- Department of Orthopedic Surgery, AlRazi National Orthopedic Hospital, Kuwait City, Kuwait
| | - Mohammad Alherz
- Department of Anatomy, Trinity College Dublin, Dublin, Ireland
| | - Carlos Prada
- St Joseph's Health Care, Hand and Upper Limb Centre, University of Western Ontario, London, ON, Canada
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5
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Abstract
Distal radius fractures are among the most common fractures treated by orthopedic surgeons. Various classification systems have been described which can help in deciding the approach for fixation. In some cases, a computed tomography scan can provide better understanding of the fracture fragments and displacement for surgical planning. Plating through the volar approach is the most common approach for fractures meeting operative criteria. Several additional approaches can be used for specific fracture patterns. These approaches can be used in isolation or in conjunction with other approaches to aid in visualization and fixation.
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Affiliation(s)
- Devan Patel
- Stanfod University, VOICES Health Policy Research Center, Department of Orthopaedic Surgery, 450 Broadway Street, MC: 6342, Redwood City, CA 94063, USA
| | - Robin Kamal
- Stanfod University, VOICES Health Policy Research Center, Department of Orthopaedic Surgery, 450 Broadway Street, MC: 6342, Redwood City, CA 94063, USA.
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Mallon ZO, Schlauch AM. A novel surgical technique for distal radius fractures using the "mini distractor". Trauma Case Rep 2023; 47:100926. [PMID: 37700739 PMCID: PMC10494307 DOI: 10.1016/j.tcr.2023.100926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2023] [Indexed: 09/14/2023] Open
Abstract
Open reduction and internal fixation of distal radius fractures is one of the most common operations for orthopaedic surgeons. A vital step of the operation is restoring radial height, which can be challenging if the surgeon is operating alone. To address this, we present a novel surgical technique called the distal radius mini distractor. The technique utilizes a compression / distraction device in tandem with a volar locking plate to aid in the reduction of impacted distal radius fractures. The written technique guide is presented alongside intra-operative surgical pictures and fluoroscopy. The objective of this article is to introduce the mini distractor technique, which can be of particular use for the surgeon operating without assistance.
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Affiliation(s)
| | - Adam M. Schlauch
- San Francisco Orthopaedic Residency Program, San Francisco, CA, United States of America
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Chung SR, Chung KC. Recognizing and Treating Unique Distal Radius Fracture Patterns that are Prone to Displacement. Hand Clin 2023; 39:279-293. [PMID: 37453757 DOI: 10.1016/j.hcl.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
An unstable distal radius fracture is one that is not capable of resisting displacement after initial closed reduction. The challenge in managing distal radius fractures is identifying which fractures are prone to displacement. Currently, there are no standard criteria for assessing the stability of distal radius fractures. The fracture pattern and patient characteristics should be taken into consideration when treating distal radius fractures. This article discusses how to recognize and manage distal radius fractures that are prone to displacement.
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Affiliation(s)
- Sze Ryn Chung
- Department of Hand and Reconstructive Microsurgery, Singapore General Hospital, 20, College Road, 169856 Singapore
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
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Husain TM, Jabbour JI, Sudduth JD, Lessard AS, Patete CL, Panthaki ZJ, Salloum GE. Pronator Quadratus Muscle Flap for Prevention of Flexor Tendon Rupture after Distal Radius Volar Plating. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5227. [PMID: 37654680 PMCID: PMC10468108 DOI: 10.1097/gox.0000000000005227] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/12/2023] [Indexed: 09/02/2023]
Abstract
Background Flexor tendon rupture is a serious but rare complication that can occur after volar plating of distal radius fractures. This study aims to introduce a novel surgical technique that uses a pronator quadratus (PQ) muscle flap transposition to protect the flexor tendons from rupture or irritation and evaluate its outcomes. Methods A retrospective review was conducted on 204 patients with unstable distal radius fractures who underwent a standard volar flexor carpi radialis approach with extended release of the PQ muscle during exposure. A PQ muscle flap was harvested and transposed over the distal edge of the plate after open reduction and internal fixation of the distal radius. Postoperatively, patients were evaluated for flexor tendon irritation and rupture. Patients who had this injury before the use of the PQ flap were compared with the patients who received the PQ flap. Results Of the 204 patients, 119 received the PQ flap, and 85 did not. The mean follow-up time was 30.4 months. Among the patients who did not receive the PQ flap, five (5.9%) required plate removal or conservative treatment for tendon irritation or rupture. In contrast, only one patient (0.8%) who received the PQ flap required plate removal for flexor tendon irritation. Conclusions The PQ muscle flap is a quick and effective surgical technique that reduces the risk of flexor tendon rupture or irritation during distal radius fracture fixation. The PQ muscle flap acts as a buffer between the plate and tendon and is more effective than not transposing the muscle.
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Affiliation(s)
| | - Jacob I. Jabbour
- The Hand Center at HOCC, Hartford Healthcare Medical Group, New Britain, Conn
| | - Jack D. Sudduth
- Division of Plastic Surgery, University of Utah Hospital, Salt Lake City, Utah
| | - Anne-Sophie Lessard
- Division of Plastic, Aesthetic, and Reconstructive Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Fla
| | - Carissa L. Patete
- University of Miami Leonard M. Miller School of Medicine, Miami, Fla
| | - Zubin J. Panthaki
- Division of Plastic, Aesthetic, and Reconstructive Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Fla
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Kwon BC, Lee YM, Lee JW, Choi HG. Can we safely place the distal volar locking plate screws into the subchondral zone of a distal radius fracture using a 45° supination oblique view under fluoroscopic guidance? Injury 2023; 54:947-953. [PMID: 36653250 DOI: 10.1016/j.injury.2023.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/06/2023] [Accepted: 01/07/2023] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Careful distal locking screw insertion into the subchondral zone is necessary to obtain proper mechanical strength of unstable distal radius fractures using volar locking plating. However, subchondral zone screw insertion increases the risk of intra-articular screw penetration, which may remain unrecognized during surgery due to complex distal radial anatomy. The purpose of this study was to evaluate the role of fluoroscopic guidance with a 45° supination oblique view technique for placing distal screws into the subchondral zone during volar locking plating for unstable distal radius fractures and to explore the factors associated with poor screw placement. METHODS We retrospectively analyzed 171 wrists of 169 patients treated with variable-angle volar locking plates for unstable radius fractures. The subchondral zone was defined as the metaphyseal area within 4 mm of the articular margin of the distal radius. The location of the distal locking screws and radiographic parameters, including the teardrop angle, were measured using computed tomography scans and X-rays. Clinical and radiographic factors were examined to determine their possible associations with screw placement failure. RESULTS Of 581 distal screws inserted, 559 screws (96.2%) were inserted into the subchondral zone and 17 screws into the metaphyseal zone (2.9%). Five screws (0.7%) in three wrists showed intra-articular placement: four screws were placed into the lunate fossa and one into the scaphoid fossa. These three wrists also exhibited significantly reduced teardrop angles. The distal screws were significantly closer to the joint line in the lunate fossa than the scaphoid fossa (1.9 ± 0.9 mm vs. 2.8 ± 1 mm, P < 0.000). CONCLUSION The 45° supination oblique view technique is a useful fluoroscopic guiding technique for accurate and safe distal screw placement in the subchondral zone in volar locking plate fixation for distal radial fractures. However, a decreased teardrop angle or extended lunate fossa should be corrected before distal screw insertion to avoid intra-articular screw placement.
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Affiliation(s)
- Bong Cheol Kwon
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Pyeongchon-dong 896, Dongan-gu, Anyang-si, Gyeonggi-do 14068, Korea (the Republic of).
| | - Yong Min Lee
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Pyeongchon-dong 896, Dongan-gu, Anyang-si, Gyeonggi-do 14068, Korea (the Republic of)
| | - Jung Woo Lee
- Department of Orthopaedic Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyo Geun Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University Sacred Heart Hospital, Gyeonggi-do, Korea
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Monárrez R, Bains SS, Margalit A, Ingari JV. Partial Resection of First Dorsal Compartment Extensor Retinaculum in De Quervain's Stenosing Tendovaginitis Release. Tech Hand Up Extrem Surg 2023; 27:14-16. [PMID: 35686888 DOI: 10.1097/bth.0000000000000402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Various surgical techniques exist to treat de Quervain's stenosing tendovaginitis. Specific surgical techniques for de Quervain's are designed to avoid complications including injury to branches of the superficial branch of the radial nerve, inadequate decompression, reflex sympathetic dystrophy, and palmar subluxation of the released tendons. A simple dorsal incision through the extensor retinaculum is advocated by many as a means to release the compartment while preventing postoperative subluxation. A single incision through the retinaculum limits exposure of the compartment and could lead to reannealing of the retinaculum and recurrent symptoms. Partial resection of the extensor retinaculum provides a more complete release and has not been found to lead to palmar tendon subluxation.
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Affiliation(s)
- Rubén Monárrez
- Rubin Institute for Advanced Orthopedics, Hand Surgery, Sinai Hospital
| | - Sandeep S Bains
- Rubin Institute for Advanced Orthopedics, Hand Surgery, Sinai Hospital
| | - Adam Margalit
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John V Ingari
- Rubin Institute for Advanced Orthopedics, Hand Surgery, Sinai Hospital
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Kaempf de Oliveira R, Brunelli JPF, Aita MA, Delgado Serrano PJ. The Flexor Carpi Radialis Portal for Arthroscopy-Assisted Reduction of the Dorsal Ulnar Fragment in Distal Radius Fractures. J Wrist Surg 2023; 12:63-66. [PMID: 36644728 PMCID: PMC9836772 DOI: 10.1055/s-0041-1730344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 04/13/2021] [Indexed: 01/18/2023]
Abstract
Background The importance of the dorsal ulnar fragment (DUF) for stability and articular congruence of the radius is widely recognized, and standard surgical techniques often fail to ensure its reduction. Description of Technique We describe a modification of volar wrist portals for arthroscopic management of the DUF of the distal radius. It is made in an outside-in fashion in line with the flexor carpi radialis (FCR) approach for the distal radius. Through this volar portal, we achieve wide and direct visualization of the DUF, with the advantage of protecting important anatomic structures such as the FCR tendon, the radial artery, and the median nerve; all protected with the previously made volar approach for the distal radius. In addition, easy manipulation and reduction of the DUF is obtained with instrumentation through standard dorsal portals. Patients and Methods We performed this procedure in 23 patients with distal radius fractures (DRF) with displaced DUF. Results Early and late postoperative evaluation demonstrated intraoperative reduction maintenance and adequate range of motion, compatible with the usual findings of standard volar plating, with the benefit of anatomic reduction of the DUF. Conclusion With our technique, volar plating associated with arthroscopy-assisted dorsal fragment specific fixation with dorsal standard and the FCR portals permits optimal surgical treatment of most DRFs.
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Affiliation(s)
- Ricardo Kaempf de Oliveira
- Department of Orthopaedics, Santa Casa de Misericórdia de Porto Alegre Hospital and Mãe de Deus Hospital, Porto Alegre, Brazil
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Liverneaux P, Amiri LE, Facca S, Sapa MC. Technique, Indications and Limitations of a Minimally Invasive Approach to Treat Distal Radius Fractures and Malunions. HANDCHIR MIKROCHIR P 2023. [PMID: 36716774 DOI: 10.1055/a-1951-1585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The minimally invasive flexor carpi radialis approach can be used for volar locking plate fixation of distal radius fractures. It offers the advantage of preserving ligamentotaxis, which facilitates the reduction and the small size of the scar improves the esthetic result of the procedure. It is indicated for extra-articular fractures of the distal radius. In the case of an intra-articular fracture, an arthroscopy may be associated. In the case of a proximal diaphyseal extension of the fracture, a second proximal approach can be added in order to use a longer plate. Relative contraindications are comminuted articular fractures in elderly osteoporotic patients. Functional and radiological results are comparable to those obtained with the extented flexor carpi radialis approach. A conversion of the procedure for a larger incision is always possible in the case of a difficult reduction.
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Affiliation(s)
- Philippe Liverneaux
- Department of Hand Surgery, Strasbourg University Hospitals, FMTS, avenue Molière, Strasbourg, France.,ICube CNRS UMR7357, Strasbourg University, rue Boussingault, Strasbourg, France
| | - Laela El Amiri
- Department of Hand Surgery, Strasbourg University Hospitals, FMTS, avenue Molière, Strasbourg, France
| | - Sybille Facca
- Department of Hand Surgery, Strasbourg University Hospitals, FMTS, avenue Molière, Strasbourg, France.,ICube CNRS UMR7357, Strasbourg University, rue Boussingault, Strasbourg, France
| | - Marie-Cécile Sapa
- Department of Hand Surgery, Strasbourg University Hospitals, FMTS, avenue Molière, Strasbourg, France
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Shim BJ, Kim DY, Lee SS, Cho MS, Hwang JT. Comparison of the conventional Henry approach and trans-flexor carpi radialis approach for the treatment of distal radius fracture: A retrospective cohort study. Medicine (Baltimore) 2022; 101:e31936. [PMID: 36626505 PMCID: PMC9750658 DOI: 10.1097/md.0000000000031936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Few studies have compared the clinical outcomes of the conventional Henry approach and trans-flexor carpi radialis (FCR) approach. The purpose of this study was to compare the clinical and radiologic outcomes of the conventional Henry approach and trans-FCR approach for the treatment of distal radius fractures. We compared 20 wrists that underwent the conventional Henry approach with 20 wrists that underwent the trans-FCR approach for open reduction and internal fixation of distal radius fracture. The clinical and radiological parameters were checked at 3 months, 6 months, and 1 year after surgery. A visual analogue scale score, the modified Mayo wrist score, range of motion, and grip strength were collected. In addition, tenderness in the area of the FCR tendon were assessed. Regarding radiologic evaluations, the radial inclination, radial height, volar tilt, and ulna variance were measured. In the trans-FCR approach group, 15 patients complained of tenderness in the area of the FCR tendon at 3 months after surgery, which was significantly higher than those of conventional Henry approach group (P < .05). In the conventional Henry approach group, the tenderness had resolved spontaneously by 1 year after surgery in 19 patients. The trans-FCR approach can cause discomfort such as tenderness to the area of the FCR tendon compared to the conventional Henry approach, but there is no significant difference in the final clinical and radiologic outcomes.
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Affiliation(s)
- Bum-Jin Shim
- Department of Orthopedic Surgery, Kyungpook National University Chilgok Hospital, Buk-gu, Daegu, Republic of Korea
| | - Do-Young Kim
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University Medical College, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Sang-Soo Lee
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University Medical College, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Min-Soo Cho
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University Medical College, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Jung-Taek Hwang
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University Medical College, Chuncheon-si, Gangwon-do, Republic of Korea
- *Correspondence: Jung-Taek Hwang, Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, 77, Sakju-ro, Chuncheon-si, Gangwon-do, 24253, Republic of Korea (e-mail: )
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14
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Orbay JL, Wahood M, Vernon LL, Mercer DM. Surgical Management of Acute on Chronic Distal Radius Fractures: Correcting Malunion Deformities Through the Secondary Fracture Plane. Tech Hand Up Extrem Surg 2022; 26:257-262. [PMID: 35698306 DOI: 10.1097/bth.0000000000000395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
It is challenging to restore the clinically acceptable alignment of the distal radius after an acute on chronic fracture or after a secondary fracture occurring after malunion of a primary distal radius fracture. In cases of insignificant primary deformity, restoration to the primary deformity may suffice to obtain a successful clinical result. A borderline acceptable primary radial deformity can be unacceptable after the second injury, resulting in functional disability. If surgery is indicated, the surgeon must contend with both primary and secondary deformities to restore proper distal radius anatomy. We present our technique to correct both primary and secondary distal radius deformities through the new or secondary fracture plane.
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Affiliation(s)
- Jorge L Orbay
- Department of Orthopaedic Surgery, The Miami Hand & Upper Extremity Institute
| | - Menar Wahood
- Orthopaedic Surgery Residency Program, Larkin University Hospital, Miami, FL
| | - Lauren L Vernon
- Department of Orthopaedic Surgery, The Miami Hand & Upper Extremity Institute
| | - Deana M Mercer
- Department of Orthopaedics & Rehabilitation, University of New Mexico, Albuquerque, NM
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15
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Yeager K, Heifner J, Rubio F, Gray R, Orbay J, Mercer D. Flexor Carpi Radialis Tendon Insertion Onto the Trapezial Ridge: An Anatomic Description. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 5:55-57. [PMID: 36704386 PMCID: PMC9870792 DOI: 10.1016/j.jhsg.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/19/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose The flexor carpi radialis (FCR) tendon is often involved in surgical procedures of the hand and wrist. The FCR tendon may be mobilized from the trapezium during distal radius fracture fixation, for tendon transfer, and during carpometacarpal joint procedures. There is a paucity of literature describing the anatomy of the FCR insertion onto the trapezial ridge. We analyzed the insertional characteristics of the FCR onto the trapezium. Methods Forty-two fresh-frozen cadaveric wrists were dissected using the extended FCR approach through the FCR tendon sheath. The length of the fibrous portion of the FCR insertion onto the trapezial ridge was measured from proximal to distal using a digital caliper. Results FCR insertion onto the trapezium was present in all specimens. The mean length of the FCR insertion was 11.8 ± 4.14 mm. The character of the tissue quality varied across specimens. Conclusions These results demonstrate the commonality of the FCR fibers that insert onto the trapezium. The length and tissue quality of this insertion varied across specimens. Clinical relevance Understanding the complex anatomy of the hand and wrist facilitates surgical planning and intraoperative techniques. The FCR tendon insertion onto the trapezium is an important component of exposure for the volar approach to the distal radius and surgical management of thumb carpometacarpal joint arthritis.
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Affiliation(s)
- Kathryn Yeager
- Department of Orthopaedics and Rehabilitation, The University of New Mexico, Albuquerque, NM
| | - John Heifner
- St George’s University School of Medicine, Great River, NY,Corresponding author: John Heifner, MD, St George’s University School of Medicine, 3500 Sunrise Hwy, Great River, NY 11739.
| | | | - Robert Gray
- Department of Orthopaedic Surgery, NorthShore University Health System, Chicago, IL
| | | | - Deana Mercer
- Department of Orthopaedics and Rehabilitation, The University of New Mexico, Albuquerque, NM
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16
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Herzberg G, Burnier M, Ly L. Arthroscopically Assisted Treatment of Volar Rim Fractures. J Wrist Surg 2022; 11:224-229. [PMID: 35837590 PMCID: PMC9276062 DOI: 10.1055/s-0041-1735980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/10/2021] [Indexed: 12/15/2022]
Abstract
Background Arthroscopically-assisted reduction and internal fixation (AARIF) for distal radius fractures (DRF) has been extensively described. Little information is available about AARIF in AO "B3" and "C" DRF with displaced lunate facet volar rim fragment (VRF) and volar carpal subluxation. However, lunate volar rim fragment (LVRF) may be very difficult to reduce and fix under arthroscopic control using the flexor carpi radialis (FCR) or FCR extended approaches while traction is applied. Purposes The aims were to describe our surgical technique of AARIF of partial or complete DRF with VRF and provide information about how often this technique may be necessary, based on a large DRF database. Methods The dual-window volar approach for complete articular AO C DRF with volar medial fragment was described in 2012 for performing open reduction internal fixation (ORIF). Since 2015, we have used the dual-window approach for AARIF of "B3" or "C" DRF with volar carpal subluxation. We analyzed our PAF database, searching for patients treated with AARIF in "B3" and "C" fractures. Results The dual-window volar approach is very useful when using AARIF for AO "B3" and "C" DRF with displaced VRF and volar carpal subluxation. The anteromedial part of the exposure allows a direct access to reduction and fixation of the LVRF under traction and arthroscopic control. Overall, 1% of all articular DRF in this series showed a displaced LVRF amenable to the dual-window volar approach. Conclusion It is almost impossible to access and properly fix a VRF using traction and arthroscopic control through the FCR or FCR extended FCR approach because of the stretched flexor tendon mass. The use of the dual-window approach during AARIF of AO "B3" or "C" DRF has not previously been reported. Displaced VRF are rare whether they were part of "B3" or "C" fractures. If AARIF is chosen, we strongly recommend the use of the dual-window volar approach for AO "B3" and "C" fractures with VRF. A single anteromedial approach can also be used for isolated "B3" anteromedial DRF.
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Affiliation(s)
- Guillaume Herzberg
- Department of Orthopedics, I-Trues Wrist Surgery Unit, Clinique Parc Lyon, Stalingrad, Clinique Val Ouest, Ch Vernique, Lyon, France
| | - Marion Burnier
- Department of Orthopedics, I-Trues Wrist Surgery Unit, Institut Main Membre Supérieur, Villeurbanne, France
| | - Lyliane Ly
- Department of Orthopaedic Surgery, Herriot Hospital, Lyon, France
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Bhashyam AR, Kao DS. Surgical Technique for Concurrent Endoscopic Carpal Tunnel Release and Distal Radius Fracture Fixation Using the Flexor Carpi Radialis Approach: A Case Series. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:166-171. [PMID: 35601523 PMCID: PMC9120784 DOI: 10.1016/j.jhsg.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/30/2021] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Abhiram R. Bhashyam
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
- Corresponding author: Abhiram R. Bhashyam, MD, PhD, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114.
| | - Dennis S. Kao
- Division of Plastic Surgery, University of Washington, Seattle, WA
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Lee JK, Yoon BH, Kim B, Ha C, Kil M, Shon JI, Lee HI. Is early mobilization after volar locking plate fixation in distal radius fractures really beneficial? A meta-analysis of prospective randomized studies. J Hand Ther 2021; 36:196-207. [PMID: 34972603 DOI: 10.1016/j.jht.2021.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 05/26/2021] [Accepted: 10/02/2021] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN This was a systematic review with a meta-analysis. INTRODUCTION Despite rising trends toward surgical treatment of distal radius fractures (DRF) with volar locking plate (VLP) fixation, there is a lack of consensus on when to start vigorous wrist range of motion (ROM) exercises after surgery. PURPOSE We performed a meta-analysis to compare early and late mobilization after VLP fixation in patients with DRF. METHODS Four prospective randomized controlled trials with a minimum of 6 months of follow-up were retrieved through MEDLINE (PubMed), EMBASE, Web of Science, the Cochrane Library, and the KoreaMed databases in March 2021. We divided patients into an early group (patients who started ROM exercises of the wrist within 2 weeks after surgery), and a late group (patients who started ROM exercises 5 or 6 weeks after surgery). The primary outcome was treatment efficacy which was measured through improvement in pain score, function score, ROM, and grip power. The secondary outcome was the incidence of postoperative complications. RESULTS This meta-analysis included 127 patients in the early group and 131 patients in the late group. The outcomes were compared at 6 weeks, 3 months, and 6 months postoperatively. There was no significant difference in pain score, though the early group had a lower average visual analog scale score. The early group had a lower arm, shoulder, and hand disability score than the late group (95 % CI, -16.25 to -8.35 points; P < .001) at 6 weeks postoperatively, suggesting significantly superior outcomes. A similar trend persisted at 3 (n = 74 in the early group and n = 77 in the late group; 95% CI, -5.45 to -0.30; P = .029) and 6 months (n = 102 in the early group and n = 100 in the late group; 95% CI, -4.81 to 0.21; P = .073), but the differences were smaller. The early group had a higher grip power at all follow-up periods, but the difference was only significant at 6 months postoperatively (n = 88 in the early group and n = 83 in the late group; 95% CI, 0.50 to 6.99; P = 0.024). The early group also had more favorable ROM in all directions at 6 weeks, but only in supination at 6 months. The complication rate was not significantly different between the 2 groups. There were no differences in the rates of secondary operation and reduction loss. CONCLUSION Early ROM exercise after VLP in DRF resulted in superior functional scores and grip power until 6 months postoperatively. The dominance of the joint ROM, which was seen at 6 weeks after surgery in the early exercise group, decreased with time and ultimately showed little difference at 6 months. Early exercise is safe and did not increase complication rates.
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Affiliation(s)
- Jun-Ku Lee
- Department of Orthopaedic Surgery National Health Insurance Service Ilsan Hospital 100, Ilsan-ro, Ilsandong-gu, Goyang-siGyeonggi-do, Republic of Korea.
| | - Byung-Ho Yoon
- Department of Orthopedic Surgery, Ewha Womans University, College of Medicine, Mokdong Hospital, Seoul, Korea.
| | - Byungsoo Kim
- Department of Statistics, Institute of Statistical Information, Inje University, Gimhae, South Korea.
| | - Cheungsoo Ha
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam-si, Gyeonggi-do, South Korea.
| | - Minkyu Kil
- Department of Orthopaedic Surgery National Health Insurance Service Ilsan Hospital 100, Ilsan-ro, Ilsandong-gu, Goyang-siGyeonggi-do, Republic of Korea.
| | - Jeong In Shon
- Department of Orthopaedic Surgery National Health Insurance Service Ilsan Hospital 100, Ilsan-ro, Ilsandong-gu, Goyang-siGyeonggi-do, Republic of Korea.
| | - Hyun Il Lee
- Department of Orthopaedic Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea.
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Werntz RL, Hadeed AJ, Cappelleti GL, Orbay JL. Flexor Carpi Radialis Brevis Resection for Treatment of a Distal Radius Fracture: A Case Report. J Wrist Surg 2021; 10:536-538. [PMID: 34877080 PMCID: PMC8635829 DOI: 10.1055/s-0041-1726407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/08/2021] [Indexed: 10/25/2022]
Abstract
The flexor carpi radialis brevis (FCRB) is an anomalous muscle of the forearm that is only present in 3.5 to 8.6% of the population. In the case of volar plating of distal radius fractures, the FCRB inhibits proper fracture exposure and thus hinders proper reduction. A 78-year-old female presented with right distal radius fracture which necessitated internal fixation. Following mobilization and retraction of the flexor carpi radialis tendon, an anomalous muscle belly was identified as the FCRB. With continued difficulty in exposure and fracture site reduction, resection of the FCRB was performed. The patient was able to return to her activities of daily living without pain and demonstrated no appreciable functional deficit. This case report demonstrates a distal radius fracture where FCRB resection was used, resulting in no detrimental clinical outcomes.
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Affiliation(s)
- Ryan L. Werntz
- Orthopaedic Surgery Residency Program, Larkin University Hospital, Miami, Florida
| | - Andrew J. Hadeed
- Orthopaedic Surgery Residency Program, Larkin University Hospital, Miami, Florida
| | - Giacomo L. Cappelleti
- Department of Orthopaedic Surgery, The Miami Hand & Upper Extremity Institute, Miami, Florida
| | - Jorge L. Orbay
- Department of Orthopaedic Surgery, The Miami Hand & Upper Extremity Institute, Miami, Florida
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20
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Extended Flexor Carpi Radialis Approach. J Orthop Trauma 2021; 35:s1-s5. [PMID: 34415874 DOI: 10.1097/bot.0000000000002207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 02/02/2023]
Abstract
Level V-Expert Opinion.
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21
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Abstract
Volar fixed-angle plate fixation is a commonly used treatment modality for distal radius fractures. However, not all fracture patterns are amenable to this type of fixation strategy. In this article, we review pertinent anatomy and radiographic landmarks that together highlight key differences when considering treatment strategies for complex distal radius fractures.
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22
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Avoiding Complications in Distal Radius Fractures. J Orthop Trauma 2021; 35:s27-s32. [PMID: 34415879 DOI: 10.1097/bot.0000000000002205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 02/02/2023]
Abstract
Managing fractures of the distal radius is a fundamental skill for orthopaedic surgeons. Given the prevalence of these fractures, complications following operative management are well described and frequently encountered. Surgeons should be observant in the acute phase for emergent conditions such as acute carpal tunnel syndrome. Careful radiographic examination intra-operatively can help prevent delayed complications by identifying surgical errors such as hardware malposition or malreduction. Many problems that arise during the treatment of distal radius fractures are the result of technical errors and can be anticipated.
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23
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Vernet P, Gouzou S, Hidalgo Diaz JJ, Facca S, Liverneaux P. Minimally invasive anterior plate osteosynthesis of the distal radius: A 710 case-series. Orthop Traumatol Surg Res 2020; 106:1619-1625. [PMID: 33153957 DOI: 10.1016/j.otsr.2020.04.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/04/2020] [Accepted: 04/21/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Since the 2000s, internal fixation of distal radius fracture by volar locking plate on an extended flexor carpi radialis (FCR) approach has become the gold standard. OBJECTIVE The present study aimed to assess medium-term results of minimally invasive plate osteosynthesis (MIPO) in distal radius fracture. MATERIAL AND METHODS The series comprised of 710 cases (512 female; mean age, 58 years). The 15mm approach was on the lateral edge of the FCR. The plate was slipped under the pronator quadratus. Closure used intradermal running suture without drain or orthosis. RESULTS At a mean 7 months' follow-up, mean scar length was 17mm (range, 10-40mm), pain 1.13/10 (0-8), Quick-DASH 13.28 (0-86.36), and patient-rated wrist evaluation (PRWE) 11.48 (0-91). Compared to contralateral values, mean flexion was 87.23%, extension 88.52%, pronation 96.17%, supination 93.41%, and grip strength 79.68%. Hardware was removed in 45.92% of cases. There were 16 cases of secondary displacement, with 4 revision procedures, one of sepsis at 6 months, 10 of complex regional pain syndrome, and 14 of median nerve paresthesia, with 4 carpal tunnel release procedures. DISCUSSION The minimally invasive FCR approach can be used for volar plate fixation of distal radial fracture. It has the advantage of conserving ligamentotaxis, facilitating reduction and improving scar esthetics. The incision can be extended if need be. LEVEL OF EVIDENCE III; single-centre retrospective study.
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Affiliation(s)
- Paul Vernet
- Department of hand surgery, SOS Hand, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 1, avenue Molière, 67000 Strasbourg, France
| | - Stéphanie Gouzou
- Department of hand surgery, SOS Hand, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 1, avenue Molière, 67000 Strasbourg, France
| | - Juan José Hidalgo Diaz
- Department of hand surgery, SOS Hand, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 1, avenue Molière, 67000 Strasbourg, France
| | - Sybille Facca
- Department of hand surgery, SOS Hand, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 1, avenue Molière, 67000 Strasbourg, France
| | - Philippe Liverneaux
- Department of hand surgery, SOS Hand, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 1, avenue Molière, 67000 Strasbourg, France.
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24
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Spies CK, Ayache A, Löw S, Langer MF, Hohendorff B, Müller LP, Oppermann J, Unglaub F. [Revision surgery after failed (partial-) arthrodesis of the wrist]. DER ORTHOPADE 2020; 49:784-796. [PMID: 32809041 DOI: 10.1007/s00132-020-03967-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
(Partial) arthrodeses of the wrist have been proven cornerstones to treat many lesions for decades, especially in the case of revision surgery. Four-corner, scapho-trapezo-trapezoidal (STT), radio-scapho-lunate (RSL) and total wrist fusions are very common techniques in hand surgery. However, even these proven surgical procedures have significant non-fusion rates. Prior to revising a failed arthrodesis, it is essential to analyse the latter failure precisely. A technically adequate revision is only feasible when based on a correct and meticulous analysis. The understanding of the biological processes and technical aspects of the implants are the basis for solving this issue.
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Affiliation(s)
- C K Spies
- Handchirurgie, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Deutschland.
| | - A Ayache
- Handchirurgie, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Deutschland
| | - S Löw
- Praxis für Handchirurgie und Unfallchirurgie, Bad Mergentheim, Deutschland
| | - M F Langer
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - B Hohendorff
- Abteilung für Hand‑, Ästhetische und Plastische Chirurgie, Elbe Klinikum Stade, Stade, Deutschland
| | - L P Müller
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Köln, Deutschland
| | - J Oppermann
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Köln, Deutschland
| | - F Unglaub
- Handchirurgie, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Deutschland.,Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
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25
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He B, Tian X, Ji G, Han A. Comparison of outcomes between nonsurgical and surgical treatment of distal radius fracture: a systematic review update and meta-analysis. Arch Orthop Trauma Surg 2020; 140:1143-1153. [PMID: 32468170 DOI: 10.1007/s00402-020-03487-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION This study was a systematic review comparing the clinical outcomes of nonsurgical and surgical management for distal radius fractures. MATERIALS AND METHODS A comprehensive literature search was conducted using multiple databases, including Medline, Embase, and Cochrane. All databases were searched from the earliest records through June 2019 using the following Boolean operators: distal radius fracture, conservative treatment, nonoperative treatment, nonsurgical treatment, surgical treatment, and operative. All prospective and retrospective controlled trials were retrieved that directly compared the functional outcomes between the nonsurgical and surgical groups. RESULTS Five prospective studies and six retrospective comparative studies were retrieved. A total of 1049 patients were included: 529 in the nonsurgical group and 520 in the surgical group. Both types of treatment led to similar results with respect to DASH and grip strength, as well as and most other functional assessments. However, there was significant difference in radial inclination, radial length, ulnar variance and range of wrist flexion. CONCLUSIONS No significant differences in most functional assessments were found when comparing surgical and nonsurgical management of distal radius fractures. Although there were significant differences in radial inclination, radial deviation, ulnar variance, and wrist flexion, they did not seem to have impacts on the quality of wrist. Nonsurgical treatment for the distal radius fractures should be considered firstly. Indications for operative fixation should be considered carefully in the treatment of DRFs. LEVEL OF EVIDENCE Therapeutic study (systematic review), Level III.
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Affiliation(s)
- Bo He
- The Central Hospital of Wuhan, Achao Han, 26 Shengli Road, Wuhan, 430014, Hubei, China
| | - Xue Tian
- The Central Hospital of Wuhan, Achao Han, 26 Shengli Road, Wuhan, 430014, Hubei, China
| | - Gang Ji
- Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Achao Han
- The Central Hospital of Wuhan, Achao Han, 26 Shengli Road, Wuhan, 430014, Hubei, China.
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26
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Park AY, Smith DW. Volar Approach to the First Extensor Compartment for Surgical Treatment of DeQuervain Tenosynovitis. Tech Hand Up Extrem Surg 2020; 25:108-110. [PMID: 32740057 DOI: 10.1097/bth.0000000000000310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Many surgical techniques have been published in regards to the operative management of DeQuervain tenosynovitis. As it has been classically described, stenosing tenosynovitis of the first extensor tendon compartment is a common tendinopathy along the radial side of the wrist causing pain and swelling in the affected area. When surgery is necessary, decompression of the abductor pollicis longus and extensor pollicis brevis tendons decreases first extensor compartment friction and has been shown to successfully alleviate symptoms. A number of varying techniques have been reported in the literature to achieve adequate decompression and minimize postoperative complications such as sensory nerve injury, incomplete decompression, and tendon subluxation. We describe a novel volar approach to the first extensor compartment, which allows direct visualization of the retinaculum and a midline retinacular release. In addition, the volar approach has an associated decreased risk of iatrogenic nerve injury by passing volar and deep to the more superficial sensory nerves that overly the retinaculum. On the basis of our experience, patients do not experience an increased risk of volar tendon subluxation with this approach.
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Affiliation(s)
- Adam Y Park
- Department of Orthopaedic Surgery, McGovern Medical School, Houston, TX
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Indications, surgical approach, reduction, and stabilization techniques of distal radius fractures. Arch Orthop Trauma Surg 2020; 140:611-621. [PMID: 32193677 DOI: 10.1007/s00402-020-03365-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Indexed: 02/09/2023]
Abstract
Distal Radius fractures (DRF) are one of the most common injuries in the upper extremity and incidence is expected to rise due to a growing elderly population. The complex decision to treat patients operatively or conservatively depends on a large variety of parameters which have to be considered. No unanimous consensus has been reached yet, which operative approach and fixation technique would produce the best postoperative functional results with lowest complication rates. This article addresses the available evidence for indications, approaches, reduction, and fixation techniques in treating DRF.
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Radiographic Evaluation of the Distal Radioulnar Joint: Technique to Detect Sigmoid Notch Intra-Articular Screw Breach in Distal Radius Fractures. Tech Orthop 2020. [DOI: 10.1097/bto.0000000000000318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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Dennison DG, Blanchard CL, Elhassan B, Moran SL, Shin AY. Early Versus Late Motion Following Volar Plating of Distal Radius Fractures. Hand (N Y) 2020; 15:125-130. [PMID: 30009627 PMCID: PMC6966284 DOI: 10.1177/1558944718787880] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Distal radius fractures are common, and the trend in fixation has included the use of locked volar plating. The duration of splinting required after surgery and the effect splinting has upon outcome of the wrist are not clear. Our aim was to compare outcome of patients treated with early versus late motion protocol after volar plating. Methods: Thirty-three patients with distal radius fractures were prospectively and randomly enrolled into an early versus late motion study including volar plating of the distal radius fracture. Early motion included an active and passive wrist motion protocol by 14 days after surgery and delayed motion was initiated at 5 weeks. Fractures were defined as intra-articular and extra-articular, and those with, and without, ulnar styloid fracture. Motion and outcome scores (Disabilities of the Arm, Shoulder and Hand [DASH]/patient-rated wrist evaluation [PRWE]), and strength were measured through 1 year. Results: Wrist motion, DASH, and PRWE scores were only significantly different at 6 weeks with no significant differences at any later time points up to 1 year. One patient had complex regional pain syndrome (CRPS) and one had adhesive capsulitis in the late motion group. Conclusions: Following locked volar plating of distal radius fractures, early motion favored earlier return of motion along with lower DASH, PRWE, and pain scores within first 6 weeks. Although the late motion group had delayed recovery, there were no long-term significant differences in motion, strength, outcome, or pain scores. The 2 cases with complications (CRPS and adhesive capsulitis) did occur in the late motion group and may implicate late motion with these problems.
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Affiliation(s)
- David G. Dennison
- Mayo Clinic, Rochester, MN, USA,David G. Dennison, Assistant Professor,
Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester,
MN 55906, USA.
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Streubel PN, Cohen MS. Isolated Partial Intra-Articular Volar Ulnar Fractures of the Distal Radius: The Tetrahedron Variant. J Hand Surg Am 2019; 44:699.e1-699.e10. [PMID: 30502017 DOI: 10.1016/j.jhsa.2018.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 08/06/2018] [Accepted: 10/09/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to assess the treatment and complications of a distinct type of partial intra-articular distal radius fracture. METHODS Seven patients treated by the senior author between 2008 and 2013 for a partial intra-articular distal radius fracture with isolated involvement of the volar lunate facet were included. All fragments had the distinctive shape of a triangular-base pyramid (tetrahedron) extending from the metaphysis distally. All fractures were preoperatively assessed with computed tomography (CT) scans. Patients underwent surgical treatment using a standard flexor carpi radialis approach (2 patients) or a volar ulnar approach (5 patients) and were followed postoperatively for a minimum of 12 months. RESULTS Patient age ranged from 33 to 66 years. On average, fragments measured 34 ± 6 mm in length (range, 27-43 mm) and were 48% as wide as the distal radius (range, 40% to 56%) and 58% as deep as the anterior-posterior dimension of the lesser sigmoid notch (range, 33% to 83%). Loss of reduction requiring revision surgery occurred at 4 weeks in 1 patient who underwent internal fixation through the flexor carpi radialis approach. The remaining cases healed uneventfully. At the final follow-up, all, except the patient requiring revision surgery, had a painless wrist. Average total wrist motion measured 87% of the opposite side. Radiographic healing with anatomic wrist alignment was observed in all except the patient requiring revision. This patient had persistent joint subluxation. The remaining patients all achieved good or excellent functional outcomes. CONCLUSIONS Isolated tetrahedron volar lunate facet fractures of the distal radius are rare. In our experience, the use of a volar ulnar approach leads to satisfactory fixation and outcomes, yielding excellent radiographic and clinical outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Philipp N Streubel
- Hand and Upper Extremity Section, Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, NE.
| | - Mark S Cohen
- Hand and Elbow Section, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Lans J, Alvarez J, Kachooei AR, Ozkan S, Jupiter JB. Dorsal Lunate Facet Fracture Reduction Using a Bone Reduction Forceps. J Wrist Surg 2019; 8:118-123. [PMID: 30941251 PMCID: PMC6443535 DOI: 10.1055/s-0038-1673407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
Abstract
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.
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Affiliation(s)
- Jonathan Lans
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Josefina Alvarez
- Department of Traumatology, British Hospital, Montevideo, Uruguay
| | - Amir R. Kachooei
- Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sezai Ozkan
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jesse B. Jupiter
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Naito K, Sugiyama Y, Kinoshita M, Obata H, Goto K, Nagura N, Iwase Y, Obayashi O, Kaneko K. Functional Outcomes in Volar-Displaced Distal Radius Fractures Patients with Marginal Rim Fragment Treated by Volar Distal Locking Plates. J Hand Microsurg 2018; 11:100-105. [PMID: 31413494 DOI: 10.1055/s-0038-1675245] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 08/10/2018] [Indexed: 10/27/2022] Open
Abstract
Background Treatment of volar-displaced distal radius fractures (DRF) accompanied by marginal rim fragment has recently been actively discussed. It is difficult to obtain a sufficient buttress effect on this fragment. Therefore, we actively apply a distal volar locking plate (DVLP) to fractures with this fragment. Here, we report the treatment outcomes and caveats of surgery of fractures with this fragment. Materials and Methods The subjects were 32 patients (male: 11, female: 21, and mean age: 59.4 years) with volar dislocated DRF accompanied by the marginal rim fragment treated using DVLP. The fracture type of AO classification was B3 in 6 patients, C1 in 12, C2 in 6, and C3 in 8. Results The mean duration of follow-up was 13.8 (12-30) months. The plate could be covered with the pronator quadratus muscle in surgery in all patients. On the final follow-up, visual analog scale score was 1.4/10, quick disabilities of the arm, shoulder, and hand score was 9.2/100, and the Mayo wrist score was 93.7/100. No complication was observed in the soft tissue, such as the nerves and flexor tendons. Conclusion The factor determining retention of the reduction position of the marginal rim fragment is a sufficient buttress effect, and DVLP is a useful implant in terms of this point.
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Affiliation(s)
- Kiyohito Naito
- Department of Orthopaedics, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoichi Sugiyama
- Department of Orthopaedics, Juntendo University School of Medicine, Tokyo, Japan
| | - Mayuko Kinoshita
- Department of Orthopaedics, Juntendo University School of Medicine, Tokyo, Japan.,Department of Orthopaedic Surgery, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Hiroyuki Obata
- Department of Orthopaedics, Juntendo University School of Medicine, Tokyo, Japan
| | - Kenji Goto
- Department of Orthopaedics, Juntendo University School of Medicine, Tokyo, Japan
| | - Nana Nagura
- Department of Orthopaedics, Juntendo University School of Medicine, Tokyo, Japan.,Department of Orthopaedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Yoshiyuki Iwase
- Department of Orthopaedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Osamu Obayashi
- Department of Orthopaedic Surgery, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Kazuo Kaneko
- Department of Orthopaedics, Juntendo University School of Medicine, Tokyo, Japan
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Ma T, Zheng X, Qin H, Xia J, Yang YY. WITHDRAWN: Comparison of fixed angle plate and variable angle plate in the treatment of AO type C distal radial fractures. J Orthop 2018. [DOI: 10.1016/j.jor.2018.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Zemirline A, Taleb C, Naito K, Vernet P, Liverneaux P, Lebailly F. Distal radius fracture fixation with a volar locking plate and endoscopic carpal tunnel release using a single 15mm approach: Feasibility study. HAND SURGERY & REHABILITATION 2018; 37:S2468-1229(18)30068-9. [PMID: 29779839 DOI: 10.1016/j.hansur.2018.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 03/09/2018] [Accepted: 03/13/2018] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- A Zemirline
- Hand Center of Brittany, Saint-Grégoire Private Hospital Center, 6, boulevard de la Boutière, 35760 Saint-Grégoire, France.
| | - C Taleb
- Department of Orthopaedic Surgery, Mulhouse Hospital Center, 20, avenue Docteur René-Laennec, 68100 Mulhouse, France
| | - K Naito
- Department of Orthopaedics, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
| | - P Vernet
- Department of Hand Surgery, Strasbourg University Hospital, 10, avenue Achille-Baumann, 67400 Illkirch, France
| | - P Liverneaux
- Department of Hand Surgery, Strasbourg University Hospital, 10, avenue Achille-Baumann, 67400 Illkirch, France
| | - F Lebailly
- Clinique Saint-Paul, 3, rue des Hibiscus, 97200 Fort-De-France, France
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Abstract
Injuries to the hands and wrist are common in athletes. Injuries include acute fractures, dislocations, ligamentous, and tendon injuries, as well as more chronic injuries such as sprains and strains. Complications in the treatment of sports injuries of the hand and wrist may be divided into 2 categories: incorrect or delayed diagnosis and iatrogenic injury related to treatment. This article highlights common sports injuries of the hand and wrist and their complications, and includes tips for successful management.
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Affiliation(s)
- Nicholas Pulos
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA
| | - Sanjeev Kakar
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA.
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Abstract
This article reviews the author's currently used minimal invasive approach for volar plating of distal radius fractures. A single longitudinal incision of 1.5 cm is drawn on the lateral aspect of the flexor carpi radialis tendon in order to insert a plate under the pronator quadratus. With the wrist flexed, the plate is applied on the anterior cortex of the radius to reduce the fracture. This approach offers the advantage of preserving ligamentotaxis, which facilitates the reduction, and the small scar improves the cosmetics. It is mainly indicated for extra-articular and simple intra-articular fractures of the distal radius. Relative contraindications are comminuted articular fractures in elderly osteoporotic patients. Functional and radiological results are comparable with those obtained with an extended flexor carpi radialis approach. My colleagues and I have used it for more than 2000 cases since 2012. This technique requires practise. Attempted conversion to a larger incision is possible in case of difficulty, but this is seldom necessary.
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Igeta Y, Vernet P, Facca S, Naroura I, Hidalgo Diaz JJ, Diaz JJH, Liverneaux PA. The minimally invasive flexor carpi radialis approach: a new perspective for distal radius fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:1515-1522. [PMID: 29368237 DOI: 10.1007/s00590-018-2124-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 01/08/2018] [Indexed: 11/25/2022]
Abstract
The minimally invasive flexor carpi radialis approach can be used for volar locking plate fixation of distal radius fractures. After 15-mm incision on the lateral aspect of the FCR tendon and all structures but the radial artery are reclined ulnarly, a plate is inserted under the pronator quadratus just proximal to the "watershed line." The distal epiphyseal screws are put in place, and the proximal part of the plate is exposed by flexion of the wrist to put in place the proximal screws. No drainage or postoperative immobilization is used. It offers the advantage of preserving ligamentotaxis which facilitates the reduction, and the small size of the scar improves the esthetic result of the procedure. It is indicated for extra-articular fractures of the distal radius. In the case of an intraarticular fracture, an arthroscopy may be associated. In the case of a proximal diaphyseal extension of the fracture, a second proximal approach can be added in order to use a longer plate. Relative contraindications are comminuted articular fractures in elderly osteoporotic patients. Functional and radiological results are comparable to those obtained with the extented flexor carpi radialis approach. A conversion of the procedure for a larger incision is always possible in the case of a difficult reduction.
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Affiliation(s)
- Yuka Igeta
- Icube CNRS 7357, Department of Hand Surgery, SOS Main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, 10 Avenue Baumann, 67400, Illkirch, France.,Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan
| | - Paul Vernet
- Icube CNRS 7357, Department of Hand Surgery, SOS Main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, 10 Avenue Baumann, 67400, Illkirch, France
| | - Sybille Facca
- Icube CNRS 7357, Department of Hand Surgery, SOS Main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, 10 Avenue Baumann, 67400, Illkirch, France
| | - Ismaël Naroura
- Icube CNRS 7357, Department of Hand Surgery, SOS Main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, 10 Avenue Baumann, 67400, Illkirch, France
| | | | - Juan José Hidalgo Diaz
- Icube CNRS 7357, Department of Hand Surgery, SOS Main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, 10 Avenue Baumann, 67400, Illkirch, France
| | - Philippe A Liverneaux
- Icube CNRS 7357, Department of Hand Surgery, SOS Main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, 10 Avenue Baumann, 67400, Illkirch, France.
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38
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The role of brachioradialis release during AO type C distal radius fracture fixation. Orthop Traumatol Surg Res 2017; 103:1099-1103. [PMID: 28782697 DOI: 10.1016/j.otsr.2017.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 05/21/2017] [Accepted: 06/06/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Open reduction and internal fixation of distal radius fractures often necessitates release of the brachioradialis from the radial styloid. However, whether this common procedure makes the reduction and fixation easier and affects the elbow function has not been fully understood. HYPOTHESIS Brachioradialis (BR) release during volar plate fixation for type C distal radius fractures makes internal reduction and fixation easier, and it does not adversely affect wrist or elbow function. MATERIAL AND METHODS A total of 74 patients treated with 2.4mm volar locking compression column plate (VCP) were analyzed for type C distal radius fractures prospectively. The patients were divided into two groups, group A with BR release and group B without BR release. The two groups were compared in terms of "internal reduction and fixation time" during the operation, wrist and elbow function including the scores of Gartland and Werley (G-W), Patient-related wrist evaluation score (PRWE), Mayo Elbow Performance Score (MEPS), the Disabilities of the arm, shoulder, and hand (DASH) and a Visual analog scale (VAS) for pain at 6 and 12 months postoperatively. The radial inclination angle, palmar tilt angle and ulnar variance were also measured from the radiographs. RESULTS According to the follow-up of the 74 patients, no significant differences were observed between the two groups on MEPS, DASH, G-W, PRWE, VAS and radiological outcomes at 6 and 12 months postoperatively. Mean time of reduction and internal fixation was significantly shorter in group A than that in group B. CONCLUSION Release of the BR for type C distal radius fractures facilitated the surgical procedure and did not adversely affect elbow and wrist function. LEVEL OF EVIDENCE II, prospective comparative study.
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Unglaub F, Langer MF, Hohendorff B, Müller LP, Unglaub JM, Hahn P, Krimmer H, Spies CK. [Distal radius fracture of the adult : Diagnostics and therapy]. DER ORTHOPADE 2017; 46:93-110. [PMID: 27815606 DOI: 10.1007/s00132-016-3347-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Fractures of the distal radius are very common. The majority of patients are elderly females. High impact trauma are often responsible for fractures in young men. Clinical and radiological diagnostics, including computer-assisted tomography (CAT) scan, are generally sufficient. The indication for conservative treatment is still recommended for specific fracture patterns. Application of palmar locking plates after open reduction proved to be efficacious for the majority of fracture patterns. Furthermore, precise detection and treatment of concomitant lesions are mandatory in order to prevent complications.
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Affiliation(s)
- F Unglaub
- Handchirurgie, Vulpius Klinik, Vulpiusstr. 29, 74906, Bad Rappenau, Deutschland. .,Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland.
| | - M F Langer
- Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - B Hohendorff
- Hand-, Ästhetische, Plastische Chirurgie, Elbe Kliniken, Stade, Deutschland
| | - L P Müller
- Klinik und Polyklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Köln, Deutschland
| | - J M Unglaub
- Handchirurgie, Vulpius Klinik, Vulpiusstr. 29, 74906, Bad Rappenau, Deutschland
| | - P Hahn
- Handchirurgie, Vulpius Klinik, Vulpiusstr. 29, 74906, Bad Rappenau, Deutschland
| | - H Krimmer
- Zentrum für Hand- und Fußchirurgie, Krankenhaus St. Elisabeth, Ravensburg, Deutschland
| | - C K Spies
- Handchirurgie, Vulpius Klinik, Vulpiusstr. 29, 74906, Bad Rappenau, Deutschland
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Yoon JO, You SL, Kim JK. Intra-articular comminution worsens outcomes of distal radial fractures treated by open reduction and palmar locking plate fixation. J Hand Surg Eur Vol 2017; 42:260-265. [PMID: 28196444 DOI: 10.1177/1753193416682943] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED We studied 50 patients with AO type C2 distal radial fractures and 35 with AO type C3 distal radial fractures treated by open reduction and palmar locking plate fixation. At 3-month clinical assessments, mean wrist flexion arcs, grip strengths and disabilities of the arm, shoulder and hand scores were significantly better for AO type C2 fractures. At 2-year post-operative clinical assessments, mean disabilities of the arm, shoulder and hand scores were significantly better for AO type C2 fractures than for AO type C3 fractures. At 2-year radiographic examinations, anterior angulations, ulnar variances and arthritis grades were also significantly better for AO type C2 fractures. This study showed that AO type C3 distal radial fractures, which have intra-articular comminution, had poorer clinical and radiographic outcomes than AO type C2 fractures, despite open reduction and palmar locking plate fixation. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- J O Yoon
- 1 Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - S L You
- 2 Department of Orthopedic Surgery, Ewha Womans Universtiy Mokdong Hospital, Seoul, South Korea
| | - J K Kim
- 1 Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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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. Tech Hand Up Extrem Surg 2016; 20:155-160. [PMID: 27801774 DOI: 10.1097/bth.0000000000000139] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Mauser NS, Benoit MY, Morrell NT, Shafritz AB. Treatment of Distal Radial Fractures by Open Reduction and Internal Fixation with a Volar Locking Plate. JBJS Essent Surg Tech 2016; 6:e31. [PMID: 30233924 DOI: 10.2106/jbjs.st.15.00075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The volar locking plate is a popular implant for surgical management of unstable distal radial fractures. We routinely utilize this system for all distal radial fractures except for those with entrapped intra-articular fragments and fractures with a displaced dorsomedial facet fracture (which is hard to capture with the volar approach alone). In this video, we describe in detail the necessary steps for successful placement of the volar locking plate, starting with preoperative planning and ending with expected outcomes. The approach that we utilize is through the flexor carpi radialis tendon sheath and avoids the radial artery. In the video, we describe 4 variations on the application of a volar locking plate: (1) the standard technique after appropriate reduction and provisional fixation with Kirschner wires, (2) regaining length through a shortened distal radial fracture, (3) using the volar plate to assist in the reduction and regain volar tilt, and (4) intraoperative management of coronal shift of the distal fragment. Complications reported for the volar locking plate have decreased with newer low-profile plate designs; however, they still include volar tendon irritation and/or rupture and median neuropathy. Postoperatively, we advise a brief 2-week period of immobilization for wound-healing, which is followed by a period during which a removable wrist splint is used and patients are instructed on the performance of a hand therapy regimen.
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Affiliation(s)
- Nathan S Mauser
- Department of Orthopedics and Rehabilitation, University of Vermont Medical Center, Burlington, Vermont
| | - Michel Y Benoit
- Department of Orthopedics and Rehabilitation, University of Vermont Medical Center, Burlington, Vermont
| | - Nathan T Morrell
- Department of Orthopedics and Rehabilitation, University of Vermont Medical Center, Burlington, Vermont
| | - Adam B Shafritz
- Department of Orthopedics and Rehabilitation, University of Vermont Medical Center, Burlington, Vermont
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Miniplatten als Ergänzungsimplantat bei der Osteosynthese komplexer distaler Radiusfrakturen. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2016; 28:402-6. [DOI: 10.1007/s00064-016-0469-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/19/2016] [Accepted: 07/12/2016] [Indexed: 10/21/2022]
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Gaspar MP, Sessions BA, Dudoussat BS, Kane PM. Single-Incision Carpal Tunnel Release and Distal Radius Open Reduction and Internal Fixation: A Cadaveric Study. J Wrist Surg 2016; 5:241-246. [PMID: 27468377 PMCID: PMC4959898 DOI: 10.1055/s-0036-1581053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 02/16/2016] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Michael P. Gaspar
- Department of Orthopedic Surgery, The Philadelphia Hand Center, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Blane A. Sessions
- Department of Orthopedic Surgery, The Philadelphia Hand Center, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Bryan S. Dudoussat
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Patrick M. Kane
- Department of Orthopedic Surgery, The Philadelphia Hand Center, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Tsuchiya F, Naito K, Mogami A, Obayashi O. New Technique for Dorsal Fragment Reduction in Distal Radius Fractures by Using Volar Bone Fenestration. J Orthop Case Rep 2016; 3:8-11. [PMID: 27298898 PMCID: PMC4719244 DOI: 10.13107/jocr.2250-0685.093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Introduction: For intra-articular distal radius fractures (AO Classification, type B2) with a displaced dorsal fragment, there remains much discussion on the fixation method for the dorsal fragment. To reduce the displaced dorsal fragment, we developed a new technique consisting of fenestration of the volar bone cortex, reduction using an intramedullary procedure, and fixation using a volar plate. This avoids necessity of dorsal approach. Technical Note: We performed this surgical technique in 2 patients and achieved a good reduced position without much injury to the bone cortex at the site of volar plate placement. This surgical technique allows reduction of the dorsal fragment using an intramedullary procedure by only a volar approach, and, therefore, does not affect the dorsal soft tissue (extensor tendon). For intra-articular distal radius fractures, complete reduction of the articular surface is extremely difficult, and, in patients with a remaining gap on the articular surface, a variable angle locking screw system may be useful. In the 2 patients, the angle of the locking screw was adjusted to catch the displaced dorsal fragment, and adequate reduction and fixation could be achieved. Conclusion: This technique using fenestration of the volar bone cortex allows reduction and fixation of the displaced dorsal fragment in distal radius fractures and thus avoids the necessity of a dorsal approach.
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Affiliation(s)
- Fumika Tsuchiya
- Department of Orthopaedic Surgery, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295 Japan; Department of Orthopaedic Surgery, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata 950-1197 Japan
| | - Kiyohito Naito
- Department of Orthopaedic Surgery, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295 Japan
| | - Atsuhiko Mogami
- Department of Orthopaedic Surgery, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295 Japan
| | - Osamu Obayashi
- Department of Orthopaedic Surgery, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295 Japan
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47
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Orbay JL, Rubio F, Vernon LL. Prevent Collapse and Salvage Failures of the Volar Rim of the Distal Radius. J Wrist Surg 2016; 5:17-21. [PMID: 26855831 PMCID: PMC4742256 DOI: 10.1055/s-0035-1570745] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 12/08/2015] [Indexed: 10/22/2022]
Abstract
Background Articular fractures of the distal radius may include a small fragment from the volar margin of the lunate fossa: volar marginal fragments (VMFs); these fragments are prone to loss of fixation and avascular necrosis, and often result in wrist subluxation. We present our experience managing acute and delayed VMFs. The first is treated using a hook plate extension to a volar locking plate and the latter using a volar opening wedge osteotomy to redistribute loads on the remaining articular surface. Materials and Methods We retrospectively reviewed the records of all patients treated at our facility with a hook plate extension for a VMF and for patients treated with a volar opening wedge osteotomy. Medical charts were examined for complications and functional results. Technique A hook plate extension was used to fix the VMF when plate buttressing was insufficient. For patients who presented a collapsed and reabsorbed VMF, a volar opening wedge osteotomy was used to reorient the articular surface, restoring joint stability. Results The hook plate extension was successful in managing 19 of the 21 acute VMFs. The volar opening wedge osteotomy provided concentric reduction and improved pain and motion in all treated patients. Conclusion We demonstrated that hook plate fixation of the VMF is an effective means of fixing the acute VMF and that a volar opening wedge osteotomy can be used to salvage a distal radius fracture with a collapsed VMF.
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Affiliation(s)
- Jorge L. Orbay
- The Miami Hand and Upper Extremity Institute, Miami, Florida
| | - Francisco Rubio
- The Miami Hand and Upper Extremity Institute, Miami, Florida
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A Brachioradialis Splitting Approach Sparing the Pronator Quadratus for Volar Plating of the Distal Radius. Tech Hand Up Extrem Surg 2015; 19:176-81. [PMID: 26535483 DOI: 10.1097/bth.0000000000000104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Fractures of the distal radius account for up to 15% of all extremity fractures. Volar plating has become more popular, as it allows locking plate technology to be applied. Traditionally, access to the volar radius has been achieved through the approach of Henry using the interval between flexor carpi radialis and the radial artery, involving incising the radial border of the pronator quadratus (PQ). With this approach, PQ repair is difficult, and when attempted is often incomplete or tenuous, as it is a direct muscle-to-muscle repair. Theoretical advantages of repairing the PQ include the provision of plate coverage, a protective gliding layer, a well-vascularized coverage of the fracture fragments, and a protective barrier against deep infection in the case of superficial infection. Techniques have been developed to try and improve on the Henry approach. We have developed a surgical approach to volar plating that utilizes the anatomic relationship between brachioradialis and PQ in a way that allows simple and stable reattachment of the PQ muscle. We have termed the technique the "Brachioradialis splitting" approach. We present it here.
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Abstract
Volar plating has become the standard of care for most distal radius fractures. When done for the right indication and with adequate mastering of the technique complication ratio is low. The concept of subchondral support is key in this technique. Osteoporotic patients will especially benefit from this type of fixation which allows early immobilization, quick return to activities of daily living and early good outcome.
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Affiliation(s)
- J Vanhaecke
- Department of Orthopaedic Surgery, Hand Surgery, AZ Groeninge, Campus Loofstraat, Loofstraat 43, 8500 Kortrijk, Belgium.
| | - D L Fernandez
- Department of Orthopaedic Surgery, Lindenhof Hospital, Bern, Switzerland.
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Farhan MFM, Wong JHK, Sreedharan S, Yong FC, Teoh LC. Combined volar and dorsal plating for complex comminuted distal radial fractures. J Orthop Surg (Hong Kong) 2015; 23:19-23. [PMID: 25920637 DOI: 10.1177/230949901502300105] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To review outcomes of combined volar and dorsal locked plating for AO type-C3 complex comminuted distal radial fractures. METHODS Records of 24 patients aged 17 to 77 (mean, 53.3) years who underwent combined volar and dorsal locked plating for AO type-C3 distal radial fractures with volar and dorsal metaphyseal and intra-articular comminution were reviewed. 21 were closed fractures, and 3 were Gustilo-Anderson type-1 open fractures. Bone union, volar tilt, radial inclination, radial height, range of motion, grip strength, and any complications were assessed by a single hand surgeon. RESULTS After a mean follow-up of 17 (range, 14-25) months, the mean palmar flexion was 49º (range, 30º-80º), dorsiflexion was 52º (range, 30º-80º), supination was 86º (range, 60º-90º), pronation was 77º (range, 30º-90º), radial deviation was 16º (range, 5º-30º), and ulnar deviation was 27º (range, 10º-50º). The mean grip strength of the injured hand was 69.2% of the uninjured side. The mean time to radiological union was 3.9 (range, 2.5-6.0) months; no patient had non-union. At the time of union, the mean volar tilt was 5º (-22º-14º), radial inclination was 18.6º (8º-28º), and radial height was 8.5 mm (5.0 mm-13.6 mm). One patient had collapse of the dorsal fragment resulting in a dorsal tilt of 22º and limited (30º) forearm pronation. The severity of dorsal metaphyseal comminution had not been recognised and bone grafting was not performed. The patient also had minor complications of little finger flexor tendon irritation and carpal tunnel syndrome. She underwent implant removal and carpal tunnel release at 8 months. One patient had implant-related extensor digitorum communis irritation. Another patient had non-specific chronic wrist pain, which was resolved at one year. No patient had infection, tendon rupture, or complex regional pain syndrome. Four patients underwent implant removal, including 2 who had no implant-related problems. CONCLUSION Combined volar and dorsal plating enables early mobilisation and good outcome for certain complex comminuted distal radial fractures.
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Affiliation(s)
- M F M Farhan
- Hand and Microsurgery Section, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
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