Complications of distal radial and scaphoid fracture treatment

Course of the extensor pollicis longus tendon considering the different functional positions of the wrist and the first ray-an anatomical study

BACKGROUND

The aim of this anatomical study was to evaluate the course of the extensor pollicis longus (EPL) tendon, its positional relationship to adjacent structures, and the resulting clinical relevance under consideration of various functional positions.

MATERIALS AND METHODS

Twenty upper extremities from ten adult human cadavers embalmed using Thiel's method were included in this study. The greatest possible movement/slippage of the EPL tendon, the angle at which the tendon wraps around Lister's tubercle, and its course across the extensor carpi radialis longus and brevis (ECRL and ECRB) were recorded and defined in all functional positions.

RESULTS

Our findings demonstrate a high range of motion of the tendon in relation to clinically relevant structures.

CONCLUSION

Understanding the anatomical course of the EPL tendon, its potential extent of movement, and its resulting positional changes is essential for the diagnosis and surgical treatment of patients with complaints or injuries in the dorsoradial wrist region.

Chronic post-traumatic pain: rheumatological and orthopedic aspects

Trauma causes a complex local and systemic reaction of the macroorganism, the consequences of which can be various functional, neurological and psychoemotional disorders. One of the most painful complications of injuries of the musculoskeletal system is chronic post-traumatic pain (CPTP), which occurs, depending on the severity of the damage, in 10–50% of cases. The pathogenesis of this syndrome is multifactorial and includes the development of chronic inflammation, degenerative changes (fibrosis, angiogenesis, heterotopic ossification), pathology of the muscular and nervous systems, neuroplastic changes leading to the development of central sensitization, as well as depression, anxiety and catastrophization. Risk factors for CPTP should be considered the severity of injury, comorbid diseases and conditions (in particular, obesity), stress and serious trauma-related experiences (within the framework of post-traumatic stress disorder), the development of post-traumatic osteoarthritis and chronic tendopathy, genetic predisposition, deficiencies in treatment and rehabilitation in the early period after injury. To date, there is no clear system of prevention and treatment of CPTP. Considering the pathogenesis of this suffering, adequate anesthesia after injury, active anti–inflammatory therapy (including local injections of glucocorticoids), the use of hyaluronic acid, slow-acting symptomatic agents and autologous cellular preparations – platelet-riched plasma, mesenchymal stem cells, etc. are of fundamental importance. However, therapeutic and surgical methods of CPTP control require further study

Wrist Fractures in Skiers and Snowboarders: Incidence, Severity, and Risk Factors Over 40 Seasons

PURPOSE

To determine and compare the incidence and severity of wrist fractures in skiers and snowboarders.

METHODS

A university-run orthopedic clinic at the base of a major ski resort has maintained an injury database spanning the years 1972 to 2012. Demographic information, equipment type, ability level, trail type and conditions, number of falls, circumstances surrounding the injury, and radiographs were collected on participants sustaining wrist fractures and compared with uninjured control participants asked the same questions, but in reference to their last fall where no injury resulted. A risk factor model for wrist fracture and severity in alpine sports was developed.

RESULTS

During the 40-year period, 679 wrist fractures were identified. The incidence of wrist fracture per 1,000 days was 0.447 in snowboarders and 0.024 in skiers. In comparison with a representative sample of uninjured skiers, bivariate analyses revealed that skiers who experienced fractures were less experienced, had a greater number of falls, were on green or double black trails, and were injured owing to jumping or other reason related to technique. A higher risk for fracture was found for beginners, males younger than age 16, women older than age 50, and 4 or fewer days skiing that season. Bivariate analyses found that injured snowboarders were more likely to be female, younger, less experienced and had received less instruction than uninjured snowboarders. Higher risk for wrist fracture among snowboarders was found to be associated with age younger than 18 and less experience.

CONCLUSIONS

Wrist fractures occur at an 18 times greater incidence in snowboarders than in skiers. Skiers with wrist fractures were beginners, males younger than 16, women older than 50, or those who had less participation. Snowboarders sustaining wrist fractures were younger than 18 or had less experience.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

Scaphoid waist fractures fixation with staple. Retrospective study of a not widespread procedure

INTRODUCTION

In carpal scaphoid fractures, the surgical treatment with screw is considered the gold standard; shape memory staple however presents substantial advantages. The authors report a study on unstable fractures of the scaphoid waist (type B1, B2, B5, according to Herbert classification) treated with shape memory staple on a large sample of patients, with the aim to confirm the usefulness of this method, the quality of reduction and fixation, the functional results, the time of union and the possible complications.

MATERIALS AND METHODS

A retrospective analysis of 131 patients with scaphoid waist fractures with minimum follow-up 1 year was performed. Staples were used in all cases; technical details are discussed. Outcome measures were: postoperative pain, flexion-extension wrist range, hand grip strength, radiographic consolidation, work absence. Herbert and Fisher Grading System was used to assess subjective, objective and radiographic results.

RESULTS

Consolidation was achieved in all cases of primary fractures (0-30 days) within three months after surgery, and within eight months in all but two cases of delayed unions (operated within 6 months of the injury). Pain was absent at follow-up in 79% of cases, never severe or unbearable, the average flexion-extension range achieved was 112°. Handgrip strength values were comparable to those of contralateral wrist in 75% of cases. Mean time lost at work was 7.4 weeks. No algo-distrophy or malunion were observed. Discussion CONCLUSIONS: Scaphoid waist fractures' treatment with shape memory staple should be considered as an excellent alternative to screw fixation.

Fixation of distal radius fracture with volar locking palmar plates while preserving pronator quadratus through the minimally invasive approach

BACKGROUND

The volar locking plate technique with an L-shaped incision of the PQ muscle through the classic volar Henry approach is a popular method for treating distal radius fractures. Recently we revised and improved this traditional technique by performing mini-invasive surgery.

OBJECTIVE

The purpose of this study was to evaluate the clinical effects after fixation of distal radius fracture with volar locking palmar plates while preserving the pronator quadratus through minimally invasive approach.

METHODS

From May 2014 to March 2017, 58 patients (38 males and 21 females) with an age range of 22-72 years (mean age 44.6 years) and with distal radius fractures underwent open reduction and internal fixation with volar locking palmar plates. The patients were classified as 23A-2 through 23C-2 according to the Orthopedic Trauma Association fracture classification system. All surgeries were completed by one trained team. The group that received volar locking palmar plates of distal radius performed with the traditional method through Henry approach involved 33 patients (21 males and 12 females) and the group that received PQ through minimally invasive approach group involved 25 patients (16 males and 9 females). We compared the two groups for wrist pain, forearm range of motion, grip strength, preoperative complications and wrist functional recovery score.

RESULTS

The minimum follow-up for the whole cohort was one year. The differences between the two groups were significant in terms of wrist pain, forearm range of motion, grip strength and wrist function at 1, 2, 6 weeks postoperatively, but insignificant at 3 and 12 months postoperatively. In the minimally invasive group a case of limited extension of the forefinger 3 months postoperatively was found. No significant differences were found for preoperative complications and radiographs postoperatively.

CONCLUSION

Fixation with volar locking palmar plates through minimally invasive approach is a satisfactory and optional method in the treatment of distal radius fractures. This technique yields better early wrist function, shortens rehabilitation time and gets high psychological satisfaction.

Complications of Corrective Osteotomies for Extra-Articular Distal Radius Malunion

PURPOSE

Osteotomy of the distal radius for a fracture malunion is a challenging procedure. The purpose of this study was to review a series of osteotomies to determine the type and risk of complications.

METHODS

A retrospective cohort study was performed, including all Kaiser Permanente Southern California patients who were aged 18 years or older between January 1, 2007, and September 25, 2015, and underwent osteotomy for an extra-articular distal radius fracture malunion. Charts were reviewed for demographic data, comorbidities, osteotomy type (hinged vs distraction), implant, and bone graft type. Complications including infection, nonunion, loss of reduction, implant failure, nerve injury, tendon injury, and complex regional pain syndrome were recorded.

RESULTS

There were 60 patients who underwent extra-articular osteotomy of the distal radius for malunion during the study period. The mean age was 54 years (range, 21-83 years). There were 24 distraction-type (intervening bone graft) and 36 hinge-type (volar cortical contact maintained) osteotomies. Twenty-five of 60 patients had complications related to the procedure requiring 13 subsequent procedures. There were 7 nonunions and 3 cases of delayed healing at the osteotomy site. One extensor carpi radialis longus tendon laceration resulted from the use of an osteotome. There were 3 delayed extensor pollicis longus (EPL) tendon ruptures after surgery. The distraction-type osteotomy was associated with a greater risk of major complications including nonunion and delayed union.

CONCLUSIONS

A complication rate of nearly 50% was observed in distal radius osteotomies. Surgeons should be aware of the risk of injury to, or delayed rupture of the EPL tendon associated with these procedures. The risk of nonunion or delayed union is higher in distraction-type compared with hinge-type osteotomies. Low surgeon volume with this procedure may be a contributing factor to the high rate of complications.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Median Nerve Injury Caused by Screw Malpositioning in Percutaneous Scaphoid Fracture Fixation

An unusual complication of percutaneous fixation of a schapoid fracture in a 36-year-old man is described. After this surgery, the patient complained of numbness and tingling within the median nerve distribution and thenar weakness. An Electromyography showing moderate CTS had led to carpal tunnel decompression, which resulted unsuccessful. When the patient presented to us, both sensory and motor median nerve impairment were present, interfering with his professional activity. A computed tomography scan performed to assess the scaphoid screw position, showed that the screw had been placed volar to the scaphoid, adjacent to the median nerve. Surgery confirmed median nerve compression by the screw, especially during complete wrist extension. The surgical removal of the screw led to immediate improvement of both the motor and sensory functions of the nerve, with complete clinical restoration of nerve function and resolution of the symptoms 2 months postoperatively.

The Incidence and Risk Factors of Scaphoid Fracture Associated With Radial Head and Neck Fracture in Trauma Patients

Background:

Scaphoid and radial head fractures are two injuries derived from the common fall on outstretched hand. How these injuries are related has not been fully investigated. The aim of this study was to evaluate risk factors for having concomitant proximal radius and scaphoid fractures. The goal was to identify at-risk patient populations and drive improvement in diagnosis and management of these injuries.

Methods:

A retrospective review of the National Trauma Data Bank from 2007 through 2012 identified 11,309 patients with proximal radius fracture, and, as a proxy for low-energy injury, an injury severity score of less than 15. These patients were then categorized by presence of concomitant scaphoid injury. Presence of scaphoid fracture was then analyzed based on age, sex, race, trauma type, mechanism, and injury severity score.

Results:

Three hundred seventy-eight (3%) scaphoid fractures among the 11,309 proximal radius fractures were identified. Both age and sex reached statistical significance as risk factors for concomitant scaphoid and radial head injury. There was an incremental increase in risk for concomitant injury with younger age. Subset analysis demonstrated a 10% incidence of concomitant fractures in men aged 18 to 30 years.

Discussion:

This study provides a better understanding of how these two fractures are related. There is a markedly higher risk for concomitant injuries in male and young patients, especially those whose mechanism is a fall. Close examination of the wrist should be performed for any proximal radius fracture, and any pain should be a cause for further investigation of scaphoid injury.

Fixation Strength in Full and Limited Fixation of Osteoporotic Distal Radius Fractures

BACKGROUND

The purpose of this investigation is to determine whether osteoporotic intra-articular distal radius fractures surgically treated by filling all 7 distal screws of a volar plate will have a higher load to failure than those treated by filling only 4 distal screws.

METHODS

Ten matched pairs of fresh frozen cadaveric forearms were randomized within each pair to be treated by using either all 7 of the distal holes of a volar plate or only 4 distal screws. The distal radius fixation was performed with unicortical screws going to but not through the dorsal cortex, and the most distal screws were placed within 4 mm of the joint surface. An AO C2 type fracture was then created. All specimens were tested cyclically, with an axial load of 60 N, at 3 Hz for 1000 cycles to simulate early postoperative motion. All specimens were subsequently tested to mechanical failure.

RESULTS

There were no failures in either group during cyclic testing. There was no difference detected between groups for mean stiffness, yield load, peak load, or load to clinical failure. In both groups, the yield load, peak load, and load to clinical failure were higher than the 60- to 100-N forces encountered during postoperative rehabilitation.

CONCLUSIONS

There was no difference detected between osteoporotic intra-articular distal radius fractures treated by utilizing all 7 of the distal screws of a volar plate compared with those treated with only 4 distal screws.

The Scaphoid Staple: A Systematic Review

BACKGROUND

The purpose of this systematic review is to analyze the indications, outcomes, and complications of scaphoid fixation with a staple.

METHODS

The literature was reviewed for all cases of the scaphoid staple. Five articles including 188 patients, of 77 primary scaphoid fractures and 111 other indications that included delayed union, nonunion, and avascular necrosis, were reviewed. Demographic data, outcomes, and complications were recorded.

RESULTS

The union rate of the scaphoid staple is 94.7%, and 95.7% of patients return to work after an average of 9.8 weeks after a 4.7-week period of immobilization. The complication rate was 9.0%, and 7.5% required hardware removal. Clinical and radiographic healing was higher in primary fractures as compared with other indications. Other indications, as compared with primary fracture, had a higher rate of hardware removal.

CONCLUSIONS

For all indications, the scaphoid staple has a high union rate and a low complication rate. In the authors' experience, the procedure is fast, not technically challenging, and may be considered for primary fracture, delayed union, nonunion, and avascular necrosis of the scaphoid.

[Extra-articular distal radius fractures in young adults]

Extra-articular distal radius fractures in young active patients are typically the result of sport injuries or traffic accidents. Displaced fractures are less well tolerated in young patients than in older people, especially in terms of dorsal tilt and radial shortening. Non-surgical treatment is only indicated when the fracture is minimally or not displaced. No fracture fixation method is superior to another, however, the treatment goal is a rapid return to previous activities.

Characterization of a Pre-Clinical Mini-Pig Model of Scaphoid Non-Union

A fractured scaphoid is a common disabling injury that is frequently complicated by non-union. The treatment of non-union remains challenging because of the scaphoid's small size and delicate blood supply. Large animal models are the most reliable method to evaluate the efficacy of new treatment modalities before their translation into clinical practice. The goal of this study was to model a human scaphoid fracture complicated by non-union in Yucatan mini-pigs. Imaging and perfusion studies were used to confirm that the anatomy and blood supply of the radiocarpal bone in mini-pigs were similar to the human scaphoid. A 3 mm osteotomy of the radiocarpal bone was generated and treated with immediate fixation or filled with a dense collagen gel followed by delayed fixation. Bone healing was assessed using quantitative micro computed tomography and histology. With immediate fixation, the osteotomy site was filled with new bone across its whole length resulting in complete bridging. The dense collagen gel, previously shown to impede neo-vascularization, followed by delayed fixation resulted in impaired bridging with less bone of lower quality. This model is an appropriate, easily reproducible model for the evaluation of novel approaches for the repair of human scaphoid fractures.

Operative Treatment of Acute Scaphoid Fractures

Optimal treatment of acute scaphoid fractures is a necessary goal for many reasons. One is that the scaphoid is the most commonly fractured carpal bone. Another is that a missed diagnosis of an acute scaphoid fracture leads to the more challenging situation of a delayed union, non-union and risk for premature radiocarpal arthrosis. Because the scaphoid has an inherent risk for nonunion due to its the tenuous blood supply, timely diagnosis and appropriate treatment are considered critical to achieving acceptable results and to avoiding the consequences of failed union.

Management of complications of distal radius fractures

Treating a fracture of the distal radius may require the surgeon to make a difficult decision between surgical treatment and nonsurgical management. The use of surgical fixation has recently increased because of complications associated with conservative treatment. However, conservative action may be necessary depending on certain patient factors. The treating surgeon must be aware of the possible complications associated with distal radius fracture treatments to prevent their occurrence. Prevention can be achieved with a proper understanding of the mechanism of these complications. This article discusses the most recent evidence on how to manage and prevent complications following a fracture of the distal radius.

Carpal and scaphoid fracture incidence in south-eastern Australia: an epidemiologic study

Carpal fractures were identified by the Geelong Osteoporosis Study Fracture Grid for 2006-2007. Incidence rates were higher in males than females. Males had a lower median age of fracture than females. Females had more fractures on the left side than males. Most fractures were the result of a fall.

PURPOSE

In this study, we report the incidence of carpal bone fractures (scaphoid and non-scaphoid) amongst residents from the Barwon Statistical Division over 2 years.

METHODS

X-ray reports from imaging centres in the region were used to identify incident fractures during 2006 and 2007. Data were collected as part of the Geelong Osteoporosis Study Fracture Grid.

RESULTS

During 2006 and 2007, there were 171 and 41 carpal fractures in males and females, respectively. Of these, 131 males and 29 females had fractured the scaphoid bone. Females had a higher proportion of left-sided fractures (>70 %) than males (∼40 %). Most fractures were the result of an accidental fall (>87 %). Patterns of incidence for males showed one major peak around 20-29 years. For females, peaks occurred around age 10-19 years and 70-79 years. Incidence rates for males (per 100,000 persons per year) were 54.6 (95 % confidence interval (CI) 53.6, 55.7) and 15.9 (95 % CI 15.4, 16.5) for scaphoid and non-scaphoid fractures, respectively. In females, the corresponding rates were 10.6 (95 % CI 10.2, 11.1) and 4.5 (95 % CI 4.2, 4.8).

CONCLUSION

Almost all fractures were the result of a fall. In males, carpal fractures were sustained mainly during early adulthood and in females during adolescence and after menopause. Incidence rates for males were higher than those in females for both scaphoid and non-scaphoid fractures.