Dorsal Plating for Intra-articular Middle Phalangeal Base Fractures With Volar Instability.
ABSTRACT: Background: Intra-articular middle phalangeal base fractures with volar instability are rare injuries with scant literature on optimal management. Our purpose is to describe our method of dorsal plating and report postoperative outcomes. Methods: This study is a retrospective case review of 5 patients with intra-articular middle phalangeal base fractures with volar proximal interphalangeal joint instability, measuring subjective, clinical, and radiographic outcomes. Results: Patient age averaged 38.2 years (range, 23-56 years), and 80% were male. Sporting injuries were the most common mechanism (80%). Time to surgery averaged 7 days, and postoperative follow-up duration averaged 19.6 months (median 8 months). All fractures were intra-articular at the proximal interphalangeal joint with volar instability. There were no complications and no patients required secondary surgery. Grip strength was maintained and range of motion was good, based on the American Society for Surgery of the Hand Total Active Motion score. Average Quick Disability of the Arm, Shoulder and Hand was 0.5 (range, 0-2.3), 100% of patients were satisfied, and average visual analog pain score was 1.2. Patients returned to work at a median of 4 days. There was radiographic union at an average of 6.6 weeks (range, 6-7 weeks) in all fractures. Conclusions: Dorsal plating using a 1.5-mm modular hand plate is a viable option for rigid fixation of intra-articular middle phalangeal base fractures with volar instability. This fixation method allows for early range of motion without complications in this case series. All fractures united, and patients had minimal functional deficits and were able to maintain good range of motion.
Project description:INTRODUCTION: Intra-articular distal radius fractures with volar and dorsal comminution present a special challenge to the hand surgeon. METHODS: Ten patients formed the study cohort. All plates were low profile and stainless steel. Radiographic parameters, range of motion, and strength compared to the uninjured side were recorded. Functional outcome was evaluated by Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and Gartland and Werley scoring system. RESULTS: Median age at surgery was 58 years (range, 24 to 86). Mean follow-up was 17 months (range, 12 to 28). According to the AO classification system, there were three type C2 and seven type C3 fractures. Median preoperative dorsal angulation was 24 deg; median postoperative dorsal angulation was 3 deg. Eighty percent (8) of the fractures also had an intra-articular step-off or gap, all of which were corrected to neutral by the procedure. Compared with the contralateral side, mean extension and flexion were 73 and 75%, respectively, pronation and supination were 95 and 88%, respectively, and grip strength and thumb pinch were 72 and 87%, respectively. Mean postoperative DASH score was 16 points, and 70% (7) of the patients had Gartland and Werley scores of good or excellent. None of the patients needed to have their plates removed, and no extensor tendon rupture was reported. CONCLUSIONS: The "sandwich" plating technique is an effective method of regaining near-anatomic reconstruction of intra-articular, volarly and dorsally comminuted distal radius fractures. Results from this study demonstrate that patients can expect to regain about 80% of their range of motion and strength. Moreover, 70% of the patients will have good to excellent functional outcomes. This is the first study to examine range of motion and functional outcome of low-profile "sandwich" plating without plate removal.
Project description:The aim of this study was to define the outcome and complications following open reduction and internal fixed-angle plating of distal radius fractures for patients on chronic immunosuppression medications. A retrospective study identified 11 patients with distal radius fractures that had been on chronic immunosuppressive medication. The mean patient age was 59.9 years (40-82 years). According to the Orthopedic Trauma Association classification, there was one 23A3, one 23B3, and nine 23C type fractures. There were two open fractures. All patients received preoperative antibiotics and underwent reduction and fixation with a volar, fixed-angle plate. Postoperative measurements included postoperative and final radiographic indices, wrist flexion and extension, forearm rotation, and grip strength. Clinical follow-up averaged 13 months, and radiographic follow-up averaged 14.9 months. Statistical analysis was performed comparing means of various parameters with a two-sided t test with an alpha value < or = 0.05. All fractures healed, and there were no infections. The final mean ulnar variance, volar tilt, and radial inclination were -0.1 mm (ulnar negative; -2.0 to +2.5 mm), 13 degrees (5-23 degrees), and 21 degrees (15-27 degrees), respectively. The mean articular gap or step was 0.4 mm. There was a small but significant decrease between the final and postoperative mean ulnar variance (p = 0.03). Mean wrist flexion was 47 degrees, extension 47 degrees , pronation 77 degrees, and supination was 76 degrees. Grip strength averaged 16.3 kg versus 25.1 kg for the opposite extremity. The one major complication included a postoperative carpal tunnel syndrome. Fixed-angle volar plate fixation for distal radius fractures in patients with chronic immunosuppression was associated with union (with acceptable radiographic alignment), no wound-healing problems or infections, and with functional wrist and forearm motion and grip strength.
Project description:Promising results have been reported after volar locked plating of unstable dorsally displaced distal radius fractures. We investigated whether volar locked plating results in better patient-perceived, objective functional and radiographic outcomes compared to the less invasive external fixation.63 patients under 70 years of age, with an unstable extra-articular or non-comminuted intra-articular dorsally displaced distal radius fracture, were randomized to volar locked plating (n = 33) or bridging external fixation. Patient-perceived outcome was assessed with the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Patient-Rated Wrist Evaluation (PRWE) questionnaire.At 3 and 6 months, the volar plate group had better DASH and PRWE scores but at 12 months the scores were similar. Objective function, measured as grip strength and range of movement, was superior in the volar plate group but the differences diminished and were small at 12 months. Axial length and volar tilt were retained slightly better in the volar plate group.Volar plate fixation is more advantageous than external fixation, in the early rehabilitation period.
Project description:<b>Background</b> ?Volar plating for distal radius fractures exposes the risk of extensor tendon rupture, mechanical problems, and osteoarthritis due to protruding screws. <b>Purposes</b> ?The purpose of this review was to identify the best intraoperative diagnostic imaging modality to identify dorsal and intra-articular protruding screws in volar plating for distal radius fractures. <b>Methods</b> ?The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed for this review. In vitro and in vivo studies that analyzed the reliability, efficacy, and/or accuracy of intraoperatively available imaging modalities for the detection of dorsal or intra-articular screw protrusion after volar plating for distal radius fractures were included. <b>Results</b> ?Described additional imaging modalities are additional fluoroscopic views (pronated views, dorsal tangential view [DTV], radial groove view [RGV], and carpal shoot through [CST] view), three-dimensional (3D) and rotational fluoroscopies, and ultrasound (US). For detection of dorsal screw penetration, additional fluoroscopic views show better results than conventional views. Based on small (pilot) studies, US seems to be promising. For intra-articular screw placement, 3D or 360 degrees fluoroscopy shows better result than conventional views. <b>Conclusion</b> ?Based on this systematic review, the authors recommend the use of at least one of the following additional imaging modalities to prevent dorsal protruding screws: CST view, DTV, or RGV. Tilt views are recommended for intra-articular assessment. Of all additional fluoroscopic views, the DTV is most studied and proves to be practical and time efficient, with higher efficacy, accuracy, and reliability compared with conventional views. <b>Level of Evidence</b> ?The level of evidence is Level III.
Project description:Pediatric hand fractures are common and approximately 10% require surgery. Methods:This retrospective cohort study reports on hand fractures in a large pediatric population and identifies the characteristics and patterns of fractures that required surgical correction. A ?2 analysis was done to evaluate the association between individual fracture variables and surgery. The STROBE checklist was applied. Results:One thousand one-hundred seventy-three hand fractures were reviewed. Peak age was 16 years for boys and 14 years for girls. Most fractures were closed (96.0%) and nonrotated (91.3%), and had no concomitant soft tissue injury (72.7%). More than half (56.3%) were nonepiphyseal plate fractures; yet as a single diagnosis, Salter-Harris II fractures were most common (30.2%). The following variables were significantly associated with surgery: open fractures, rotational deformity, distal phalangeal fracture location, multiple fractures, oblique pattern, comminution, displacement >2?mm, intra-articular involvement, and angulation >15°. Most fractures required only immobilization and early range of motion (64.3%). Closed reduction was required in 22.7%. Minor surgery by the primary provider was performed in 3.2% of fractures. Surgery by a hand surgeon was performed in 9.8%. The most common patterns requiring surgery were proximal or middle phalanx head or neck fractures (38.2%) and metacarpal midshaft fractures (20.9%). The most common operation was open reduction internal fixation (52.2%). Conclusions:Pediatric hand fractures are common, but 90.2% do not require surgery and, as such, primary providers play a key role in management. Certain fracture variables and patterns are more likely to lead to surgery.
Project description:Outcomes after implant arthroplasty for primary degenerative and posttraumatic osteoarthritis of the proximal interphalangeal joint were different according to the implant design and surgical approach. The purpose of this systematic review was to evaluate outcomes of various types of implant arthroplasty for proximal interphalangeal joint osteoarthritis, with an emphasis on different surgical approaches.The authors searched all available literature in the PubMed and EMBASE databases for articles reporting on outcomes of implant arthroplasty for proximal interphalangeal joint osteoarthritis. Data collection included active arc of motion, extension lag, and complications. The authors combined the data of various types of surface replacement arthroplasty into one group for comparison with silicone arthroplasty.A total of 849 articles were screened, yielding 40 studies for final review. The mean postoperative arc of motion and the mean gain in arc of motion of silicone implant with the volar approach were 58 and 17 degrees, respectively, which was greater than surface replacement implant with the dorsal approach at 51 and 8 degrees, respectively. The mean postoperative extension lag of silicone implant with the volar approach and surface replacement with the dorsal approach was 5 and 14 degrees, respectively. The revision rate of silicone implant with the volar approach and surface replacement with the dorsal approach was 6 percent and 18 percent at a mean follow-up of 41.2 and 51 months, respectively.Silicone implant with the volar approach showed the best arc of motion, with less extension lag and fewer complications after surgery among all the implant designs and surgical approaches.
Project description:We applied quantitative 3D computed tomography to 50 complete articular AO type C fractures of the distal radius and tested the null hypothesis that fracture fragments can be divided according to Melone's concept (radial styloid and volar and dorsal lunate facet fragments) and that each fragment has similar (1) displacement and (2) articular surface area. Thirty-eight fractures fit the Melone distribution of fragments. Radial styloid fragments were most displaced, and volar lunate fragments were least displaced. Volar lunate fragments had the largest articular surface area. While these findings confirm Melone's concepts, the finding that volar lunate fragments are relatively large and dorsal lunate fragments relatively small suggests that alignment of the volar lunate fragment with the radial styloid may be the key element of treatment and the dorsal lunate fragment may not routinely benefit from specific reduction and fixation.
Project description:Of all distal radius fractures, 25 % are complete articular fractures (AO/OTA type C fractures). Two thirds of those fractures are displaced and require reduction. According to several International Guidelines, adequately reduced intra-articular distal radius fractures are best treated non-operatively with plaster immobilisation, while surgical fixation is suggested only when the articular step exceeds 2 mm after reduction. However, these recommendations are based on studies that did not differentiate between intra- and extra-articular distal radius fractures. Thus, no clear consensus about the best treatment for patients with displaced intra-articular distal radius fractures can be reached. Despite the lack of evidence, an increase in internal fixation of intra-articular distal radius fractures has been observed over the last decade. The aim of this study is to determine the difference in functional outcome following open reduction and plate fixation compared with non-operative treatment with closed reduction and plaster immobilisation in patients with a displaced intra articular distal radius fracture.This multicentre randomised controlled trial will randomise between open reduction and internal plate fixation (intervention group) and closed reduction and plaster immobilisation (control group). All consecutive adult patients from 18 to 65 years with a displaced intra-articular distal radius fracture (AO/OTA type C), which has been adequately reduced at the Emergency Department according to the Dutch National Guidelines, are eligible for inclusion in this study. The primary outcome is function and pain of the wrist assessed with the Patient-Rated Wrist Evaluation score (PRWE). Secondary outcomes are the Disability of the Arm, Shoulder and Hand score (DASH), pain, quality of life (SF-36), range of motion, grip strength, radiological parameters, complications, crossovers and cost-effectiveness of both treatments. A total of 90 patients will be included in this study.Although displaced intra-articular distal radius fractures are common, there is still no evidence on the optimal treatment for these fractures in patients aged 18 to 65 years. Therefore we aim to determine the difference in functional outcome between open reduction and plate fixation and closed reduction and plaster immobilisation.This study is registered at ClinicalTrials.gov ( NCT02651779 ) on January 4(th) 2016.
Project description:Most gunshot injuries to the hand involve a combination of tissue types. The goal of this study is to report the results of early definitive treatment in extra-articular metacarpal and proximal phalangeal fractures due to low velocity gunshot wounds and to analyse their outcomes. A retrospective analysis of 51 metacarpal and 41 proximal phalangeal fractures of 76 patients due to low velocity gunshot wounds treated between January 2001 and December 2004 was carried out. We applied acute fixation in the first 24 hours. The patients were evaluated with total active motion scores, radiographic control, complication rate and the need for revision surgery. The infection frequency was 10.5% and the need for a revision surgery was 7%. The plate fixation group had significantly higher total active motion scores than the external fixation group. The K wire group had the highest revision rate. The bone grafting group was associated with good total active motion scores and low complication rates. The majority of the low velocity gunshot injuries are surgically clean wounds which allow not only early fracture fixation, but also early bone grafting and soft tissue reconstruction. Plate and screw fixation is associated with significantly better functional outcomes than the minimal fixation group.
Project description:Background Fractures of the distal radius are among the most common injuries treated by orthopedic surgeons worldwide. Failure to restore distal radius alignment can lead to fracture malunion and poor clinical outcomes, including distal radioulnar joint (DRUJ) instability and limitation of motion. Case Description We present a unique case of DRUJ dysfunction following volar plate fixation of bilateral distal radius fractures and analyze the biomechanical causes of this complication. As a result of a relatively excessive tilt of the precontoured locking plate (in comparison to the patient's particular anatomy), the fracture on one side was "over-reduced," disrupting the biomechanics of the DRUJ, causing a supination block. Clinical Relevance Volar locking plates are not a panacea to all distal radius fractures. Plate selection and fixation technique must include consideration of patient anatomy. Robust plates offer the advantage of providing rigid fixation but can be difficult to contour when reconstructing normal anatomy. Restoration of patient-specific anatomy is crucial to the management of distal radius fractures.