Comparison of functional recovery of distal radius fracture by suture of pronator muscle through modified Henry approach / 中国骨伤

OBJECTIVE@#To investigate the effect of suture of pronator muscle on forearm function after modified Henry approach for distal radius fractures.@*METHODS@#from January 2018 to December 2020, 220 patients with distal radius fractures were treated with open reduction and locking plate internal fixation through the modified Henry approach. They were divided into two groups according to different suture methods. There were 112 cases in the intraoperative suture group, including 35 males and 77 females;The age ranged from 37 to 65(48.5±7.4) years;AO classification of fracture, 46 cases of type B and 66 cases of type C;After fracture reduction and locking plate fixation, the pronator muscle was opened and sutured. There were 108 cases in the non suture group, 32 males and 76 females;The age ranged from 34 to 67(47.6±7.8) years;There were 41 cases of fracture type B and 67 cases of fracture type C;After fracture reduction and locking plate fixation, the open pronator muscle was not sutured, and it was laid on the surface of the plate in situ. The range of wrist motion (pronation, supination, palmar inclination and dorsiflexion), the score of disability of arm shoulder and hand dash and visual analog scale(VAS) were compared between the two groups at 6 weeks and 6 months after operation.@*RESULTS@#All 220 patients were followed up for 6 to 18 (8.5±1.3) months. There was no significant difference in the range of motion and DASH score of forearm and wrist between the two groups 6 weeks after operation (P>0.05);There was significant difference in VAS score between suture group (2.6±1.2) and non suture group (5.8±2.3)(P<0.05). Six months after operation, there was no significant difference in the range of motion, DASH score and VAS score of forearm and wrist between the two groups(P>0.05).@*CONCLUSION@#The modified Henry approach has no obvious advantages in the range of wrist movement and upper limb function, but the intraoperative suture of pronator can reduce the early postoperative pain. It is suggested that the pronator should be sutured during the operation.

Pronator quadratus pedicled bone graft for scaphoid non-unions

Scaphoid fractures frequently present with nonunion and proximal pole necrosis, the treatment of which is bone grafting. Pronator quadratus pedicled vascularized bone graft is an option especially in the setting of proximal pole necrosis. We describe our experience of managing such scaphoid non-unions using pronator quadratus pedicled vascularized bone graft. Six patients were managed using pronator quadratus pedicled vascularized bone graft following scaphoid fracture nonunion with proximal pole necrosis. All patients had good fracture healing and symptom resolution. Mild deficit in wrist extension was noted in all patients. Pronator quadratus pedicled vascularized bone graft is an attractive option for managing scaphoid nonunion. Lying adjacent to the fracture site, bone can be harvested and transferred without making any other incisions. This procedure introduces another source of blood supply to the fracture site and hence improves fracture healing.

Effectiveness of pronator quadratus muscle sparing in volar plate fixation for unstable distal radius fracture in adults / 中国修复重建外科杂志

Objective: To investigate the effectiveness of pronator quadratus muscle sparing in volar plate fixation for unstable distal radius fracture in adults. Methods: The clinical data of 62 cases of unstable distal radius fractures between January 2017 and December 2018 were retrospectively analyzed. According to the different methods of intraoperative exposure, the patients were divided into the observe group (28 cases with the pronator quadratus muscle sparing surgery) and the control group (32 cases with cutting the pronator quadratus muscle in operation and repairing it after volar plate fixation). There was no significant difference in general data such as gender, age, handedness, cause of injury, fracture classification, time from injury to operation, visual analogue scale (VAS) score, and range of motion (ROM) of wrist (flexion, extension, pronation, and supination) before operation between the two groups ( P>0.05). The operation time, intraoperative blood loss, postoperative hospital stay, fracture healing time, and postoperative complications were recorded and compared between the two groups. VAS score and ROM of wrist of two groups before operation and at 3 days and 3 months after operation were calculated and compared. The wrist function was evaluated according to the Krimmer evaluation criteria at 6 months after operation. Results: There was no significant difference in operation time and intraoperative blood loss between the two groups ( P>0.05). The postoperative hospital stay and fracture healing time of the observe group were significantly shorter than those of the control group ( P0.05). At 6 months after operation, according to Krimmer evaluation criteria, the wrist function of the observe group was excellent in 21 cases and good in 7 cases, with an excellent and good rate of 100%; and the wrist function of the control group was excellent in 22 cases, good in 11 cases, and fair in 1 case, with an excellent and good rate of 97.1%. There was no significant difference in wrist function between the two groups ( χ2=1.344, P=0.511). One case of poor incision healing occurred in the observe group, and 7 cases of poor incision healing and 5 cases of tendon pain occurred in the control group after operation. The incidence of postoperative complications was less in the observe group (3.6%) than in the control group (35.3%) ( χ2=9.325, P=0.002). Conclusion: It is feasible of the pronator quadratus muscle sparing in the volar plate fixation for unstable distal radius fracture in adults. It is beneficial to recover wrist function early after operation, reduce postoperative complications, shorten the length of hospitalization, protect the soft tissue of fracture site, and promote fracture healing.

Do we really need to repair the pronator quadratus after distal radius plating? / 中华创伤杂志(英文版)

Purpose:@#Fractures of distal radius are one of the common orthopaedic injuries. Placing the plate on volar surface requires release of underlying pronator quadratus (PQ) muscle. No consensus is present in the literature about the repair or not of the PQ. The purpose of this study was to evaluate the influence of PQ repair on functional outcome and complications.@*Methods:@#Retrospectively 83 patients of distal radius fractures managed with volar plating between 2014 and 2016 were evaluated. Demographic data, operative notes and physical therapy records were retrieved. Patients were divided into group A where PQ repair was done and group B where no repair was done. Functional data such as range of motion (ROM), grip strength, visual analogue scale (VAS) score and disabilities of arm, shoulder and hand (DASH) score at 4 weeks, 3 months, 6 months and finial follow-up were retrieved.@*Results:@#Totally 63 patients (n = 29 in group A and n = 34 in group B) with the mean age of 51.64 years were examined. Patients were followed up for a mean of 35.2 months (range 27.2-47.1 months) in group A and 38.6 months (range 28.6-51.0 months) in group B. Though functional outcome of the affected limb was not significantly different between two groups after 3 months, PQ repair did affect the recovery at an early stage. Repair group had significantly better ROM (p = 0.0383) and VAS score at 4 weeks (p = 0.017) while grip strength (p = 0.014) was significantly better at 3 months.@*Conclusions:@#Repair of PQ may provide pain relief and increased ROM in early postoperative period and hence every attempt should be made to achieve the repair.

Anatomical and clinical study of internal fixation for distal radius fractures with pronator quadratus preserved / 中华创伤骨科杂志

Objective To explore the anatomic basis for and clinical outcomes of the internal fixation which preserves the pronator quadratus (PQ) for distal radius fractures.Methods Twenty cadaveric specimens of adult upper extremity were used for this study (14 males and 6 females).The radial and ulnar lengths of PQ,the distal and proximal widths of PQ,the distances from the distal end of PQ to the articular surface of the distal radius and to the transverse line of the wrist,and the width of the bony tunnel of PQ were dissected and measured to study the anatomical features of PQ.A retrospective study was conducted of the 18 distal radius fractures which had been treated from March 2015 to March 2017 by internal fixation with T-shaped anatomic locking compression plate (LCP) with PQ preserved.They were 8 males and 10 females,with an average age of 52.7 years (range,from 28 to 65 years).According to the AO classification,there were 8 cases of type 23-A,5 ones of type 23-B and 5 ones of type 23-C1.The functional outcomes of the wrist were assessed using the Cooney scoring system at the last follow-ups.Results The PQ muscle was flat and like a right angle trapezoid with rich blood vessels.The radial and ulnar lengths of PQ were about 4.60 cm and 4.46 cm;the distal and proximal widths of PQ were about 4.41 cm and 4.48 cm;the distance from the distal end of PQ to the transverse line of the wrist was about 3.61 cm;the widths of the distal and proximal bony tunnels were about 3.08 cm and 1.91 cm.The 18 patients were followed up for 6 to 36 months (average,11.5 months).Bone union was achieved in all the patients after a mean time of 2.5 months (range,from 2 to 3 months).The mean Cooney score for the wrist function was 97.7 (range,from 95 to 100) at the last follow-up,yielding an excellent rate of 100％.Conclusions The transverse line of the distal radius fracture is located between 1/4 and 1/2 of the distal PQ.The bony tunnel of PQ is wide enough.It is feasible to preserve the distal PQ muscle in the internal fixation of distal radius fractures of types 23-A,23-B and 23-C1,because it may lead to rapid recovery of the patients and satisfactory wrist function.

Ultrasonographic Assessment of the Pronator Quadratus Muscle after Surgical Treatment for Distal Radius Fractures

PURPOSE: This study was to assess the morphological changes of the pronator quadratus (PQ) muscle using an ultrasonography in the volar locking plate fixation group and in the percutaneous K-wire fixation group for distal radius fracture, and to evaluate the impact on clinical outcomes. MATERIALS AND METHODS: Fifty-four patients who received surgical treatment for distal radius fracture were enrolled in this study. They were divided into two groups according to treatment modality: Group 1 included 34 patients who underwent internal fixation with volar locking plate and Group 2 included 20 patients with percutaneous K-wire fixation. Thickness of the PQ muscle was measured using an ultrasonography at the final follow-up. We evaluated the outcomes using the Mayo wrist score, wrist range of motion, and grip strength at the final follow-up. RESULTS: Compared with the uninjured side, thickness of the PQ muscle showed 31.9% of mean atrophy in Group 1 and 11.4% in Group 2. The atrophy of PQ muscle was severe in Group 1 (p=0.01). However, there was no significant difference in the mean Mayo wrist score between the two groups (83.1±10.9 in Group 1 and 80.2±8.9 in Group 2, p=0.28), except a mild limitation of pronation in Group 1. CONCLUSION: The healed PQ muscle from fracture itself after distal radius fracture revealed a morphological atrophy. Moreover, the volar locking plate resulted in greater atrophy of the PQ muscle, but there was no specific impact on clinical outcomes.

Anatomic Characteristics of Pronator Quadratus Muscle: A Cadaver Study

OBJECTIVE: To identify the anatomic characteristics of the pronator quadratus (PQ) muscle and the entry zone (EZ) of the anterior interosseous nerve (AIN) to this muscle by means of cadaver dissection. METHODS: We examined the PQ muscle and AIN in 20 forearms from 10 fresh cadavers. After identifying the PQ muscle and the EZ of the AIN, we measured the distances from the midpoint (MidP) of the PQ muscle and EZ to the vertical line passing the tip of the ulnar styloid process (MidP_X and EZ_X, respectively) and to the medial border of the ulna (MidP_Y and EZ_Y, respectively). Forearm length (FL) and wrist width (WW) were also measured, and the ratios of MidP and EZ to FL and of MidP and EZ to WW were calculated. RESULTS: The MidP was found to be 3.0 cm proximal to the ulnar styloid process or distal 13% of the FL and 2.0 cm lateral to the medial border of the ulna or ulnar 40% side of the WW, which was similar to the location of EZ. The results reveal a more distal site than was reported in previous studies. CONCLUSION: We suggest that the proper site for needle insertion and motor point block of the PQ muscle is 3 cm proximal to the ulnar styloid process or distal 13% of the FL and 2 cm lateral to the medial border of the ulna or ulnar 40% side of the WW.

Fractura de radio distal: abordaje mininvasivo con preservación del pronador cuadrado / Distal radius fracture: minimally invasive approach with pronator quadratus preservation

Objetivo: Describir y analizar una técnica de osteosíntesis palmar de radio distal con preservación del pronador cuadrado. Materiales y Métodos: Se revisaron, en forma retrospectiva, 24 pacientes operados con esta técnica (16 mujeres y 8 hombres; edad promedio 65 años). Doce fracturas eran de tipo A; 7, de tipo B y 5, de tipo C. La técnica quirúrgica consiste en practicar una incisión cutánea de 25 mm y profundizar hasta observar el pronador cuadrado. Sin seccionarlo, se realiza una disección de su borde distal, a fin de introducir la placa bloqueada volar por debajo del músculo. Se colocan los tornillos distales bajo visión directa y los tornillos proximales, en forma percutánea. La evaluación posoperatoria se llevó a cabo mediante análisis clínico-funcional y radiográfico. Resultados: En el último control, todos los pacientes presentaban signos clínicos y radiográficos de consolidación ósea. El puntaje en la escala DASH fue, en promedio, de 4,8. Se observó una inclinación palmar posoperatoria de la superficie articular del radio de 14,3º promedio y una inclinación radial de 26,3º promedio. No se detectaron complicaciones relacionadas con la fractura, el implante o la herida quirúrgica en ninguno de los controles posoperatorios. Conclusiones: Sin bien no existe bibliografía que demuestre que la técnica mininvasiva sea superior, sostenemos que el hecho de obtener resultados similares con ambos abordajes (mininvasivo y convencional) justifica llevar a cabo esta técnica con preservación del pronador cuadrado, sobre todo en los pacientes preocupados por el aspecto estético de la cicatriz. Nivel de evidencia: IV.

Objective: To describe and analyze a volar locking plate technique for distal radius fractures with pronator quadratus preservation. Methods: We retrospectively reviewed 24 patients who underwent minimally invasive approach (16 women, 8 men; mean age 65 years). Twelve fractures were type A, 7 type B and 5 type C. The surgical technique involves making an incision of 25 mm and deepened to expose the pronator quadratus. Afterwards, a distal edge dissection of the pronator quadratus is performed in order to introduce the volar locking plate under the muscle. Distal screws are placed under direct vision and proximal screws are placed percutaneously. Postoperative evaluation included clinical, functional and radiological analyses. Results: At last control, all patients had clinical and radiographic signs of bone healing. The average score on the DASH scale was 4.8 points. Postoperative average volar tilt was 14.3° and the average radial inclination was 26.3°. There were no complications related to the fracture, implant or surgical wound in the postoperative controls. Conclusions: Although we did not obtain better results with this technique than with the conventional one, and there is no literature available which demonstrates that the minimally invasive technique is superior, we believe that the fact of getting similar results with both approaches justifies carrying out this technique with pronator quadratus preservation, especially in patients concerned about the cosmetic appearance of the scar. Level of evidence: IV.

The Fate of Pronator Quadratus Muscle after Volar Locking Plating of Unstable Distal Radius Fractures

PURPOSE: The purpose of this study is to evaluate the pronator quadrates muscle in patients who underwent internal fixation with a volar locking plate for unstable distal radius fractures. MATERIALS AND METHODS: Forty patients who underwent internal fixation with a volar locking plate for unstable distal radius fracture were enrolled. We evaluated the clinical results according to the Mayo wrist score, the wrist range of motion, and the grip strength at the last follow-up. Using ultrasonography, muscle thickness of the pronator quadrates was compared between injured and uninjured arm. RESULTS: Bone union was achieved in all cases. The mean Mayo wrist score was 82.79 points. The grip strength of the injured arm was decreased to 89.1% of the uninjured side. The decrease of pronation range of the injured wrist motions was significant (82.3degrees, p=0.004). There was significant atrophy of the pronator quadrates muscle on the injured side (injured side: 3.19 mm, uninjured side: 4.72 mm, p=0.001); and the decrement of muscle thickness in pronator quadrates showed an association with the Mayo wrist score (r=-0.35, p=0.042). CONCLUSION: These results suggest that continuity of the muscle is maintained after use of the volar locking plating for unstable distal radius fractures with repair of pronator quadrates; however, there is atrophy of pronator quadrates muscle and limitation of pronation in the injured wrist.

Examination of the Pronator Quadratus Muscle during Hardware Removal Procedures after Volar Plating for Distal Radius Fractures

BACKGROUND: It is not clear whether the pronator quadratus (PQ) muscle actually heals and provides a meaningful pronation force after volar plating for distal radius fractures (DRFs). We aimed to determine whether the length of the PQ muscle, which is dissected and then repaired during volar plating for a DRF, affects the forearm rotation strength and clinical outcomes. METHODS: We examined 41 patients who requested hardware removal after volar plating. We measured the isokinetic forearm rotation strength and clinical outcomes including grip strength, wrist range of motion, and disabilities of the arm, shoulder and hand (DASH) scores at 6 months after fracture fixation. During the hardware removal surgery, which was performed at an average of 9 months (range, 8.3 to 11.5 months) after fracture fixation, we measured the PQ muscle length. RESULTS: The average PQ muscle length was 68% of the normal muscle length, and no significant relationship was found between the PQ muscle length and the outcomes including isokinetic forearm rotation strength, grip strength, wrist range of motion, and DASH scores. CONCLUSIONS: This study demonstrates that the length of the healed PQ muscle does not affect isokinetic forearm rotation strength and clinical outcomes after volar plating for DRFs. The results of this study support our current practice of loose repair of the PQ that is performed by most of the surgeons to prevent tendon irritation over the plate, and suggest that tight repair of the PQ is not necessary for achieving improved forearm function.

Anatomical Study of the Pronator Quadratus Muscle and Comparison to Fracture Sites of the Distal Radius / 대한정형외과학회잡지

PURPOSE: To collect data regarding the pronator-sparing approach using an anatomical study, which compared the fractures of the distal radius and pronator quadratus (PQ) muscle of an adult cadaveric radius. MATERIALS AND METHODS: Fourteen adult cadaver wrists that did not have previous fractures or previous surgery and computed tomography data 32 fractures of the distal radius, were obtained. The size of the distal fracture fragment was measured using the picture archiving and communication system. The distance between the distal margin of the PQ muscles and the articular margin was measured using a caliper. RESULTS: The PQ muscles had an average distance of 10.9 mm (range, 8-13 mm) from the radial styloid process and 10 mm (range, 8-12 mm) from the distal radioulnar joint (DRUJ). The fracture sites were located an average of 21.8 mm (range, 10-39 mm) from the radial styloid process and an average of 14.4 mm (range, 10-28 mm) from the DRUJ. Distal radial fractures overlapped an average of 11.8 mm from the radial styloid process and an average of 3.5 mm from the DRUJ. CONCLUSION: The pronator-sparing approach could be applied to a functionally reduced fracture because the non-overlapping area of the distal fracture fragment was > or =10 mm and it is possible to repair the anatomic plate without detaching the PQ muscle.

The Anterior Interosseous Nerve Syndrome: Clinical Investigation of Surgically Treated 7 Cases

PURPOSE: The etiology and treatment strategy of the anterior interosseous nerve (AIN) syndrome are still controversial. Seven patients with the AIN syndrome who were treated by surgical exploration and neurolysis were reviewed at a mean of 35.9 months follow up period. MATERIALS & METHODS: There were six men and one woman. The mean age was 37.3 years, ranging from 26 to 59. No patient was related to trauma and associated neurological lesion. Surgical exploration was performed at 7.7 months after onset of paralysis. RESULTS: All except one patients experienced pain around the elbow region before the onset of the palsy. On 7 patients, only the flexor pollicis longus was paralysed in 1, only the index flexor digitorum profundus in 2, and none had paralysis of the middle. The most common compression structures were fibrous bands within flexor digitorum sublimis arcade. However there was no demonstrable abnormality in three. Recovery was complete in all cases within 12 months after surgery. CONCLUSION: We recommended surgical exploration and neurolysis in patients who have shown no improvement after 6 months of conservative treatment. And careful preoperative examination is essential to avoid misdiagnosis and inappropriate surgery, especially in incomplete AIN syndrome.

Interpositional Arthroplasty using Pronator Quadratus Pedicled Bone for the Treatment of Stage III Kienbock's Disease / 대한정형외과학회잡지

Between 1984 and 1996, 8 patients who were suffered from stage g Kienbock's disease underwent interpositional arthroplasty using pronator quadratus pedicled bone. Patients comprised 2 males and 6 females, with an average age of 33 years(range 19-47). Range of motion of the wrist, residual pain, grip strength, and carpal height ratio of the patients were analyzed. The follow-up period was between 1.5 years and 12.5 years(average 5.5 years). The arc of flexion-extension of the wrist was increased from average 74 degrees preoperatively to 96 degrees postoperatively. Among eight patients, five were free of pain and three had intermittent pain during heavy work. None of eight patients had any discomfort in daily work and changed his or her occupation. The grip strength was average 83% of the normal side. Carpal height ratio was average 0.48 preoperatively and was not changed postoperatively. Clinical results, assessed by Lichtman-Evans criteria, showed 4 good and 4 fair. The interpositional arthroplasty using pronator quadratus pedicled bone was considered as a very effective method for the treatment of stage III Kienbock's disease.

Pronator Quadratus Pedicled Bone Graft for the Kienbock's disease: Three cases report / 대한정형외과학회잡지

Pedicled bone flap raised from the volar aspect of lower end of the radius, pedicled by the pronator quadratus has been used for the treatment of scaphoid nonunion and Kienbock's disease. From July 1991 to Jan. 1992, authors performed this procedures for 3 cases of Kienbock's disease. Patients were 2 cases in the left hand, l case in the right hand. There was no critial trauma history. Age at operation were 25, 37 and 57 years. All patients were in Stage I in 2 cases and stage II-A in 1 case of Lichtman's radiologic classification. Preoperative grip powers were 11%, 38%, 63% and pinch powers were 20%, 41%, 61% of that of normal opposite hand. Follow up periods were 28, 31 and 33 months. At last follow up roentgenographic finding shows no progression of necrosis of lunate, new bone formation, decreased sclerosis, and joint space were preserved in all cases. The fuctional results at the last follow up were as follows. Pain during motion was markedly diminished in all patients. Grip power were 57%, 89% and 96% and pinch powers were 68%, 83% and 100% of that of normal opposite hand with use of calibrated Jamar dynamometer which showes significant increase than preoperative state. The ranges of motion of wrist were as follows. Volar flexion were 40, 45 and 80 degree. Dorsiflexion were 10, 20 and 45 degree. Ulnar deviation were 10, 20 and 30 degree. Radial deviation were 10, 25 and 30 degree. This viable bone graft with blood supply gives very satisfactory clinical results.