Mechanical failure of the distal radius volar locking plate.

PURPOSE: To review 9 cases of mechanical failure of the volar locking plate for distal radial fractures. METHODS: Records of 374 consecutive patients who underwent volar locking plating for distal radial fractures were reviewed. Mechanical failures of the volar locking plate were defined as plate breakage or bending, screw breakage or loosening, or collapse of articular fragments resulting in intra-articular screw extrusion. RESULTS: Nine mechanical failures occurred between 2 weeks and 3 months in 8 (2.4%) of the patients aged 25 to 82 (median, 74) years with AO fracture types of A3 (n=4), C1 (n=1), C2 (n=1), and C3 (n=3). Mechanical failures included screw pullout (n=5), locking plate bending (n=2), locking screws breakage (n=1), and loosening of locked variable angle screws (n=1). One patient underwent revision of fixation and 2 underwent implant removal. The remainder were treated conservatively. All patients were followed up for a minimum of 12 months; their mean flexion arc was 87 degrees (standard deviation [SD], 17) and the mean rotation arc was 136 degrees (SD, 29 degrees). According to the Green and O'Brien score, their outcomes were good (n=1), fair (n=4), and poor (n=3). CONCLUSION: Although mechanical failure of volar locking plate is uncommon, some are potentially preventable.

Safe and easy method to preserve fingertip contour in VY-plasty.

VY-plasty is a well-known technique to reconstruct fingertip defects. A simplified method combining pinning of flap and healing of donor site by secondary intention is described. These steps preserve the rounded appearance of the fingertip and restore the convexity of the hyponychium. Flap ischemia due to suture-line tension is also averted.

Volar plating for unstable proximal interphalangeal joint dorsal fracture-dislocations.

PURPOSE: To report our results of open reduction internal fixation with volar mini plate and screw fixation for unstable dorsal fracture dislocations (DFDs) of the proximal interphalangeal (PIP) joint. METHODS: We performed a retrospective review of 13 consecutive DFDs of the PIP joint treated with volar mini plate and screw fixation, measuring both clinical and radiological outcomes. RESULTS: The age range of our patients was 15 to 56 years (average, 33 y). Six injuries were related to work, 5 to sports, and 2 to motor vehicle accidents. Of the 13 DFDs, 6 were comminuted. Articular involvement ranged from 30% to 70% (average, 44%). The average time to surgery was 7 days (range, 0-23 d). Patients had follow-up of 12 to 60 months (average, 25 mo). Four patients had a postoperative course complicated by plate and screw removal at an average of 4 months later, either as part of a secondary procedure to improve range of motion or owing to patient request. All patients returned to their original occupation. Of the 13 patients, 11 were satisfied with the result, and 12 of 13 had either no or mild pain. All 13 DFDs united in good alignment but 3 showed degenerative changes. Average grip strength was 85% of the unaffected side, and average active PIP joint and distal interphalangeal joint motion arcs were 75° and 65°, respectively. Average Quick Disabilities of Arm, Shoulder, and Hand score was 4 (range, 0-9). All patients had non-tender swelling of the proximal interphalangeal joints but no signs of flexor tenosynovitis or infection. CONCLUSIONS: Fixation of unstable PIP joint DFDs via a volar approach is technically feasible with mini plates and screws. This treatment allows early active range of motion and provides good objective and subjective outcomes; however, noteworthy complications occurred in 39% of patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Volar plate and screw fixation for dorsal fracture-dislocation of the proximal interphalangeal joint: case report.

We present a case of a man who sustained a closed dorsal fracture-dislocation of his left ring finger proximal interphalangeal joint in a fall. The patient was treated surgically with plate and screw fixation via a volar approach. This method theoretically provides more secure fixation than internal fixation with screws alone, allowing early rehabilitation with active range of motion and potentially better functional outcome.

Prospective randomised study of intra-articular fractures of the distal radius: comparison between external fixation and plate fixation.

INTRODUCTION: Intra-articular fractures of the distal radius represent high energy, complex, unstable injuries and the optimal method of treatment remains controversial. MATERIALS AND METHODS: The aim of the paper is to compare the outcomes of external fixation (EF) with open reduction internal fixation (ORIF) with plates and screw fixation in the treatment of intra-articular fractures of the distal radius. Thirty-five patients were enlisted from December 2003 to September 2005 after a failure of initial conservative treatment. The patients were randomised into EF or ORIF groups. The patients were followed-up at 1 week, 3, 6, 12 and 24 months. Clinical and radiological outcomes were measured. They were scored using the Green and O'Brien or the Gartland and Wertley score. RESULTS: Of the 35 patients, 5 defaulted the 6-month follow-up and were excluded. We found that the clinical and radiological outcomes for the 2 groups were not significantly different. Complication rates were also similar. CONCLUSION: There is no significant difference in the outcome of intra-articular distal radius fractures treated with either EF or ORIF.

Atypical glomus tumour of the wrist: a case report.

Wrist glomus tumours are extremely rare. We report a case of an unusually large wrist glomus tumour with atypical presentation. Magnetic resonance imaging (MRI) findings correlated well to those previously described for digital glomus tumours. This rare differential should be considered when evaluating lesions around the wrist.

Comparison of external and percutaneous pin fixation with plate fixation for intra-articular distal radial fractures. A randomized study.

BACKGROUND: The most effective method for the fixation of an intra-articular distal radial fracture has not been established. Two commonly used treatment methods are external fixation combined with percutaneous pin fixation and plate fixation. We performed a prospective multicenter randomized trial to compare these two treatment strategies. METHODS: A total of 137 patients with 144 intra-articular distal radial fractures were recruited into the study. The average age of the patients was forty-two years, and all patients were sixty years old or less. The patients were randomized to fracture fixation with one of the two methods. At six, twelve, and twenty-four months postoperatively, the patients were assessed with use of the Gartland and Werley point system and the modified Green and O'Brien scoring system. Arthritis was graded on radiographs according to a modification of the Knirk and Jupiter criteria. RESULTS: Seventy-four (51%) of the fractures were treated with external fixation and percutaneous pin fixation, and seventy were treated with dorsal, volar, or combined plate fixation. At the time of the twenty-four-month follow-up, the results for the plate fixation group were significantly better than those for the external fixation and percutaneous pin fixation group according to the Gartland and Werley point system (p = 0.04) and the radiographic arthritis grading system (p = 0.01). The difference was especially notable among patients with AO group-C2 fractures. CONCLUSIONS: Plate fixation is better than external fixation combined with percutaneous pin fixation for the treatment of intra-articular fractures of the distal part of the radius.

A biomechanical comparison of four extensor tendon repair techniques in zone IV.

BACKGROUND: This study was designed to evaluate the biomechanical parameters of four different suture techniques specifically designed for zone IV extensor tendon injuries: the double figure of eight, the double modified Kessler, the six-strand double-loop, and the modified Becker suturing techniques. Ease of repair, tendon shortening, strength to 1-mm gap, strength to 2-mm gap, ultimate strength, and mode of repair failure were evaluated. METHODS: Twelve fresh-frozen cadaver hand-forearm units (48 fingers) were randomly assigned to the four suture repair treatments. The speed of tendon repair as performed by two matched-hand surgeons was recorded. Prerepair and postrepair tendon lengths were measured to document tendon shortening. The repair was stressed by linear distraction at 2.0 mm/minute using a servohydraulic frame. Video recordings of each distraction were independently reviewed for biomechanical parameters by three physician-observers in a double-blind setup. A one-way analysis of variance and t test analysis was performed. RESULTS: Results show that the double figure-of-eight technique and the double modified Kessler were significantly (p < 0.05) easier to perform at 7 minutes 31 seconds and 7 minutes 58 seconds, respectively, than the other two techniques. Tendon shortening ranged from 1.9 to 2.4 mm. There was no statistically significant difference in tendon shortening among the four techniques. Strength to 1-mm gap was significantly higher with the modified Becker technique, with a mean 28.8 +/- 8.0 N. This was followed by the six-strand double-loop technique, with 21.0 +/- 6.6 N, the double modified Kessler at 17.7 +/- 4.5 N, and the figure-of-eight technique at 17.5 +/- 2.4 N. Strength to 2-mm gap was significantly (p < 0.05) greater for the modified Becker technique and the modified Kessler technique at 56.0 +/- 9.2 N and 48.6 +/- 12.6 N, respectively, as compared with the other two suture methods. The modified Becker technique showed the highest ultimate strength at maximal loading at 63.3 +/- 7.8 N, followed by the double modified Kessler technique with strength of 56.8 +/- 14.8 N. Both were significantly stronger than the other two techniques. CONCLUSIONS: This study shows that the modified Becker suture technique, although not easily performed, proved to be the strongest repair, with a significantly greater resistance to 1-mm and 2-mm gap and the greatest ultimate strength on maximal loading.

Intra-articular loop wire fixation allows joint preservation and early motion in replantation around the proximal interphalangeal joint.

Restoration of motion is an important component of success in digital replantation. This is achieved only with rigid bony fixation that allows early post-operative mobilisation. In addition, the technique used should be simple and avoid excessive soft tissue stripping. These aims are difficult to achieve in amputations near the base of the proximal phalanx with existing bone fixation techniques. We describe a modification of the perpendicular loop wiring technique, where one wire loop is intra-articular, which satisfies the above criteria, and describe its application and results in two clinical cases.

An isolated ring finger metacarpal shaft fracture?--beware an associated little finger carpometacarpal joint dislocation.

Dislocations of the ulnar carpometacarpal joint are easily missed because of a low index of suspicion as well as their subtle clinical and radiological features. Often, the presence of a more obvious adjacent injury also draws attention away from the carpometacarpal joint. Two cases of ring finger metacarpal shaft fractures with associated little finger carpometacarpal joint dislocations are presented. In both cases, the metacarpal fractures were diagnosed but the carpometacarpal joint dislocations were initially overlooked. The presence of an apparently isolated ring finger metacarpal fracture due to an indirect force should raise the possibility of an associated carpometacarpal joint injury.