Biomechanical considerations on a CT-based treatment-oriented classification in radius fractures.

A wide range of different classifications exist for distal radius fractures (DRF). Most of them are based on plane X-rays and do not give us any information on how to treat these fractures. A biomechanical understanding of the mechanical forces underlying each fracture type is important to treat each injury specifically and ensure the optimal choice for stabilization. The main cause of DRFs are forces acting on the carpus and the radius as well as the position of the wrist in relation to the radius. Reconstructing the mechanism of the injury gives insight into which structures are involved, such as ruptured ligaments, bone fragments as well as the dislocated osteoligamentous units. This article attempts to define certain key fragments, which seem crucial to reduce and stabilize each type of DRF. Once the definition is established, an ideal implant can be selected to sufficiently maintain reduction of these key fragments. Additionally, the perfect approach is selected. By applying the following principles, the surgeon may be assisted in choosing the ideal form of treatment approach and implant selection.

[Percutaneous treatment of unstable fractures of the base of the middle phalanx : Technique according to Hintringer and Ender]. / Perkutane Behandlung geschlossener instabiler Basisfrakturen der Fingermittelglieder : Operationstechnik nach Hintringer und Ender.

OBJECTIVE: Reconstruction of intra-articular impression fractures of the middle phalanx by percutaneous reduction over a small dorsal cortical window. Stabilization by lattice-like arranged K­wires. INDICATIONS: Impression fractures of the base of the middle phalanx with or without dislocation in the proximal interphalangeal joint. CONTRAINDICATIONS: Fractures extending to the shaft of the middle phalanx. SURGICAL TECHNIQUE: By a cortical window at the dorsum of the middle phalanx (through the tendon free triangle) the impression fracture is reduced from the medullary cavity. Reduction is secured and the articular surface is supported by lattice-like arranged K­wires. POSTOPERATIVE MANAGEMENT: Thermoplastic splint for the finger for 6 weeks, subsequently K­wire removal, active range of motion exercises and hand occupational therapy. RESULTS: In two case series already published, good clinical and radiological results were reported. No complications were detected in either series.

[Clinical examination of the distal radioulnar joint]. / Klinische Untersuchung des distalen Radioulnargelenks.

BACKGROUND: The distal radioulnar joint (DRUJ) provides the distal link between radius and ulnar and is the centre of rotation during pronation and supination. Pronation and supination are essential in controlling the posture and optimal presentation of the hand to grasp an object. In addition, pronation and supination enable us to rotate tools when they are in the longitudinal axis of the forearm. Due to this, the DRUJ plays a central role in the performance of activities in daily life. DIAGNOSTICS: Examination of the ulnar-side of the wrist remains challenging for hand surgeons due to a wide range of pathologies with overlapping clinical symptoms. Therefore, the clinical examination must be carried out carefully to detect the origin of the patient's complaints. Several special examination techniques are available, but their application and interpretation strongly depend on the skills and experience of the physician. Most tests are not evaluated in comparison to the gold standard of wrist arthroscopy with respect to sensitivity and specificity. The most reliable test for the DRUJ are the ulnar fovea sign, the dorsopalmar stress test and the press test.

[Arthrotenolysis of the proximal interphalangeal joint of the fingers. Operative technique and results]. / Arthrotenolyse der Fingermittelgelenke (PIP). Technik und Ergebnisse.

From 1994 to1999, 24 patients were subjected to tenoarthrolysis of the PIP joint by a single surgeon for various reasons. All cases were documented by the surgeon in photographs and the achieved extent of mobility was followed up to at least one year postoperatively. All results were documented in photographs or on video films. The patients did not have conventional arthrolysis following injury of the capsular ligaments of the PIP joint (with the exception of one case), but complex injuries of bone, flexor tendons, diseases, and conditions after infections, some of which had occurred up to seven years previously. Four patients had been subjected to tenoarthrolysis twice, one had undergone tenoarthrolysis even three times. Five joints were fully ankylotic before surgery and had 0 degrees of mobility. All cases were referred from external surgeons. It was not possible to find common denominators for these cases and to include them in a regular study. The sole criterion used for assessment, which has also been used in comparable studies, was preoperative mobility and the postoperative mobility achieved after one year. Preoperative mobility in the PIP joint was on average 27.5 degrees (range, 0 - 60) and could be increased to a mean of 70 degrees (range, 0 to 120) after one year. Thus, an improvement of 42.5 degrees was achieved. As the cases were very different, this study will probably be no more than a case presentation. Nevertheless, based on a careful assessment of video films and photographs and the results achieved in individual cases, conclusions may be drawn regarding technique, surgical planning and prognosis. The author believes that although the data does not suffice to make up a valid study, they still are worthy of presentation.

[Dorsal V-ligament reconstruction in scapholunate instability]. / Die dorsale V-Bandplastik zur Therapie der posttraumatischen skapholunären Instabilität.

In dynamic and static scapholunate instability after trauma, the repair of the scapholunate ligament is important to avoid scapholunate advanced collapse of the wrist. Direct suture even of fresh-torn ligaments can be technically demanding and occasionally unreliable, thus reconstruction may require additional tissue beside the ligament. Eighteen patients suffering from dynamic (n = 10) and static (n = 8) scapholunate instability were treated by a dorsal ligament reconstruction six months after trauma. A clinical wrist score according to Cooney showed an average of 86 points (maximum 100) within a follow-up of nineteen months after surgery. X-ray films documented no significant loss of scapholunate reduction. Using local tissue only, this method is always possible, very reliable and easy to perform.

[Case report of segmental neurofibromatosis of the 3rd finger ray]. / Fallbericht uber eine segmentale Neurofibromatose des dritten Fingerstrahls.

We report on a 36-year-old woman suffering from a segmental neurofibromatosis solely confined to the third finger. Microscopically, the tumor showed mesenchymal tissue containing myxoid material with features of the nerve sheath--myxoid neurofibroma. The tumor was characterized by the peculiar tendency to grow in a multifocal pattern involving the distribution of every nerve of one finger, by an extreme proneness to local recurrences as well as by a concomitant bone defect.

[Distorsions and dislocations of the finger joints]. / Distorsionen und Luxationen der Fingergelenke.

Injuries of the finger joints with damage to the capsule and ligaments are quite common. Nevertheless early diagnosis may be missed since patients look for relief only after a period of longstanding pain. A careful clinical and X-ray diagnosis is the prerequisite for appropriate treatment. Surgery is still indicated for most of the injuries of the ulnar ligament of the MP-joint of the thumb. Sprains or dislocations of the middle joint of fingers are quite usual. In most instances they may be treated by immobilisation or functional treatment. Persistent subluxation after reduction of the joint or large avulsion-fractures have to be treated by open surgery. Injuries of the MP-ligaments are frequently misinterpreted. Their treatment should be based on a very careful evaluation of the case.

[Functional treatment of basal joint fractures of three-joint fingers]. / Die funktionelle Behandlung von Grundgliedfrakturen der dreigliedrigen Finger.

Phalangeal fractures have up to now always been treated using a conservative static form of splint. Open reduction and stabilisation is preferred in the case of injuries with severe displacement, shortening, open fractures and joint involvement. In this study, we have shown the results of 86 proximal phalangeal fractures that were treated with "dynamic splinting". In the "intrinsic plus" position a dorsopalmar plaster splint is affixed in combination with a Bedford double finger stall, splinting the injured finger securely to its neighbour. Clinical and X-ray results were evaluated. Oblique, rotational and transverse fractures can be reduced and treated showing good results with dynamic splinting. Bending fractures cannot always be treated with this method. Especially basal fractures with dorsal comminution can be problematic. Comminuted fractures can only be treated with dynamic splinting if they have been primarily adequately reduced. Intraarticular condylar fractures have to be treated surgically. Our results have also shown that the fingers still are freely mobile even when the bone has not healed in an anatomical position.

[Intramedullary nailing of unstable forearm shaft fractures in children]. / Markdrahtung instabiler Unterarmschaftbrüche bei Kindern.

Forearm diaphyseal fractures in children are commonly treated by conservative management. In about 5% of cases, however, unstable fractures occur and require surgical intervention. We prefer the intramedullary pinning procedure, which has already been published in a similar version in 1913 by Schöne and in 1947 by Bsteh. 41 patients were followed up between 1979 and 1988. One instance with a severe infection of a second-degree open fracture required two reoperations and was completely restored with a very good result. An overall assessment of our collective yielded 31 patients with findings rated as very good, four patients rated as good, five as satisfactory and one as moderate.

[Osseous or ligamentous injuries of the phalango-interphalangeal joint and their treatment]. / Knöcherne oder ligamentäre Verletzungen am Mittelgelenk und ihre Behandlung.

To understand the types of injuries occurring in PIP joints, the anatomical and biomechanical aspects are described. Bony abruptions of the palmar plate of the PIP joint are important indicators of the severity of accompanying capsular and ligamentous injuries and assist in determining specific forms of treatment. A classification of the different injury types is presented. The indication for conservative or operative treatment is based on this classification.

[Percutaneous management of intra-articular fractures of the interphalangeal joints of the fingers]. / Perkutane Versorgung von intraartikulären Frakturen der Fingermittelglieder.

Open reduction of intra-articular fractures of the proximal interphalangeal joints of the fingers requires extensive exposure of the bone. This often leads to disturbance of the delicate mechanics of the joint. The results are, therefore, sometimes not as good as expected. The authors describe a new method of treatment, using the image intensifier with magnification. The fragments are reduced by means of a golf-club shaped instrument, which is inserted into the medullary cavity through a small skin incision and a drill hole in the bone. After reduction, the position is held by a framework of percutaneously introduced thin Kirschner-wires.

[Percutaneous management of osseous avulsions of extensor tendons and lateral ligaments of the fingers with the hooked wire]. / Die perkutane Versorgung von knöchernen Ausrissen der Strecksehnen und Seitenbänder an den Fingern mit dem "Hakendraht".

A new method of percutaneous treatment of some fractures of the fingers is being described. With the use of a magnification table, fitted onto the X-ray intensifier, evulsion fractures of extensor tendons or collateral ligaments can be reduced and fixed by means of a K-wire. After insertion, the end of the wire is being bent in the shape of a hook ("wire hook"), into which a pull-out wire is inserted. By anchoring the wire-hook at the opposite side of the finger under tension, the fragment is held in position by the hook. After four weeks the wire-hook is cut below its anchorage and can easily be removed by the pull-out wire. Technique and results of 85 patients are being presented.