The Conservative and Operative Treatment of Carpal Fractures.

BACKGROUND: Carpal fractures (incidence: 30-60 per 100 000 persons per year) are one of the more commonly overlooked fracture types. They can have serious consequences, as the use of the hand is indispensable in everyday life. In the following article, we present the elements of the diagnosis and treatment of fractures of the carpal bones. METHODS: This review is based on meta-analyses and randomized controlled trials (RCTs) published from 2013 to 2023 that were retrieved by a structured literature search, supplemented by guideline recommendations and expert consensus statements. In addition, data on the administrative prevalence of carpal fractures were obtained from the German Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung, KV) and from the German Statutory Accident Insurance (Deutsche Gesetzliche Unfallversicherung, DGUV). RESULTS: The administrative prevalence of carpal fractures in 2022 was 44 496 outpatient cases (KV, DGUV) in one year. After clinical history-taking, physical examination and x-ray have been performed, thin-slice computed tomography is recommended as part of the diagnostic evaluation. Treatment recommendations are based on evidence of levels II to IV. Multiple RCTs have been carried out on the treatment of scaphoid fractures, and a clinical guideline exists. Proximal, dislocated and unstable scaphoid fractures should be treated surgically. Non-displaced or minimally displaced fractures of the middle third of the scaphoid bone require a shorter period of immobilization with surgical treatment (2-4 weeks) than with conservative treatment (6-8 weeks). The use of plaster casts that do not hinder elbow and thumb mobility yields healing rates similar to those obtained with the immobilization of both of these joints. Failure to treat an unrecognized scaphoid fracture can lead to pseudarthrosis, avascular bony necrosis, and misalignment. Other, rarer types of carpal fractures must be managed on an individual basis, as the available evidence is limited to expert consensus. CONCLUSION: Early recognition and appropriate treatment of carpal fractures lead to healing in more than 90% of cases. Although the available evidence on their proper treatment is growing, many questions are subject to expert consensus, and decisions about treatment must be made individually.

[Standardized reduction and palmar plating of dorsally displaced distal radius fractures for safe and atraumatic reconstruction of the anatomy of the radius]. / Standardisierte Reposition und palmare Plattenosteosynthese dorsal dislozierter distaler Radiusfrakturen zur sicheren und atraumatischen Wiederherstellung der Radiusanatomie.

OBJECTIVE: Standardization of palmar plate osteosynthesis in order to consequently achieve physiologic anatomy of the distal radius end. INDICATIONS: Unstable dorsally displaced distal radius fractures or fractures that should be treated functionally. CONTRAINDICATIONS: Severe intraarticular joint depression that cannot be reduced with either a palmar or arthroscopic assisted approach. SURGICAL TECHNIQUE: Patient in supine position with the forearm supinated on arm table. Radiopalmar incision along the radial border of the flexor carpi radialis tendon. Detachment of the pronator quadratus muscle from radial to ulnar. Gross reduction with eventual correction of a dorsal or radial shift. Placement of the angular stable plate and preliminary fixation with a nonangular stable cortical screw in the long hole at the radius shaft. Fluoroscopic control of axial alignment in the anteroposterior view and of correct distal position of the plate in the lateral view under reduction condition. Placement of one or two angular stable screws at the shaft. Under subtle reduction with flexion, ulnar deviation and axial traction placement of two K­wires via the holes at the distal edge of the plate. These wires mostly keep reduction maintained while reduction maneuver can be paused. Fluoroscopic control in two planes. Replacement of the wires by distal angular stable screws with the help of the wires as an orientation. In case of insufficient reduction, reduction maneuver can be repeated while the first angular stable screw is locked. Final fluoroscopic control in two planes and ulnar deviation, eventually also in tangential view and clinical testing for stability of the distal radioulnar joint. Wound closure only by skin suture. Application of a sterile dressing and a palmar cast. POSTOPERATIVE MANAGEMENT: Arm consequently in upright position and active and complete movement of fingers. Palmar below-elbow cast for 2 weeks, then movement of wrist without exertion. After regular radiographic control 4-5 weeks postoperatively, increase of axial load to normal and, if needed, physiotherapy. Clinical control for irritation of tendons by plate or screws after 1 year and eventual plate removal.

Long-term preservation of metacarpophalangeal joint function in traumatic defects by metatarsophalangeal osteochondral transplantation.

INTRODUCTION: The integrity of the metacarpophalangeal (MCP) joints is essential for finger and hand function. Preservation of range-of-motion is one of the aims in reconstruction of complex injuries to these joints. Osteochondral transplants have shown to be reliable in reconstruction of various joint defects. This series presents three patients with traumatic injuries to four MCP joints, which were reconstructed by seven avascular osteochondral transplants of metatarsophalangeal (MTP) joints. The joints were examined for radiographic signs of resorption or joint space narrowing, and if this would affect the joints' function in the long term. METHODS: In three patients (40, 45 and 48 years) with complex injuries to their MCP joints (one milling, two saw injuries), four joints were reconstructed by three metatarsal head and four osteochondral transplants of the base of the proximal toe phalanges. Beside the joint itself, various soft tissue defects were reconstructed in each patient. The patients were clinically and radiographically examined after 9, 6, respectively, 7 years. RESULTS: All patients were satisfied with the result without any pain in the MCP joints. Range-of-motion in the four affected joints rated 25, 60, 75, and 80°, DASH scores rated 13, 29, and 17, respectively. None of the patients complained of problems at their feet. Radiographic examination revealed moderate joint space narrowing in one of the four joints. In another patient, localized osteolysis was found around the screws' heads, so that the screws were removed 7 years post-op. CONCLUSIONS: Osteochondral transplants for reconstruction of MCP defects are able to preserve function in severely injured joints even in the long term. Joint space narrowing may occur, which is not accompanied by pain, however. Since localized osteolysis can cause screw head prominence, mid-term radiographic follow-up is necessary to prevent damage to the joint. In the long term, remaining bone stock may be adequate for total joint replacement.

[Arthroscopic reconstruction of scaphoid nonunions]. / Arthroskopische Rekonstruktion des Skaphoids bei Pseudarthrose.

OBJECTIVE: Minimally invasive arthroscopically assisted reconstruction of scaphoid nonunions. INDICATIONS: Delayed union or nonunion of the scaphoid with sclerosis and with indication for bone transplantation. Limited arthritic changes at the radial styloid. CONTRAINDICATIONS: Severe humpback deformity with dorsal intercalated segment instability. Midcarpal arthritic changes. SURGICAL TECHNIQUE: Supine position with the forearm upright and in neutral position, the elbow flexed by 90°, axial traction of 3 to 4 kg. Standard wrist arthroscopy via the 3-4 and the 4-5 portal and the midcarpal joint via the radial and ulnar portal, respectively, with sodium chloride as arthroscopy medium. Change of the optic to the ulnar midcarpal portal and opening of the nonunion with an elevator via the radial midcarpal portal. Resection of the sclerosis with a 3.0 mm burr while irrigating the joint. Harvesting of cancellous bone via the second extensor compartment. On the hand table, closed reduction by joy-stick K­wires if needed and insertion of K­wires for the scaphoid screw. Insertion of the screw without entering of the distal thread into the bone. Arthroscopic insertion of the bone transplant by a blunt drill sleeve via the radial portal with steady compression by the obturator. Complete insertion of the screw under arthroscopic control of the compression of the nonunion space with arthroscopic control of stability with the probe. POSTOPERATIVE MANAGEMENT: Six weeks forearm cast including the thumb metacarpophalangeal joint, radiographic control and non-load bearing movements for two more weeks, CT scan in the oblique sagittal plane after 8 weeks, and increase of load, as well as physiotherapy on demand depending on the radiographic results. RESULTS: To date, 17 patients with a mean age of the nonunion of 18 months were treated. In 14 patients, bony union was achieved after 8 weeks. In one patient, an extraosseous screw placement was corrected. In another patient with extraosseous screw placement, persisting nonunion was treated with an angular stable plate. One scaphoid demonstrated an asymptomatic tight nonunion after 14 months, while one scaphoid with sclerosis of the proximal pole did not heal.

[Homodigital neurovascular island flap according to Venkataswami]. / Defektdeckung mit dem anterograden homodigitalen Insellappen nach Venkataswami.

OBJECTIVE: Reliable wound coverage of the fingertip and palmar aspect of the middle finger with a sensate flap in order to restore early function. INDICATIONS: Palmar, oblique pulp defects or amputations at the distal finger phalange with uncovered bone, tendons, and/or neurovascular structures. CONTRAINDICATIONS: Peripheral perfusion deficiency, size of defect exceeding flap capacity, obliteration of the flap artery, i.e. contralateral finger artery. SURGICAL TECHNIQUE: Harvesting of adipocutane, midlateral triangle based on proper digital vessel flap; distal flap transposition and primary closure of the harvesting defect, flap dimension 4-5 mm larger than defect. POSTOPERATIVE MANAGEMENT: Finger splint for 2 weeks, followed by exercises with flap conditioning. RESULTS: Very reliable defect coverage with 9% minor and temporary complications, all of which healed without consequences.

The Requirement for Closed Reduction of Dorsally Displaced Unstable Distal Radius Fractures Before Operative Treatment.

BACKGROUND: Dorsally displaced distal radius fractures are generally treated with closed reduction followed by casting. Current evidence suggests that fracture reduction is of no benefit before either conservative or surgical treatment. It has not been studied to date whether the degree of pain suffered by the patient during preoperative casting is any different if the fracture is reduced beforehand. METHODS: In a prospective, randomized trial, dorsally displaced unstable distal radius fractures were treated surgically, either with or without prior closed reduction (22 and 25 patients, respectively). The primary endpoint was the difference between the pain score (on the Visual Analog Scale) on day 1 after treatment and the initial pain score on presentation. The secondary endpoints included the clinical and radiological outcome and any damage to the median nerve. Moreover, the Krimmer score (strength, mobility, pain, and function of the wrist joint) an the DASH score (Disability of the Arm, Shoulder and Hand) were determined 3 and 12 months after treatment. This trial has been registered with the number DRKS00010570. RESULTS: With regard to the primary endpoint on day 1 after treatment, there was a statistically significant non-inferiority of the group without reduction, compared to the group with reduction. Sensory disturbances appeared at similar frequencies in the two groups four to six weeks after treatment (9.5% with reduction, 9.1% without). At 12 months, the Krimmer and DASH scores of patients whose fractures had not been reduced were no worse than those of patients whose fractures had been reduced (96 and 7 versus 96.5 and 4.5, respectively; p-values for non-inferiority, 0.004 and 0.008). CONCLUSION: This trial shows that dispensing with closed reduction before casting as a preliminary to planned surgery yields no disadvantage. Thus, in the authors' view, routine reduction is not warranted.

Pain Perception following Initial Closed Reduction in the Preoperative Care of Unstable, Dorsally Displaced Distal Radius Fractures.

Introduction Closed reduction and cast immobilization is a common practice as initial treatment for distal radius fractures. This study examines the pain perception that accompanies this approach. Materials and Methods Thirty dorsally displaced distal radius fractures were reduced and casted under finger-trap traction with intravenous analgesics. Patients rated their pain perception on visual analog scale prior to presentation, during reduction, during casting, and for every day until surgery. Closed reduction improved palmar tilt from -26.3 to -10.8 degrees. Surgery improved palmar tilt from -10.8 to +6.1 degrees. Closed reduction improved radial inclination from 15.5 to 19.1 degrees. Surgery improved radial inclination from 19.1 to 21.6 degrees. Mean pain perception was 5.8 at presentation. Reduction increased pain to 7.5 ( p < 0.001), whereas casting was less painful (3.7; p < 0.001). At the evening following casting and the following days until surgery, mean pain was still as high as 4.1, 4.2, 4.1, 3.6, 3.9, 2.8, 3.0, and 3.0, with some patients experiencing more pain than initially. Conclusion Reduction generates significant pain with only minor relief during cast immobilization. The indication for closed reduction prior to cast application is therefore questionable.

Treatment of Ulnar Impaction Syndrome with and without Central TFC Lesion.

Background Arthroscopic debridement of the triangular fibrocartilage (TFC) is well accepted in patients with ulnar impaction syndrome with central TFC lesions. Treatment remains controversial, however, when there is no such lesion from radiocarpal view. Purpose This study assessed the clinical outcome of arthroscopic central TFC resection and debridement and secondary ulnar shortening in patients with ulnar impaction with central TFC lesion compared with patients without TFC lesion. Patients and Methods Thirty-two consecutive patients with ulnar impaction syndrome were arthroscopically treated, 16 of whom had a central lesion of the TFC that was debrided. In the 16 patients with no lesion from the radiocarpal view, the TFC was centrally resected and debrided to decompress the ulnocarpal joint. Persisting symptoms necessitated ulnar shortening in four patients in each group. Two patients underwent repeat arthroscopic TFC debridement. All patients were examined at 3, 6, and 12 months, and at final follow-up (mean: 1.7 years) following arthroscopy, respectively ulnar shortening or hardware removal. Results In both groups, pain, Krimmer, and DASH scores significantly improved. Improvements of DASH scores were significantly higher in patients without lesion at 12 months and at final follow-up. For other parameters, no significant difference was found between the two groups. Conclusion In both situations, with and without central TFC lesion, resection and debridement sufficiently reduced the ulnar-sided wrist pain and improved function in three out of four patients, and therefore qualified as the first-line treatment of ulnar impaction syndrome as arthroscopy is performed, anyway. Those patients who complained of persisting or recurrent ulnar-sided wrist pain finally benefitted from ulnar shortening osteotomy as the secondary procedure. Level of Evidence Therapeutic III, case-control study.

Significance of Scapholunate Gap Width as Measured by Probe from Midcarpal.

Background Geissler's classification is widely accepted in arthroscopic diagnostics of scapholunate (SL) ligament injury. Thereby, probe insertion into the SL gap from the midcarpal would indicate treatment necessity in patients with SL tear as seen from radiocarpal view. Purpose In this review, the SL gap width, examined by the probe from midcarpal, was arthroscopically assessed in patients with intact SL ligaments, who were treated for ulnar impaction syndrome. The review examined how often lax SL joints can be found in patients with no complaints with respect to the SL ligaments and in which the SL ligaments were proven to be intact from radiocarpal view. We suspected that probe insertion, as an indicator for a lax joint, does not affect the outcome in ulnar impaction treatment. Patients and Methods A total of 32 patients with clinically diagnosed ulnar impaction syndrome were arthroscopically treated by central resection and debridement of the triangular fibrocartilage; 8 patients underwent concurrent ulnar shortening, and 4 of them finally hardware removal. All patients were examined preoperatively as well as after 3, 6, and 12 months following arthroscopy, respectively, after ulnar shortening or hardware removal. Results In 14 patients, the probe could not, in 18 patients, the probe could be inserted into the SL gap. There was neither any significant difference in the improvement of pain, grip strength, Krimmer, or DASH score, nor for any of the radiographic angles between the two groups. Conclusion Laxity of the SL ligament allows the probe to be inserted into the SL gap from midcarpal in some patients. This finding, therefore, does not necessarily imply the necessity of treatment when there is partial rupture seen from radiocarpal view. Level of Evidence Level III, case-control study.

[Lundborg's resection arthroplasty vs. Pyrocarbon spacer (Pyrocardan®) for the treatment of trapeziometacarpal joint osteoarthritis: a two-centre study]. / Resektionsarthroplastik nach Lundborg vs. Pyrocarbon-Spacer (Pyrocardan®) bei fortgeschrittener Rhizarthrose ­ Eine Zwei-Center-Studie.

Background Various operative approaches exist for osteoarthritis of the trapeziometacarpal joint. The aim of this two-centre study was to compare the results of Lundsborg's resection arthroplasty with the implantation of the Pyrocardan® spacer. Patients and methods We treated 20 patients with symptomatic osteoarthritis of the trapeziometacarpal joint in stage III / IV (Eaton-Littler classification). Twelve patients received Lundsborg's resection arthroplasty (centre 1), and in 8 patients a Pyrocardan® spacer was implanted (centre 2). Both groups were comparable regarding patients´ age, the preoperative pain level, the osteoarthritis stage according to Eaton-Littler, and the duration from the onset of symptoms until surgery. Patient data were retrospectively collected from patient records, and we performed a follow-up examination at least 18 months postoperatively, thereby evaluating the DASH sore, the postoperative time until freedom of symptoms, the pain level according to the visual analogue scale, grip force (Jamar dynamometer), pinch force, and patients' treatment satisfaction (0-10; 10 = highest satisfaction). Results Both groups had a similar length of follow-up with 23.6 ±â€…5.2 months for the resection group and 26.1 ±â€…4.0 months for the spacer group. The duration of the operation was 31 ±â€…5 min for the resection group and 29 ±â€…7 min for the spacer group (p > 0.05). The DASH score was 21.9 ±â€…6.2 in the resection group and 18.3 ±â€…5.0 in the spacer group (p > 0.05). The pain level at the current follow-up was 1.5 ±â€…0.83 in the spacer group and 1.0 ±â€…0.74 in the resection group (p > 0.05). The time until freedom of symptoms was significantly shorter in the spacer group with 3.7 ±â€…1.9 months compared to the resection group with 5.7 ±â€…3.1 months (p = 0.0001). Grip force and pinch force were not significantly different between both groups. Treatment satisfaction was 9.3 ±â€…1.6 in the resection group and 7.4 ±â€…3.0 in the spacer group (p > 0.05). Conclusion Over a follow-up period of 1.5 years, both techniques resulted in a satisfactory usability of the operated hand and a clear reduction of symptoms. The implantation of the Pyrocardan® spacer seems to have slight advantages regarding a shorter time until freedom of symptoms. However, the implantation of the spacer is associated with additional material costs of a few hundred Euros, which are not incurred in resection arthroplasties. The implantation of the Pyrocardan® spacer seems to have slight advantages regarding a shorter time until freedom of symptoms.

[Atypical Lipomatous Tumour of the Hand]. / Atypischer lipomatöser Tumor der Hand.

Atypical lipomatous tumours (ALT) are rare semi-malignant adipose tissue tumours with the potential to transform into sarcomas. They may occur throughout the body, although the hands are very rarely involved. We present the case of a 49-year-old man with a lipomatous tumour measuring 8×4 cm at the dorsum of the right thumb. MRI demonstrated an inhomogeneous signal after contrast medium application. The tumour was excised in its entirety. Since histology confirmed the diagnosis of an ALT, the thumb was irradiated. The patient remained free of recurrence. An ALT has to be suspected if a lipomatous tumour is very large. We recommend an MRI prior to surgery in tumours larger than 5 cm. Excision should follow oncologic principles.

Preventable Repeat Wrist Arthroscopies: Analysis of the Indications for 133 Cases.

Background Frequently, patients undergo repeated wrist arthroscopies for single wrist problems. Purpose The purposes of this study were to assess the indications for repeat wrist arthroscopies and to identify potentially preventable procedures. Methods For this retrospective, two-center study, the electronic patient records were examined for patients, who underwent repeat wrist arthroscopy in a 5-year period. The cases were sorted by the underlying pathologies and the causes that necessitated repeat arthroscopies. Results Ulnar-sided wrist pain accounted for 100 (77%) of all 133 revision arthroscopies: 67 of which due to suspected ulnar triangular fibrocartilage complex (TFCC) avulsions, 33 due to ulnar impaction syndromes. Cartilage was reassessed in 22 (17%) wrists. Thereby, insufficient preoperative diagnostics necessitated pure diagnostic before therapeutic arthroscopy in 49 (37%) wrists: 48 of which for TFCC pathologies, one for a scapholunate (SL) ligament lesion. The uncertainty of diagnosis despite previous arthroscopy necessitated 18 (14%) revision arthroscopies: 15 for ulnar TFCC avulsions, 1 for a central TFCC lesion, 2 to reevaluate the SL ligament. Inadequate photo or video documentation of the cartilage necessitated arthroscopic reassessment in 16 (12%) wrists. Conclusion In this series, two out of three revision arthroscopies could potentially have been prevented. Inadequate preoperative diagnostics with the lack of reliable preoperative diagnoses necessitated pure diagnostic arthroscopies for ulnar-sided wrist pain. However, even arthroscopically, the diagnosis of ulnar TFCC avulsions or SL ligament lesions is not trivial. Surgical skills and experience are necessary to detect such lesions. Finally, adequate photo or video documentation may prevent repeated arthroscopic diagnostic procedures. Level of Evidence Level IV.

The efficacy of open partial aponeurectomy for recurrent Dupuytren's contracture.

INTRODUCTION: To evaluate the efficacy of open partial aponeurectomy for recurrent Dupuytren's contracture. METHODS: Eighteen patients with recurrent Dupuytren's contracture of 22 fingers were retrospectively assessed with a mean follow-up time of 94 months (range: 70-114 months). Examination parameters included the determination of range of motion (ROM), grip strength, pain and subjective outcome (disabilities of the arm, shoulder and hand (DASH) questionnaire). SURGICAL TECHNIQUE: Dissection with special regard to former skin incision and expected wound defect. Modified incisions after Bruner (Mini-Bruner incisions) were facilitated. Dissection started at the palm. Fibrous tissue was resected proximally within the palm including vertical fibrotic septae. Direct preparation of the neurovascular bundles (NVB) was facilitated from proximal to distal. If the anatomy of the neurovascular structures became unclear around the natatory ligament preparation of the NVB at the distal end of the fibrous cord was performed. After complete preparation of a NVB, dissection was continued from medial to lateral until the other bundle was completely released. Transposition flaps and skin transplants were often used for sufficient wound closure. RESULTS: Recurrence rate was 36 % applying the definition of van Rijssen et al. Fifteen patients had a grip strength of 90 % or higher in comparison to the contralateral side. Ten patients had a pinch strength of 90 % or higher in comparison to the contralateral side. All patients except for one had pain reduction or none postoperatively. Fifteen patients had a DASH score of 15 or lower (range: 0-47). An unrelated ray amputation was suffered due to wound healing complications. CONCLUSIONS: Open partial aponeurectomy performed by a board certified hand surgeon proved to be safe. The postoperative functional outcome seemed to be related to the individual course of the disease.

The required minimum length of video sequences for obtaining a reliable interobserver diagnosis in wrist arthroscopies.

PURPOSE: To examine the relationship between video length for wrist arthroscopy and interobserver reliability. MATERIALS AND METHODS: 100 consecutive wrist arthroscopies were documented by long and short videos of the radiocarpal and the midcarpal joints. The long videos were about twice as long as the short videos. They were presented randomly to two independent and blinded examiners. Their diagnoses were compared to the diagnoses made by the surgeon who performed the arthroscopies. Kappa coefficients were calculated. RESULTS: Kappa statistics were inconsistent and did not show that the long video provided an obvious advantage over the short video. The Kappa coefficients of the two examiners for the assessment of the cartilage status were 0.524 and 0.700 for the long videos and 0.465 and 0.639 for the short videos, respectively. The examiners diagnosed twice as many false-positive cartilage lesions on short videos than on long videos. The assessment of ligament lesions was more accurate on long than on short videos. CONCLUSIONS: The results confirmed the hypothesis that the reproducibility of diagnoses based on video documents was influenced by the length of the video sequences. Therefore, it may be advisable for video documentation to be done diligently. The video sequence of the radiocarpal joint should last about 60 s, and that of a midcarpal joint should last about 45 s. Videos of difficult joints should last appropriately longer. LEVEL OF EVIDENCE: Diagnostic II.

Endoscopically assisted release of the superficial radial nerve.

INTRODUCTION: The feasibility of endoscopically assisted decompression of the superficial radial nerve at the midportion and distal forearm was assessed. SURGICAL TECHNIQUE: After a 3 cm longitudinal skin incision at the Tinel's sign at the forearm, the subcutaneous tissue is dissected until forearm fascia is detected. The fascia is opened cautiously under direct visualization and the superficial radial nerve is identified. Blunt forceps mobilize the subcutaneous tissue upon the fascia before the illuminated speculum is inserted. Then further dissection of the fascia is performed proximally using the Metzenbaum scissors. After further blunt tunneling by forceps the endoscope is introduced proximally in order to release the superficial radial nerve completely. Then the speculum is inserted distally to identify the nerve within the subcutaneous tissue. Then further visualization is facilitated using the endoscope. CONCLUSION: The endoscopically assisted release of the superficial radial nerve may be feasible in a safe and sufficient way.

Ulnar shortening osteotomy for malunited distal radius fractures: results of a 7-year follow-up with special regard to the grade of radial displacement and post-operative ulnar variance.

INTRODUCTION: The treatment of ulnar-sided wrist pain after malunited distal radius fractures remains controversial. Radial corrective osteotomy can restore congruity in the distal radioulnar joint (DRUJ) as well as adequate length of the radius. Ulnar shortening osteotomies leave the radius' angular deformities unchanged, risking secondary DRUJ osteoarthritis. We supposed that, even within the widely accepted limit of 20°, a greater angulation of the radius in the sagittal plane correlates with a higher rate of DRUJ osteoarthritis. Furthermore, we suspected worse results from an ulna shortened to a negative rather than a neutral or positive ulnar variance. MATERIALS AND METHODS: For this retrospective study, we reviewed 23 patients a mean 7.2 (range 5.6-8.5) years after ulnar shortening osteotomy for malunion of distal radius fractures. We compared 14 patients with up to 10° dorsal or palmar displacement from the normal palmar tilt of 10° to 9 patients with more than 10° displacement, and 15 patients whose post-operative ulnar variance was neutral or positive to 8 who had a negative one. RESULTS: Ulnar-sided wrist pain decreased enough to satisfy 21 of the 23 patients. Clinical results tended to be better when radial displacement was minor and when post-operative ulnar variance was positive or neutral. A shorter ulna significantly increased the rate of DRUJ osteoarthritis, whereas a greater degree of radial displacement only increased the rate slightly. CONCLUSIONS: Radial corrective osteotomy should be discussed as alternative when displacement of the radius in the sagittal plane exceeds 10°. The ulna should be shortened moderately to reduce the risk of osteoarthritis in the distal radioulnar joint.

Standardized palmar plating of dorsally displaced distal radius fractures.

With the inauguration of fixed-angle plates, palmar plating has become a widely accepted way to treat dorsally displaced distal radius fractures. The technique by which the plate is applied to the radius varies. Such plates are primarily fixed either distally or at the proximal limbs. In this article, the standardized technique by which osteosynthesis is conducted in our institution is described step by step. The plate is first fixed to the shaft. Reduction is temporarily maintained by K-wires that run through the plate's distal margin. These K-wires are usually reliable in maintaining adequate reduction and are gradually replaced by locking screws in the distal row. Of 96 consecutive procedures, the duration of operation, the amount of fluoroscopy needed, and the intraoperative radiographic results are reported. Using this method, constantly good results can be achieved, even if the operation is done by less experienced surgeons.

The effect of additional video documentation to photo documentation in wrist arthroscopies on intra- and interobserver reliability.

INTRODUCTION: The reproducibility of diagnoses based on photo documents in wrist arthroscopies is limited and is expected to improve through the addition of video documents. AIM: The purpose of this study was to determine the effect of additional video documentation to photo documentation on intra- and interobserver reliability in wrist arthroscopies. MATERIALS AND METHODS: Sixty consecutive arthroscopies were documented by photographs of at least eight standard views and videos of the radiocarpal and midcarpal joints. After 3 months, the photographs and then the photographs together with the videos were reevaluated by the surgeon and by two hand surgeons to determine intra- and interobserver reliability. Percentage agreement and kappa coefficients were calculated. RESULTS: Using videos along with the photographs did not improve reproducibility in general. The assessments of the cartilage status were even worse. Some of the videos were criticized as being too short to allow adequate assessment of the cartilage. Lesions of the TFCC as well as its tension were assessed notably better by the videos, whereas assessment of SL and LT ligaments was not improved by the videos. Intraobserver reliability was better than interobserver reliability. CONCLUSION: As long as videos do not meet further quality criteria, they are not able to improve reliability in general. Nevertheless, videos should be used for documentation of the TFCC.

Results after radioscapholunate arthrodesis with or without resection of the distal scaphoid pole.

PURPOSE: To evaluate the differences between radioscapholunate (RSL) arthrodesis alone versus RSL arthrodesis with additional distal scaphoidectomy. METHODS: We retrospectively evaluated 61 patients who were treated with RSL arthrodesis for painful posttraumatic osteoarthritis. Thirty patients had an RSL arthrodesis with additional resection of the distal scaphoid pole (group A), and 31 had RSL arthrodesis alone (group B). Six patients in group A and 8 in group B had the RSL arthrodesis converted to a complete wrist arthrodesis during follow-up. Those patients were excluded from the survey. Of the remaining 47 patients, 35 (20 from group A, 15 from group B) returned for a clinical and radiological examination at an average of 28 (range, 10-47) months after the index surgery. The results were rated by the Disabilities of the Arm, Shoulder, and Hand score and the modified Mayo Wrist Score. The patients' outcomes after RSL arthrodesis with or without distal scaphoidectomy were compared for pain, wrist motion, grip strength, nonunion rate, osteoarthritis of the adjacent joints, the Disabilities of the Arm, Shoulder, and Hand score and the modified Mayo Wrist Score. RESULTS: Three patients with RSL arthrodesis alone showed a radioscaphoid nonunion. All arthrodeses in group A healed. In the clinical evaluation, there was no significant difference between groups A and B in the Disabilities of the Arm, Shoulder, and Hand score, the modified Mayo Wrist Score, grip strength, pain, or wrist motion. Assuming that wrist motion might be better in patients with a nonunion, the average wrist motion was recalculated after eliminating 3 patients with a radioscaphoid nonunion from group B. Radial deviation was then found to be significantly better in group A. CONCLUSIONS: Additional distal scaphoidectomy with RSL arthrodesis seems to improve postoperative radial deviation of the wrist. The radioscaphoid nonunion rate is high with RSL arthrodesis alone. Distal scaphoidectomy appeared to increase the successful fusion rate of RSL arthrodeses. No significant effect on wrist extension, flexion, ulnar deviation, pain level, restriction in activities of daily living, or grip strength was noted.

The effect of labeling photo documents in wrist arthroscopies on intra- and interobserver reliability.

INTRODUCTION: The reproducibility of diagnoses based on photo documents in wrist arthroscopies is limited and is expected to improve if the photos are labeled with illustrated structures. AIM: The purpose of this study was to determine the effect of labeling photo documents on intra- and interobserver agreement and reliability of standard photo documentation in wrist arthroscopies. MATERIALS AND METHODS: Digital photographs of 50 arthroscopies were re-evaluated by the surgeon as well as by two independent hand surgeons. First the photos were presented unlabeled in a random order, then the labeled photos in a uniform order. Intra- and interobserver reliability was assessed, and expressed by kappa coefficients. RESULTS: Overall, labeling the photos resulted in a slight improvement in intra- and interobserver reliability (0.573/0.444/0.420 vs. 0.518/0.412/0.212). The time needed to conceive the photo documents, however, was shortened when the photos were labeled. The cartilage status was assessed considerably more accurately if the photos were labeled (0.556/0.560/0.422 vs. 0.459/0.326/0.240; t test: P = 0.094). Whereas the SL ligament was assessed more accurately according to labeled photos (P = 0.100), the agreement rates for the assessment of other ligament structures (TFCC, LT and radiopalmar ligaments) were not substantially affected by labeling the photos. On re-evaluation of the unlabeled as well as the labeled photos, intraobserver reliability was better than interobserver reliability (0.518 vs. 0.412/0.212 and 0.573 vs. 0.444/0.420). CONCLUSION: Labeling simplifies but does not necessarily improve the reproducibility of photo documents in wrist arthroscopies. To display the cartilage status and the integrity of the SL ligament, digital photo documents should be labeled with the illustrated structure or joint surface.