Internal fixation sets for use in the hand. A comparison of available instrumentation.

Optimal clinical results of internal fixation in the hand depend on appropriate patient selection criteria, good surgical techniques, and appropriate implant selection. A variety of implant sets with plates and screws from different manufacturers are available for hand bone fixation. Traditionally, such sets have been made of stainless steel, but more recently, implants have been manufactured from titanium. Sizes and configurations vary significantly between manufacturers. In this article, commonly available internal fixation sets are compared. Plate, screw, and instrument design are considered. These comparisons should help the surgeon make an enlightened choice of implant sets.

Internal fixation for small joint arthrodeses in the hand. The interphalangeal joints.

Interphalangeal arthrodeses are performed frequently for disabling pain and deformity in the proximal and distal interphalangeal joints. Such arthrodeses are the gold standard for eliminating pain in arthritic joints of the fingers. Kirschner wire fixation is simple to perform but often leads to nonunion or delayed union. Fixation with tension band wires and Herbert and Accutrak screws is discussed in this article. The techniques are simple and straightforward, and they afford considerably more stability and a higher union rate than Kirschner wires alone.

Fixation for distal radius fractures.

Distal radius fractures are common fractures that can cause significant disability. As techniques and implants have improved, better results can be expected from internal and external fixation of complex wrist fractures. With meticulous technique, articular alignment can be secured and small articular fragments can be replaced in anatomic locations through limited open or arthroscopic techniques. Bone graft should be used liberally in comminuted articular fractures. Such procedures are demanding, however. Familiarity with the techniques described in this article will enhance the surgeon's ability to restore function in this group of patients.

Arthroscopy of the distal radioulnar joint.

Arthroscopy of the distal radioulnar joint is challenging. Its indications are evolving. When the experienced hand surgeon believes that the procedure is justified, unusual discoveries may be made. Patients with distal radioulnar joint pain who remain a diagnostic challenge before arthroscopy may sometimes be helped by the results of arthroscopy of this small joint.

Treatment of complex intra-articular distal radius fractures.

Techniques for reduction and fixation of intra-articular distal radius fractures have improved in recent years such that fractures that were once thought doomed to a poor result may now be successfully treated operatively. This article explores open, semi-open, and arthroscopically assisted techniques for reduction and fixation of complex distal radius fractures. The reader should gain an appreciation of which fractures can benefit from operative treatment and which techniques may be most useful for specific fracture types. A number of fixation techniques are described, and familiarity with diverse methods will aid the surgeon in complex cases.

Anatomy of the proximal interphalangeal joint.

The proximal interphalangeal joints (PIPs) of the fingers are crucial for normal digital and hand function. Studies of their anatomy reveal subtle bony differences that dictate the precise planes of motion allowed in the constrained joint. Soft tissue restraints guide the cartilaginous surfaces through permissible ranges of motion. Understanding these restraints and the precise orientation of other joint structures assists treatment of conditions affecting the PIP joint.

Arthrodesis of the proximal interphalangeal joint of the finger: comparison of the use of the Herbert screw with other fixation methods.

We report a retrospective review of 224 proximal interphalangeal joint arthrodeses in the digits using Herbert screws (37), Kirschner wires (100), tension band wiring (69), plates (11), and other miscellaneous techniques (7) for fixation. Average time to clinical union was 7 weeks and time to radiographic union was 10 weeks. Nonunion occurred in 31 cases (24 digits). The primary nonunion rate was highest in psoriatic arthritis, intermediate in rheumatoid arthritis, lower in acute trauma and post-traumatic reconstruction, and nonexistent in osteoarthritis. The primary nonunion rate was highest using Kirschner wires, intermediate using tension band wires, and lowest using Herbert screws. All Kirschner wires, six tension band wires and one Herbert screw were removed after fusion. The Herbert screw provides secure fixation, is easy to insert, and affords a rapid and reliable arthrodesis at the proximal interphalangeal joint.

Indications and techniques of open reduction. Internal fixation of distal radius fractures.

Complex distal radius fractures present in a variety of patterns that differ by the area and degree of involvement of the articular and metaphyseal fracture components. No single method of treatment is appropriate for all fractures. This article discusses the types of fractures that either require or are best handled by formal open reduction and internal or external fixation.

Martin-Gruber revisited.

A new classification system for Martin-Gruber connections is described. This comprises four types of connection that can theoretically exist and that differ by their source and destination. The world literature has been reexamined and the incidence of Martin-Gruber connections was found to be 17% overall. By the new classification, 60% are type I, sending motor branches from the median to the ulnar nerve to innervate "median" muscles; 35% are type II, sending motor branches from median to ulnar nerves to innervate "ulnar" muscles; 3% are type III, sending motor fibers from the ulnar to the median nerve to innervate "median" muscles; and 1% are type IV, sending motor fibers from the ulnar to the median nerve to innervate "ulnar" muscles.

Anatomy and pathogenesis of the digital cords and nodules.

Current theories on the origin of the diseased tissue in Dupuytren's contracture are reviewed, and previous descriptions of the pathologic anatomy are clarified. The pathogenesis of Dupuytren's contracture is cited, with emphasis on the development of the contracture at various sites.

The posterior Monteggia lesion.

Thirteen posterior Monteggia fracture-dislocations in adults were treated surgically at the Massachusetts General Hospital from 1980 to 1988. A characteristic lesion was observed, consisting of a proximal ulna fracture with a triangular or quandrangular fracture at or near the level of the coronoid, a posterior or posterolateral radiocapitellar dislocation, and, in 10 cases, a radial head fracture. Nine patients were women and four were men, with an average age of 56 years. Following reduction of the radiocapitellar dislocation, the ulnar fractures were treated with plates in each case. Seven fractured radial heads were excised, one replaced with a silicone prosthesis, and three treated by open reduction and internal fixation. The 11 surviving patients were observed using the performance index of Broberg and Morrey at an average follow-up time of 38.4 months. The conditions of three were rated excellent, three good, four fair, and one poor. Incomplete reduction of the ulnar fracture with residual posterior radiocapitellar subluxation was observed in four cases, all leading to loss of forearm supination. We believe this lesion to be more common than previously reported. Recognition of its specific anatomic features is essential to achieve a functional outcome.

Sprengel deformity.

Eighteen cases of Sprengel deformity in sixteen patients were treated by the same surgeon. The operation was a modification of Green's procedure; all muscular attachments to the scapula are freed, the omovertebral band is cut, and the scapula is sutured into a pocket in the latissimus dorsi after the scapula has been rotated and moved caudad to a more normal position. No spring or wire traction is employed. The ages of the patients at operation ranged from twenty months to five years and ten months. The duration of follow-up ranged from three years to fourteen years and three months. In eleven of the fifteen patients who were available for follow-up, there was a moderate or dramatic improvement in appearance postoperatively. Preoperatively, the total abduction of the shoulder averaged 91 degrees (range, 60 to 120 degrees), and postoperatively, the abduction averaged 148 degrees. A radiographic geometric method was devised to quantitate lowering and derotation of the scapula. The lowering did not change appreciably with time. The original malrotation of the scapula was corrected initially but usually recurred after two years; however, this did not compromise the large increase in abduction postoperatively.

Gastrointestinal fluoroscopy: patient dose and methods for its reduction.

The aim of this study was to demonstrate a method which could be used to identify factors which contribute to the radiation exposure to patients from fluoroscopy during contrast examinations of the gastro-intestinal tract. Measurements of exposure made at the level of the X-ray tube collimator were extrapolated to obtain entrance exposure at the centre of the field and used as an index of the integral dose to the patient. Such data have heretofore been unavailable. The population studied included 65 patients ranging in age from 1 month to 21 years. In an initial study, median entrance exposure at the field centre for barium swallow examinations ranged from 0.98 to 1.7 mC/kg (3.8 to 6.6 R); barium meal: 1.9-5.7 mC/kg (7.4-22 R); barium meal with small bowel: 1.4-7.7 mC/kg (5.3-30 R); barium enema: 0.93-7.7 mC/kg (3.6-41 R). Gonadal dose, measured in males, ranged from undetectable to 0.71 mGy (71 mrad). The presence of contrast medium in the fluoroscopic field increased the exposure from a single 100 mm spot film, taken with automatic exposure control, by a factor of up to 16, and fluoroscopic exposure rate, using automatic brightness control, by a factor of 2 or more. We recommend modifications in the operation and design of fluoroscopic equipment, especially when fitted with brightness and exposure controls, for the reduction of patient exposure. Implementation of two modifications, a high/low dose switch, and a variable aperture iris diaphragm, reduced patient exposure from 1.4 to 3.4 times.

Patient radiation exposure during pediatric cardiac catheterization.

Exposure area product (EAP) and center field entrance exposure (free-in-air) were measured in seventeen pediatric patients undergoing cardiac catheterization. Exposures were recorded separately for biplane fluoroscopy and cine angiocardiography using flat-plate ionization chambers. In the posterior-anterior (PA) projections, median EAP was 425 Roentgen-square centimeter (R-cm2), with a range of 90.5-3,882 R-cm2;29-35% of this exposure occurred during cine filming. In the lateral projection, median EAP was 276 R-cm2 (range 117-1,173); 52-59% of this exposure was due to cine filming. Median center field entrance exposure in the PA view was 7.86 Roentgens (R) with a range 2.16-73.9 of and in the lateral projection 7.39 R (range 2.64-24.6). As much as 25% of the exposure from the entire examination was contributed by manual "test" exposures to set cine radiographic kVp. We recommend use of testing circuits, which determine cine radiographic factors automatically and thus should lower levels of exposure.