Double screw versus angular stable plate fixation of scaphoid waist nonunions in combination with intraoperative extracorporeal shockwave therapy (ESWT).

INTRODUCTION: Over the past years, different fixation techniques focused on rotational stability in order to increase stability and stimulate union rates. Additionally, extracorporeal shockwave therapy (ESWT) has gained importance in the treatment of delayed and nonunions. Purpose of this study was to compare the radiological and clinical outcome of two headless compression screws (HCS) and plate fixation in scaphoid nonunions, in combination with intraoperative high energy ESWT. MATERIALS AND METHODS: Thirty-eight patients with scaphoid nonunions were treated by using a nonvascularized bone graft from the iliac crest and stabilization with either two HCS or a volar angular stable scaphoid plate. All patients received one ESWT session with 3000 impulses and energy flux per pulse of 0.41 mJ/mm2 intraoperatively. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien (Mayo) Wrist Score. To confirm union, a CT scan of the wrist was performed. RESULTS: Thirty-two patients returned for clinical and radiological examination. Out of these, 29 (91%) showed bony union. All patients treated with two HCS compared to 16 out of 19 (84%) patients treated by plate showed bony union on the CT scans. The difference was not statistically significant. However, at a mean follow-up interval of 34 months, no significant differences could be found in ROM, pain, grip strength and patient-reported outcome measurements between the two HCS and plate group. Height-to-length ratio and capitolunate angle improved significantly in both groups compared to preoperative. CONCLUSIONS: Scaphoid nonunion stabilization by using two HCS or angular stable volar plate fixation and intraoperative ESWT results in comparable high union rates and good functional outcome. Due to the higher rate for a secondary intervention (plate removal), HCS might be preferable as first choice, whereas the scaphoid plate fixation should be reserved for recalcitrant (substantial bone loss, humpback deformity or failed prior surgical intervention) scaphoid nonunions.

Rehabilitation after distal radius fractures: is there a need for immobilization and physiotherapy?

Although the literature generally agrees that displaced distal radius fractures require surgery, no single consensus exists concerning the length of immobilization and type of post-operative physiotherapeutic rehabilitation program. Palmar locking plate fixation represents a very stable fixation of the distal radius, and was assessed biomechanically in various studies. Surprisingly, most authors report additional immobilization after plate fixation. One reason might be due to the pain caused during active wrist mobilization in the early post-operative stages or secondly to protect the osteosynthesis in the early healing stages preventing secondary loss of reduction. This article addresses the biomechanical principles, current available evidence for early mobilization/immobilization and impact of physiotherapy after operatively treated distal radius fractures.

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.

Salvage procedure after malunited distal radius fractures and management of pain and stiffness.

Indications for surgical treatment of distal radius fractures (DRF) remain controversial in the literature, especially in elderly patients. Complication rates after operatively treated DRF are low and well documented. These include malunion, degenerative osteoarthritis in the radiocarpal joint and subsequently pain and impaired hand function. If conservative treatment fails then salvage procedures are necessary. This review summarizes the therapeutic options available to treat degenerative osteoarthritis after malunited distal radius fractures, regardless of the initial operative or conservative treatment.

Complications after operatively treated distal radius fractures.

In the recent years, treatment of distal radius fractures (DRF) has advanced considerably. Surgical fixation with palmar angular stable plate has gained popularity, due to a reported lower complication rate when compared to dorsal fixation. The type of trauma or injury, surgical procedure and impaired bone quality are all contributors to complications in DRF. The main aim of this review is to summarize the most common complications and possible therapeutic solutions. In addition, strategies for minimizing these complications will be discussed.

Indications, surgical approach, reduction, and stabilization techniques of distal radius fractures.

Distal Radius fractures (DRF) are one of the most common injuries in the upper extremity and incidence is expected to rise due to a growing elderly population. The complex decision to treat patients operatively or conservatively depends on a large variety of parameters which have to be considered. No unanimous consensus has been reached yet, which operative approach and fixation technique would produce the best postoperative functional results with lowest complication rates. This article addresses the available evidence for indications, approaches, reduction, and fixation techniques in treating DRF.

[Palmar angular stable plate fixation of nonunions and comminuted fractures of the scaphoid]. / Palmare winkelstabile Verplattung von Pseudarthrosen und Trümmerfrakturen des Kahnbeins.

OBJECTIVE: Stabilization of comminuted fractures and nonunions of the scaphoid with an angular stable low-profile scaphoid plate. INDICATIONS: Scaphoid nonunions with a large palmar defect, second and third surgical procedure after previous stabilization by headless compression screw (HCS). Comminuted fractures of the scaphoid that cannot be sufficiently stabilized by screws. CONTRAINDICATIONS: Radio- and midcarpal osteoarthritis, small proximal pole fragments, fragmentation of the proximal pole. SURGICAL TECHNIQUE: The scaphoid is accessed by a palmar approach. After correcting the DISI (dorsal intercalated segment instability) deformity of the lunate and humpback deformity of the scaphoid, the reduction is secured by temporary Kirschner wires. The nonunion is debrided and the bone defect filled with cancellous bone graft. Subsequently the scaphoid plate and the angular stable screw are positioned in the order to place three screws in the proximal and distal fragment of the scaphoid. Comminuted fractures of the scaphoid are fixated by temporary Kirschner wires, then the plate is positioned in the same way as nonunions. POSTOPERATIVE MANAGEMENT: Comminuted fractures and nonunions of the scaphoid are immobilized by a below-elbow cast or thermoplastic splint with inclusion of the thumb for 8 weeks. No heavy work, high-risk or contact sport activities for 12 weeks. Plate removal is recommended after 6 months or after bony healing. RESULTS: By stabilizing scaphoid nonunions with a plate, high union rates with good clinical outcome can be achieved if the indication is correct.

[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.

Treatment of scaphoid waist nonunion by one, two headless compression screws or plate with or without additional extracorporeal shockwave therapy.

INTRODUCTION: Scaphoid nonunion remains challenging for hand surgeons. Several treatment options are available such as: non-vascularized or vascularized bone grafting, with or without additional stabilization. In the last few decades, extracorporeal shockwave therapy (ESWT) has become an established procedure for treating delayed and nonunions. Purpose of this retrospective follow-up study was (a) to investigate union rate and clinical outcome of the different implants [either one/two headless compression screws (HCS) or a plate] and (b) union rate and clinical outcome using only surgery, or a combination of surgery and ESWT. MATERIALS AND METHODS: The study included 42 patients with scaphoid nonunions of the waist with a mean follow-up of 52 months. All patients received a non-vascularized bone graft from the iliac crest and stabilization was achieved by using one, two HCS or a plate. ESWT was performed with 3000 impulses, energy flux density per pulse 0.41 mJ/mm2 within 2 weeks after surgery. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, Disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien (Mayo) Wrist Score. In addition, each patient had a CT scan of the wrist. RESULTS: A total of 33/42 (79%) patients showed union at the follow-up investigation. Patients treated with additional ESWT showed bony healing in 21/26 (81%) and without ESWT in 12/16 (75%). Patients that were stabilized using one HCS showed bony healing in 6/10 (60%), with two HCS 10/12 (83%) and by plate 17/20 (85%). The ESWT group had a significantly lower pain score according to the VAS and better modified Green O'Brien (Mayo) Score. No differences could be found in respect of ROM, grip strength, functional outcome score depending of which stabilization method was used. CONCLUSIONS: Stabilization of scaphoid waist nonunions with two HCS or plate showed higher union rates than a stabilization using only one HCS. In addition, ESWT combined with a nonvascularized bone graft from the iliac crest seems a suitable option for treating scaphoid nonunions.

Three-dimensional kinematics of the flexor pollicis longus tendon in relation to the position of the FPL plate and distal radius width.

INTRODUCTION: The standard therapy of intra-articular and extra-articular distal radius fractures consists of open reduction and stabilization using palmar osteosynthesis with an angularly stable plate. The integrity of the flexor pollicis longus tendon (FPLT) may be mechanically affected by the plate, with rupture rates between 1 and 12% reported in the literature, occurring during a postoperative time period from 4 to 120 months. The aim of this study was to investigate the position of the tendon in relation to the distal edge of the plate using high-resolution ultrasonic imaging. MATERIALS AND METHODS: Nineteen patients undergoing osteosynthesis for distal radius fracture in 2015 with the Medartis® APTUS® FPL plate were included in this study. Of these, seven dropped out for various reasons. Therefore,  twelve patients with a median age of 52 years (range 24-82 years) were included in the final analysis. High-frequency ultrasound was performed within a median of 28 (range 10-52) weeks by an experienced radiology specialist to locate the FPLT position in two separate wrist positions: (1) wrist held in 0° position and fingers extended and (2) wrist held in 45° of dorsal extension and actively flexed fingers II to V (functional position). For analysis, we used the axial ultrasound videos. Postoperative X-rays and CT scans were included for the analysis, especially the soft-tissue CT scan window for the exact localization of the FPLT.  Dynamic ultrasound scanning was used to localize the FPLT in relation to the plate in 0° and functional position of the hand. Using CT scanning, the position of the plate relative to the bone was determined. In this way, we were able to correlate the functional FPLT position with the osseous structures of the distal radius. RESULTS: In all cases, the FPLT was positioned closer to the volar distal edge of the FPL plate in functional position than in 0° position. In four cases, the FPLT did not touch the plate at all and was shown to shift diagonally from radio-volar in ulno-dorsal direction during wrist movement from 0° to functional position, similarly to the sliding of the tendon in the assumed physiological motion sequence. In these cases, in the functional position the center of the FPLT was positioned slightly ulnarly of the center of the distal radius (i.e., less than 50% of the distal radius width measured from the radial border of DRUJ), and positioned more ulnarly than in all other cases (i.e., in which the FPLT came into contact with the plate). In the remaining two-thirds of the cases (eight patients), the FPLT touched the plate during wrist movement from 0° to functional position, shifted in dorsal direction and slid into the plate indentation, irrespective of whether the tendon entered the indentation from the radial or the ulnar side, and independent of the ulnoradial position of the plate. No signs of tendinopathy of the FPLT were found in any of the cases. CONCLUSION: The results show that the indentation of the Medartis® APTUS® FPL plate reduces the tendon-plate contact and ideally even prevents it entirely. In particular, ulnar positioning of the plate lowers the risk of tendon-plate contact. If the FPLT touches the plate, the tendon pulls into the plate indentation, thus lowering the contact. Consequently, the Soong criteria are not applicable when a FPL plate is used.

[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.

Stabilization of scaphoid type B2 fractures with one or two headless compression screws.

INTRODUCTION: Fractures of the scaphoid account for the most commonly injured carpal bone. Minimally displaced fractures of the waist will heal in 85-90% when using a below elbow cast. However, fractures with displacement have a higher risk for nonunion. Therefore, open reduction and fixation with headless compression screws (HCS) have become the preferred method of treatment. The aim of this study was to compare the radiological and clinical outcome of unstable scaphoid B2 type fractures, stabilized using one or two headless compression screws. PATIENTS AND METHODS: A total of 47 unstable scaphoid B2 type fractures were included in this retrospective follow-up study. Twelve patients were not accessable and three refused to attend follow-up checks. Therefore, a total of 32 patients were included in this study with a mean follow-up interval of 43 (12-81) months. Twenty-two patients were treated using one HCS and ten with two HCS. Clinical assessment included range of motion (ROM), pain according to the visual analogue scale (VAS), grip strength, Disability of the Arm, Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien Wrist Score. The follow-up study on each patient included a CT-Scan of the wrist which was analyzed for union, osteoarthritis, dorsiflexed intercalated segment instability and humpback deformity. RESULTS: Radiologically, 29/32 (91%) of the scaphoid B2 type fractures showed union, 10/10 (100%) in the two HCS group and 19/22 (86%) in the one HCS group (p < 0.05). No significant differences could be found in respect to ROM, grip strength, VAS and scores between the groups. Screw removal was necessary in two patients in the two HCS group and one in the one HCS group. CONCLUSION: The unstable B2 type fractures of the scaphoid, when using two HCS without bone grafting is a safe method, shows a significantly higher union rate and equal clinical outcome compared to stabilization using only one HCS.

Spontaneous radioscapholunate fusion after septic arthritis of the wrist: a case report.

Bacterial septic arthritis rarely occurs in the upper extremities. Yet, early diagnosis and treatment is important, as a delay in diagnosis results in pain, impaired hand function, and degenerative joint disease. Radioscapholunate (RSL) arthrodesis is a well-established procedure for treating inflammatory arthritis and osteoarthritis (primary or posttraumatic), primarily to achieve pain relief. The wrist deformity correction offers an alternative option to total wrist arthrodesis. Indications for a RSL arthrodesis are osteoarthritis of the radiolunate and radioscaphoid joint with a concomitant intact midcarpal joint. We present a case study of spontaneous RSL fusion post wrist infection caused by a dog bite.

[Hands well - all's well : Prevention campaign of the Austrian General Accident Insurance Institution (AUVA) to reduce hand injuries]. / Hände gut ­ Alles gut : Die Präventionskampagne der österreichischen Allgemeinen Unfallversicherungsanstalt (AUVA) zur Reduzierung von Handverletzungen.

Overall, 41% of all work-related accidents lead to a hand injury. In the younger generation, the incidence rate even rises to 50%. In Austria, these accidents result in approximately half a million sick leave days per annum, an average of 12.5 days per accident. In comparison, leisure-time hand injuries show a significantly higher accident rate: 60% of hand injuries occur during leisure time. Far fewer safety measures are taken and a lack of adequate training and a disregard for safety recommendations are observed.This large number of hand injuries led to the launch of a campaign in Austria in 2014-2015 called "Hände gut - Alles Gut", (Hands well - all's well). This campaign was aimed at reducing the costs, a sum of 309 million Euros, incurred solely from work-related hand accidents, by at least 5-10%.These exorbitantly high costs are not only due to severe hand trauma, most result from a multitude of slight and superficial wounds.

[The semi-occlusive dressing in treating Allen III and IV fingertip injuries as an alternative to local skin flaps]. / Der Okklusionsverband zur Behandlung von Allen III und IV Fingerkuppenverletzungen als Alternative zu lokalen Lappenplastiken.

BACKGROUND: Fingertip injuries are very common in emergency departments. According to the literature, Allen III and IV fingertip injuries should be treated with local skin flaps. Instead, we have treated these kinds of injuries in recent years with a semi-occlusive dressing. The main purpose of this study was to evaluate the outcome after semi-occlusive dressing therapy with respect to soft tissue cover, recovery of sensibility and duration of disability. METHODS: We retrospectively analysed 77 fingertip injuries (39 Allen I, 25 Allen II, 9 Allen III, 4 Allen IV) from 2008-2011 in 23 women and 54 men who were treated with a semi-occlusive dressing. The mean age was 36 ± 14 years and the mean follow-up was seven months. The bone was not shortened even if the bone was exposed up to the wound level. The primarily occlusive dressing was left as long as possible and was sealed when necessary. Furthermore, the treatment time with the semi-occlusive dressing and the period of disability was recorded. Patient sensitivity recovery was also analysed. RESULTS: The mean treatment duration was 21 ± 10 days and the mean duration of disability was 30 ± 17 days. The mean duration of disability was 19 ± 8 days for Allen I injuries, 36 ± 16 days for Allen II, 45 ± 20 days for Allen III and 58 ± 7 days for Allen IV. All patients developed satisfactory tissue cover and sensibility recovery. For amputation injuries of Allen III and IV, we recorded a normal light-touch 2­point discrimination in the Semmes-Weinstein Test in 77 % and diminished in 23 %. There were no complications like tissue infections, neuroma or osteitis. Also, no secondary flap supply was necessary. CONCLUSIONS: The semi-occlusive dressing is a good therapy for all kind of fingertip injuries, regardless of the amputation level. Even if the bone is exposed up to the wound level, satisfactory soft tissue cover can be achieved.

Rotational stability in screw-fixed scaphoid fractures compared to plate-fixed scaphoid fractures.

BACKGROUND: The literature describes the treatment of scaphoid fractures comparing the volar and dorsal approaches, the advantages and disadvantages of percutaneous screw fixation, as well as the treatment of scaphoid nonunions using different types of cancellous or corticocancellous bone grafts. Yet, to date no studies are available comparing the outcome of rotational stability in screw-fixed scaphoid fractures to angular stable systems. The purpose of this study is to provide reliable data about rotational stability in stabilised scaphoid fractures and to gain information about the rigidity and the stability of the different types of fixation. METHODS: Three groups of different stabilisation methods on standardised scaphoid B2 fractures were tested for rotational stability. Stabilisation was achieved using one or two cannulated compression screws (CCS) or angular stable plating. We performed ten repetitive cycles up to 10°, 20° and 30° rotation, measuring the maximum torque and the average dissipated work at angle level. RESULTS: Our study showed that rotational stability using a two CCS fixation is significantly (p < 0.05) higher than single CCS fixation. Using the angular stable plate system was also superior to the single CCS (p < 0.05). There was, however, no significant difference between two CCS fixation and angular stable plate fixation. CONCLUSION: Even though indications of using screws or plate systems might be different and plate osteosynthesis may be preferable in treatment of dislocated or comminuted fractures as well as for nonunions, our study showed a better rotational stability by choosing more than just one screw for osteosynthesis. Angular stable plating of scaphoid fractures also provides more rotational stability than single CCS fixation. The authors therefore hypothesise higher union rates in scaphoid fractures using more stable fixation systems.

Early Passive Movement in flexor tendon injuries of the hand.

INTRODUCTION: Flexor tendon injuries are underestimated considering their anatomical function in the hand. According to the publications of Kleinert, Verdan and Kessler, primary suturing of the flexor tendon combined with immediate postoperative physiotherapy in terms of "Early Passive Movement" became the standard form of therapy following acute flexor tendon injuries of the hand. MATERIALS AND METHODS: In a study between 2007 and 2009, a total of 115 flexor tendon injuries were analysed retrospectively. All patients were treated using a two-strand repair technique according to Zechner. They received physiotherapy from the first postoperative day according to the Viennese flexor tendon rehabilitation protocol. For statistical purposes, the factors: age, gender, range of motion (ROM), follow up interval, affected flexor tendon and zone were analysed. The time between injury and surgery was also determined, classified into groups and included in the study. On the basis of the range of motion AROM, the Buck-Gramcko and modified Strickland Score was calculated. RESULTS: The mean follow-up interval was 7 months. Using the Buck-Gramcko and Strickland Score an "excellent" overall result was achieved. Complications occurred in 3.5 %, one secondary rupture (0.9 %), two tendon adhaesions requiring tenolysis (1.7 %) and one case of infection (0.9 %). The time interval between injury and operation, gender, affected zone, flexor tendon and affected finger nerve had no influence on the Buck-Gramcko and Strickland Score. CONCLUSIONS: Using Zechner's core suture technique as the primary treatment, combined with immediate postoperative physiotherapy in terms of "Early Passive Movement" according to the Viennese flexor tendon rehabilitation programme, an excellent clinical outcome and low complication rate was acchieved. LEVEL OF EVIDENCE: IV: case series.

[Prevention of hand injuries - current situation in Europe]. / Prävention von Handverletzungen - Aktueller Stand in Europa.

Hand injuries are a frequent occurrence and account for 41% of all occupational injuries. In general such accidents are the result of stress, inattention, tiredness, use of defective or poorly maintained machinery. However, artention must equally be directed at the large number of accidents occurring in leisure time activities since the inability to work due to a leisure time accident is similarly cost-intensive. Throughout Europe attempts have been made in the past 10 years to improve prevention. At the initiative of the Hand Trauma Committee (HTC) of FESSH prevention conferences were stated in 2009. These have in part reduced the number of hand injuries in -Europe. In Austria a special controlling committee was founded by the Austrian Workers' Compensation Board (AUVA) with the specific objective of reducing the number of hand injuries. Similarly the "Circle for Leisure Time Hand Injury Prevention" was created to specifically deal with hand injuries occurring during leisure time activities. Through the cooperation of these 2 committees and implementation of the thus decided measures, a reduction in the number of accidents involving the hand is to be expected with a concomitant reduction in the associated costs.