Treatment goals for distal radius fractures in 2018: recommendations and practical advice.

The goals of distal radius fracture treatment in patients above 65 years of age would not change over time if the fracture were the only factor to consider. However, people change, and fixation methods also change. Since this fracture heals in nearly every case and volar plates have eliminated the worry of malunion, we are left with two main goals. In active patients with weakened bones, the aim is to help them regain their quality of life as quickly as possible while avoiding iatrogenic conditions. This compromise is possible because of new tools-but at what price?

Cementless and locked prosthesis for the treatment of 3-part and 4-part proximal humerus fractures: prospective clinical evaluation of hemi- and reverse arthroplasty.

INTRODUCTION: Cemented stem remains the gold standard for prosthesis in trauma. The purpose of this study was to evaluate the functional and radiological outcomes of a cementless, trauma-specific locked stem (hemi and reverse) for 3- and 4-part proximal humeral fractures. MATERIALS AND METHODS: One hundred and thirty-four 3- and 4-part fractures have been treated by locked stem, 69 with hemiarthroplasty [mean age 68 years (50-90)] and 65 with reversed [mean age 78 years (66-91)]. The length of the stem was 15 cm with a proximal coating of HA automatic locking system (two screws) and four different diameters. Preliminary cadaver study allowed us to validate the system (22 shoulders, no injuries of nerves, locking system efficient). RESULTS: In the group of hemi, Constant score with ponderation reached 72 (11-120) and QDash 31.2 (4.5-77.27) with a mean FU of 25 months (6-96). In the group of reversed, Constant score with ponderation reached 77.6 (28.8-119) and QDash 36.2 (2-84) with a mean FU of 15 months (6-41). Specific complications due to locking system reached 3% but without reoperation. Other complications were capsulitis and infection. DISCUSSION: In this population of elderly patient, new fall with periprosthetic fracture or infection led the surgeon to remove the stem. At shoulder level, the removal of a cemented stem remains a highly demanding procedure with sometimes bad functional results and elevated level of complications. This series is the first one of locked stem without significant complications. Locked stem remains a new but logical tool in trauma.

[The chondrocostal graft to treat articular distal radius malunion]. / Place du greffon chondrocostal dans le traitement des cals vicieux articulaires de l'extrémité distale du radius.

Intra-articular malunion of the distal radius in high-demand patients can be treated reliably with an osteocartilaginous autograft from the rib. This graft is simple to harvest and it is used to resurface the carpal articular surface of the radius.

Proximal ulnar fractures in adults: a review of 163 cases.

The aim of this study was to report the epidemiological characteristics and the experience of 5 departments of trauma, in France, in the management of fractures of the proximal ulna. 163 patients with fractures of the proximal ulna with a mean age of 49.9 years (range 16-97) were managed. The most common mode of injury was a motor vehicle collision (48%). 18% sustained associated injuries to the ipsilateral limb. Open fractures were present in 42 patients (25%). A total of 109 patients had a fracture of the olecranon, with the Mayo 2A and B types most frequently seen (66%). The patients were invited for clinical examination at a mean duration of 16 months, retrospectively. Validated patient-oriented assessment scores involving the Mayo Elbow Performance Index (MEPI) and the Broberg and Morrey score were evaluated. All patients had follow-up radiographs. The mean arc of elbow motion was 130° (70-150°). The mean MEPI was 91 (20-100) with good results in 23% and excellent results in 52% of the patients. The mean Broberg and Morrey score was 90 after isolated olecranon fracture, and decreased with the complexity of the lesion. 117 fractures (72%) healed with ulnohumeral congruity. 9 fracture non-unions occurred (6%). Although the fracture of the proximal ulna can be described in several classifications, none of them accommodate it satisfactorily, because of the complexity of the lesion. The coronoid process is the keystone for the stability of the elbow. It forms the anterior buttress with the radial head. Tension band wire fixation is by far the commonest technique of internal fixation used for the treatment of non-comminuted olecranon fractures. Dorsal plate fixation is a useful option by providing improved fixation of complex comminuted fractures and fracture-dislocations. The radiocapitellar joint has to be restored appropriately, preserving the radial head when possible and replacing it with a prosthesis otherwise. The lateral collateral ligament complex is commonly disrupted and usually can be reattached to its origin from the lateral epicondyle. In addition, a brief period of hinged external fixation should be considered.

Interest of emergency arthroscopic stabilization in primary shoulder dislocation in young athletes.

INTRODUCTION: The recurrence rate after primary shoulder dislocation in young subjects with high functional demand is close to 75%. The present study assessed the interest of emergency arthroscopic stabilization in this specific population. MATERIAL AND METHODS: A non-randomized prospective study included 31 athletes under 30 years of age with primary anterior shoulder dislocation. Fifteen were offered emergency stabilization; after informed consent, 14 were enrolled in the "emergency stabilization" group. This was compared to a group matched for age, sport and lesion, managed 1 year previously by "non-operative" treatment (n=17), divided into 2 subgroups: "immobilization" and "secondary stabilization". Continuous prospective assessment of recurrence, return to sport and function (QuickDASH, QDsport, Duplay and Rowe scores) enabled comparison between the 3 groups. RESULTS: Mean follow-up was 19 months for the "emergency stabilization" group and 25 months for the "non-operative" group. There were no failures in the "emergency stabilization" group, compared to a 77% rate in the "non-operative" group with onset at a mean 7.5 months and a mean 2.6 episodes of recurrence. Seven (54%) of the failures of non-operative treatment required secondary stabilization. Ninety-three percent of the "emergency stabilization" group, 44% of the "immobilization" group and 71% of the "secondary stabilization" group resumed sport at least at their pre-dislocation level. Mean Quick DASH was 1.46 in the "emergency stabilization" group, versus 15.28 the "immobilization" group (P<0.05) and 16.96 in the "secondary stabilization" group. Mean Duplay and Rowe scores were respectively 92.9 and 95 in the "emergency stabilization" group, versus 59.44 and 61.1 in the "immobilization" group (P<0.05) and 85 and 93.57 in the "secondary stabilization" group. DISCUSSION: Emergency arthroscopic stabilization limits recurrence (Kirkley et al.), with better functional results than for secondary stabilization, lesion "freshness" providing a more favorable environment for labral and ligamentary healing. These encouraging results need confirmation over longer follow-up.

Technical note: How to spare the pronator quadratus during MIPO of distal radius fractures by using a mini-volar plate.

Few surgical approaches have been described that spare the pronator quadratus (PQ) during the treatment of distal radius fractures. The PQ supplies blood to the distal radial epiphysis, helps stabilize the distal radio-ulnar joint, and contributes 21% of pronation strength. Sparing the PQ should result in faster bone union and shorter recovery time. To achieve these goals, we currently use a minimally-invasive volar procedure using a specially-designed short plate (APTUS Wrist 2.5 XS, Medartis(©)). A 20mm incision is made over the fracture line as described by Henry. The PQ is dissected and then detached from the volar side of the radius. Forceps are used to slide the plate under the muscle. The screws are locked after carefully elevating the distal edge of the PQ. A preliminary study of distal radius fracture fixation by this technique was performed in 31 patients. The scar was 26mm in length and the duration of surgery was 34minutes on average. Patients wore a removable brace for 15 days, and passive wrist motion without loading was allowed during the first week. Functional recovery was faster than seen in previously published series. An average Quick DASH score of 10 was achieved by the 10th post-operative week. Although there are no contraindications to this technique, the quality of the reduction is more important than the scar size and desire to spare the PQ. Never hesitate to convert the incision to a classical Henry approach if technical difficulties arise. Our technique seems best suited to patients with high functional demands. It is currently being evaluated in a prospective series.

Fixation of distal radius fractures in adults: a review.

In patients for whom function is a priority, anatomic reduction and stable fixation are prerequisites for good outcomes. Several therapeutic options exist, including orthopedic treatment and internal fixation with pins (intra- and extrafocal), external fixation which may or may not bridge the wrist, and different internal fixation techniques with dorsal or palmar plates using or not, locking screws. Arthroscopy may be necessary in case of articular fracture. In the presence of significant metaphyseal bone defects, filling of the comminution with phosphocalcic cements provides better graft stability. The level of evidence is too low to allow recommending one type of fixation for one type of fracture; and different fixation options to achieve stable reduction exist, each with its own specific complications. With the new generations of palmar plate, secondary displacement is becoming a thing of the past.

[Anatomy and biomechanics of distal radius fractures: a literature review]. / Aspects anatomiques et biomécaniques des fractures du radius distal de l'adulte : revue de la littérature.

Distal radius fractures remain the most frequent fractures in the adult. Associated osteoporosis increases morbidity risk (secondary displacement is the most frequent) and mortality risk (in women older than 60). Severity of the fracture and functional results are related to the bone mineral density. Anatomy has been recently revisited with better description of palmar and dorsal aspects in order to avoid material-related complications. Standard postero-anterior, lateral and oblique radiographs of the wrist show the fracture and the displacement. CT scan is warranted if conventional X-rays are insufficient to show the articular surface. The involvement of the metaphysis (comminution), the epiphysis (articular fracture) and the ulna is different in each case and each fracture is an association of these three components. The MEU classification describes the fracture with sufficient inter-observer reliability and intra-observer reproducibility to be a useful tool for treatment and prognosis. The PAF system is used to propose the most appropriate treatment for each patient. Anatomical reduction and stable fixation are associated with good functional results but in high demanding patients.

Post-traumatic malunion of the distal radius treated with autologous costal cartilage graft: a technical note on seven cases.

UNLABELLED: Seven cases of post-traumatic intra-articular malunion of the distal radius treated using costal cartilage graft with a minimum follow-up of 2 years are reported. Location of the articular defect was dorsal in two cases and volar in the others. The approach (dorsal or volar) depended on the main location of the defect. A costal cartilage graft harvested on the eighth rib was implanted in a trough created at the epiphysis metaphyseal junction. This trough removed the defective area on the distal radius articular surface. A plate or wire fixation was used to stabilize in place the graft. Plaster cast wear was prescribed for 3 months in the first case and for 1 month in the other cases following joint reconstruction. No complications were observed. Union was achieved in all seven cases. Graft integration and viability were evaluated with MRI and biopsy. At the longest follow-up, the functional results were excellent in the first (youngest) case (male, 22 years old) in whom motion and grasp were similar to the contralateral side. In the other cases of malunion, the patients were pain-free in daily activities with a functional wrist score of 72/100 (range, 54-82) and a DASH score of 38.3 (range, 22.5-51.7). Only the case with a septic problem failed, with pain reported at follow-up. Reconstruction of a partially destroyed articular surface using a costal graft is reliable and allows filling and resurfacing an articular cartilage void. Although costal cartilage graft is currently used in maxillofacial surgery, this is the first report in post-traumatic osteoarthritis secondary to intra-articular malunion. LEVEL OF EVIDENCE: Level IV.

[New treatment of advanced Kienböck disease: replacement of lunate with costochondral autograft]. / Nouveau traitement de la maladie de Kienböck avancée : remplacement du semi-lunaire par greffon cartilagineux costal.

Treatment of advanced Kienböck's disease (Lichtmann IV) is commonly proximal row carpectomy or partial arthrodesis. The purpose of this study is to evaluate a more conservative treatment of advanced Kienböck's disease for young people: replacement of the lunate with a costochondral autograft. Between 2007 and 2009, four patients of mean age 40 years (32-51) were operated by two surgeons using this technique. This is a prospective study with a final follow-up by an independent operator. Mean follow-up was 27 months (6-36). Surgery is in two stages: excision of lunate and replacement with costochondral autograft taken from the ninth rib. Patients were evaluated with DASH and Cooney scores, pain, satisfaction, mobility and strength. Results show disappearance of pain at rest and during daily activities for all patients and a mean DASH of 6. Flexion-extension was 108° and grip strength 83% compared with the opposite side. Radiological evaluation showed no disease evolution. No complication was noted. Functional improvement was significant with good results compared to conventional techniques. Alternative techniques have been proposed for the replacement of the lunate, each with its specific problems. Lunate replacement by a costochondral graft is possible because studies showed vitality of this free graft up to five years. It also allows subsequent surgery. The absence of carpal collapse and good functional results are encouraging but the follow up is short. A long-term study is needed to confirm findings.

Proximal ulna comminuted fractures: fixation using a double-plating technique.

INTRODUCTION: Comminuted fractures of the proximal ulna are severe injuries often associated with bone and ligament injuries of the elbow joint (Monteggia lesion, radial head fractures, dislocation of the elbow). The treatment of these fractures is very demanding and the functional results often fairly mediocre due to associated injuries. Based on a single-center retrospective study, we report the results of the treatment of these fractures fixed using a double-plate technique. The aim was to evaluate the feasibility and reliability of this fixation mode and to compare it with other fractures series using a single plate fixation (in terms of bone union, elbow joint function, and complications stemming from the plates). PATIENTS AND METHODS: Eighteen patients sustained a comminuted proximal ulna fracture between 2002 and 2006. The fractures were associated in five cases with a Monteggia type lesion, in two cases with elbow dislocation, and in four cases with a Mason 3 radial head fracture. Four patients had an open fracture. These comminuted ulna fractures included nine Mayo Clinic IIIB fractures. Bone fixation was performed with two third-cylinder tubular plates, one plate on each side of the proximal ulna. This allows more versatile solutions for screw insertion. Functional assessment (according to Broberg and Morrey) and radiological evaluation (bone healing) were provided at 6 months and at the longest follow-up by an independent surgeon. RESULTS: Sixteen of 18 patients achieved bone union. No septic complications occurred and no hardware removal was required on patient request. In 67% of the cases, the Morrey score indicated excellent or good results with a mean score of 82. DISCUSSION: There are no reports in the literature on the technical point of fixation concerning complex fractures of the ulna. Two plates mean the possibility of twice the number of screw insertions for epiphyseal reconstruction . This fixation remains easy to perform and provides stable anatomic reconstruction of the ulna. LEVEL OF EVIDENCE: Level IV. Retrospective study.

[Fractures of the distal radius in patients over 70 years old: Volar plates or K-wires?]. / Les fractures du radius distal après 70 ans : ostéosynthèse par plaque palmaire ou broches ?

In a growing elderly osteoporotic population, the management of distal radius fractures remains without consensus as to volar distal plate versus K-wires. The goal of this retrospective study was to evaluate these treatments in elderly people. In a series of 38 patients over 70 years, 21 were treated by a volar plate and 17 by percutaneous K-wire fixation. Follow-up was at least 6 months. Results were analyzed using the disabilities of the arm, shoulder and hand (DASH), patient-rated wrist evaluation (PRWE) and Herzberg score by an independent operator. Radiological parameters were radio-ulnar variance, radial inclination and palmar or dorsal tilt. Radio-ulnar variance was better for the plate group (-0.7mm versus -0.1mm in K-wires). Mean functional outcomes were good but there were more satisfied patients in the plate group (67% versus 39% for the K-wire group). Secondary displacements were frequent in both groups but more with K-wires (50% versus 37% in case of plates). Six articles about surgical treatment of elderly radius distal fractures were published up to 2009 showing similar results. However, they analyze only global mean scores. Volar plates give more stability and a higher rate of satisfaction, with similar results of wrist mobility and grasp strength. The main advantage of the plates is earlier return to daily activities.

Post-traumatic reconstruction of digital joints by costal cartilage grafting: a preliminary prospective study.

In digital joint defects, reconstruction is meant to obtain a stable, mobile and pain-free finger. Six patients aged 29 years in average (15-46) and who were prospectively followed-up presented with digital joint defects that affected at least half of either the proximal interphalangeal (PIP) joint or the metacarpophalangeal (MCP) joint. These defects were treated in emergency (four cases) or scheduled for an autograft of costal cartilage harvested from the ninth rib. Four digits showed lesions of the extensor system which were repaired. One digit grafted after complete amputation was no more vascularized. All patients were reviewed and prospectively followed-up by the surgeons and were also reviewed by an independent operator 16.1 months post-surgery in average (9-25). No infection occurred. None of the grafted fingers had to undergo arthrodesis or secondary amputation. One case of type 1 complex regional pain syndrome occurred. No functional or aesthetic complaint was reported, and no complication was observed at the donor site. The mean arc of motion was 33° (20-50) for the PIP joint and 37° (30-40) for the MCP joint. Mean total active motion (TAM) was 191° (160-250°), whichever the injured finger, i.e. 79.1% compared with the contralateral finger. The Buck-Gramko score averaged 11/15 (8-15). The Strickland score (interphalangeal TAM) was 57.8%, which corresponds to a medium result. The quick DASH assessment averaged 17.42 (0-47.72). Even if arthrodesis or amputation remain the conventional option in case of joint defect, prosthesis or cartilage grafting constitute solutions that allow the preservation of a functional painless finger.

[Use of the induced membrane technique for the treatment of bone defects in the hand or wrist, in emergency]. / Pertes de substance osseuse à la main et au poignet traitées en urgence par technique de la membrane induite (technique de Masquelet).

A prospective study is reported concerning 11 cases of bone defect of the hand and wrist treated by the induced membrane technique. Ten men and one woman with an average age of 49 yrs (17-72) sustained a high-energy trauma with severe mutilation of digit and hand but with intact pulp. Eight cases of open finger fractures with composite loss of substance and three cases of bone and joint infection (thumb, wrist, fifth finger) were included. All cases were treated by the induced membrane technique which consists in stable fixation, flap if necessary, and in filling the bone defect by a cement methyl methacrylate polymere (PMMA) spacer. A secondary procedure at two months is needed where the cement is removed and the void is filled by cancellous bone. The key point of this induced membrane technique is to respect the foreign body membrane which formed around the cement spacer creating a biologic chamber. Bone union was evaluated prospectively by X-ray and CT scan by a surgeon not involved in the treatment. Failure was defined as non-union at one year, or uncontrolled sepsis at one month. Two cases failed to achieve bone union. No septic complications occurred and all septic cases were controlled. In nine cases, bone union was achieved within four months (three to 12). Evidence of osteoid formation was determined by a bone biopsy in one case. Masquelet first reported 35 cases of large tibial non-union defects treated by the induced membrane technique. The cement spacer promotes foreign body membrane induction constituting a biological chamber. Works on animal models reported by Pellissier and Viateau demonstrated membrane properties: secretion of growths factors (VEGF, TGF beta1, BMP2) and osteoinductive cellular activity. The induced membrane seems to mimic a neoperiosteum. This technique is useful in emergency or septic conditions where bone defects cannot be treated by shortening. It avoids microsurgery and is limited by availability of cancellous bone.

Extra-articular distal radius malunion: The phosphate cement alternative.

UNLABELLED: Five consecutive patients (mean age: 40.4 yrs (range, 19-58 yrs)), with symptomatic distal radius malunion underwent corrective opening wedge osteotomy using phosphate cement as an alternative to bone autograft, at a mean 9 months (4-16mo) of fracture. Internal fixation used a plate placed just above the distal radioulnar joint, with soft-tissue release. Radiographic and functional parameters were measured before surgery, and at 6 months and 1 year. At a mean 32.4 months (range, 16-47mo), all patients were satisfied and all the osteotomies were united. At 1 year's follow-up, wrist range of motion reached 75% compared to the contralateral side. Two biopsies performed during plate removal showed osteoid tissue at the cement-bone junction. It is reasonable to consider injectable phosphate cement as a viable alternative to bone grafting in conjunction with surgical correction of distal radius malunion. LEVEL OF EVIDENCE: level IV.

[Addition of antithrombosis in situ in the case of digital replantation: preliminary prospective study of 13 cases]. / Adjonction d'antithrombotiques in situ en cas de replantation digitale: étude prospective préliminaire de 13 cas.

Antithrombotic agents are not routinely used in microsurgery for finger replantation. A prospective monocentric study of 13 cases of replantation at hand level is reported with local irrigation of anastomosis with urokinase and low-molecular-weight heparin. Thirteen consecutive patients have been included and treated in the first six hours by three senior surgeons in microsurgery. The injuries consisted in one devascularisation of hand, two complete amputations of hand, four ring fingers and six complete amputations of finger. Crush injury was always pointed in case of amputation. During anastomoses, the arterial lumina were topically irrigated with 50,000 UI of urokinase and the venous lumina by 1.2 ml of Lovenox®. Bleeding was encouraged in case of digit replantation. In all cases, patients received Aspegic® 10mg/day and Fonzylane® three times per day for three weeks. Three failures have been reported and blood transfusion was necessary in one patient. The results showed that topical irrigation with urokinase and low-molecular-weight heparin or enoxaparin solution significantly reduced the thrombosis rate at the anastomosis site of the crushed arteries in clinical practice without uncontrolled adverse effect.

[The flexor digitorum superficialis flap in treatment of neuroma in continuity of the median nerve]. / Le lambeau de fléchisseur superficiel des doigts dans le traitement des névromes en continuité du nerf médian.

The purpose of the study was to evaluate the flexor digitorum superficialis flap in treatment of neuroma-in-continuity of the median nerve at the wrist. We reviewed six patients operated from September 2000 to March 2007. In all cases, daily disabling pain has been significantly reduced. Four patients are very satisfied. It is a local flap, easy to harvest with few morbidity. We compare it with the various options described for this pathology.

[Filling a humeral head defect with a chondrocostal autograft combined with subscapularis transfer for chronic posterior glenohumeral dislocations]. / Comblement d'une encoche antérieure de la tête humérale par autogreffe cartilagineuse costale et transposition du muscle sub-scapulaire dans le cadre d'une luxation postérieure invétérée de l'épaule. A propos d'un cas.

Mac Lauglhin defects of the right humeral head developed in a 44-year-old woman with drug-resistant epileptic seizures, subsequent to recurrent posterior dislocations. The preoperative work-up demonstrated a large anterior defect corresponding to more than 50% loss of the osterochondral tissue. The humeral head lodged on the posterior rim of the scapular glenoid, like an inveterate posterior dislocation, causing major pain and joint dysfunction. After adjustment of the antiepilepsy treatment, the patient underwent joint reconstruction with a chondrocostal autograft harvested from the ninth homolateral rib combined with transfer of the lesser tubercle. At three years follow-up, the patient has a stable pain-free shoulder with a satisfactory range of motion. The graft was integrated.

[Rupture of the thumb ulnar collateral ligament of the metacarpophalangeal joint: is it possible to operate according to the position of sesamoides on dynamic Xray]. / Entorse grave du pouce: opérer selon la position des sésamoïdes lors des clichés en stress.

AIM: Acute complete ruptures of the ulnar collateral ligament should be treated with surgical repair of the ligament. But diagnosis using ultrasound, dynamic X ray and magnetic resonance imaging are unable to diagnose surely the complete rupture. According to Rotella and Urpi if the radiograph shows no parallelism between the sesamoid bones and the metacarpal head, the injury of ulnar collateral ligament is total and complete and requires surgical reparation. The aim of this work was to verify the finding of Rotella and Urpi and the relationship between the lost of parallelism and the Stener lesion (interposition of adductor aponeurosis between the ruptured ulnar collateral ligament and its site of insertion on the base of the proximal phalanx). MATERIAL AND METHODS: Embalmed anatomical specimens were used to systematically investigate and document the role played in joint stability by each of the anatomical elements. Each ligament was sectioned and instability documented. A retrospective radiological study was performed on 93 patients who had an history of injured ulnar collateral ligament of the thumb. RESULTS: The anatomical study confirmed the result of Rotella and Urpi in showing that the loss of parallelism between the sesamoid bones and the metacarpal head was associated with complete rupture of ulbnar collateral ligement The clinical study showed that the lost of parallelism was associated with a Stener lesion (N=23). CONCLUSION: The association between the lost of parallelism of sesamoid bones and Stener lesion confirm that the rupture of all elements of the ulnar collateral ligament. This anatomical and clinical findings have to be confirmed by a prospective clinical study.