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.

The Treatment of Closed Finger and Metacarpal Fractures.

BACKGROUND: Fractures of the fingers and metacarpal bones are the most common fracture type in the upper limb, with an incidence of 114 to 1483 per 100 000 persons per year. The clinical importance of closed finger and metacarpal fractures is often underestimated; inadequate diagnostic and therapeutic measures may result in serious harm. This review concerns the basic elements of the diagnosis and treatment of finger and metacarpal fractures. METHODS: This review of the incidence, diagnosis and treatment of finger and metacarpal fractures is based on pertinent publications retrieved by a selective search of the literature. RESULTS: The main focus of treatment lies on restoration of hand function in consideration of the requirements of the individual patient. The currently available evidence provides little guidance to optimal treatment (level II evidence). Although most closed fractures can be managed conservatively, individualized surgical treatment is advisable in comminuted fractures and fractures with a relevant degree of torsional malposition, axis deviation, or shortening, as well as in intra-articular fractures. Minimally invasive techniques are, in principle, to be performed wherever possible, yet open surgery is sometimes needed because of fracture morphology. Postsurgical complication rates are in the range of 32-36%, with joint fusion accounting for 67-76% of the complications. 15% involve delayed fracture healing and pseudarthrosis. CONCLUSION: Individualized treatment for finger and metacarpal fractures can improve patients' outcomes, with major socioeconomic and societal benefits. Further high-quality studies evaluating the relative merits of the available treatments are needed as a guide to optimized therapy.

[Arthroplasty of the hand and wrist]. / Endoprothetik an Hand und Handgelenk.

Arthrosis and autoimmune arthritis frequently lead to major impairment of hand function. Primary therapy consists of well- tried conservative treatments and joint preserving surgical options for special indications. In advanced stages silicon spacers remain the gold standard surgical option for replacement of proximal interphalangeal and metacarpophalgeal joints of the fingers. Alternatively, surface replacement prostheses can restore the biomechanical properties of these joints more porperly. In case of the carpometacarpal (CMC) joint of the thumb, arthroplasty is gaining popularity as modern implants show excellent mid-term outcome. Although current forth generation implants for wrist replacement are promising, total wrist arthroplasty is currently reserved for exceptional indications.

[Radiocarpal dislocations and fracture dislocations]. / Radiokarpale Luxationen und Luxationsfrakturen.

Radiocarpal dislocations and fracture dislocations are rare but always severe and complex injuries. They occur frequently in young and active patients as a result of high energy accidents. A detailed clinical and imaging examination and an accurate classification leads to a suitable and mostly surgical treatment strategy. The strategy should consider the most important components of the injury, the bony, the ligamentous and the intracarpal lesions. Delayed sequelae, residual pain and functional impairment are frequent after these severe injuries, but with adequate treatment, good, even long-term functional results are possible.

[Resection arthroplasty for thumb basal joint arthritis]. / Die Resektionsarthroplastik bei Rhizarthrose.

Due to the crucial role of the thumb for gripping, osteoarthritis of the first carpometacarpal joint leads to a substantial impairment of hand function. There are effective nonoperative and joint-preserving surgical treatment options for early stages of the disease. In advanced cases, after exploiting conservative treatment, carpometacarpal thumb arthrodesis or arthroplasty may be indicated in selected cases but trapeziectomy with or without interposition or suspension constitutes the gold standard surgical procedure. This reliably provides favorable results, irrespective of the technique, with pain relief, good physical function, excellent patient global assessment and low complication rates.

[Pyogenic Flexor Tenosynovitis]. / Infektionen der Beugesehnenscheide.

Pyogenic flexor tenosynovitis (PFT) is still the most serious infections of the hand. If the typical cardinal signs of PFT according to Kanavel exist, the indication for surgery should be made immediately. The consequential damage of a delayed surgery with enormous restrictions on the movement of the fingers due to the destruction of the sliding layers and massive adhesions are so serious that conservative therapy attempts are very difficult to justify. The results of Hand therapy after delayed surgery are often disappointing. The rapid surgical intervention and the early opening and relief as well as the irrigation of the tendon sheath can end the disease, the destruction of the sliding layers and the severe pain almost immediately. Quick recognition and quick action are important. With early intervention, normal hand function can often be completely restored.

[Resection arthoplasty of the trapezium with ligament reconstruction and tendon interposition and variations]. / Resektionsarthroplastik des Daumensattelgelenks mit ihren Varianten.

OBJECTIVE: Creation of a pain-free, flexible and stable (pseudo) joint between the carpus and the base of the 1st metacarpal bone. INDICATIONS: Painful carpometacarpal (CMC)­I joint due to primary or secondary osteoarthritis, CMC­I instability. CONTRAINDICATIONS: Carpal instability, local infection, tumors. SURGICAL TECHNIQUE: Resection of the trapezium (and of the arthritic joint surfaces in CMC­I and STT [scaphoid-trapezium-trapezoid-joint]), stabilization of the base of the 1st metacarpal bone by suspension with a distally pedicled strip of the flexor carpi radialis tendon or variants thereof. POSTOPERATIVE MANAGEMENT: Immobilization in a splint for 3-5 weeks, followed by hand therapy. RESULTS: Worldwide for almost 40 years, regardless of the exact technique, almost always (90%) significant pain reduction, increased strength in the grip and slightly less in the pinch grip, very good mobility, 85-95% very satisfied patients and very good long-term results.

[Extensor tendon injuries of fingers in the region of the metacarpophalangeal joint (zone V)]. / Strecksehnenverletzungen der Finger im Bereich der Grundgelenke (Zone V).

Due to the exposed situation of the extension side of the metacarpophalangeal joint when the fingers are bent, injuries in this region are not uncommon. The extensor apparatus lies directly below the skin and the various parts can be easily injured. Due to the complex anatomical structure, the different clinical appearances and the various forms of treatment, injuries of the extensor tendons in the region of the metacarpophalangeal joint must be examined in a very differentiated manner. The not uncommonly occurring deviation phenomenon makes all injuries in zone V suspicious and special attention must be paid to them. The alarming multitude of revision surgeries with tenolysis, arthrolysis and restoration of the balance of extensor tendons or centering show that these operations are much more demanding than the way they are appreciated in the literature and by many surgeons (beginner's operation). The article presents the surgical treatment with suture techniques and reconstruction possibilities as well as the aftercare, in addition to the special anatomy and diagnostics.

[Fractures of the carpal bones without the scaphoid bone]. / Frakturen der Handwurzel ohne Os scaphoideum.

With the exception of the relatively frequent fractures of the scaphoid bone, isolated fractures of individual carpal bones are rare. Because these injuries are uncommon and because of the complex anatomy and function of the carpus, treatment of carpal bone fractures can be challenging. Carpal bone fractures generally occur in young, sports active and professional patients, can be easily overlooked in plain radiographs and are frequently associated with ligamentous instability, neurovascular injuries and tendon lesions. Small posttraumatic alterations of the precisely aligned carpal structure can cause chronic pain and functional impairment. Therefore, if a wrist fracture is suspected a thorough clinical examination and appropriate differentiated imaging is always necessary, at the end of which a fracture can be excluded or an appropriate conservative or surgical treatment is initiated, with the aim of restoration of carpal anatomy and function.

The Proximal Femoral Bone Geometry in Plain Radiographs.

BACKGROUND: Osteoporosis represents the most common bone disease and has to be respected in planning total hip replacement, especially against the background of increasing uncemented total hip replacement. In this context, the radiographic geometry of the proximal femur got into focus and is controversially discussed.The aim of the presented study was to find any difference regarding known indices for proximal femur bone geometry between patients with high-grade osteoarthritis and patients suffering from a femoral neck fracture caused by low impact trauma. METHODS: Retrospective matched-paired analysis of 100 plane pelvic radiographs from 50 patients who suffered from high-grade hip osteoarthritis and 50 patients who suffered from femoral neck fracture was performed. Measurement of Canal-Bone Ratio (CBR), Canal-Calcar Ratio (CCR), Mineral Cortical Index (MCI) and Canal Flare Index (CFI) were performed. RESULTS: CBR was significantly higher in the fracture-group (0.45 +/- 0.06 vs. 0.41 +/- 0.08) (P-value= 0.008). Moreover, the femoral thickness 10 cm below the trochanter minor [F] was significantly higher in the osteoarthritis-group (34.68 +/- 4.14 vs 32.11 +/- 3.43) (P-value 0.001). CONCLUSION: In conclusion, patients with a femoral neck fracture demonstrated a higher CBR, which indicates a poorer bone quality. In case of planning a THA, the CBR is an index which can easily be measured and can be seen as one decision criterion in THA regarding fixation technique.

[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.

Distal radioulnar joint instability: current concepts of treatment.

Distal radioulnar joint (DRUJ) instability is often an underestimated or missed lesion which may entail fatal consequences. The triangular fibrocartilage complex is a biomechanically very important stabilizer of the DRUJ and guarantees unrestricted range of motion of the forearm. To detect DRUJ instability a systematic examination is of uppermost importance. The contralateral healthy arm will be used for comparison during clinical examination. X-rays are required to exclude osseous lesions or deformities. Computed tomography of both wrists in neutral forearm rotation, supination, and pronation may be necessary to verify DRUJ instability in ambiguous situations. Following a systematic clinical examination wrist and DRUJ arthroscopy detects lesions definitely. Tears of the distal radioulnar ligaments which entail DRUJ instability should be repaired preferably anatomically. Ulnar-sided ligament ruptures which cause instability are detected more often than radial-sided ones. Osseous ligament avulsions are mostly refixated osteosynthetically. Ligamentous tears of the distal radioulnar ligaments may be reconstructed using anchor suture or transosseous refixation. Secondary procedures such as tendon transplants are necessary for anatomical reconstruction in cases of unrepairable ligament tears.

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.

[Secondary reconstruction of flexor tendons]. / Sekundäre Wiederherstellung von Beugesehnen.

The secondary reconstruction of flexor tendons is in most cases very demanding and tedious. The indications, selection of the correct surgical procedure, operative technique and further treatment have to be individually adjusted and are mostly very difficult. Due to the previous operations unpleasant surprises may occur intraoperatively, which must be recognized and treated by the surgeon. Nevertheless, a significant improvement of the function of the whole hand can be achieved for most patients, e.g. by a two-stage flexor tendon transplantation or other techniques described in this article.

[Reconstruction of the deep fibers of the distal radioulnar ligaments facilitating a tendon graft-Adams' procedure]. / Rekonstruktion der tiefen Anteile der distalen radioulnaren Bandstrukturen mit einem Sehnentransplantat ­ Operation nach Adams.

GOAL: Anatomical reconstruction of the deep fibers of the distal radioulnar ligaments to stabilise the distal radioulnar joint. INDICATIONS: Multidirectional instability of the distal radioulnar joint without the possibility for anatomic refixation of the distal radioulnar ligaments. CONTRAINDICATIONS: General operative contraindications, infection, insufficient soft tissue coverage, osteoarthritis of the distal radioulnar joint, excessive ulna impaction syndrome, osseous deformation. SURGICAL TECHNIQUE: Dorsal approach to the distal radioulnar joint, preparation of the ulna head, transosseous transfer of tendon graft through the distal ulnar corner of the radius at the sigmoid notch, transfer through the ulnar fovea and transosseous fixation within the ulna head using an interference screw. POSTOPERATIVE MANAGEMENT: Long arm cast for 4-6 weeks, then Bowers splint for further 4 weeks; optional long arm orthosis without limiting elbow flexion and extension for 4-6 weeks, then Bowers splint for further 4 weeks; starting exercises after 12 weeks. RESULTS: Reconstruction of the distal radioulnar ligaments using tendon grafts stabilises the distal radioulnar joint with restoration of joint kinematics.

Non-vascularized partial joint transfer for Finger Proximal Interphalangeal joint reconstruction: a series of 9 patients.

INTRODUCTION: Finger proximal interphalangeal joint (PIP) reconstruction after the destruction of parts of the joint remains challenging. Surgical techniques include implant arthroplasty, arthrodesis, free vascularized joint transfer, and non-vascularized bone and joint transfer. This study analyzes our experience after non-vascularized transfer in terms of range of motion, postoperative rehabilitation, and patient satisfaction. MATERIALS AND METHODS: Between 2009 and 2014, ten patients underwent non-vascularized partial joint transfer for PIP joint reconstruction. One of them was lost to follow-up. Included patients had osteochondral partial joint transplants of 25-50% of the toes (n = 4) and the hand (n = 5). Range of motion (ROM), grip-, and pinch-strength were measured at the last follow-up control and compared to the healthy side. Patients were asked to score the pain at rest/ on load on a visual scale (VAS: 0 = no pain; 10 = excruciating pain). Satisfaction self-assessment was evaluated by asking the patients to grade their postoperative result as excellent, very good, good or poor. RESULTS: Mean follow-up period was 4.0 years (range 1.2-7.9 years). Mean PIP joint flexion was 93 ± 26° at the last follow-up control. Mean grip- and pinch-strength of the operated side at the last control were, respectively, 43 ± 18 kg and 8 ± 5 kg, close to the healthy side values (45 ± 15 kg and 9 ± 4 kg). Mean pain at rest/on load measured on a visual scale was, respectively, 0.3 ± 1 and 1.8 ± 2. Eight patients (89%) rated their operation as excellent, and one as poor. CONCLUSION: In this study, non-vascularized partial joint transfer provides a mobile and stable PIP joint 4 years after reconstruction. The surgical technique presented herein is complex depending on additional injuries but results in great patient satisfaction.