[Concomitant injuries of the wrist, distal ulna and distal radioulnar joint in distal radius fractures : Primary operative cotreatment vs. healing with no additional treatment]. / Begleitende Verletzungen von Karpus, distaler Elle und distalem Radioulnargelenk bei distaler Radiusfraktur : Primäre operative Mitversorgung vs. Heilung ohne zusätzliche Therapie.

Distal radius fractures are the most common fractures in adults and account for one quarter of all fractures, with increasing incidence. The number of patients and the requirement of an exact treatment are high. Continuous developments in diagnostic and operative possibilities enable in many cases a high-quality treatment with good clinical outcome; however, radius fractures rarely occur alone but in combination with additional fractures or ligamentous injuries. The frequency and extent of these injuries are not linked to the complexity of the primary injury. The aim is to recognize and correctly diagnose potential concomitant injuries. Many injuries do not need immediate treatment but heal without additional treatment after the radius has been treated. It is important to recognize those injuries which can cause severe complications if untreated; however, exactly this is often difficult. In many cases there is still no consensus if and how concomitant injuries should be treated. This article highlights the most frequent concomitant injuries in distal radius fractures with the possible advantages and disadvantages of cotreatment in order to facilitate decision making.

Cone-beam computed tomography in the treatment of distal radius fractures / Digitale Volumentomografie bei der Behandlung von Radiusfrakturen.

Cone-beam computed tomography (CBCT) is a relatively new imaging technique in hand surgery. Being the most common fractures in adults, distal radius fractures are of special importance not only to hand surgeons. The quantity alone calls for fast, efficient and reliable diagnostic procedures. Surgical techniques and possibilities are progressing, especially regarding intra-articular fracture patterns. The demand for exact anatomic reduction is high. There is an overall consensus regarding the indication for preoperative three-dimensional imaging and it is frequently used. Typically, it is obtained by multi-detector computed tomography (MDCT). Postoperative diagnostic procedures are usually limited to plain x-rays. Commonly accepted recommendations regarding postoperative 3D imaging are not yet established. There is a lack of relevant literature. In case of an indication for a postoperative CT scan, it is generally also obtained by MDCT. CBCT for the wrist is not widely used as yet. This review focuses on the potential role of CBCT in the perioperative management of distal radius fractures. CBCT allows for high-resolution imaging with a potentially lower radiation dose compared with MDCT, both with and without implants. It is easily available and can be operated independently, thus being time-efficient and making daily practice easier. Due to its many advantages, CBCT is a recommendable alternative to MDCT in the perioperative management of distal radius fractures.

Clinical Outcomes of Arthroscopic Ligament-Sparing Dorsal Capsulodesis for Partial Scapholunate Ligament Tear.

Introduction Various wrist arthroscopy techniques can be used in the management of scapholunate ligament (SLL) partial tears but their success has not been proven. Arthroscopic techniques including thermal shrinkage are becoming more popular in the management of partial SLL injuries. We hypothesized that arthroscopic ligament-sparing capsular tightening yields reliable and satisfactory results for the management of partial SLL tears. Methods A prospective cohort study was conducted on adult (age ≥18 years) patients with chronic partial SLL tears. All patients failed a trial of conservative management consisting of scapholunate strengthening exercises. Patients underwent an arthroscopic dorsal capsular tightening of the radiocarpal joint capsule radial to the origin of the dorsal radiocarpal ligament and proximal to the dorsal intercarpal ligament by either thermal shrinkage or dorsal capsule abrasion. Demographic data, radiological outcomes, patient-rated outcome measures and objective measures of wrist range of motion (ROM), and grip and pinch strength were recorded. Postoperative outcome scores were collected at 3, 6, 12, and 24 months. Data are reported as median and interquartile range, and comparisons were drawn between baseline and last follow-up. Clinical outcome data were analyzed using a linear mixed model method, while radiographic outcomes were assessed with nonparametric analysis with p < 0.05 indicating statistical significance. Results Twenty-three wrists (22 patients) underwent SLL treatment by thermal capsular shrinkage (19 wrists) or dorsal capsular abrasion (4 wrists). Median age at surgery was 41 years (range: 32-48) and median follow-up time was 12 months (range: 3-24). Pain significantly decreased from 62 (45-76) to 18 (7-41) and satisfaction significantly increased from 2 (0-24) to 86 (52-92). Patient-Rated Wrist and Hand Evaluation and Quick Disabilities of the Arm, Shoulder, and Hand significantly improved from 68 (38-78) to 34 (13-49) and from 48 (27-55) to 36 (4-58), respectively. Median grip and tip pinch strength significantly increased at final review. Range of movement and lateral pinch strength were satisfactory and maintained. Four patients required further surgery for ongoing pain or reinjury. All were successfully managed with partial wrist fusion or wrist denervation. Conclusion Arthroscopic ligament-sparing dorsal capsular tightening is a safe and effective treatment for partial SLL tears. Dorsal capsular tightening demonstrates good pain relief and patient satisfaction while improving patient-reported outcomes, grip strength, and maintaining ROM. Longer term studies are required to determine the longevity of these results.

[WALANT - Wide Awake Local Anaesthesia No Tourniquet: Complications in elective and acute traumatological Hand Surgery Procedures]. / WALANT ­ Wide Awake Local Anaesthesia No Tourniquet: Komplikationen bei elektiven und akut-traumatologischen handchirurgischen Eingriffen.

INTRODUCTION: The WALANT (Wide Awake Local Anaesthesia No Tourniquet) technique has rapidly gained popularity. The advantages are often described, whereas information about complications is rare. Therefore, we followed up on our own patients regarding complications.Patients and Method Between January 2013 und June 2017, the complications experienced by one single surgeon were evaluated. The study included all elective (n = 195) and acute (n = 90) surgical procedures performed in WALANT. Minimum age of the patients was 18 years. All patients received Articaine 1 % and Suprarenine (1:200.000). Different volumes were injected with a minimum delay to surgery of 30 minutes. Complications were identified retrospectively by evaluation of patient files and a survey via telephone using a standardised questionnaire. Mean follow-up was 73 weeks. RESULTS: In 285 patients, there were 13 (4.6 %) complications. After injection of 16 ml of Articaine/Suprarenine, one patient had coronary symptoms, which ceased when two puffs of nitroglycerin spray were given. In one patient with a neurovascular injury in the palm, a bloodless field could not be obtained. A short tourniquet time was necessary for exploration. In one patient undergoing flexor tendon tenolysis, there was a need to convert to general anaesthesia with tourniquet because there was insufficient vasoconstriction due to marked scar tissue. One patient had an erythema around the injection site for a prolonged time, two had extensive erythema on the dorsum of the hand and seven patients reported swelling of the hand that lasted more than one week. SUMMARY: The WALANT method is safe. Perioperative complications are rare. Nevertheless, there are some disadvantages that should be considered.Vascular injuries, especially in fingers, are to be monitored closely regarding perfusion, and the off-label use should be remembered. Also, caution should be exercised in patients with cardiac disease. Larger injuries may need a short tourniquet time. Tissue that was operated on before does not always seem to be suitable for the technique as diffusion may be compromised. In rare cases, patients may suffer from prolonged erythema or swelling. Generally, patients should be evaluated for suitability to an operation in local anaesthesia.

The Declining Number of Finger Replantations in Germany.

INTRODUCTION: Data from the United States have shown that finger replantation numbers have declined significantly in recent years. It is unclear whether this is due to a decrease in amputation injuries or other reasons. MATERIALS METHODS: Since 2005, all German hospitals have been required to produce structured quality reports. Based on these reports, we analyzed finger and hand replantation development and the incidence of amputation injuries between 2006 and 2018. RESULTS: Replantations decreased by 30%, whereas amputation injuries increased slightly. In 2018, only 17 centers carried out more than 10 replantations. Most hospitals had replanted less than 4 times a year. The majority of residents participated in fewer than 1 replantation per year. Most specialists performed fewer than 1 replantation per year. The reasons for the decline in replantation remain speculative. CONCLUSIONS: However, a reduction in amputation injuries was not observed. A change in medical indications, technical skills, and economic motivations needs to be considered. A further loss of specialized technical skills and experience with replantations might be a future consequence of this trend.

Interrater-Reliabilität bei der Beurteilung von Skaphoidfrakturen in CT-Aufnahmen des Skaphoids in der Ebene des Handgelenkes vs. in der Ebene der langen Achse des Skaphoids.

BACKGROUND: Because of its form, size and position, the scaphoid is known to be the foundation stone of the carpus, with an exceptionally important biomechanical function. Therefore evaluation of fracture morphology is essential. Experts already agree that computed tomography (CT scan) in the long axis of the scaphoid is the best approach for diagnosing scaphoid fractures, but also for therapy planning. But this method is hardly a standard in most hospitals and studies showing superiority of this technique for therapy planning are non-existent. HYPOTHESIS: The purpose of this retrospective study was to test if the interobserver reliability for the evaluation of scaphoid fracture morphology in CT scans in the long axis of the scaphoid is greater than in CT scans in the plane of the wrist, and thus more reliable. METHOD: 42 patients with scaphoid fractures had a CT scan in the long axis of the scaphoid (CT-scaphoid). CT reformations along planes relative to the wrist (CT -wrist) were made. Those 84 cases were anonymised and put in a random order. They were presented to 4 clinical observers (2 hand surgeons and 2 radiologists) for fracture evaluation with respect to: localisation, humpback deformity, offset (radial/ulnar and palmar/dorsal) and classification by Herbert. Surgeons have to select a palmar or dorsal approach as well as an open or percutaneous technique. Statistical analysis was made between 2 and 4 observers by an impartial statistician, using Cohen's kappa coefficient, Pearson coefficient, Fleiss' kappa, interclass correlation coefficient (Shrout and Fleiss) and Spearman rho coefficient. RESULTS: In all evaluated parameters, the interobserver reliabilty was higher in the CT scan in the long axis of the scaphoid, although statistical significance was only found for the humpback deformity. CONCLUSION: For evaluation and understanding scaphoid fractures, the CT scan along the long axis of the scaphoid is more significant and reliable than the scan in the plane of the wrist and is therefore preferable.