The Interobserver Reliability of Grading of Distal Radius Volar Plate Prominence.

PURPOSE: The 3-category rating of volar plate prominence in relation to the most volar edge of the distal radius (the watershed line) on lateral radiographs was reliable among a small group of surgeons and associated with the probability of flexor tendon irritation and potential rupture. Classifications are often less reliable when tested among a large group of practicing surgeons in different environments. METHODS: In this survey-based experiment, an international group of 115 fracture and upper extremity surgeons viewed 1 of 4 sets of 24 lateral radiographs (96 unique lateral radiographs) of patients with distal radius fractures who underwent volar plating in the practice of a single surgeon using 2 types of plates. Surgeons were asked to rate the following metrics: (1) the grade of plate prominence according to Soong, (2) whether the plate was more prominent than the watershed line, (3) whether the plate was separate from the bone distally, and (4) whether there is more than 5° of dorsal angulation of the distal radius articular surface. RESULTS: The interobserver agreement of the classification was "fair" (κ = 0.32; 95% confidence interval [CI] = 0.27-0.36), and grading was more reliable among surgeons who do not supervise trainees. Volar prominence was less reliable (κ = 0.034; 95% CI = 0.013-0.055) than plate separation from bone (κ = 0.50; 95% CI = 0.42-0.59) and more than 5° of dorsal angulation (κ = 0.42; 95% CI = 0.35-0.48). CONCLUSIONS: Among a large number of international practicing surgeons, the classification of volar plate prominence in 3 categories was fair. CLINICAL RELEVANCE: The diagnosis of plate prominence might develop toward criteria with moderate reliability, such as separation of the plate from the bone and residual angulation of the distal radius.

Rotatory subluxation of the proximal interphalangeal joint: an easily missed diagnosis.

We present a case of volar rotatory subluxation of index finger proximal interphalangeal joint (PIPJ) following a skiing accident. The injury was initially perceived to be a central slip rupture and treatment was directed as such. After the initial delay in the diagnosis, the patient underwent surgery during which his radial collateral ligament was found to be avulsed from the proximal origin, the radial lateral band palmarly subluxed and was interposed in the joint space. This structure was also adhered to the uninjured volar plate.PIPJ volar rotatory subluxation could be readily missed in the acute setting. Without surgery, the functional outcome could be mediocre and to the patient's detriment.

Uncommon hand injury to the batsman in 'gully cricket': report of two cases.

Volar plate injuries are typically caused by hyperextension of the proximal interphalangeal joint. These injuries are usually seen in sports where the ball comes in direct contact with the hands. Forceful dorsiflexion of the finger caused by the speeding ball leads to volar plate avulsion. In cricket, such finger injuries predominantly occur in fielders trying to catch or stop the speeding ball with bare hands. We report two unusual cases of volar plate avulsion injury occurring in batsmen that occurred during 'gully cricket' (street-cricket). We propose the possibility of a novel contrecoup-type mechanism causing this type of injury in the two cases. Both were successfully managed with splinting and had excellent recovery without any residual deformity or instability.

Assessment of Pronator Quadratus Repair Integrity Using Dynamic Ultrasonography Following Volar Plate Fixation for Distal Radius Fractures.

Background: Previous work evaluating the pronator quadratus (PQ) muscle following volar plate fixation (VPF) of distal radius fractures (DRF) suggests that PQ repair often fails in the postoperative period. The purpose of this investigation was to assess PQ repair integrity following VPF of DRF using dynamic musculoskeletal ultrasonography. Methods: Twenty adult patients who underwent VPF of DRF with repair of the PQ with a minimum follow-up of 3 months underwent bilateral dynamic wrist ultrasonography. The integrity of the PQ repair, wrist range of motion (ROM) and strength, and functional outcome scores were assessed. Results: Mean patient age at the time of surgery was 59 ± 14 years, and 50% underwent VPF of their dominant wrist. Patients were evaluated at a mean 9 ± 4 months after VPF. All patients had an intact PQ repair. The volar plate was completely covered by the PQ in 55% of patients and was associated with a larger PQ when compared to patients with an incompletely covered volar plate (P = .026). The flexor pollicis longus tendon was in contact with the volar plate in 20% of patients, with those patients demonstrating a trend toward significantly increased wrist flexion (P = .053). No difference in ROM, strength, or outcome scores was noted among wrists with completely or incompletely covered volar plates. Conclusions: The PQ demonstrates substantial durability after repair following VPF. Wrist ROM, strength, and functional outcomes are similar in wrists in which the volar plate is completely or incompletely covered by the repaired PQ.

Size and stabilization of the dorsoulnar fragment in AO C3-type distal radius fractures.

INTRODUCTION: Volar locking plate (VLP) fixation has become the gold-standard treatment for distal radius fractures (DRFs). Especially, internal fixation of the volar lunate facet fragment is essential for the treatment of AO C3-type DRFs. On the other hand, the necessity of the fixation of the dorsal lunate facet fragment (dorsoulnar fragment) remains unclear. The purpose of the present study was to measure three-dimensionally the size of the dorsoulnar fragments in AO C3-type DRFs using computed tomography (CT) images in detail, and to reveal relationships of the size and stabilization of the dorsoulnar fragment with postoperative fracture displacement after VLP fixation. MATERIALS AND METHODS: We retrospectively reviewed the 101 consecutive Japanese patients who underwent surgical treatment for AO C3-type distal radius fractures. If patient had dorsoulnar fragment, the three-dimensional size of this fragment and the occupying ratio to the radiocarpal joint (RCJ) and the distal radioulnar joint (DRUJ) were anatomically evaluated using the preoperative CT images. In addition, we investigated the relationship of the size and stabilization of the dorsoulnar fragment with fracture displacement after VLP fixation. We statistically compared the size parameters and occupying ratio of the dorsoulnar fragment between the displaced group and the stable groups using a two-tailed t-test. We also statistically compared the numbers of screws inserted into the dorsoulnar fragments between the displaced and stable groups using a chi-square test. RESULTS: The mean dorsoulnar fragment size was 9.4 mm × 7.9 mm × 11.0 mm and the occupying ratio to the DRUJ and RCJ was 50% and 10%, respectively. The number of patients treated with volar locking plate fixation was 77, of which 12 patients had postoperative displacements. Although the size of the dorsoulnar fragment was not associated with postoperative displacement, stabilization following screw insertion into the dorsoulnar fragment was significantly associated with displacement. CONCLUSION: Stabilization of the dorsoulnar fragment with at least one screw of the volar locking plate was necessary to prevent postoperative fracture displacement regardless of dorsoulnar fragment size in AO C3-type distal radius fractures.

Sex-related differences in carpal arch morphology.

The purpose of this study was to investigate the sex-based differences in the carpal arch morphology. Carpal arch morphology was quantified using palmar bowing and area of the arch formed by the transverse carpal ligament. The carpal arch was imaged at the distal and proximal tunnel levels using ultrasonography in 20 healthy young adults (10 women and 10 men). It was found that females had a smaller carpal arch height compared to men at both distal and proximal levels (p<0.05) and smaller carpal arch width only at the proximal level (p<0.05) but not distally. Palmar bowing index, the carpal arch height to width ratio, was significantly smaller in females at the distal level (p<0.05) but not at the proximal level. Carpal arch cross-sectional area normalized to the wrist cross-sectional area was found to be significantly smaller in females at both tunnel levels compared to men (p<0.05). This study demonstrates that females have a smaller carpal arch compared to men with a reduced palmar bowing distally and a smaller arch area at both tunnel levels. The findings help explain the higher incidence of carpal tunnel syndrome in women as a smaller carpal arch makes the median nerve more vulnerable to compression neuropathy.

Accuracy and Reliability of Radiographic Estimation of Volar Lip Fragment Size in PIP Dorsal Fracture-Dislocations.

Background: A cadaveric study was performed to evaluate the accuracy and reliability of radiographic estimation of the volar lip fragment size in proximal interphalangeal joint fracture-dislocations. Methods: Middle phalangeal base volar lip fractures of varying size and morphology were simulated in 18 digits. Radiographs and digital photographs of the middle phalangeal joint surface were obtained pre- and postinjury. Ten orthopedic surgeons of varying levels of training estimated the fracture size based on radiographs. The estimated joint involvement on radiograph was compared with the digitally measured joint involvement. Results: Radiographic estimation underestimated the volar lip fragment size by 9.02%. Estimations possessed high intraobserver (0.76-0.98) and interobserver (0.88-0.97) reliabilities. No differences were detected between levels of surgeon training. Conclusions: The significant underestimation of the volar lip fragment size demonstrates the lack of radiographic estimation accuracy and suggests that surgeons should be mindful of these results when making treatment plans.

The distal radius palmar cortical angle in adolescent versus adult populations.

PURPOSE: Volar distal radius plates are pre-contoured to aid restoration of anatomy during open reduction internal fixation of distal radius fractures. Incorrectly contoured plates can result in malreduction, leading to malunion, pain, and loss of function. The purpose of this study was to investigate whether adolescent distal radius anatomy on the palmar cortical surface differs from that in adults, in order to determine whether adult plates are suitable for use in adolescents. METHODS: Lateral wrist radiographs were used to measure the distal radius palmar cortical angle (PCA) in adolescent age groups (12-13, 14-15, and 16-17 years old) and compared to a skeletally mature control group (30-50 years old). Two assessors measured 423 PCAs twice. RESULTS: There was a statistically significant ( p = <0.05) difference in the PCA of the control group compared to each adolescent group. The mean PCA for both males and females decreased as age increased (increasing curvature of the volar distal radius with age). The mean PCA (male/female) was 164.38°/163.00° in ages 12-13, 162.14°/160.92° in ages 14-15, 157.52°/158.18° in ages 16-17, and 149.65°/154.03° in the control group aged 30-50 years. Agreement between assessors was high with an Interclass correlation coefficient (ICC) of 0.97. CONCLUSION: There is a statistically significant and potentially clinically important difference in the curvature of the distal radius volar cortex between adolescents and adults. This difference persists even in the 16-17 age group. As the PCA curvature is significantly greater in adults compared to adolescents, plates pre-contoured for adults may lead to malreduction of distal radius fractures into flexion in adolescent patients.

Swan neck deformity due to chronic radial collateral ligament injury of the little finger proximal interphalangeal joint.

We present seven cases of a relatively rare swan neck deformity resulting from chronic radial collateral ligament (RCL) injury of the proximal interphalangeal (PIP) joint in the little finger. All patients were middle-aged women (mean 51 years old, range 42-55), and the duration between the initial injury and surgery was 20 years (range 5-40). The chief complaint was painful snapping of the PIP joint. All patients had hyperextension and ulnar deviation of the PIP joint with mobile swan neck deformities that had not improved with conservative treatment. Radiographs revealed osteoarthritis and ulnar deviation of the PIP joints in all cases. We describe a method for reconstruction of both the palmar plate and the RCL of the affected PIP joint using a distally-based ulnar slip of flexor superficialis tendon. The prevention of PIP joint hyperextension was critical for successful resolution of symptoms; the aim of RCL augmentation was to prevent the recurrence of the deformity. LEVEL OF EVIDENCE: IV.

Evaluation of flexor pollicis longus tendon attrition using color Doppler imaging after volar plate fixation for distal radius fracture.

PURPOSE: Early diagnosis of attritional wear of the flexor pollicis longus (FPL) tendon is essential in preventing subsequent tendon rupture. There are currently few objective methods of assessing FPL attrition. We hypothesized that color Doppler imaging could visibly detect FPL tendon attrition, and analyzed our results. METHODS: We evaluated ultrasound imaging of the contact between the FPL tendon and a volar locking plate using the real-time B-mode and Doppler waveforms of the FPL tendon using the continuous Doppler wave mode in 40 patients who underwent fixation of the distal volar locking plate for distal radius fracture. Twenty out of 40 patients underwent plate removal surgery after ultrasound evaluation. We also assessed the relationship between the Doppler waveforms and attrition of the FPL tendon in these 20 patients. RESULTS: Based on the ultrasound findings (n = 40), we divided Doppler waveforms of the FPL tendon into three categories: type 1, spindle wave; type 2, spindle wave with spike; and type 3, spike wave. There were 23, 11, and six patients with type 1, 2, and 3 waveforms in the affected hand, respectively. There were 37 patients with type 1, three with type 2, and no patient with type 3 waveforms in the contralateral wrist. Of the 20 patients who underwent plate removal, five had type 3 waveforms. We found tendon fraying or partial tears in three of these five patients. In addition, all five patients showed changes to type 1 or 2 waveforms after plate removal. None of the other 15 patients with type 1 or 2 waveforms had any tendon injuries during plate removal. CONCLUSIONS: Spike Doppler waveform can indicate abnormal findings, and may be a useful method to predict tendon attrition, because of its visibility. DIAGNOSTIC STUDY: Level III evidence.

The Diagnostic Value of Nerve Ultrasound in an Atypical Palmar Cutaneous Nerve Lesion.

Detailed knowledge of the fascicular anatomy of peripheral nerves is important for microsurgical repair and functional electrostimulation.We report a patient with a lesion on the left palmar cutaneous branch of the median nerve (PCBMN) and sensory signs expanding outside the PCBMN cutaneous innervation territory. Nerve conduction study showed the absence of left PCBMN sensory nerve action potential, but apparently, no median nerve (MN) involvement. Nerve ultrasound documented a neuroma of the left PCBMN and a coexistent lateral neuroma of the left MN in the carpal tunnel after the PCBMN left the main nerve trunk.Nerve ultrasound may offer important information in patients with peripheral nerve lesions and atypical clinical and/or nerve conduction study findings. The present case may shed some light on the somatotopy of MN fascicles at the wrist.

Comparative study of treatment for distal radius fractures with two different palmar locking plates.

Few randomized trials have shown how the placement of a palmar locking plate affects outcomes. The purpose of this study was to compare clinical and radiological outcomes of fixation using locking plates with different concepts for placement relative to the watershed line in a prospective randomized trial. Sixty-four patients with a displaced distal radius fracture were divided into two groups according to the plates used for fixation: distal-type (AcuLoc(TM), Group A) and proximal-type (VariAx(TM), Group V). Wrist function including the range of motion and grip strength was compared at 1, 2, 3 and 6 months postoperatively. Loss of reduction was assessed radiologically. Both groups demonstrated overall satisfactory function at 6 months with no significant difference found between the groups. Minimal loss of reduction was demonstrated in both groups. Internal fixation using the palmar locking plates with two different placements provided satisfactory outcomes at 6-month follow-up, but our results indicate that plates placed distal to the watershed line may delay recovery of wrist motion.

Sonographic evaluation of effects of the volar plate on trigger finger.

BACKGROUND: We evaluated trigger fingers ultrasonographically and clarified differences between fingers with and without continuous locking or snapping symptoms according to the thicknesses of the A1 pulley, flexor tendon and volar plate. METHODS: We evaluated 26 trigger fingers, divided into two groups: Group 1, 14 fingers with locking or snapping; and Group 2, 12 fingers without such symptoms. We also evaluated 26 contralateral fingers as controls (Control 1 and 2 groups). We compared each group to the respective control group according to thickness of the A1 pulley and volar plate, and cross-sectional area of the flexor tendon. In addition, nine fingers with locking or snapping and treated using corticosteroid injection were evaluated according to symptoms and sonographic findings 3-4 weeks after treatment. RESULTS: Thickness of the A1 pulley and cross-sectional area of the flexor tendon were greater in both Groups 1 and 2 than in controls. Thickness of the volar plate was greater in Group 1 than in Control 1, although no significant difference was seen between Group 2 and Control 2. In Group 1, eight of the nine fingers showed an alleviation of locking or snapping symptoms with corticosteroid injection, and sonographic findings showed that thickness of the volar plate was significantly decreased with corticosteroid injection, in addition to reduced thickness of the A1 pulley. CONCLUSION: In addition to thickening of the A1 pulley, thickening of the volar plate may represent an important contributor to continuous snapping or locking symptoms.

A Review of Published Radiographic Indicators of Carpometacarpal Dislocation Including Their Application to Volar Dislocations Through a Case Study.

BACKGROUND: Carpometacarpal joint dislocation is an uncommon injury that is at risk of being overlooked on initial presentation. Dislocation in a volar direction is rare, with a number of case reports published in the literature. CASE REPORT: We report a case of volar dislocation at our institution, and review the application of two reported radiographic signs of carpometacarpal dislocation to volar dislocation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Radiographic signs provide an aid to the emergency physician in the busy department. These are particularly helpful to rule out rare injuries. Carpometacarpal dislocations in a volar direction risk being missed by one radiographic sign reported in the literature, as this article highlights.

Volar locking plate versus external fixation for the treatment of unstable distal radial fractures: a meta-analysis of randomized controlled trials.

BACKGROUND: The choice between volar locking plates (VLP) and external fixation (EF) for unstable distal radius fractures have not reached a consensus. The meta-analysis of randomized controlled trials was performed to compare VLP with EF to determine the dominant strategy. MATERIALS AND METHODS: Meta-analysis was performed with a systematic search of studies conducted by using the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. The randomized controlled trials that compared VLP with EF was identified. Characteristics, functional outcomes, radiological results, and complications were manually extracted from all the selected studies. RESULTS: Six studies encompassing 445 patients met the inclusion criteria. There was significant difference between two procedures in disabilities of the arm shoulder and hand scores at 3,6, and 12 mo, visual analogue scale at 6 mo, grip strength at 3 mo, supination at 3 and 6 mo, extension at 3 mo, ulnar variance at 12 mo, and reoperation rate at 12 mo, postoperatively. However, there was no significant difference between flexion, pronation, radial deviation, and ulnar deviation at all follow-up points postoperatively and overall complications at 12 mo, postoperatively. CONCLUSIONS: EF had less reoperative rate due to complications, however, VLP had advantages in functional recovery in the early period after surgery, but two methods had similar functional recovery at 12 mo, postoperatively. Clinician should make the treatment decision with great caution for the patients who sustained unstable distal radial fractures.

A comparative study about ionizing radiation emitted during radiological "skyline" view of the wrist in pronation versus supination.

The dorsal tangential view to the distal radius or "skyline," used to control the length of the screws for the ORIF with volar plates, is carried out in supination (fluoroscope vertical) or in pronation (fluoroscope horizontal). The purpose of this study was to compare the dose of ionizing radiation emitted during a "skyline" view in supination versus pronation. A "skyline" was performed on 14 fresh cadaveric wrists. In group 1, the fluoroscope was positioned vertically and the wrist was held in supination. In group 2, the fluoroscope was positioned horizontally and the wrist held in pronation. The average dose of ionizing radiation was 0.9286 cGy/cm(2) (group 1) and 0.8751 cGy/cm(2) (group 2). The difference was not statistically significant. Overall, the emitted dose for the "skyline" is negligible compared to that of a standard wrist radiography with no difference between the vertical and horizontal positioning. Peroperatively, the vertical "skyline" seems easier to setup, less time consuming and less prone to asepsis faults.

Volar morphology of the distal radius in axial planes: a quantitative analysis.

To investigate the cause of rupture of the flexor pollicis longus (FPL) after volar plate fixation of distal radius fractures, previous studies have examined the shape of the distal radius in the sagittal plane or in the lateral view. However, there are no reports on the anatomical shape of the volar surface concavity of the distal radius in the axial plane. We hypothesized that this concavity might contribute to the mismatch between the plate and the surface of the radius. To test this hypothesis, we constructed three-dimensional models of the radius and FPL based on computed tomography scans of 70 normal forearms. We analyzed axial cross-sectional views with 2 mm intervals. In all cases, the volar surface of the distal radius was concave in the axial plane. The concavity depth was maximum at 6 mm proximal to the palmar edge of the lunate fossa and progressively decreased toward the proximal radius. FPL was closest to the radius at 2 mm proximal to the palmar edge of the lunate fossa. The volar surface of the distal radius was externally rotated from proximal to distal. These results may help to develop new implants which fit better to the radius and decrease tendon irritation.

Restoration of the volar cortex: predicting instability after manipulation of distal radial fractures.

INTRODUCTION: Distal radial fractures are one of the most common fractures that are presented to the emergency department (ed). The management of non-emergent cases often involves closed reduction and immobilisation before referral to orthopaedic services. Surgical intervention is offered based on the criteria for instability. This can be predicted from the initial and post-manipulation radiographs. The purpose of this study was to assess the role of various predictors of instability in the requirement for surgery, based on specific evidence-based criteria. PATIENTS AND METHOD: We audited 87 consecutive distal radial fractures that had been manipulated by the ED and analysed what factors predicted instability. RESULTS: The most significant predictor of instability and hence further surgery was the failure to anatomically restore the volar cortex (VC) (p = 0.002) during the manipulation. Other significant factors were increasing age (p = 0.006) and fracture of the ulna styloid (p = 0.028). If the VC was restored or remained intact during the manipulation, only 38% required further surgery. If the VC was displaced or not restored, 65% required further surgery. CONCLUSION: The restoration or maintenance of volar cortical alignment during the manipulation of distal radial fractures offers patients the best chance of avoiding the need for further surgery. This factor should be taken into account in the decision-making process for these fractures.

Intra-operative correction of volar tilt of distal radius fractures using volar locking plate as reduction tool: review of 24 cases.

In surgical fixation of distal radius fractures with metaphyseal comminution, volar tilt can be restored using an anatomical volar locking plate as a reduction tool. The purpose of our study is to assess the degree of over or under correction of volar tilt that can result with our 'lift' technique and to determine the ratio between theoretical and actual angular correction. We retrospectively reviewed 24 patients who underwent distal radius fracture fixation using this technique and assessed intra-operative radiographs for parameters including pre-'lift' and post-'lift' volar tilt and pre-'lift' plate-shaft angles. The ratio between actual angular correction and theoretical angular correction was calculated. The 'lift' technique is found to be reliable in restoring volar tilt in most fractures. Over- or under-correction does occur due to errors in visual estimation and actual angular correction is generally less than the theoretical angular correction.