Volar plate arthroplasty of the distal interphalangeal joint.

Ten patients with chronic dorsal fracture subluxation of the distal interphalangeal joint were managed over 5 years with volar plate advancement arthroplasty. The mean time from injury to definitive surgical treatment was 8 weeks (range, 2 weeks to 4 months). All injuries were characterized by volar comminution and impaction of the distal phalanx, with associated dorsal subluxation. Surgical treatment included volar plate advancement arthroplasty and K-wire fixation of the reduced joint for 4 weeks. All patients were evaluated at an average postoperative duration of 25 months (range, 10-60 months). The average arc of motion of the distal interphalangeal joint of the 4 fingers (6) was 42 degrees and of the interphalangeal joint of the thumb (4) was 51 degrees. All patients had a residual flexion contracture averaging 12 degrees (range, 6 degrees to 25 degrees ). Volar plate advancement arthroplasty is an effective treatment for chronic distal interphalangeal joint dorsal fracture subluxation.

Galeazzi fracture-dislocation: a new treatment-oriented classification.

Forty patients with Galeazzi fracture-dislocations were treated with open reduction and internal fixation of the radial shaft fracture. Intraoperative distal radioulnar joint (DRUJ) instability after anatomic reduction was managed with supplemental wire transfixion of the DRUJ (10 patients) or open reduction and triangular fibrocartilage complex repair (3 patients). Two patterns of fracture-dislocation were identified based on the location of the radial shaft fracture. Twenty-two type I fractures were in the distal third of the radius within 7.5 cm of the midarticular surface of the distal radius; 12 of these cases were associated with intraoperative DRUJ instability. Eighteen type II fractures were in the middle third of the radial shaft more than 7.5 cm from the midarticular surface of the distal radius. Only one of these fractures had intraoperative DRUJ instability after open reduction and internal fixation of the radial shaft fracture. A high index of suspicion, early recognition, and acute treatment of DRUJ instability will avoid chronic problems in this complex injury.

Open reduction and internal fixation of acute displaced scaphoid waist fractures.

Fourteen consecutive patients with acute displaced scaphoid waist fractures were treated with open reduction and internal fixation. The operative technique consisted of anatomic reduction of the displaced scaphoid waist fracture, correction of carpal instability, radial bone grafting for comminution, and internal fixation with K-wires or Herbert screw. The patients were evaluated an average of 26 months (range, 4-48 months) after surgery. Thirteen of the 14 (93%) fractures united. The average time to union was 11.5 weeks (range, 8-20 weeks). Fracture union was confirmed with trispiral tomography. Final radiographic assessment consistently revealed a healed scaphoid fracture, restored intrascaphoid alignment, and no evidence of carpal instability. All patients regained functional wrist range of motion (wrist extension, 57 degrees; wrist flexion, 52 degrees ) and grip strength. Open reduction and internal fixation of acute displaced scaphoid waist fractures restores scaphoid alignment and leads to predictable union. Early operative intervention avoids malunion and carpal instability that often occurs with closed management of these complex fractures.

Dorsal open repair of proximal pole scaphoid fractures.

Proximal pole fractures of the scaphoid are well suited for comprehension screw fixation. A dorsal approach allows for direct visualization of the fracture site, accurate reduction, and internal fixation. Bone grafting can also be achieved through the same incision without additional significant dissection. Successful uncomplicated union in the majority of cases with a considerably shortened period of immobilization has lead to a growing interest in this surgical procedure.

Acute fractures of the distal radius.

Distal radius fractures commonly are sustained by athletes during competition. Typically, these are high energy injuries with severe displacement, metaphyseal comminution, and articular surface disruption. Each fracture is distinguished by its degree of articular displacement, stability, and reducibility. Management is contingent on recognition of the variable magnitude of articular disruption and skillful treatment based on specific fracture configuration.

The digital extensor mechanism of the hand.

In summary, there is a complex interplay between the extrinsic and intrinsic components of the digital extensor mechanism. Numerous examples of dynamic anatomy and pathology of the extensor mechanism in common clinical settings have been described. Treatment principles have been outlined. This review should provide the orthopaedic surgeon with a framework for management of common hand problems.

Retrograde compression screw fixation of acute proximal pole scaphoid fractures.

Seventeen consecutive patients with acute unstable proximal pole scaphoid fractures were managed over the past 5 years with open reduction and internal fixation. Four fractures were displaced, with greater than 1 mm of fragment offset and intercarpal malalignment. The operative technique consisted of a dorsal approach to the scaphoid, radius bone grafting, and freehand retrograde Herbert compression screw fixation. The patients were evaluated at an average of 37 months (range, 12-63 months) after surgery. All fractures healed within 13 weeks (average, 10 weeks). Functional wrist range of motion and grip strength were achieved in all patients. No patients developed osteonecrosis or radioscaphoid arthritis. Open reduction and internal fixation rather than primary casting is a better means of reducing the complications of delayed union, nonunion, and irreparable osteonecrosis that often occur after acute proximal pole scaphoid fracture treated with cast immobilization.

Long-term assessment of proximal row carpectomy for chronic perilunate dislocations.

Twelve patients with chronic stage III or stage IV perilunate dislocations were managed over the past 7 years by proximal row carpectomy. All dislocations were untreated or incompletely reduced for a minimum of 8 weeks after injury. The mean time from injury to definitive treatment was 15 weeks (range, 8 weeks to 6 months). Surgical management was inclusive of a dual dorsal and volar approach. Median nerve decompression, lunate excision, and capsuloligament repair was performed volarly and scaphoid and triquetrum carpectomy was accomplished dorsally. Temporary radio capitate K-wire fixation during early soft tissue healing was uniformly performed. All patients were evaluated at an average postoperative duration of 40 months (range, 28 months to 7 years). Marked relief of wrist pain and median nerve dysesthesias was routinely achieved. Effective wrist range of motion and grip strength were restored. Untreated stage III and IV chronic perilunate dislocation treated by proximal row carpectomy eliminates pain and restores function to a severely injured wrist.

Wrist fractures in the athlete. Distal radius and carpal fractures.

The primary prerequisites for optimal management of the athlete's fractured wrist are prompt diagnosis, anatomic and stable reduction, effective immobilization until healing is thorough, and comprehensive rehabilitation of the injured parts. Fulfillment of these fundamental criteria consistently leads to a highly favorable outcome with minimal risk of re-injury. In contrast, a compromise of these principles, especially for the sake of a speedy return to sports, invariably results in suboptimal recovery and, not infrequently, a permanent loss of skills. The exceptions to the cardinal rule that successful treatment of wrist fractures requires precise restoration of anatomic relationships are specific: displaced hamate hook fractures, displaced trapezial ridge fractures, and comminuted pisiform fractures. In such instances, successful union essentially is precluded, and early excision of the displaced fragments is the logical means of facilitating an uncomplicated recovery. For the more complex fractures requiring stabilization, continual refinements in methods of fixation are considerably diminishing fracture morbidity. The availability of small screws that provide rigid fixation of the carpus is, with increasing consistency, promoting accelerated union and rapid rehabilitation. Well-conceived combinations of low-profile, mechanically efficient external fixators and precisely used Kirschner wires achieve highly secure fracture stability for the distal radius that similarly enhances recovery with a minimum of complications. Improvements in both design and application of internal and external fixation techniques undoubtedly constitute a major advance in the management of wrist fractures among athletes. For some athletes, the return to competition can be safely expedited by the use of custom-fit protective gloves, splints, or casts. For most, however, the treatment regimen usually entails a minimum of 3 to 4 months. Although the healing and rehabilitation process is often lengthy and may seem costly, particularly in terms of time lost from competition, seldom do athletes regret the investment once they return to their highly skillful activities unencumbered by wrist impairment. Never does the sports medicine physician regret compliance with the principles of optimal care.

Clinical applications of MR imaging in hand and wrist surgery.

MR imaging is emerging as an invaluable tool in the diagnosis of hand and wrist disorders. It is extremely accurate in the diagnosis of stage 1 Kienbock's disease when plain radiographs are equivocal and in evaluating bone and soft-tissue tumors of the hand and wrist. MR imaging is replacing arthrography as the imaging modality of choice for disruptions of the TFCC. With refined technology and improved resolution, abnormalities involving the intercarpal ligaments ultimately will be able to be detected with a high degree of precision.

Wrist arthroscopy. Indications and clinical applications.

We reviewed retrospectively a series of 128 consecutive patients who had wrist arthroscopy at our institution between January 1988 and July 1991. The aim of the procedure was to establish a diagnosis in 27 patients, to challenge a pre-operative diagnosis in 95 patients and to evaluate joint surfaces in six patients. For the 27 patients with a previously unknown diagnosis, the diagnostic sensitivity was 67% and the specificity 100%. Arthrotomy or other intervention was avoided in 18. For the 95 patients with an established pre-operative diagnosis, arthrotomy was avoided in 45: in 26 the desired procedure could be done arthroscopically, and in 19 the diagnosis, as improved by arthroscopy, was felt not to require further treatment. Procedures performed arthroscopically included débridement of triangular fibrocartilage and inter-carpal ligament tears; lysis of adhesions, and synovectomy. In six patients, arthroscopy was performed to evaluate joint surfaces after fracture reduction or before ulnar shortening osteotomy. In none of the six was arthrotomy felt necessary after arthroscopy. Wrist arthroscopy avoided the need for further surgery in 66 (52%) of our patients; arthrotomy was avoided in 69 (54%). In cases with significant carpal instability evident pre-operatively, arthroscopy was unlikely to avoid the need for open treatment.

Revision total wrist arthroplasty.

Biaxial design total wrist arthroplasty was used to salvage 13 failed total wrist arthroplasties of various designs. After a follow-up period of 31 months, two wrists had undergone further prosthetic revision for loosening and one wrist was arthrodesed. In the remaining 10 wrists, 8 had no pain, 1 had mild pain, and 1 had moderate pain. Eight patients reported feeling much better, one reported feeling better, and one reported no change. Postoperative range of motion averaged 36 degrees of extension, 19 degrees of flexion, 6 degrees of radial deviation, and 15 degrees of ulnar deviation. X-ray films at follow-up evaluation showed that two revision arthroplasties still in place were loose. The majority of patients had a satisfactory clinical result after revision total wrist arthroplasty with a biaxial design. Loosening of the revision is a significant problem.

Interobserver reliability in the Gustilo and Anderson classification of open fractures.

The Gustilo and Anderson classification system is widely used to categorize open fractures. To assess its interobserver reliability, 10 patients with open fractures had photographic slides taken of their wound before and after operative treatment. These slides were then shown to a group of orthopaedic surgeons. After an explanation of the Gustilo and Anderson classification system and each patient's pertinent history and physical examination, the physicians were asked to classify the fracture. Agreement among the various raters was determined by Kappa analysis, which is the preferred measurement of interobserver reliability for nominal data such as classification schemes. Kappa analysis demonstrated only moderate agreement among the observers classifying open fractures using the Gustilo and Anderson system. This seems to indicate that, although useful, the Gustilo and Anderson open fracture classification system does have limitations; studies and treatment recommendations based on it should be interpreted with caution.