A randomized prospective study on the treatment of intra-articular distal radius fractures: open reduction and internal fixation with dorsal plating versus mini open reduction, percutaneous fixation, and external fixation.

PURPOSE: To compare 2 methods of surgical treatment for displaced intra-articular fractures of the distal radius: open reduction and internal fixation with dorsal plating (Pi Plate; Synthes, Paoli, PA) versus mini open reduction with percutaneous K-wire and external fixation. METHODS: Patients with AO type C intra-articular distal radius fractures were randomized into 2 groups: open reduction and internal fixation and dorsal plating or external fixation and K-wires and mini-open reduction. Patients over the age of 70 years with any associated soft-tissue or skeletal injury to the same limb and pre-existing wrist arthrosis or disability were excluded from the study. Objective, subjective, and radiographic outcomes were assessed at 2 weeks, 4 to 6 weeks, 10 to 12 weeks, 6 months, and 1- and 2-year intervals. The minimum follow-up period was 6 months; the average follow-up period was 18 months. The principal outcome analyzed was the Disabilities of the Arm, Shoulder, and Hand score. Secondary outcomes included grip strength, range of motion, surgical procedure time, complications, and radiographic parameters. The groups were equal with respect to age, gender, fracture subtype, and number of workers' compensation cases. RESULTS: No significant difference was found in the Disabilities of the Arm, Shoulder, and Hand scores, our primary outcome. The dorsal plate group, however, showed a higher complication rate when compared with the external fixator group. The plate group had significantly longer tourniquet times when compared with the external fixator group. The plate group also had higher levels of pain at 1 year when compared with the external fixator group; however, this equalized after hardware removal. The external fixator group showed an average grip strength of 97% compared with the normal side and 86% in the dorsal plate group. CONCLUSIONS: At midterm analysis the dorsal plate group showed a significantly higher complication rate compared with the external fixator group; therefore enrollment in the study was terminated. The dorsal plate group also showed statistically significant higher levels of pain, weaker grip strength, and longer surgical and tourniquet times. Based on these results we cannot recommend the use of dorsal plates in treating complex intra-articular fractures of the distal radius.

Arthroscopy of the elbow: anatomy, portal sites, and a description of the proximal lateral portal.

Cadaveric studies were carried out to evaluate the safety and value of the standard portals used in elbow arthroscopy. The dissections were performed in 12 fresh cadaveric specimens. Each portal was assessed in terms of its safety with respect to nearby important structures. A proximal lateral portal was evaluated and has subsequently been used in 62 patients. A straight posterior (transhumeral) portal was also studied. We have found that in arthroscopy of the elbow joint, the proximal approaches (proximal medial and proximal lateral), are safer than the anteromedial and anterolateral approaches. All areas of the anterior compartment can be visualized using these two portals, and we recommend that they be the standard anterior portals used in elbow arthroscopy. All of the posterior approaches are safe.

Arthrography of the contralateral, asymptomatic wrist in patients with unilateral wrist pain.

To determine the significance of arthrographic abnormalities in patients with unilateral wrist pain, the authors compared the prevalence and site of intra-articular ligament perforation in asymptomatic and symptomatic wrists of the same group of patients and correlated asymptomatic perforation with age, hand dominance and hand overuse. Thirty-seven patients (29 men and 8 women ranging in age from 19 to 61 years) who had unilateral wrist pain and positive arthrographic findings for the symptomatic wrist underwent radiocarpal arthrography of the asymptomatic wrist. Three radiologists blinded as to the clinical findings examined the images for perforation in the triangular fibrocartilage complex, the lunotriquetral ligament and the scapholunate ligament. Intra-articular ligament perforations were found in 33 (89%) of the 37 asymptomatic wrists. Seventeen (46%) of the 37 patients had symmetric sites of perforation in the two wrists. Perforation of the triangular fibrocartilage complex occurred in 22 (59%) and 19 (51%) of the symptomatic and asymptomatic wrists respectively, of the lunotriquetral ligament in 13 (35%) and 7 (19%) respectively and of the scapholunate ligament in 13 (35%) and 11 (30%) respectively. No significant correlation between asymptomatic perforation and age or hand overuse was found (chi 2 test, Fisher's exact test). The authors conclude that asymptomatic perforation is common, even in young patients, so ligament perforation is not necessarily the cause of wrist pain in patients with such pain. However, for patients with the appropriate clinical findings, arthrography can be used to confirm or exclude ligament perforation.