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Articular distal radius fractures (DRFs) have increased in incidence in recent years, especially among the economically active population. Most of the treatment approaches are based on plain X- rays, and do not give us any information on how to treat these fractures. In the search for solutions with greater precision in diagnosis, in reducing the joint surface of the fracture, and envolving minimally-invasive techniques, we found arthroscopy as the main tool for these patients. Therefore, an enhanced understanding of the biomechanics of the different types of fracture associated with ligamentous lesions should facilitate the right decision regarding the treatment. The present paper aims at providing a management-oriented concept to diagnose and treat ligamentous lesions associated with intra-articular DRFs based on a arthroscopy-assisted procedure, and showing the objective and patient-reported outcomes and a new classification. The objective and patient-reported outcomes were: the mean range of motion (ROM) was of 94.80% on the non-affected side; the mean score on the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) was of 3.6 (range: 1 to 12). The score on the Visual Analog Scale (VAS) was of 1.66 (range: 1 to 3). Complications were observed in 2 (13.33%) patients: extensor tendon synovitis in 1 patient, and a limitation (stiffness) in ROM in 1 patient, both treated with wrist arthroscopy release. The mean time until the return to work was of 6.4 weeks. In patients with unstable intra-articular DRFs associated with ligamentous lesions, the fixation of specific osseous-ligamentous fragments and ligamentous repair/reconstruction by wrist arthroscopy prove to be a safe and reliable treatment. The clinical and functional results predict that the patients can return to work more quickly.

Background Distal radius fracture is one of the most common lesions in adults. Surgical techniques have evolved considerably with a clear tendency toward mini-invasive techniques. Objective Our aim is to push the limits to a 12 mm approach and evaluate its clinical and radiological results. Patients and Methods Ten fractures in nine patients were operated by a double incision with mean size 11.50 ± 3.41 mm (range 8.00–1.00) and using a specially designed volar distal locking plate. Results At the latest follow-up, visual analogue scale score for pain (0.20 ± 0.63 during rest and 0.60 ± 1.07 while making efforts) and quick DASH (quick Disabilities of the Arm, Shoulder and Hand) score (6.14 ± 7.43) were extremely low. All the range of motion parameters and grip strength were above the 95% barrier of the contralateral side, with exception of ulnar deviation. Radiological parameters obtained were located within the normal ranges. Time to return to independent daily tasks and work was 6.67 ± 5.15 and 10.14 ± 14.24 days, respectively. One case of transient carpal tunnel syndrome was solved with watchful waiting and one case of extensor tendons impingement was improved after plate removal. All patients were completely satisfied at the end of the treatment. Conclusion In conclusion, mini-invasive volar technique for distal radius fractures with special designed plates in carefully selected patients allowed us to obtain good clinical and radiological results, minimal complications, fast recovery, and high-satisfactory rates. Level of Evidence This is a Level IV, case series study.

Purpose To measure clinical and radiographic outcomes using external fixation in distal humeral fractures. Methods A total of 10 elderly patients, with a mean age of 71 (range 64–84 years) years old, with unstable distal humeral fractures were treated by percutaneous reduction and fixation with an articulated external fixator. The patients were assessed on range of elbow motion, patient disabilities of the arm, shoulder, and hand (DASH), and pain visual analog scale (VAS) and radiographic evaluation at 12 months. Results The mean range of motion was 134° of flexion, extension was of - 5°. All of the elbows were clinically stable. The mean VAS was 2.2, and the mean DASH score was 14.3. Radiographic analysis showed satisfactory reduction and consolidation. All of the patients showed congruence of concentric humerus-ulnar and radius and no patient had joint stiffness or posttraumatic arthritis of the elbow. Regarding complications, we observed a patient who presented with pain in the location of the ulnar pin, which was resolved with the removal of the pin. After two months, another patient had pneumonia and died. The follow-up was of 15.44 months. Conclusions A radiographic analysis of the patients showed fracture healing with joint congruity. In the functional clinical aspect, it was noted that patients had functional range of motionType of study/level of evidence Therapeutic IV

Ganglion cysts are common wrist lesions and, in about 20% of patients, they appear on a volar and radial location. Volar ganglions typically arise from the volar radiocarpal joint in the interval between the radioscaphocapitate (RSC) and the long radiolunate (LRL) ligaments. We report two patients with volar and radial ganglion cysts that originated at the dorsum of the scapholunate (SL) ligament. This may lead to inadequate treatment with a risk of recurrence. Level of Evidence: Level V (Therapeutic)

Background Despite the high prevalence of unstable distal radius fractures (DRFs), there is no consensus regarding the optimal method and treatment timing, especially for elderly patients with multiple associated injuries. Purpose This study aimed to compare the grip strength achieved with two different methods for definitive dynamic external fixation of DRFs in elderly patients with polytrauma operated on within the first 24 hours. Methods In this prospective randomized trial, 35 patients were assigned to undergo definitive external dynamic fixation of DRFs using the nonbridging (group A) or bridging (group B) method. The grip strength, range of motion (ROM), Disabilities of the Arm, Shoulder and Hand (QuickDASH) outcome measure, visual analog scale (VAS) score for pain, and radiographic characteristics were evaluated at 6 and 12 months. Results At 12 months, no significant between-group difference was observed with respect to grip strength. All patients showed results in the third or fourth quartiles. The mean ROMs were 96.94 and 96.38% and the mean QuickDASH scores were 3.53 and 3.85 in groups A and B, respectively. The VAS scores were 1.60 and 1.85 in groups A and B, respectively. The overall complication rates were 13.3 and 15% in groups A and B, respectively. Initial fracture reduction was maintained in 86.67 and 95% of the patients in groups A and B, respectively. Conclusions Both bridging and nonbridging external definitive dynamic fixation proved safe and reliable for the treatment of unstable DRFs in elderly patients with polytrauma. The grip strength results in both groups predicted the restoration of ability in elderly patients to perform activities of daily living independently.

To measure the quality of life, the time to work return, and clinical, functional, and radiographic parameters of patients treated with dorsal capsulodesis associated with scapholunate (SL) reconstruction, assisted by arthroscopy.From January 2015 to September 2016, 14 adult patients with SL dissociation underwent surgical treatment with the SL reconstruction procedure assisted by arthroscopy, using the new technique proposed in this study. All patients were assessed by the occupational therapy department at regular intervals after surgery and performed the same sequence of rehabilitation. The parameters analyzed were: range of motion (ROM), Disability of the Arm, Shoulder, and Hand (DASH), visual analog scale (VAS), and radiographic analysis to visualize the pre- and postoperative SL gap and the pre- and postoperative dorsal intercalated segment instability (DISI) deformity the. The complications and the time to return to work activities were described.The follow-up time was 12 months (3-17). The ROM averaged 321° (96.9% of the normal side). VAS was 1.79/10 (1-6). DASH was 6.50/100 (1-30). The time to work return work was 4.42 months (2-17). As for complications, one patient developed SLAC, and underwent four-corner fusion one year after ligament reconstruction. Currently, he has experienced pain relief, with a functional range of motion of the wrist, and has not yet returned to professional activities.The preoperative SL gap was 4.29 mm (2-7); in the postoperative period, it was 1.79 mm (1-4). The DISI deformity was present in ten patients with SL angle 70° (preoperative) and it was corrected after surgery, in all patients. SLAC stage I was identified in a patient. Arthroscopy was performed in all cases. The SL instability was classified as Geissler grade III in four cases and as grade IV in ten cases.The new approach (dorsal capsulodesis associated with SL reconstruction, assisted by arthroscopy) presented in this study is safe and effective in the treatment of SL dissociation, since it offers satisfactory clinical, radiographic and functional results, showing low rates of complications. For patients, it allows the return to their social and professional activities, and increases their life quality.Mensurar a qualidade de vida, o tempo de retorno ao trabalho, os resultados clínicos, funcionais e radiográficos dos pacientes submetidos à capsulodese dorsal associada à reconstrução ligamentar escafossemilunar assistida por artroscopia.De janeiro de 2015 a setembro de 2016, 14 pacientes, esqueleticamente maduros, adultos, com dissociação escafolunar (SL), foram submetidos ao tratamento cirúrgico com o procedimento de reconstrução do ligamento escafossemilunar assistido por artroscopia com a nova técnica proposta neste estudo. Todos os pacientes foram avaliados pelo setor de terapia ocupacional em intervalos regulares de pós-operatório e fizeram a mesma sequência de reabilitação. Os parâmetros analisados foram: arco de movimento (ADM),O tempo de seguimento foi de 12 meses [3-17]. O ADM foi em média 321,07° (96,9% do lado normal). O valor da avaliação subjetiva da dor (VAS) foi 1,79/10 [1-6]. A mensuração da qualidade de vida pelo Dash foi de 6,50/100 [1-30]. O tempo de retorno ao trabalho foi de 4,42 meses [2-17]. Quanto às complicações, uma paciente evoluiu com SLAC e foi submetida à artrodese dos quatro cantos um ano após a reconstrução ligamentar. Evoluiu com melhoria da dor e está com o ADM do punho funcional, mas ainda não retornou às atividades profissionais. O intervalo do SL (A nova abordagem (capsulodese dorsal associada à reconstrução ligamentar escafossemilunar assistida por artroscopia) apresentada neste estudo é segura e eficaz no tratamento da dissociação escafolunar, já que apresenta resultados radiográficos, clínicos e funcionais satisfatórios, demonstra baixas taxas de complicações, permite o retorno às atividades sociais e profissionais e aumenta a qualidade de vida desses pacientes.

Loss of contact between radial head fracture fragments is strongly associated with other elbow or forearm injuries. If this finding has adequate interobserver reliability, it could help examiners identify and treat associated ligament injuries and fractures (eg, forearm interosseous ligament injury or elbow dislocation). (1) What is the interobserver agreement on radiographic loss of contact between radial head fracture fragments? (2) Are there factors associated with the observer such as location of practice or subspecialization that increase interobserver reliability? Fully trained practicing orthopaedic and trauma surgeons from around the world evaluated 27 anteroposterior and lateral radiographs of radial head fractures on a web-based platform for the following characteristics: (1) loss of contact between at least one radial head fracture fragment and the remaining radial head and neck; (2) a gap between fragments of 2 mm or greater; (3) anticipated fracture instability (mobility) on operative exposure; (4) anticipated associated ligament injuries; and (5) recommendation for treatment. Agreement among observers was measured using the multirater kappa measure. Kappas for various observer characteristics were compared using 95% confidence intervals. The overall interobserver agreement was moderate (range, 0.49-0.55) for each question except associated ligament injury, which was fair (0.33). Shoulder and elbow surgeons had substantial agreement (range, 0.51-0.61) in many areas, but kappas were generally in the moderate range (0.41-0.59) based on number of years in practice, radial head fractures treated per year, and trainee supervision. Radiographic signs of radial head fracture instability such as loss of contact have moderate reliability. This characteristic seems clinically useful, because loss of contact between at least one radial head fracture fragment and the remaining radial head and neck is strongly associated with associated ligament injury or other fractures. Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence

Resumo Objetivos Mensurar a qualidade de vida, o tempo de retorno ao trabalho, os resultados clinicos, funcionais e radiograficos dos pacientes submetidos a capsulodese dorsal associada a reconstrucao ligamentar escafossemilunar assistida por artroscopia. Metodos De janeiro de 2015 a setembro de 2016, 14 pacientes, esqueleticamente maduros, adultos, com dissociacao escafolunar (SL), foram submetidos ao tratamento cirurgico com o procedimento de reconstrucao do ligamento escafossemilunar assistido por artroscopia com a nova tecnica proposta neste estudo. Todos os pacientes foram avaliados pelo setor de terapia ocupacional em intervalos regulares de pos‐operatorio e fizeram a mesma sequencia de reabilitacao. Os parâmetros analisados foram: arco de movimento (ADM), Disability Arm, Shoulder and Hand (Dash), escala visual analogica (EVA) e analise radiografica pre e pos‐operatoria para visualizar o espaco escafolunar (sinal de Terry‐Thomas) e deformidade em Dorsal Intercalated Segment Instability (DISI) pre e pos‐operatoria. Descricao das complicacoes e o tempo de retorno ao trabalho. Resultados O tempo de seguimento foi de 12 meses [3‐17]. O ADM foi em media 321,07° (96,9% do lado normal). O valor da avaliacao subjetiva da dor (VAS) foi 1,79/10 [1‐6]. A mensuracao da qualidade de vida pelo Dash foi de 6,50/100 [1‐30]. O tempo de retorno ao trabalho foi de 4,42 meses [2‐17]. Quanto as complicacoes, uma paciente evoluiu com SLAC e foi submetida a artrodese dos quatro cantos um ano apos a reconstrucao ligamentar. Evoluiu com melhoria da dor e esta com o ADM do punho funcional, mas ainda nao retornou as atividades profissionais. O intervalo do SL (gap) pre‐operatorio foi de 4,29 mm [2‐7] e o pos‐operatorio foi de 1,79 mm [1‐4]. A deformidade DISI estava presente em dez pacientes, com um ângulo SL acima de 70° (pre‐operatorio), e foi corrigida apos a cirurgia em todos os pacientes. SLAC estagio I foi identificado em um paciente. A artroscopia foi feita em todos os casos. A instabilidade SL foi classificada como um grau Geissler III em quatro casos e grau IV em dez casos. Conclusao A nova abordagem (capsulodese dorsal associada a reconstrucao ligamentar escafossemilunar assistida por artroscopia) apresentada neste estudo e segura e eficaz no tratamento da dissociacao escafolunar, ja que apresenta resultados radiograficos, clinicos e funcionais satisfatorios, demonstra baixas taxas de complicacoes, permite o retorno as atividades sociais e profissionais e aumenta a qualidade de vida desses pacientes.

Injury to the flexor pollicis longus (FPL) tendon is one of the most frequent complications when fixing distal radius fractures with the volar locking plates. The author proposed a simple surgical technique providing a reliable soft tissue protection to prevent friction on the FPL with the volar locking plate, using a flap of the FCR sheath sutured to attachments of the volar capsule on the lunate buttress facet of the distal radius.

Most of the literature about the sural flap deals with soft tissue defects at the lower leg and foot based on the classical description of Masquelet et al. Nevertheless, some authors have shown that the lesser saphenous vein and its accompanying artery play an important role in the vascularization of the posterior skin of the leg. This finding allowed a more proximal design of the flap, increasing its arc of rotation. Thirteen cases of distally based sural flaps were performed and divided in two groups according to the level where the flaps were harvested. In group A, the entire flap was outlined distal to the midpoint of the leg, and in group B, the flap was outlined proximal to the midpoint of the leg. In group A, all the soft tissue defects were located at the lower leg and the foot, and in group B, they involved the anterior the tibia. In group A, the complication rate was 33.33% and the flap survival rate was 83.33%. In group B, the complication rate was 42.85% and survival rate was 100%. The proximally designed sural flap can safely reach the anterior aspect of the tibia in its middle and distal thirds.

Purpose To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most important factors when evidence shows no difference between 2 surgeries were "fewer complications," "quicker recovery," "burns fewer bridges," "works in my hands" and "familiarity with the procedure." Europeans rated "works in my hands" and "cheapest/most resourceful" of significantly greater importance and "what others are doing," "highest reimbursement," and "shorter procedure" of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated "what my mentor taught me," "what others are doing" and "highest reimbursement" of significantly lower importance compared to observers with 10 or more years in independent practice. Conclusions Surgeons deciding between 2 treatment options, when the evidence is inconclusive, fall back to factors that relate to their perspective and reflect their culture and circumstances, more so than factors related to the patient's perspective, although this may be different for younger surgeons. Clinical relevance Hand surgeons might benefit from consensus fallback preferences when evidence is inconclusive. It is possible that falling back to personal comfort makes us vulnerable to unhelpful commercial and societal influences.

Introducao: A sindrome do tunel carpal e constituida por um conjunto de sinais e sintomas caracteristicos como parestesia, formigamento, dor e perda da forca nas maos. Inicialmente os sintomas sao brandos, progredindo ao longo do tempo. Objetivo: Apresentar os resultados do tratamento cirurgico com mini-incisao, bem como discutir a relacao entre os resultados e a tecnica cirurgica utilizada. Metodo: Esta pesquisa foi realizada na Faculdade de Medicina do ABC, onde foram avaliados 79 punhos de 71 pacientes, todos submetidos ao tratamento cirurgico da sindrome do tunel carpal por “mini-incisao”, entre janeiro de 1996 e maio de 2007. A media de idade entre os pacientes foi de 52,4 anos, sendo a idade minima 27 e a maxima 80 anos. Sessenta e cinco pacientes eram do sexo feminino e seis do masculino. Quanto ao lado acometido, foram obtidos 36 punhos do lado direito e 27 do lado esquerdo, sendo 8 bilaterais. Resultados: Os resultados clinicos mostraram que 60 pacientes ficaram satisfeitos com os sintomas, com os resultados esteticos e funcionais e com a melhora da forca muscular para apreensao. Dois pacientes apresentaram complicacoes cutaneas com infeccao superficial e necessitaram de antibioticoterapia oral. Conclusoes: Concluimos que o tratamento cirurgico por “mini-incisao” e uma tecnica segura, com poucas complicacoes e resultados clinicos e esteticos satisfatorios para o tratamento da sindrome do tunel do carpo.

Introducao: o polegar em gatilho congenito ou tenossinovite estenosante do polegar e a dificuldade de extensao do polegar, identificada nos primeiros meses de vida. Objetivo: a proposta deste estudo foi discutir o tratamento cirurgico com os resultados, as complicacoes e as vantagens na utilizacao da internacao hospital-dia. Metodo: no periodo de fevereiro de 2001 ate janeiro de 2008, verificaram-se 25 criancas entre 3 meses e 6 anos, portadoras de polegar em gatilho congenito. Foram operadas 35 maos, e 10 casos eram bilaterais. Observamos que a manifestacao clinica quanto a dificuldade de extensao do polegar estava presente em todas as maos operadas e nenhuma crianca queixava-se de dor. As criancas foram submetidas a mesma tecnica cirurgica, anestesia geral inalatoria, com incisao transversa na prega volar metacarpofalangeana do polegar acometido e abertura longitudinal da polia flexora A1. Nao foi utilizado antibiotico e as criancas foram internadas pelo sistema hospital-dia. Resultados: Quinze criancas eram do sexo masculino e dez do sexo feminino. Dos pacientes com lesao bilateral, sete eram do sexo masculino e tres do feminino. Quanto ao lado acometido, obtivemos sete polegares direitos, oito esquerdos e dez bilaterais. Como complicacoes, nao houve nenhuma recidiva; um polegar evoluiu com infeccao cutânea superficial e dois polegares apresentaram deiscencia parcial da sutura apos a retirada dos pontos. Conclusoes: o polegar em gatilho congenito ou tenossinovite estenosante do polegar na crianca pode ser tratado com seguranca atraves da abertura simples da polia flexora A1, utilizando-se a internacao hospital-dia.

A restauracao de lesoes nos tendoes flexores da zona II e um procedimento dificil devido a sua complexidade anatomica, facilidade de formar aderencias e dificuldade de estabelecer protocolos de reabilitacao que reduzam o numero de rupturas. O objetivo deste trabalho foi atualizar o tratamento cirurgico das lesoes nos tendoes flexores da zona II. Foram analisados cinco artigos, tres sobre avaliacao de diferentes tecnicas de sutura e dois sobre reabilitacao pos-operatoria. No estudo de Buendia et al ., os valores absolutos mostraram a tecnica de ancoragem como sendo a melhor, apesar do desvio padrao ser grande. Ja na analise estatistica, a ancoragem e o protocolo de Indiana possuem mesma significância. No grupo de imobilizacao ocorreu tenolise em 21,2% dos casos sem ruptura tendinosa. Entretanto, no grupo de flexao ativa ocorreu ruptura de tendao em 13,5% dos casos apos duas semanas de mobilizacao ativa. A sutura de lesao tendinosa na zona II de tendoes flexores com quatro passadas apresenta melhores resultados, mas realcamos a importância de analisar a tecnica de sutura segundo a resistencia, o tempo cirurgico, a quantidade de material utilizado, o aumento do volume, a capacidade traumatica e a dificuldade da tecnica.