Search

Zusammenfassung Hintergrund Unser 2011 veröffentlichtes Behandlungsregime bei Infektionen eines Fingermittel- und Fingerendgelenkes sah bei bereits vorhandenem Knorpelschaden die Resektion des betroffenen Gelenkes mit nachfolgender Ruhigstellung mittels Fixateur externe für 6 Wochen bis zur sekundären Arthrodese vor. 2013 reduzierten wir im Rahmen einer prospektiven Studie die Ruhigstellungsdauer auf 4 Wochen. Ziel Die vorliegende Arbeit untersucht die Auswirkungen der Verkürzung der Ruhigstellung von 6 auf 4 Wochen zwischen Primäreingriff und sekundärer Arthrodese bei einer bakteriellen Infektion eines Fingermittel- und Endgelenkes. Patienten und Methoden 20 Patienten, bei denen aufgrund eines Infektes eines Fingermittel- oder Endgelenkes zwischen März 2013 und Juli 2014 primär eine Gelenkresektion mit sekundärer Arthrodese nach einer verkürzten Immobilisierung von 4 Wochen erfolgte, wurden nach median 5,7 (4,6–10,5) Monaten klinisch und radiologisch nachuntersucht. Die Ergebnisse wurden statistisch ausgewertet und mit den Ergebnissen von 2011 verglichen. Ergebnisse Die Reduktion der Ruhigstellung von 6 auf 4 Wochen führte zu keinem signifikanten Unterschied in der Revisionsrate (p = 0,148). Bei 18/20 Patienten war die Infektion nach 4 Wochen zuverlässig saniert und die folgende Arthrodese konsolidierte. Eine Patientin benötigte eine Revision aufgrund eines persistierenden Infektes, ein zweiter Patient erhielt eine Revision der Arthrodese aufgrund einer Materialdislokation. Das Bewegungsausmaß des betroffenen Fingers betrug 147,5 (30–220)°. Mit einer Griffkraft von 26 (4–64) kg erreichte die operierte Hand 88,5 (47,8–223,1) % der Gegenseite. Die subjektive Handfunktion war gut (DASH-Score 37,9 (3,3–71,7), Krimmer-Score 2 (1–4)). Eine anhaltende Schmerzsymptomatik in Ruhe (VAS 0 (0–3)) und bei Belastung (VAS 1,3 (0–7)) bestand nicht. Eine Kälteempfindlichkeit wurde von 50 % der Patienten bejaht. Die Ergebnisse der Nachuntersuchung von 2011 ergaben vergleichbare Werte (ROM des betroffenen Fingers 142,5 (30–220)°, Griffkraft 95 (33–127)%, DASH-Score 23,3 (0–130), Krimmer Score 2 (1–4), VAS Ruhe 0 (0–7), VAS Belastung 4,5 (0–9), Kälteempfindlichkeit bei 41 % der 27 Patienten). Schlussfolgerung Eine Verkürzung der Ruhigstellungszeit zwischen Primäreingriff mit Gelenkresektion und sekundärer Arthrodese bei Infekt des Fingermittel- und Fingerendgelenkes von 6 auf 4 Wochen hat keine negativen Auswirkungen. Die beschriebene Therapie führt zu einer sicheren Infektionsausheilung mit guter postoperativer Funktion des Fingers und geringer, subjektiver Beschwerdesymptomatik.

The aim of this study was to compare the short-, mid-, and long-term results of pyrocarbon PIPJ arthroplasty. Twenty-seven consecutive patients (9 males, 18 females) had arthroplasty for 32 pyrocarbon PIPJ prostheses. Two patients (two joints) were lost for follow-up. Four implants were removed during follow-up. Fifteen patients (18 implants) were available for a long-term follow-up assessment on average 9.7 (9–10.8) years postoperatively and seven patients with eight implants had telephone interviews to calculate the implant survival and complications. Of the 15 patients who came to the latest follow-up, 12 (14 implants) passed each of the three follow-up visits for short-term (o 19 months), mid-term (o 54 months), and long-term follow-up (o 9.8 years) to compare functional and radiological parameters longitudinally. In total, seven of the 30 joints (23%) required a revision surgery, all within the first 2 years postoperatively, including three arthrodesis due to early infection or dislocation, and one distal component removal due to primary loosening. Three patients required soft tissue revisions. The implant survival after 9 years was 87%. There was minimal pain at rest throughout the 9-year follow-up analysis; pain with activity was rated 1.9 at the short-term assessment, 1.5 at mid-term, and 1.6 at long-term. The average active range of motion was at short-, mid-, and long-term examination 49°, 50°, and 48° and grip strength averaged 24, 24, and 21 kg, respectively. The DASH score was stable with 35, 36, and 33 points. At the long-term follow-up, all evaluated implants showed radiological signs of implant loosening or migration. According to the PIP joint outcome score, 57% resulted finally in a “good” outcome. Pyrocarbon PIPJ arthroplasty has a risk of early complications necessitating revision surgeries. In spite of radiological implant migration, good pain relief, grip strength, and high quality-of-life ratings are stable for a long time.

The flexor digitorum superficialis tendon of the ring finger can be transferred to the thumb flexor. We followed ten patients after such a transfer for 5–128 months and measured grip strength and force transmission of the fingers and individual phalanges while the patients gripped 10-cm or 20-cm diameter cylinders. The grip strength of the middle, ring and little fingers was reduced when gripping the 10-cm cylinder, with a significantly larger decrease in the ring finger. With the 20-cm cylinder, grip forces of all fingers were almost identical, with slightly lower force of the ring finger and slightly higher forces in the index and small fingers. We conclude that after transfer of flexor digitorum superficialis tendon from a ring finger, grip strength of the ring finger is reduced. Finger forces are more hampered while gripping objects with smaller circumferences than large ones.

Wir berichten uber eine 35-jahrige Patientin mit einer ausgepragten Madelung-Deformitat, bei der es in Folge einer Kapandji-Sauve-Operation mit hoher Resektion der Ulna zu einer schmerzhaften Instabilitat des Ulnastumpfes kam. Obwohl schon eine Radiuskorrekturosteotomie durchgefuhrt wurde, bestand zusatzlich noch eine deutlich erhohte Ulnarinklination des distalen Radius mit anhaltenden Schmerzen. Es erfolgte die Implantation einer gekoppelten Prothese fur den Komplettersatz des distalen Radioulnargelenkes in Verbindung mit einer erneuten, extraartikularen Korrekturosteotomie des distalen Radius, wobei der Zapfen der radialen Prothesentragerplatte im Loch der entfernten Grosfragmentschraube nach Kapandji-Sauve-Operation platziert wurde.

Therapieziel Wiederherstellen eines belastungsfahigen Weichteilmantels mit guter Sensibilitat und Remodellierung der Weichteilkontur bei Defektverletzungen der Fingerkuppe.

Background and Purpose Midcarpal arthrodesis is a well-accepted treatment option for advanced carpal collapse. In this study, we retrospectively assessed survival, analyzed complications and reviewed the long-term follow-up after midcarpal fusion. Materials and Methods The computerized medical records of 572 patients who had undergone 594 four-corner fusions between 1992 and 2001 were explored. Furthermore 56 patients with 60 midcarpal fusions were randomized for clinical and radiological follow-up at a mean of 14.7 years. Results Forty midcarpal fusions (6.7%) had to be converted into complete wrist arthrodesis. The reasons were ongoing pain in spite of a well-healed midcarpal fusion (31) or nonunion (9). Sixty-three patients (11%) required revision surgery because of nonunion (22), hematoma (8), wound infection (3) or persisting pain (31). In clinical follow-up the mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 20.4. Pain at rest was infrequent, a mild increase with daily activity was complained of (mean visual analog scale [VAS] 3.3). The mean active range of wrist motion for extension and flexion, ulnar and radial deviation and supination and pronation reached 62.5%, 68.4%, 94.7%, and mean grip strength 84.9% of the unaffected side. All patients had radiographic abnormalities, with frequent evidence of osteoarthritis of the lunate fossa. Patients with preserved carpal height appeared to have less pain, better DASH scores and a better range of motion. Conclusions The midcarpal arthrodesis is a long-lasting treatment option for advanced carpal collapse and has good long-term results. Level of Evidence Level IV, Therapeutic study.

Purpose This study evaluated the functional outcome of corrective osteotomy for combined intra- and extra-articular malunions of the distal radius using multiple outcome scores. Methods We evaluated 18 skeletally mature patients at an average of 78 months after corrective osteotomy for a combined intra- and extra-articular malunion of the distal part of the radius. The indication for osteotomy in all patients was the combination of an extra-articular deformity (≥ 15° volar or ≥ 10° dorsal angulation or ≥ 3 mm radial shortening) and intra-articular incongruity of 2 mm or greater (maximum stepoff or gap), as measured on lateral and posteroanterior radiographs. The average interval from the injury to the osteotomy was 9 months. The average maximum stepoff or gap of the articular surface before surgery was 4 mm. Results All 18 patients healed uneventfully and the final articular incongruity was reduced to 2 mm or less. Final range of motion and grip strength significantly improved, averaging 89% and 84% of the uninjured side and 185% and 241% of the preoperative measures, respectively. The rate of excellent or good results was 72% according to the validated rating system Mayo Modified Wrist Score, and 89% according to the unvalidated system of Gartland and Werley. The mean Disabilities of the Arm, Shoulder, and Hand score was 11, which corresponds to mild perceived disability. Of the 18 cases, 11 normalized upper limb function. Five patients had complications; all were successfully treated. According to the rating system of Knirk and Jupiter, 4 had grade 1 and 1 had grade 2 osteoarthritis of the radiocarpal joint on radiographs. Two of those patients reported occasional mild pain. Radiographic osteoarthritis did not correlate with strength, motion, and wrist scores. Conclusions Outcomes of corrective osteotomy for combined intra- and extra-articular malunions were comparable to those of osteotomy for isolated intra- and extra-articular malunions. A successful corrective osteotomy for the treatment of complex intra- and extra-articular distal radius malunions can improve wrist function. Type of study/level of evidence Therapeutic IV.

Scapho-trapezial-trapezoidal (STT) arthrodesis and proximal row carpectomy (PRC) are used for the treatment of Lichtman stage IIIB Kienböck's disease. This study prospectively compares 1-year results of STT arthrodesis and PRC in Lichtman stage IIIB Kienböck's disease.Nineteen patients were operated: eight with STT arthrodesis and 11 with PRC. Preoperatively and 1-year postoperatively, mobility and grip strength were examined. Both DASH and Mayo Wrist Scores were obtained from the patients.In the STT arthrodesis group, mean extension/flexion worsened from 54 to 39 % of the opposite hand. Grip strength improved from 52.9 to 62.1 %. The DASH Score improved from 32.6 to 21.4, and the Mayo Wrist Score from 50.6 to 57.9. In the PRC group, extension/flexion decreased from 62.5 to 57.0 % of the opposite hand. Grip strength improved from 38.6 to 69.0 %, the DASH Score from 36.7 to 18.9, and the Mayo Wrist Score from 54.6 to 66.0.One year after operation, slightly better results were observed in patients with PRC compared to STT arthrodesis.

Fractures of the distal radius are extremely common injuries, which are steadily becoming a public health issue. One of the most common complications following distal radius fractures is still malunion of the distal radius. This review of the literature surrounding distal radius malunion covers the biomechanics of distal radial malunion, treatment options, indications for surgery, surgical techniques, and results.

Problem For shortening osteotomy, two exactly parallel osteotomies are needed to assure a congruent adaption of the shortened bone after segment resection. This is required for regular bone healing. In addition, it is difficult to shorten a bone to a precise distance using an oblique segment resection. Solution A mobile spacer between two saw blades keeps the distance of the blades exactly parallel during an osteotomy cut. The parallel saw blades from Synthes® are designed for 2, 2.5, 3, 4, and 5 mm shortening distances. Two types of blades are available (e.g., for transverse or oblique osteotomies) to assure precise shortening. Surgical technique Preoperatively, the desired type of osteotomy (transverse or oblique) and the shortening distance has to be determined. Then, the appropriate parallel saw blade is chosen, which is compatible to Synthes® Colibri with an oscillating saw attachment. During the osteotomy cut, the spacer should be kept as close to the bone as possible. Excessive force that may deform the blades should be avoided. Before manipulating the bone ends, it is important to determine that the bone is completely dissected by both saw blades to prevent fracturing of the corticalis with bony spurs. The shortening osteotomy is mainly fixated by plate osteosynthesis. For compression of the bone ends, the screws should be placed eccentrically in the plate holes. For an oblique osteotomy, an additional lag screw should be used.

Purpose/background Kienbock's disease is a rare condition in children or juvenile patients with unique features. This article presents a review of the literature on this topic and an evaluation of our own patients to help to establish therapeutic guidelines. Patients/material and method From 1994-2005 we treated 23 patients. The 2 paediatric patients could be followed - one for 102 months after vascularised transposition of the pisiform and the other one for 24 months after conservative treatment. 15 out of the 21 juvenile patients could be followed: 9 patients on average for 47 months after radial shortening osteotomy, 5 patients on average for 94 months after partial wrist fusion and one for 24 months after arthroscopic debridement. Beginning in 2006 our therapeutic strategy has been changed. Since then one paediatric and one juvenile patient could be followed after temporary transfixation of the scaphotrapezoidal joint as well as one juvenile patient after spontaneous healing of the lunate bone. We measured motion, grip strength and pain level in rest and under load using the visual analogue scale, as well as the DASH score. Furthermore, standard X-rays of the wrist were performed. Results The 3 paediatric patients demonstrated good clinical and radiological results with healing of the lunate bone. The juvenile patients with radial shortening osteotomy had a better motion than those with partial wrist fusion. Reduction of pain level was similar in both groups. Radiologically we found no progression of lunate disease in these patients. In spite of a temporary ST transfixation the 17-year-old boy with advanced Kienbock's disease developed symptomatic progression of the disease. Conclusion In paediatric and juvenile patients with Kienbock's disease we find an age-related potential for spontaneous remodelling and revascularisation. Therefore in paediatric and in juvenile patients not older than 14 years our method of choice is an immobilisation with regular gadolinium-enhanced MRI studies. In those who do not improve and in older juvenile patients we prefer temporary transfixation of the scaphotrapezoidal joint. Alternatively, in cases of the ulnar minus variant, radial shortening osteotomy or a combination of these 2 methods is indicated as the primary approach. In our opinion there is no longer an indication for partial wrist fusions as a primary procedure in these patients.

Purpose/background What are the medium-term results after a radioscapholunate fusion in the treatment of a post-traumatic osteoarthtritis of wrist? Patients and method Between 1/92 and 8/04 73 Patients with post-traumatic radiocarpal osteoarthritis (mostly following an intra-articular distal radius fracture) were treated by radioscapholunate (RSL) fusion. These patients were retrospectively evaluated with a minimum follow-up period of 18 months. In 16 of the 73 patients (22%) the RSL fusion was converted to a complete wrist arthrodesis at an average of 9 (3-69) months after the partial fusion. Of the remaining 57 patients 39 returned for a clinical and radiological examination at an average of 59 (19-140) months postoperatively. Pain, functional limitations, range of motion, grip strength, return to work, and patient satisfaction were evaluated. Non-union of the fusion and carpal osteoarthritis were assessed radiologically. Results The DASH score averaged 39 points (3-80). 7 patients (18%) had no pain. 19 patients (49%) had pain only with activities. 13 patients (32%) complained of pain at rest, but 38 of 39 patients reported an improvement in comparison to the preoperative situation. 28 patients (72%) returned to work. 38 of 39 patients would have the operation done again (97%). Wrist extension averaged 31 degrees and flexion 29 degrees , ulnar deviation was 20 degrees and radial deviation 14 degrees on average, pronation averaged 81 degrees and supination 71 degrees . Grip strength was 32 kg on average (72% of the opposite side). The radiological assessment showed in 8 patients (21%) a radiocarpal non-union (7 RS, 1 RL). Arthritic changes of the adjacent carpal joints (STT, SC, LC or LT) were found in 20 patients (51 %) without a significant effect on the clinical outcome. Conclusion Radioscapholunate fusion is a treatment option for radiocarpal osteoarthritis to preserve a functional range of motion. Patient satisfaction is high although functional limitations and residual pain can exist. A progressive arthrosis of the adjacent carpal joints can frequently be observed, but mostly without affecting the clinical outcome. The non-union rate is high, but mostly well tolerated. If the procedure fails a conversion to a complete wrist fusion may be necessary. In most cases this occurs early following the partial wrist fusion.

Five different palmar fixation plate designs were compared in a distal radial osteotomy cadaver model with regard to their biomechanical properties. A metaphyseal osteotomy gap of 1 cm was performed and the osteosynthesis was plated according to the manufacturer's instructions. Axial load was applied to the construct by a pneumatic material testing machine. Five implant groups with eight cadavers each were tested concerning stiffness. None of the constructs developed deformity and movement of the fracture gap larger than 2 mm with a load of 100 N. Increasing the load to 250 N revealed significant differences in stiffness and failure load between the different plates. The mean stiffness under axial load (mean+/-standard deviation) was 356.4+/- 138.6 N/mm for the radius correction plate without lateral tongue, 299.7+/-86.3 N/mm for the radius correction plate with lateral tongue, 132.8+/-41.5 N/mm for the distal volar radius plate, 112.5+/-40.2 N/mm for the 3.5 mm titanium locking compression plate and 91.9+/-29.2 N/mm for the standard stainless steel 3.5 mm T-Plate. The non-angular stable implant (STP plate) had the lowest stiffness. Unexpectedly, there were differences over 100% concerning the stiffness between the at first glance nearly similar angular stable implants. Additionally, a review of the literature concerning biomechanical investigations of the distal radial fracture was performed.

QUESTION: Is there a difference in the results of free tendon grafting or transfer of the extensor indicis tendon for the reconstruction of the extensor pollicis longus tendon? PATIENTS AND METHODS: Two groups of patients, who underwent surgery between 1992 and 1998, were compared. From 58 patients with tendon grafts 48 were re-examined. For reconstruction, a graft harvested from the palmaris longus tendon was applied that was woven into the proximal and distal stump of the extensor pollicis tendon according to the technique of Pulvertaft. From 56 patients with transfer of the extensor indicis tendon, 40 were re-examined. The extensor indicis transfer was performed by the standard technique. Extension and flexion of the metacarpophalangeal and interphalangeal joints of the thumb, retroposition, abduction and opposition were examined. In addition, the span of the hand, grip strength and pinch strength were measured. A summarising assessment was performed according to the Geldmacher score, the subjective impairment was assessed by the DASH score. RESULTS: Both groups were comparable according to demographic data and aetiology of the rupture. The range of motion was nearly identical after both surgical techniques. Range of motion of the joints of the thumb, abduction and opposition reached normal values but both methods restored only 60 % of the normal retroposition. According to the Geldmacher score, both methods showed good and excellent results. The DASH score resulted in low values with 10 and, respectively, 14 points. After extensor indicis transfer all patients demonstrated isolated extension of the index. CONCLUSIONS: Both methods establish equally good results. Free tendon grafting is technically more demanding but preserves a more powerful isolated extension of the index finger and should, therefore, be preferred in patients with special demands on this function (e.g., musicians). The transfer of the extensor indicis tendon is technically less demanding, requires retraining and may impair the isolated function of the index finger.

Summary Bone injuries are a daily challenge for the hand surgeon. The majority of the injuries are extra-articular, closed, simple, undisplaced or minimally displaced fractures and are best treated nonoperatively. Most closed fractures requiring manipulation and fixation are amenable to closed reduction and minimally invasive surgery. Open reduction and internal fixation, using mini plates or screws, of closed fractures is generally reserved for irreducible, displaced, intra-articular, comminuted, multiple displaced unstable or pathological fractures as well as displaced unstable fractures accompanied by ipsilateral extremity injuries or bilateral injuries. Open injuries of the hand are not only frequently associated with bone fractures but accompanied by additional soft tissue damage. The functional outcome of these injuries correlates with the severity of the injury but can be favourably influenced by the surgical treatment of all the involved structures, including stabilization and/or reconstruction of the bones. Most of these injuries have to be addressed individually. The hand surgeon treating these injuries has to be familiar with all techniques of bone reconstruction and stabilization to be able to individually choose the optimal combination of internal and external fixations.

Compartment syndrome of the upper extremity is rare, but happens frequently. It most often affects the forearm, compartment syndromes of the upper arm and hand are seen much more seldom. Early diagnosis and efficient fasciotomy is of highest importance to achieve good outcome and prevent development of Volkmann's ischemic contracture.

Despite all progress in the treatment of distal radius fractures, malunion is still one of the most common complications. It may be true that not all non-anatomically aligned fractures of the distal radius are causing disabilities. However, most patients with a distal radial malunion complain about loss of wrist motion and forearm rotation, loss of grip strength, and pain. These complaints should lead to a sophisticated clinical examination and a careful evaluation of the radiographs of the wrist, and - if needed - to further investigations. Treatment options are procedures solely aimed to diminish pain, procedures aimed to improve wrist and forearm function without restoration of the anatomic relationships, and procedures aimed to restore the anatomy of the wrist joint, especially corrective osteotomy of the radius. Radial corrective osteotomy improves significantly wrist and forearm function, grip strength, and diminishes pain. The clinical results are as good or better than the radiological results.

BACKGROUND: Corrective osteotomy of the distal radius is a well accepted procedure in younger, manual working and active patients with a malunited distal radius fracture. These functional improving procedures are often abandoned in elderly patients on accout of an uncertain benefit. PURPOSE: To investigate the radiological and clinical outcome after corrective osteotomy for malunited fractures of the distal radius in the elderly and to answer the question, whether there is a benefit or not. METHODS: In a prospective study the results of corrective osteotomy for malunion of distal radius fractures in 17 patients aged 65 years and more were investigated and compared with the results of 31 patients below an age of 65 years. Radiological parameters were radius tilt, ulnar inclination and ulnar variance. Clinically wrist motion, forearm rotation, pain at activity and grip strength were measured. Both groups were comparable according to their preoperative data. The statistical analyses were performed with use of the Mann-Whitney-U-test and the Wilcoxon test for paired differences, accepting p < 0.05 as significant. RESULTS: All osteotomies achieved bony union. Loss of correction or other complications did not occur. Postoperatively both groups demonstrated improvement of all clinical and radiological parameters. Improvement was significant in eleven of twelve parameters in the group below 65 years and for eight of twelve parameters in the elderly. A comparison among the two groups revealed significant better results for five of the twelve parameters in the younger patients. CONCLUSION: Radial corrective osteotomy leads to an improvement of the clinical situation not only in the younger but also in the elderly patient. Therefore, radial corrective osteotomy can be recommended for elderly patients. However, elderly patients may not experience the same amount of benefit from a corrective osteotomy of the distal radius as the younger patients. An age-related higher complication rate or unsatisfying long term results were not detected.

BACKGROUND: Corrective osteotomy is an appealing treatment for malunited articular fractures of the distal part of the radius since articular incongruity may be the factor most strongly associated with arthrosis and diminished function after such fractures. Enthusiasm for osteotomy has been limited by concerns regarding the difficulty of the technique and the potential for additional injury, osteonecrosis, and nonunion. METHODS: Twenty-three skeletally mature patients were evaluated at an average of thirty-eight months after corrective osteotomy for an intra-articular malunion of the distal part of the radius. The indication for the osteotomy included dorsal or volar subluxation of the radiocarpal joint in fourteen patients and articular incongruity of ≥2 mm as measured on a posteroanterior radiograph in seventeen patients. Six patients had combined intra-articular and extra-articular malunion. The average interval from the injury to the osteotomy was six months. The average maximum step-off or gap of the articular surface prior to the operation was 4 mm. RESULTS: One patient had a subsequent partial wrist arthrodesis because of radiocarpal arthrosis, and three patients had additional surgery because of dysfunction of the distal radioulnar joint. One patient had a rupture of the extensor pollicis longus, which was treated with a tendon transfer. The final articular incongruity averaged 0.4 mm, and the final grip strength averaged 85% of that on the contralateral side. The rate of excellent or good results was 83% according to the rating systems of Fernandez and of Gartland and Werley, and 43% according to a modification of the rating system of Green and O9Brien. CONCLUSIONS: The results of corrective osteotomy for the treatment of intraarticular malunion are comparable with those of osteotomy for the treatment of extra-articular malunion. Intra-articular osteotomy can be performed with acceptable safety and efficacy, it improves wrist function, and it may help to limit the need for salvage procedures such as partial or total wrist arthrodesis.

BACKGROUND: Corrective osteotomy is an appealing treatment for malunited articular fractures of the distal part of the radius since articular incongruity may be the factor most strongly associated with arthrosis and diminished function after such fractures. Enthusiasm for osteotomy has been limited by concerns regarding the difficulty of the technique and the potential for additional injury, osteonecrosis, and nonunion. METHODS: Twenty-three skeletally mature patients were evaluated at an average of thirty-eight months after corrective osteotomy for an intra-articular malunion of the distal part of the radius. The indication for the osteotomy included dorsal or volar subluxation of the radiocarpal joint in fourteen patients and articular incongruity of ≥2 mm as measured on a posteroanterior radiograph in seventeen patients. Six patients had combined intra-articular and extra-articular malunion. The average interval from the injury to the osteotomy was six months. The average maximum step-off or gap of the articular surface prior to the operation was 4 mm. RESULTS: One patient had a subsequent partial wrist arthrodesis because of radiocarpal arthrosis, and three patients had additional surgery because of dysfunction of the distal radioulnar joint. One patient had a rupture of the extensor pollicis longus, which was treated with a tendon transfer. The final articular incongruity averaged 0.4 mm, and the final grip strength averaged 85% of that on the contralateral side. The rate of excellent or good results was 83% according to the rating systems of Fernandez and of Gartland and Werley, and 43% according to a modification of the rating system of Green and O'Brien. CONCLUSIONS: The results of corrective osteotomy for the treatment of intraarticular malunion are comparable with those of osteotomy for the treatment of extra-articular malunion. Intra-articular osteotomy can be performed with acceptable safety and efficacy, it improves wrist function, and it may help to limit the need for salvage procedures such as partial or total wrist arthrodesis.

Background The diagnosis of a chondrosarcoma of the hand can be difficult for the surgeon as well as for the pathologist. The histological criteria for differentiation between chondrosarcoma and chondroma are not well-defined. Nevertheless, distinguishing the two entities is clinically relevant, as chondrosarcomas of the hand, despite their low tendency for metastatic spread, require a prompt and more radical treatment than chondromas. Method and material From 1996 to 2003, we treated four patients with a histologically diagnosed chondrosarcoma of the metacarpal bones and phalanges. Two patients were female and two male with a mean age of 42 years. The duration between the first clinical symptoms and first surgery ranged from two months to 30 years. Three out of four patients underwent primary treatment in other institutions, always under the histologic diagnosis of a chondroma. The mean follow-up ranged from nine months to seven years. Results The histological diagnosis of chondrosarcoma was followed by ray resection in three cases. Two tumors were grade 1 and two tumors grade 2. During follow-up, the patients showed no local recurrence and no metastatic spread. Conclusion Since the differentiation between chondroma and chondrosarcoma is difficult, a good cooperation between surgeon, radiologist and pathologist is required. Despite the low metastatic potential of chondrosarcomas of the hand in comparison with other sites, ray resection or digital amputation is recommended to avoid local recurrence. In cases with only local excision, close follow-up is recommended.

BACKGROUND: Scapho-trapezio-trapezoid (STT)/triscaphe fusion is used to stabilize the radial column of the wrist. However the reported results are controversial. MATERIAL AND METHODS: 111 patients were treated with STT fusion from 1992 to 1997. Indications were chronic dissociation of the scapholunate joint (n = 15), idiopathic arthrosis of the scaphotrapeziotrapezoid joint (n = 11), Kienbock's disease in advanced stage (n = 84) and dislocation of the trapezium (n = 1). This study reviews the results after an average follow-up period of four years (range, two to eight years). RESULTS: Patients showed an average wrist motion (ROM) in extension and flexion of 81 % of the preoperative range and in radial and ulnar deviation of 68 % of the preoperative range. Preoperative pain values (VAS) were reduced 76 % (non-stress) and 55 % (stress). The average grip strength improved to 65 % of the contra-lateral side. Good results were reached according to the modified Mayo wrist score with a score of 66 points (71 points in arthritis of the STT joint; 62 points in Kienbock's disease, 60 points in SL-dissociation). The patients described low disability in the DASH scores, with an average of 27 points. CONCLUSIONS: Our data show that STT fusion is reliable and effective for treatment and pain relief and offers reasonable functional results in the above mentioned indications.

The indication and treatment of malunited fractures of the distal radius in the growing skeleton differ from those for adults. The literature results are scarce. In this study we examined the results of surgical correction following fractures of the distal radius in infants. Seven infant patients with malaligned fractures of the distal radius that demonstrated significant functional deficit and poor prognosis for spontanous recovery were treated with surgical correction. Two of them were treated because of growth disturbance from post-traumatic closure of the distal radial physis. All seven osteotomies healed with acceptable radiologic alignment. After an average follow-up period of 3 years and 1 month (range 10 months to 8 years and 4 months), patients had an average range of wrist motion (ROM) of 131 deg in extension and flexion (93% of the contralateral side, 130% of presurgical situation); 65 deg in ulnar and radial deviation (94% of the contralateral side, 122% of presurgical situation); and 177 deg in pronation and supination of the forearm (97% of the contralateral side, 115% of presurgical situation). The average grip strength of 71.4 kPa was nearly equal to the other side with 72.8 kPa. The average postoperative angulation of the distal radius was 12 (range 10–17) deg, the radial inclination 20 (range 12–30) deg, and the ulnar variance was −0.6 (range −3 to +2) mm. According to the Fernandez point score system as well as the scale of Fernandez, there were five excellent results and two good results. The patients described low disability on the DASH scores, with a median of 4 (range 0–41) points. Surgical correction for malunited fractures of the distal radius provides good and excellent radiological and functional results in the growing skeleton. It should be considered immediately if there is poor remodeling capacity and disabling loss of function.

The ulnar head prosthesis has been the subject of a prospective multicenter-study since 1995. Until 2000, it has been used in 57 patients by the study group. In 35 patients, the indication was painful instability of the distal end of the ulna following previous resection arthroplasties, and in 22 patients it was painful arthritis of the distal radioulnar joint (DRUJ). The mean follow-up was 38 months. Pronation increased from a preoperative mean of 63 degrees to a postoperative value of 78 degrees, while supination increased from 43 degrees to 76 degrees. Grip strength improved from a preoperative mean of 51% to a postoperative mean of 77% of the opposite limb. Pain, measured on the verbal pain scale (1-4), was reduced remarkably from a preoperative mean level of 3.6 to a postoperative mean of 1.7. Patient' satisfaction was evaluated using the visual analog scale (0-10) and improved from a preoperative mean of 2.1 to a postoperative mean of 7.9. With one exception of loosening, we consistently found bony integration of the shaft of the prosthesis. Stability of the DRUJ was achieved in all but three patients. This method has given reliable and excellent results as a salvage procedure for failed resection arthroplasties of the DRUJ with painful instability of the distal end of the ulna. We consider the method an alternative treatment option for the arthritically destroyed DRUJ. Sufficient soft tissue to stabilise the prosthesis is needed to successfully reconstruct the DRUJ.

Purpose. Evaluation of effectiveness of capsuloligamentous release in severe PIP joint contractures in Dupuytren's disease. Method. Prospective study to compare the clinical outcome of eleven patients with severe contracture of the PIP joint due to Dupuytren's disease, in whom an additional capsulotomy was performed to reduce a residual flexion contracture of the PIP joint of 20 degree and more after release and excision of all diseased fascia, with the outcome of 32 patients with severe contracture of the PIP joint due to Dupuytren's disease, in whom the PIP joint contracture could be reduced by fasciectomy alone. Preoperatively all patients had a severe flexion contracture (60 degrees or greater) of one PIP joint. All patients underwent standardized operative treatment and postoperative extension splinting program for six months. Follow-up examinations included assessment of active range of motion at two, four, ten, 16 and 24 weeks after surgery. Results. In the noncapsulotomy group, preoperative contracture averaged 70.6 degrees and intraoperative residual contracture averaged 2 degrees. In the capsulotomy group, preoperative contracture averaged 78.6 degrees. Intraoperative residual contracture averaged 61.8 degrees before and 2 degrees after capsulotomy. At the final follow-up examination, PIP joint flexion contracture averaged 15 degrees in the noncapsulotomy group compared to 16 degrees in the capsulotomy group. Conclusion. Residual flexion contracture of a PIP joint after release and excision of all diseased fascia in Dupuytren's disease can be reduced by capsuloligamentous release. The data of this study showed no significant differences in the outcome at the final follow-up examination between patients with and without capsulotomy. Therefore, we recommend capsulotomy as treatment of residual flexion contracture of the PIP joint in Dupuytren's disease.

This retrospective study evaluated the outcome of corrective osteotomy for malunited distal radial fractures and investigated the influence of the radiological result on the clinical outcome. Twenty-nine patients underwent corrective osteotomy for malunited, dorsally tilted fractures of the distal radius and 20 underwent corrective osteotomy for malunited, palmarly angulated distal radial fractures. All were surveyed at an average of 18 months after surgery and assessed for: pain; grip strength; range of motion; radial tilt; radial inclination; and ulnar variance. Postoperative radial tilt, radial inclination and ulnar variance were significantly improved by corrective osteotomy. Patients with no, or only minor residual deformity after corrective osteotomy had significantly better results than those with gross residual deformity.

Deep frostbites of the fingertips mostly result in some form of amputation. To preserve functional length and to achieve good sensibility, we managed deep frostbites of five fingertips of a mountain climber with semiocclusive dressings. The method was described by Mennen and Wiese (1993) for the management of fingertip injuries. To our knowledge, the method has not been used so far in the treatment of frostbites. The two fingertips presenting only deep soft-tissue damage achieved a nearly normal recovery of pulp shape and sensibility. The three fingers with bone involvement required a long period of time for complete healing. In two of these fingers, additional bone shortening had to be performed.

In spite of the considerable information regarding the indications for, and the techniques and results of, corrective osteotomy of malunited, dorsally displaced fractures of the distal radius, there have been few reports concerning osteotomy of palmarly angulated malunions of the distal radius. The purpose of the current study was to evaluate our experience with this condition.

Severe crush injuries with avulsion require specific treatment strategies. Usually we find complete loss of soft tissue, nerves and vessels, where only tendons and parts of the phalanges are preserved. Primary reconstructive procedures are usually not possible due to the complexity of the injury with severely destroyed structures. Bone shortening should be avoided in order to maintain finger length and motion. Therefore, emergency soft-tissue coverage represents the first step. Later, sensibility and mechanical stability of the skin should be restored. In our clinic, seven patients with this injury pattern were treated. Three cases involved four finger crush-avulsion injuries. In all cases, we performed a primary soft-tissue coverage with a pedicled flap. In a second session, the skin areas of the first web space of both feet were transplanted as neurovascular flaps. With this strategy, a useful hand function could be restored. The functional results are described and advantages and disadvantages of various techniques discussed.

Reconstruction of the articular anatomy can be extremely difficult in distal radius fractures with severe comminution of both the dorsal and palmar cortices. In these cases, neither open reduction using an unilateral approach nor closed reduction with ligamentotaxis and fixateur externe will be successful. Reconstruction of both the dorsal and palmar cortical column is necessary. Sixteen of nineteen patients with unstable bicolumnar distal radius fractures treated by a combined plate osteosynthesis were studied retrospectively. Follow-up time averaged 32.5 months (8 to 74). At the time of re-examination the average grip strength and range of motion were reduced by 30% compared with the uninjured side. The average DASH-score was 11.2 points. Radiographic measurements revealed a satisfactory restoration of the radius concerning length and form. There were no signs of higher graded arthrosis.

Clinically most patients complain about ulnar sided wrist pain and limited forearm rotation following malunited distal radius fractures. Possible bony reasons consist of intraarticular incongruency, malalignement of the sigmoid notch of the distal radius or the ulna-plus-situation at the wrist level. A persisting luxation of the distal radioulnar joint (DRUJ) will present itself with complete loss of forearm rotation. The ligamentous or bony detachment of the triangular fibrocartilage complex (TFCC) will lead to instability of the DRUJ. Uncorrected, each of these components will lead to arthrosis of the DRUJ. The presence of arthrosis only allows salvage procedures for the DRUJ and will lead to functional loss. Reconstructive options consist of radius correction osteotomy, ulnar shortening osteotomy, reposition of a luxation and refixation of the TFCC. To chose the necessary reconstructive procedure, the individual pathological situation has to be analysed.

Stable fixation of small proximal pole nonunions of the scaphoid by conventional techniques of bone grafting remains difficult. Because of this, long-lasting immobilisation is necessary. Treatment by retrograde Herbert-screw fixation offers the possibility of stable osteosynthesis resulting in shorter immobilisation. Even in case of avascular proximal fragments, it allows healing of the nonunion. We report on the 29 months follow-up of 23 patients treated in this manner showing bony consolidation in 17 cases (74%). Four patients demonstrated fibrous nonunion with minor symptoms, and in two patients persistent nonunion with slight impairment was seen. Evaluation with the DASH-questionnaire revealed slight disability with an average score of ten points. The availability of the mini-Herbert-screw has improved this treatment concept.

This paper describes the surgical technique to reconstruct the distal radioulnar ligaments using the palmaris longus tendon as inaugurated by Brian Adams. A video can be approach online.

The treatment of ulnar-sided wrist pain after malunited distal radius fractures remains controversial. Radial corrective osteotomy can restore congruity in the distal radioulnar joint (DRUJ) as well as adequate length of the radius. Ulnar shortening osteotomies leave the radius' angular deformities unchanged, risking secondary DRUJ osteoarthritis. We supposed that, even within the widely accepted limit of 20°, a greater angulation of the radius in the sagittal plane correlates with a higher rate of DRUJ osteoarthritis. Furthermore, we suspected worse results from an ulna shortened to a negative rather than a neutral or positive ulnar variance.For this retrospective study, we reviewed 23 patients a mean 7.2 (range 5.6-8.5) years after ulnar shortening osteotomy for malunion of distal radius fractures. We compared 14 patients with up to 10° dorsal or palmar displacement from the normal palmar tilt of 10° to 9 patients with more than 10° displacement, and 15 patients whose post-operative ulnar variance was neutral or positive to 8 who had a negative one.Ulnar-sided wrist pain decreased enough to satisfy 21 of the 23 patients. Clinical results tended to be better when radial displacement was minor and when post-operative ulnar variance was positive or neutral. A shorter ulna significantly increased the rate of DRUJ osteoarthritis, whereas a greater degree of radial displacement only increased the rate slightly.Radial corrective osteotomy should be discussed as alternative when displacement of the radius in the sagittal plane exceeds 10°. The ulna should be shortened moderately to reduce the risk of osteoarthritis in the distal radioulnar joint.

The purpose of this study was to quantify the clinical and radiographic outcomes after corrective osteotomy for malunions of the distal radius following failed internal fixation. Results of 18 patients (8 women, 10 men; mean age 41 years) are presented an average of 7 years after osteotomy of a malunited distal radius fracture. We assessed active range of motion, grip strength, radiographic alignment, pain and disability. Subjective and objective data were summarized using the modified Mayo Wrist Score and the point-score system of Fernandez. Wrist motion, pain and deformity improved with the operation in all cases. The modified Mayo Wrist Score averaged 79 points. The scale of Fernandez indicated ten good, two fair and six poor results. The results of this study suggest that the operative correction of a distal radius malunion following an unsuccessful internal fixation can be achieved with outcomes comparable to those reported after initial nonoperative treatment.

Intra-articular fractures of the distal radius (DRF) are associated with a twofold increase in the risk of scapholunate ligament injury (SLI). The aim of this study was to compare functional outcome, pain, and disability between patients with operatively treated DRF and either an acute, repaired scapholunate ligament injury or no ligament injury.We retrospectively analyzed 18 patients with an intraarticular DRF and SLI that was diagnosed and treated (Group I) and compared them with 20 patients with DRF without associated ligament injury (Group II) (20 women, 18 men; average age 55 years, range 19-72). The two cohorts were analyzed for differences in motion, grip strength, pain, Mayo wrist score, and Quick Disabilities of the Arm, Shoulder, and Hand (DASH) score an average of 43 months (range 12-73) after surgery. Radiographic assessment included fracture union, palmar tilt, radial inclination, ulnar variance, intercarpal angles, and arthrosis (according to Knirk and Jupiter). We used T-tests to compare range of motion, grip strength, pain (visual analog scale), DASH scores, and radiographic alignment between cohorts. A Chi-squared analysis was used to determine radiographic differences of arthritis.There were no significant differences in mean range of motion, grip strength, Quick DASH score, Mayo wrist score, pain level, or radiographic arthrosis between cohorts. There was no correlation between radiographic signs of osteoarthritis and the QuickDASH score, and pain level.The outcomes of intraarticular fractures of the distal radius with operatively treated associated SLI are comparable with the outcomes of intraarticular fractures of the distal radius without associated SLI.

Severe intra-articular fractures of the distal radius with comminuted, displaced, and malrotated fragments are the most challenging fracture patterns. Reconstruction faces 3 major problems: fixation of fragments that are too small for stabilization by standard plates or screws, restoration of substantial cartilage loss in the articular surfaces, and extended metaphyseal/subchondral bony defects. For addressing these problems, a strategy is reported, by applying small, subchondrally placed Kirschner wires for the realignment of the articular surfaces, temporary inlay of a silicone foil in case of lost articular cartilage, and iliac crest bone grafting for bony defects. Stability is further augmented by buttress plates. This study reviews the historical perspective, indications, technique, complications, and rehabilitation of this strategy.

Purpose To evaluate the differences between radioscapholunate (RSL) arthrodesis alone versus RSL arthrodesis with additional distal scaphoidectomy. Methods We retrospectively evaluated 61 patients who were treated with RSL arthrodesis for painful posttraumatic osteoarthritis. Thirty patients had an RSL arthrodesis with additional resection of the distal scaphoid pole (group A), and 31 had RSL arthrodesis alone (group B). Six patients in group A and 8 in group B had the RSL arthrodesis converted to a complete wrist arthrodesis during follow-up. Those patients were excluded from the survey. Of the remaining 47 patients, 35 (20 from group A, 15 from group B) returned for a clinical and radiological examination at an average of 28 (range, 10–47) months after the index surgery. The results were rated by the Disabilities of the Arm, Shoulder, and Hand score and the modified Mayo Wrist Score. The patients' outcomes after RSL arthrodesis with or without distal scaphoidectomy were compared for pain, wrist motion, grip strength, nonunion rate, osteoarthritis of the adjacent joints, the Disabilities of the Arm, Shoulder, and Hand score and the modified Mayo Wrist Score. Results Three patients with RSL arthrodesis alone showed a radioscaphoid nonunion. All arthrodeses in group A healed. In the clinical evaluation, there was no significant difference between groups A and B in the Disabilities of the Arm, Shoulder, and Hand score, the modified Mayo Wrist Score, grip strength, pain, or wrist motion. Assuming that wrist motion might be better in patients with a nonunion, the average wrist motion was recalculated after eliminating 3 patients with a radioscaphoid nonunion from group B. Radial deviation was then found to be significantly better in group A. Conclusions Additional distal scaphoidectomy with RSL arthrodesis seems to improve postoperative radial deviation of the wrist. The radioscaphoid nonunion rate is high with RSL arthrodesis alone. Distal scaphoidectomy appeared to increase the successful fusion rate of RSL arthrodeses. No significant effect on wrist extension, flexion, ulnar deviation, pain level, restriction in activities of daily living, or grip strength was noted. Type of study/level of evidence Therapeutic III.

Four-corner arthrodesis is an accepted surgical option for treatment of scapholunate advanced collapse, scaphoid non-union advanced collapse and midcarpal instability. A preferred source of bone graft for performing four-corner arthrodesis is the iliac crest. An alternative and more convenient donor site is the distal radius. The aim of this study was to investigate whether the union rate after four-corner arthrodesis is influenced by the source of bone graft, that is, iliac crest or distal radius. In a retrospective analysis, charts and radiographs of 180 patients were identified. In 109 patients, iliac crest bone grafts were used, whereas 71 patients received distal radius bone grafts. In the iliac crest bone graft group, 101 out of 109 patients obtained a solid radiographic union of the arthrodesis at an average of 10 weeks after surgery, and non-union in eight patients (7.3%). In the distal radius bone graft group, X-rays of 66 patients showed bone union after an average of 10 weeks after surgery as well and five patients with non-union (7.0%) respectively. There was no statistical difference in bone union. Our data show that distal radius bone graft compares equally to iliac crest bone graft in performing four-corner arthrodesis. The advantages of the distal radius bone graft include a minor surgical exposure and the avoidance of using a distant anatomic site with associated donor-site morbidity.

Patient safety in surgery 5, 23 (2011). doi:10.1186/1754-9493-5-23, Published by BioMed Central, London

Open reduction and internal fixation of radial neck fractures can lead to secondary loss of reduction and nonunion due to insufficient stability. Nevertheless, there are only a few biomechanical studies about the stability achieved by different osteosynthesis constructs.Forty-eight formalin-fixed, human proximal radii were divided into 6 groups according to their bone density (measured by dual-energy x-ray absorptiometry). A 2.7-mm gap osteotomy was performed to simulate an unstable radial neck fracture, which was fixed with 3 nonlocking implants: a 2.4-mm T plate, a 2.4-mm blade plate, and 2.0-mm crossed screws, and 3 locking plates: a 2.0-mm LCP T plate, a 2.0-mm 6x2 grid plate, and a 2.0-mm radial head plate. Implants were tested under axial (N/mm) and torsional (Ncm/ degrees ) loads with a servohydraulic materials testing machine.The radial head plate was significantly stiffer than all other implants under axial as well as under torsional loads, with values of 36 N/mm and 13 Ncm/ degrees . The second-stiffest implant was the blade plate, with values of 20 N/mm and 6 Ncm/ degrees . The weakest implants were the 2.0-mm LCP, with values of 6 N/mm and 2 Ncm/ degrees , and the 2.0-mm crossed screws, with values of 18 N/mm and 2 Ncm/ degrees . The 2.4-mm T plate, with values of 14 N/mm and 4 Ncm/ degrees , and the 2.0-mm grid plate, with values of 8 N/mm and 4 Ncm/ degrees came to lie in the midfield.The 2.0-mm angle-stable plates-depending on their design-allow fixation with comparable or even higher stability than the bulky 2.4-mm nonlocking implants and 2.0-mm crossed screws.

Purpose To evaluate rotational deformity in malunited fractures of the distal radius and its efffect on forearm rotation. Methods Thirty-seven patients with a symptomatic malunion of the distal radius (25 with dorsal angulation and 12 with volar angulation) were assessed for rotational deformity of the distal fragment. Spiral computed tomographic scans were taken of both wrists. Rotational deformity was evaluated by comparing the radial torsion angle of the injured and uninjured sides according to Frahm. Multivariable regression analyses were used to identify the radiologic parameter that had the most important influence on forearm rotation. Results Of the 37 patients, 23 showed a rotational deformity of the distal radius. In both dorsally and volarly angulated malunions, pronation and supination deformities were identified. There was a tendency toward more pronation deformities with volar malunion. Volar angulated malunion with a rotational deformity of less than 10° showed the smallest amount of forearm supination. Losses of pronation-supination did not correlate with the amount of rotational deformity. Conclusions This study showed that rotational deformity is common with angulated malunions of the distal radius. The effect on forearm rotation should not be overestimated. Pretreatment computed tomographic scanning of both wrists to identify and measure malrotation of the distal radius may be helpful to improve the outcome after corrective osteotomy.

The arthrotically destroyed distal radioulnar joint will lead to painful limitation of forearm rotation. Alternative treatment options are the hemiresection-interposition arthroplasty or the Kapandji-Sauve procedure. The aim of our study was to evaluate the clinical and functional results following the hemiresection-interposition arthroplasty in non-rheumatoid patients. The most common posttraumatic cause of the arthrosis was the malunited distal radius fracture. In a retrospective study we examined 36 of 51 patients with a mean age of 53 years after an average follow up of 34 months clinically, radiologically and using the DASH questionnaire. The average preoperative pain measured 7.8 on the visual analog scale and was reduced statistically highly significant (p < 0.01) to 3.9. Whilst pronation increased statistically not significantly from a mean of 74 degrees to 76 degrees (p = 0.428), supination improved significantly from 54 degrees to 69 degrees (p - 0.012). The average grip strength increased statistically highly significant (p

Two cohort populations consisting of 13 patients with an un-united fracture of the distal radius in whom the distal fragment had more than 5 mm of subchondral bone supporting the articular surface distal to the site of the nonunion and ten patients with an un-united fracture of the distal radius with a smaller distal fragment were compared. There were no preoperative differences with respect to age, gender, interval between injury and index procedure, preoperative amount of radius tilt, ulnar inclination and ulnar variance, or the preoperative function. Independent of the size of the distal fragment in all patients the distal radius was restored to gain bony union and realignment with preservation of some wrist motion. The length of the follow-up period averaged 30 months for the small fragment group compared with 22 months for the large fragment group. Bony union was achieved in 22 patients. One patient out of the large fragment group failed to heal the fracture and had wrist fusion. At the follow-up examination there were no significant differences in the radiological and clinical outcome between the two groups. No differences were seen on total range of motion of forearm supination and pronation with an average of 135 degrees in the large fragment group and 145 degrees in the small fragment group. Wrist motion revealed no significant differences in the flexion-extension arc, averaging 90 degrees in the large fragment group and 83 degrees in the small fragment group. Total range of motion of radial and ulnar deviation of the wrist was similar, averaging 39 degrees in the large fragment group and 43 degrees in the small fragment group. Grip strength averaged 59% compared with the opposite limb for the large fragment group and 67% for the small fragment group. We believe that the results of reconstruction of un-united fractures of the distal end of the radius for patients in whom the distal fragment had less than 5 mm of subchondral bone supporting the articular surface distal to the site of the nonunion are comparable to the results for patients with a larger distal fragment. Therefore, we believe that surgeons should try to preserve even a small amount of wrist motion and reserve wrist fusion as a final resort.

Purpose. Evaluation of effectiveness of capsuloligamentous release in severe PIP joint contractures in Dupuytren's disease. Method. Prospective study to compare the clinical outcome of eleven patients with severe contracture of the PIP joint due to Dupuytren's disease, in whom an additional capsulotomy was performed to reduce a residual flexion contracture of the PIP joint of 20 degree and more after release and excision of all diseased fascia, with the outcome of 32 patients with severe contracture of the PIP joint due to Dupuytren's disease, in whom the PIP joint contracture could be reduced by fasciectomy alone. Preoperatively all patients had a severe flexion contracture (60 degrees or greater) of one PIP joint. All patients underwent standardized operative treatment and postoperative extension splinting program for six months. Follow-up examinations included assessment of active range of motion at two, four, ten, 16 and 24 weeks after surgery. Results. In the noncapsulotomy group, preoperative contracture averaged 70.6 degrees and intraoperative residual contracture averaged 2 degrees. In the capsulotomy group, preoperative contracture averaged 78.6 degrees. Intraoperative residual contracture averaged 61.8 degrees before and 2 degrees after capsulotomy. At the final follow-up examination, PIP joint flexion contracture averaged 15 degrees in the noncapsulotomy group compared to 16 degrees in the capsulotomy group. Conclusion. Residual flexion contracture of a PIP joint after release and excision of all diseased fascia in Dupuytren's disease can be reduced by capsuloligamentous release. The data of this study showed no significant differences in the outcome at the final follow-up examination between patients with and without capsulotomy. Therefore, we recommend capsulotomy as treatment of residual flexion contracture of the PIP joint in Dupuytren's disease.