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Distal radius fractures are the most common fractures in adults. Because of the prevalence of these injuries, patients may present with a repeat distal radius fracture on the same wrist through the site of a malunion. We clinically refer to this as an acute on chronic distal radius fracture. In this setting, the restoration of acceptable alignment can be challenging. There is little guidance in the literature for the management of these fractures. We report our experience with acute on chronic distal radius fractures. The secondary fracture plane was used to correct the prior deformity, and the construct was fixated with a fixed angle volar locking plate.Records of patients with malunion of the distal radius who experienced an acute fracture of the ipsilateral distal radius were reviewed. Inclusion required treatment with open reduction internal fixation using a distal fragment first technique and a volar locking plate through the extended flexor carpi radialis approach. Clinical outcomes and complications were collected.Across 13 patients, the mean follow-up term was 13 months (range, 6-40 months). Radiographic union was noted in all patients. The mean visual analog scale score for pain was 1.8, and the mean Quick Disabilities of the Arm, Shoulder, and Hand score was 21.9. There were no recorded complications.Our results and described technique provide reproducible guidance for the management of acute on chronic distal radius fractures. These cases can be managed using the secondary fracture plane, a distal fragment first technique, and a volar locking plate to correct the preexisting deformity.Therapeutic IV.

It is challenging to restore the clinically acceptable alignment of the distal radius after an acute on chronic fracture or after a secondary fracture occurring after malunion of a primary distal radius fracture. In cases of insignificant primary deformity, restoration to the primary deformity may suffice to obtain a successful clinical result. A borderline acceptable primary radial deformity can be unacceptable after the second injury, resulting in functional disability. If surgery is indicated, the surgeon must contend with both primary and secondary deformities to restore proper distal radius anatomy. We present our technique to correct both primary and secondary distal radius deformities through the new or secondary fracture plane.

Distal radius fractures are common. Volar plating is a valuable approach for many fractures. There are also difficult fractures that require careful attention to the exposure and technique for successful volar plating. Classic approaches, such as external fixation with additional percutaneous reduction and pinning or bone graft and fragment-specific fixation, remain valuable especially when volar plating is not applicable. The main objectives are to review the intricacies of volar plating and the use of external fixation with distal radius fractures. This also includes an understanding of the associated injuries that are present with these fractures and the expected outcome of these injuries relative to the distal radius fracture. First, the challenges with volar locked plating as well as many tips and tricks to help with reduction and stabilization of these fractures are reviewed. Second, the benefits and tips and tricks of external fixation are discussed. Finally, the management of common combined injuries with distal radius fractures is reviewed.

In the forearm, ligaments and joints act in unison to facilitate placement of the hand in 3-dimensional space and transmit loads across the upper extremity. Intricate, effective forearm stabilizers facilitate physiologic motions and restrict abnormal ones. The proximal radioulnar joint, interosseous ligament complex, and distal radioulnar joint work together to ensure the forearm is stable. Each ligament and joint is designed to leverage its biomechanical advantages. Damage destabilizes the synergy of the forearm and results in debilitating injury patterns. Physicians need to understand how all these structures work together to be able to quickly diagnose and treat these forearm injuries.

The flexor carpi radialis brevis (FCRB) is an anomalous muscle of the forearm that is only present in 3.5 to 8.6% of the population. In the case of volar plating of distal radius fractures, the FCRB inhibits proper fracture exposure and thus hinders proper reduction. A 78-year-old female presented with right distal radius fracture which necessitated internal fixation. Following mobilization and retraction of the flexor carpi radialis tendon, an anomalous muscle belly was identified as the FCRB. With continued difficulty in exposure and fracture site reduction, resection of the FCRB was performed. The patient was able to return to her activities of daily living without pain and demonstrated no appreciable functional deficit. This case report demonstrates a distal radius fracture where FCRB resection was used, resulting in no detrimental clinical outcomes.

Greater understanding of specific fracture patterns following distal radius fractures has arisen with the advent of volar plating. The volar marginal fragment (VMF) is a small peripheral piece of bone which is critical to carpal stability. Failure to achieve good fixation of the VMF can result in volar subluxation of the carpus and distal radioulnar joint instability. Due to its small, distal nature, this fragment can be easily missed and difficult to fix. Loss of reduction of the VMF following operative fixation presents specific challenges and surgical considerations dictated by patient characteristics and timing. Our goal of this review is to present a classification system for these failed VMFs which can help guide surgical treatment as well as expected outcomes.

The volar rim of the distal radius is the only bony restraint to volar carpal subluxation. Higher loads across the volar rim require stable and rigid fixation to maintain reduction and allow healing while rehabilitation begins. Volar marginal fragments are not amenable to buttressing by fixed angle volar locking plates. Appropriate management of volar marginal fragments comprises two steps—recognition of their presence and rigid anatomical repair. The best opportunity for success in the presence of a volar marginal fragment is its adequate initial treatment. The purpose of this review is to reinforce the importance of a complete preoperative and intraoperative evaluation of distal radius fractures. Volar marginal fragments can easily be overlooked even following initial reduction and fixation. Understanding the relevant anatomy and loading parameters can facilitate intraoperative decisions on approach and fixation, which are integral to achieving optimal clinical outcomes.

Hypothesis The proximal radius is asymmetrical, is mostly articular, and rotates through a large arc of motion. Because of these anatomic factors, there is limited space for hardware. This is magnified in the setting of complex fractures. The portion of the radial head where a radial head plate can be placed without compromising forearm motion has been termed the “safe zone.” We hypothesized that the bicipital tuberosity could be used as a reproducible intraoperative fluoroscopic landmark to confirm radial head plate position in the safe zone. Methods Seventeen cadaveric radii were evaluated. First, the anatomic safe zone was identified using the method previously described by Caputo et al. A proximal radial plate was then placed in the center of this safe zone. The relationship of the plate to the tuberosity was evaluated, and the angle from the point of the greatest tuberosity profile to the center of the safe zone was measured. Results The maximum profile of the bicipital tuberosity is 166° ± 10° from the center of the safe zone as described by Caputo et al. By use of radiographic imaging, a radial head plate placed directly opposite the bicipital tuberosity will be within the safe zone. This position can be ascertained fluoroscopically with an anteroposterior view of the proximal forearm, in which the surgeon rotates the forearm into full supination. The plate should be placed opposite the bicipital tuberosity as seen on the greatest profile at maximum supination. With this method, the plate will be consistently placed within the safe zone. Conclusion The bicipital tuberosity can be used as a consistent radiographic anatomic landmark to ensure proximal radial plate placement within the safe zone. If the proximal radial head plate is placed 166° ± 10° opposite the bicipital tuberosity, a landmark easily identified on intraoperative imaging, the implant will be in the safe zone and will not impinge on the ulna in rotation.

Purpose Ulnar impaction syndrome is a poorly understood degenerative wrist condition characterized by symptoms of pain thought to be caused by increased loads between the ulnar head and the carpals. Radiographic evaluation often reveals an ulnar-positive wrist. We hypothesize that progressive elongation of the central band of the forearm interosseous ligaments changes the longitudinal radial–ulnar relationships, resulting in an ulnar-positive wrist. The objective of the study was to identify a relationship between the loss of integrity of the forearm interosseous ligaments and increased ulnar variance. Methods Six cadaveric human forearms were used to measure displacement of the radius relative to the ulna during axial loading of the lunate fossa of the radius. Radial heights were measured in supination and pronation under a 5-lbF (22-N) preload. Gradual axial loads were applied up to 50 lbF (222N); the resultant axial displacement was measured in supination and pronation. All measurements were evaluated with the interosseous ligament intact and repeated with the central band cut. Results With an applied 5-lbF preload, cutting the central band increased ulnar variance by 3.02 ± 0.80 mm in supination and by 2.15 ± 0.79 mm in pronation. In supination, when the loads were increased from the 5-lbF preload to 50 lbF, the radius displaced 2.1 times further after the central band was cut (3.00 mm) compared with the group with the intact forearm construct (1.41 mm). In pronation, when the loads were increased from the 5-lbF preload to 50 lbF, the radius displaced 1.8 times further when the central band was cut (2.84 mm) than with the intact forearm construct (1.57 mm). Conclusions Because of a parallelogram effect, the radius shifted proximally under a 5-lbF preload, creating an ulnar-positive wrist relationship. Dynamic loading of the forearm after ligament excision resulted in significant additional radial displacement relative to the intact forearm. Clinical relevance Deficiency in the ligamentous restraints of the central band leads to positive ulnar variance, which could be a factor (among others) that contributes to idiopathic ulnar impaction syndrome.

Locked volar plating is the most common surgical procedure to address distal radius fractures. The extended flexor carpi radialis approach continues to be an excellent method for visualizing distal radius fractures and applying a volar plate. A new understanding of the anatomy allows for better visualization and reduction of the many different distal radius fracture patterns surgeons commonly see. Within the extended flexor carpi radialis approach, we describe the radial septum in further detail including the anatomy which comprises the radial septum triangle. Knowledge of this area allows for better visualization, more anatomic reductions, and fewer complications.

Purpose A complete ulnar head replacement may be indicated in cases of distal radial ulnar joint (DRUJ) dysfunction to address bony pathology in lieu of using a constrained total DRUJ prosthesis . Complete ulnar head implants are simple, but they may be unstable if soft tissue tension is not adequately restored. We hypothesized that incorporating an increased offset in the complete ulnar head replacement would lead to increased tension on the distal oblique interosseous ligament, increased contact force at the DRUJ, and improved joint stability. Methods Using a specially designed jig, we measured instability by comparing displacement under load (stiffness) of the DRUJ in 10 cadaveric specimens under 4 different conditions: (1) intact, (2) native head after excision of the triangular fibrocartilage complex, (3) replacement of the ulnar head with a standard offset ulnar head, and (4) replacement of the ulnar head with an increased offset ulnar head. No soft tissue repair was done. We measured anteroposterior displacement under load with maximum translation of 10 mm or maximum loads of 50 N. We tested all specimens with the forearm positioned in neutral, supination , and pronation . Results Excising the triangular fibrocartilage complex decreased the average stiffness of the DRUJ to 46% of the intact state, creating a simulated state of DRUJ instability. Replacing the ulnar head with the standard offset head increased average stiffness to 54% of the intact state. Increasing the ulnar head offset with the simulated total ulnar head replacement increased average stiffness to 77% of the intact state. Conclusions An increased offset ulnar head replacement improves DRUJ stability compared with a standard anatomic offset ulnar head replacement. Clinical relevance Understanding DRUJ morphology and offset is important in the treatment of DRUJ arthritis and instability.

An internal joint stabilizer (IJS) is indicated when there is need for temporary stabilization of the elbow joint. The management of acute trauma, chronic, or postsurgical instability can be augmented by its use. The implant provides initial stability, which then allows joint mobilization.

Carpometacarpal (CMC) osteoarthritis is an exclusively human disease. It occurs because of recent modifications to basic primate hand anatomy that resulted in our modern dexterous hand. This debilitating condition is common and may cause severe pain and loss of hand function. Various surgical procedures aim at providing pain relief and restoring satisfactory function. However, the CMC joint is a challenging joint to reconstruct and the root cause of its degeneration is not well understood, resulting in the development of a wide range of surgical options. This article analyzes the basic biomechanical disorder in thumb CMC joint disease, presents a stabilized saddle CMC hemiarthroplasty as a treatment option, and describes the surgical technique.

Background Articular fractures of the distal radius may include a small fragment from the volar margin of the lunate fossa: volar marginal fragments (VMFs); these fragments are prone to loss of fixation and avascular necrosis, and often result in wrist subluxation. We present our experience managing acute and delayed VMFs. The first is treated using a hook plate extension to a volar locking plate and the latter using a volar opening wedge osteotomy to redistribute loads on the remaining articular surface. Materials and Methods We retrospectively reviewed the records of all patients treated at our facility with a hook plate extension for a VMF and for patients treated with a volar opening wedge osteotomy. Medical charts were examined for complications and functional results. Technique A hook plate extension was used to fix the VMF when plate buttressing was insufficient. For patients who presented a collapsed and reabsorbed VMF, a volar opening wedge osteotomy was used to reorient the articular surface, restoring joint stability. Results The hook plate extension was successful in managing 19 of the 21 acute VMFs. The volar opening wedge osteotomy provided concentric reduction and improved pain and motion in all treated patients. Conclusion We demonstrated that hook plate fixation of the VMF is an effective means of fixing the acute VMF and that a volar opening wedge osteotomy can be used to salvage a distal radius fracture with a collapsed VMF.

Background Several neural interface technologies that stimulate and/or record from groups of axons have been developed. The longitudinal intrafascicular electrode (LIFE) is a fine wire that can provide access to a discrete population of axons within a peripheral nerve fascicle. Some applications require, or would benefit greatly from, technology that could provide access to multiple discrete sites in several fascicles. New method The distributed intrafascicular multi-electrode (DIME) lead was developed to deploy multiple LIFEs to several fascicles. It consists of several (e.g. six) LIFEs that are coiled and placed in a sheath for strength and durability, with a portion left uncoiled to allow insertion at distinct sites. We have also developed a multi-lead multi-electrode (MLME) management system that includes a set of sheaths and procedures for fabrication and deployment. Results A prototype with 3 DIME leads was fabricated and tested in a procedure in a cadaver arm. The leads were successfully routed through skin and connective tissue and the deployment procedures were utilized to insert the LIFEs into fascicles of two nerves. Comparison with existing method(s) Most multi-electrode systems use a single-lead, multi-electrode design. For some applications, this design may be limited by the bulk of the multi-contact array and/or by the spatial distribution of the electrodes. Conclusion We have designed a system that can be used to access multiple sets of discrete groups of fibers that are spatially distributed in one or more fascicles of peripheral nerves. This system may be useful for neural-enabled prostheses or other applications.

Background Our primary efficacy objective was to evaluate the effectiveness of the internal joint stabilizer of the elbow (IJS-E) in maintaining concentric location of the elbow during and after removal of the device in the treatment of persistent or recurrent instability after elbow fracture or dislocations, or both. The secondary study objectives were to assess range of motion, Broberg-Morrey functional score, Broberg-Morrey categorical rating, the Disabilities of the Arm, Shoulder and Hand score, and the rate of complications and adverse events after the use of IJS-E. Methods Twenty-four patients were studied in a multicenter, nonrandomized, prospective, single-arm study. The IJS-E was used to provide temporary stabilization of the elbow joint and allow a functional range of motion while ligaments and fractures healed. Results The elbow remained concentrically aligned in 23 of 24 patients. One coronoid-deficient elbow did not maintain concentric reduction. At the last evaluation a minimum of 6 months after device removal, the mean arc of elbow flexion was 119° (range, 80°-150°; standard deviation [SD], 18°), and the mean arc of forearm rotation was 151° (range, 90°-190°; SD, 24°). The mean and median Broberg-Morrey scores were 93 and 97, respectively. Categorically the results were excellent in 14, good in 8, fair in 1, and poor in 1. The mean Disabilities of the Arm, Shoulder and Hand score was 16 (range, 0-68; SD, 18). Conclusion The IJS-E maintains concentric reduction, allows elbow motion, and avoids the inconveniences and pin problems of percutaneous fixation.

UNLABELLED This report cites new developments in the treatment of extra-articular hand fractures in adults. Recent reports confirm that small amounts of metacarpal shortening or dorsal angulation cause minimal functional impairment. Unilateral excision of the lateral band and oblique fibers of the extensor apparatus of the metacarpophalangeal joint facilitates proximal phalangeal fracture exposure and may improve functional recovery. Results using open mini screw fixation of oblique extra-articular metacarpal and phalangeal fractures may be comparable to those of percutaneous Kirschner wire fixation. Bicortical self-tapping mini screw fixation of extra-articular oblique metacarpal and phalangeal fractures simplifies screw insertion and provides stability comparable to that of fractures fixed with lag screws. Percutaneous intramedullary wire fixation may afford suitable fixation for unstable extra-articular oblique as well as transverse metacarpal fractures. Locked intramedullary nails may offer similar advantages. Unicortical screw fixation of mini plates securing transverse extra-articular metacarpal fractures affords stability comparable to that of bicortical screw fixation while creating less bone damage. The dissection required for plate fixation and the small surface area of transverse fractures delay and occasionally impair bone healing. Primary bone grafting of diaphyseal defects in clean stable wounds may shorten and simplify treatment and decrease morbidity. As little as 1.7 mm of flexor tendon excursion during the first 4 weeks after reduction or repair may substantially diminish peritendonous adhesions at the fracture site. Synchronous wrist and digital exercises may also reduce peritendonous fracture adhesions. Early motion of adjacent joints in closed simple metacarpal fractures expedites recovery of motion and strength without adversely affecting fracture alignment and leads to earlier return to work. LEVEL OF EVIDENCE Level V (expert opinion).

We present new developments in the volar treatment of unstable distal radius fractures in adults. New perspectives on the anatomy of the wrist, the watershed line on the volar radius and the usefulness of the pronator fossa are presented and these help to avoid flexor and extensor tendon disturbance when using a volar approach. Other new insights on the bony anatomy of the distal end of the radius are discussed, which are important in improving the quality of fracture fixation, including the benefits of constructing a precise fixed-angle scaffold underneath the articular surface in order to stabilize it. A volar fixed-angle plate must support the dorsal, central and volar aspects of the subchondral bone in order to stabilize the most complex fractures. Awareness of the anatomy of blood supply to the distal radius: the dorsal retinaculum that feeds the distal fragments and the blood supply to the diaphysis through branches of the anterior interosseous artery is necessary to maximize healing potential and avoid complications. Volar fixed-angle plates need to withstand very high forces during rehabilitation, the magnitude of these forces are up to five times the loads applied on the hand.Level V (expert opinion).

Treating unstable distal radius fractures in osteoporotic patients remains a challenge for the surgeon. Fixed angle plate fixation requires ample surgical dissection but has been shown to improve stability, allow early functional use of the hand and facilitate rehabilitation. We herein describe a treatment method that provides the benefits of fixed angle fixation while utilizing a minimally invasive approach. Stability is achieved by the use of a new implant that is placed through a small dorsal incision and minimizes extensor tendon disruption. This method finds application in the unstable extra-articular fracture of the high risk patient where minimal surgical morbidity is desirable and when reduction can be obtained without the need of extensive dissection. Clinical examples are fractures in the elderly patient where confusion can follow prolonged anesthesia, fractures in the patient with a bleeding disorder where a small wound volume is desirable and fractures in the polytraumatized patient where surgical time must be kept to a minimum. This technique allows anatomic reduction and stable fixation to be achieved in a short operative time and with minimal surgical insult while providing the compromised patient with a rapid recovery.

Uncorrected bony deformity or stiffness resulting from a metacarpal shaft fracture can produce a significant functional or cosmetic deficit. Intramedullary fixation of metacarpal shaft fractures using small flexible rods can provide stable internal fixation while minimizing the extent of soft tissue trauma that is associated with more extensive surgical techniques such as plate or screw fixation. The flexible rod is usually introduced in a proximal to distal direction to avoid injury to the metacarpophalangeal joint and extensor mechanism. Closed reduction of the fracture and percutaneous insertion of the rod improve operative efficiency and allow what is truly a minimally invasive procedure. The use of a proximal locking pin greatly enhances fixation and has resulted in an expansion of the surgical indications to include spiral and comminuted fractures. Usually a single locked nail is used, although it is possible to insert multiple nails if necessary. A radiopaque plastic cap can be applied over the cut end of the nail to minimize irritation of the adjacent soft tissues during rehabilitation. Post-operatively, splint or cast immobilization is often unnecessary. The nails are routinely removed after the fracture has completely healed.

Background: The purpose of the present study is to report on a cohort of patients with a volar shearing fracture of the distal end of the radius in whom the unique anatomy of the distal cortical rim of the radius led to failure of support of a volar ulnar lunate facet fracture fragment. Methods: Seven patients with a volar shearing fracture of the distal part of the radius who lost fixation of a volar lunate facet fragment with subsequent carpal displacement after open reduction and internal fixation were evaluated at an average of twenty-four months after surgery. One fracture was classified as B3.2 and six were classified as B3.3 according to the AO comprehensive classification system. All seven fractures initially were deemed to have an adequate reduction and internal fixation. Four patients required repeat open reduction and internal fixation, and one underwent a radiocarpal arthrodesis. At the time of the final follow-up, all patients were assessed with regard to their self-reported level of functioning and with use of Sarmiento's modification of the system of Gartland and Werley. Results: At a mean of two years after the injury, six patients had returned to their previous level of function. The result was considered to be excellent for one patient, good for four, and fair for two. The average wrist extension was 48°, or 75% of that of the uninjured extremity. The average wrist flexion was 37°, or 64% of that of the uninjured extremity. The one patient who underwent radiocarpal arthrodesis had achievement of a solid union. The four patients who underwent repeat internal fixation had maintenance of reduction of the lunate facet fragment. The two patients who declined additional operative intervention had persistent dislocation of the carpus with the volar lunate facet fragment. Conclusions: The stability of comminuted fractures of the distal part of the radius with volar fragmentation is determined not only by the reduction of the major fragments but also by the reduction of the small volar lunate fragment. The unique anatomy of this region may prevent standard fixation devices for distal radial fractures from supporting the entire volar surface effectively. It is preferable to recognize the complexity of the injury prior to the initial surgical intervention and to plan accordingly. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Metacarpal shaft fractures are common but consensus on the best mode of treatment has not been established. Open reduction and internal fixation with plates or screws has been performed for severely displaced fractures. Unfortunately, extensor tendon adhesions and/or unsightly scars frequently follow this form of treatment. Percutaneous flexible intramedulary nailing of metacarpal fractures provides an alternative method that minimizes these problems. The technique is simple and provides the ability to lock the nails to control length and rotation. The nails are inserted using a manually operated slotted awl and usually in an anterograde direction to prevent soft tissue irritation around the metacarpo-phalangeal joints. This method utilizes flexible nails (1.5 and 1.0 mm.) and closed fluoroscopically assisted reduction. Rotationally unstable or fractures with a tendency to shorten can be locked proximally using a captured transverse pin which effectively controls length and rotation. Metacarpo-phalangeal flexion block splinting can be used postoperatively and the nails are routinely removed after fracture healing. Experience with this technique has been favorable as it avoids exposure of the fracture, dissection around the extensor mechanism, and scar problems. It has provided excellent functional results and has presented a low complication rate.

ISTAL RADIUS FRACTURES ARE frequently associated with distal radioulnar joint (DRUJ) injury and a substantial proportion of patients develop symptomatic instability after fracture union. Distal radioulnar joint instability can lead to ulnarsided wrist pain, painful or limited forearm rotation, grip strength weakness, and/or degenerative arthritis. Distal radioulnar joint stability depends on the triangular fibrocartilage complex (TFCC), bony articulation between the ulnar head and sigmoid notch of the radius with its fibrocartilaginous rim, dorsal and palmar radioulnar ligaments, distal interosseous membrane (DIOM), and the musculotendinous units of the extensor carpi ulnaris and pronator quadratus. Cadaveric studies have demonstrated that the primary stabilizer of the DRUJ is the TFCC (specifically the radioulnar ligaments) and that the DIOM is an important secondary stabilizer of the DRUJ. 1,2 In the setting of a distal radius fracture, the usually intact DIOM has a central role in DRUJ stability because the TFCC is frequently injured. The DIOM is an isometric stabilizer of the forearm and its stabilizing effect has been attributed to its resting tension. 1 A recent anatomic study defined the DIOM as originating palmar and proximal on the ulna and inserting distal and dorsal on the radius, thus providing a structural basis for its function in resisting dorsal translation of the radius in supination. 3 In addition, approximately 40% of patients have a distinct ligamentous thickening of the DIOM known

Background Nonsurgical and surgical treatments such as immobilization, transarticular pinning, and hinged or nonhinged external fixation have been used to treat unstable elbows. These methods all have drawbacks. We thought that a bent Steinmann pin introduced through the axis of ulnohumeral rotation and attached to the ulna could provide an improved method of treatment and that this could result in the development of a proper internal joint fixator that may have widespread application. Questions/purposes Does a fully internal hinged fixator crafted intraoperatively by the surgeon from a Steinmann pin for patients undergoing surgery for severe elbow instability result in restoration of range of motion and elbow stability? Does it result in new complications? Methods We reviewed the first 10 patients treated with the method for elbow instability. Diagnoses included fracture-dislocations of the elbow that remain unstable after fracture repair and unstable elbows that result from release of contracture or ulnohumeral synostosis. During that time, all patients meeting these criteria who underwent surgery by this surgeon (JLO) were treated with this approach. Charts, radiographs, and therapy notes were assessed at a minimum of 14 months (mean, 32 months; range, 14–59 months); no patients were lost to followup. Data recorded included age, sex, and elbow and forearm range of motion as well as any complications and reoperations that occurred. The absence of elbow instability was determined initially by radiographically observing concentric reduction of the ulnohumeral and radiocapitellar joints and later by radiography plus the absence of clinical signs and symptoms of elbow instability. Results Mean range of motion at latest followup was flexion 134°, extension −19°, pronation 75°, and supination 64°. All elbows were clinically and radiographically stable. Complications resulting in additional procedures occurred in four patients, including one recurrent deep infection in a patient with a remote history of sepsis, one wound hematoma that resolved after a drainage procedure performed in the office, one prominent implant treated by partial removal, and one patient with heterotopic ossification treated with excision of the heterotopic bone. Conclusions This technique restores elbow stability and permits motion without the use of transcutaneous pins. It seems promising for the treatment of patients with severe elbow instability but requires a second procedure for removal. Further investigation is needed to understand its place in the surgeon’s toolbox and what drawbacks it may have. Level of Evidence Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Reconstruction of the damaged proximal interphalangeal (PIP) joint is a challenge in the young active patient. Arthrodesis is disabling and implant arthoplasty is not satisfactory. Microvascular transfer of the second toe PIP joint is technically demanding, requires sacrifice of the toe, and achieves only 40° of average arc of motion in most reported series. The distal interphalangeal (DIP) joint of the same digit is conveniently located for potential transfer and its loss is well tolerated. We hereby describe our technique of homodigital DIP to PIP joint island flap transfer. With this procedure, the traumatized digit serves as its own donor and no other digit or toe is compromised. It exchanges the DIP joint, which contributes only 15% to the digital flexion arc for the PIP joint whose functional contribution is 85%. In addition, it provides the opportunity to shorten the stiff finger, making it less prone to interfere with hand activities. It is currently our preferred procedure, and because of its excellent result, has superseded the microvascular toe joint transfer.

Total wrist arthrodesis is commonly performed using fixation plates, which can produce soft tissue irritation, often require removal, and limit the ability to position the hand in space. The Skeletal Dynamics IMPLATE is an intramedullary total wrist fusion device designed to provide stable fixation while avoiding the problems associated with plates. Radial and metacarpal locked intramedullary nails are inserted and joined by a connector. Desired hand placement is achieved by selecting the proper connector length and angle, then orienting it appropriately. Fusion mass compression is obtained by virtue of longitudinal threads on the radial nail that allow for length adjustment. Seven wrists in three men and four women were treated with this device and followed for a minimum of 24 weeks. In all cases, local cancellous bone graft was used and the third carpometacarpal (CMC) joint incorporated into the fusion. The median age was 49 (range, 28–71) years. Indications for fusion were two posttraumatic arthritides, three rheumatoid arthritides, one spastic deformity, and one infection. Patients were evaluated before surgery and at final follow-up using the Fernandez pain score and grip strength measurements using a hand-held dynamometer. All patients improved their grip strength and decreased their pain scores. All fusions united, and none of the patients presented dorsal soft tissue problems or required implant removal. One rheumatoid patient required secondary surgery for removal of a retained palmar osteophyte. This device delivers stable fixation, facilitates hand placement, and does not require removal.

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.

Purpose The aim of the study is to evaluate the safety and utility of the extended flexor carpi radialis (FCR) exposure and volar locking plate fixation for partially healed malaligned fractures of distal radius. Materials and methods Thirty-five patients with a partially healed malaligned fracture of the distal radius had realignment of the fracture using an extended FCR approach (release of the insertion of the brachioradialis and dorsal periosteum) and volar locked plate and screw fixation. Results Retrospective review an average of 20 months after the index operation patients identified an average wrist extension of 68°, flexion of 64°, pronation of 84° and supination of 85°. Radial inclination, volar tilt and ulnar variance significantly improved compared to preoperative radiographs. All fractures healed, and there were no infections, implant loosening or breakage or tendon ruptures. Conclusions This study demonstrated that the extended FCR approach is safe and effective as a treatment method for nascent malunions of the distal radius.

We devised a new flap using the palmar cutaneous branch of the superficial radial artery proximally and anastomosed with a cutaneous perforator of the superficial palmar arch distally. We named our flap "the volar glabrous palmar flap." The flap was used both as a free flap and as a reverse-flow island flap. Thirty-six patients with volar hand defects (24 digits, 7 palms, and 5 first web space) were reconstructed with this flap. The flap was used as a proximally based free flap in 15 patients and was used as a reverse-flow island flap based on distal communication in the remaining 21 patients. Free flaps were supplied by the palmar branch of the superficial radial artery and its fasciocutaneous extensions; reverse-flow island flaps were supplied by one of the perforating branches of the superficial palmar arch, which is connected to the proximal fasciocutaneous branches. Flaps extended from the wrist crease to the proximal palmar crease and were designed medially on the thenar crease, extending 2 to 2.5 cm laterally. Flap sizes ranged from 1.5 x 2.2 cm to 2.5 x 10 cm. The palmar cutaneous branch of the median nerve within the flap area was identified and then was sutured to the divided digital nerve in 6 cases of finger pulp defect. The donor sites were closed and repaired primarily in most cases. The postoperative course was uneventful, and all the flaps survived without major complications. Follow-up (minimum 6 mo, mean 24 mo) showed excellent functional and cosmetic results. Satisfactory sensory reinnervation was achieved in patients who underwent sensory flap transfer for pulp defects. At the same time, we studied 6 cadaver hands to understand the vascular anatomy of the thenar area of the hand. We also revised several published anatomic papers to obtain a refined and scrutinized understanding of the palmar anatomy.

Metacarpal and phalangeal shaft fracture fixation can be achieved by closed IM nailing. This technique provides sufficient stability to commence early unsupported joint motion and minimize soft-tissue irritation and scar formation. Stability is enhanced by proximal nail locking; a measure that extends the indications to spiral and comminuted fractures. The surgical technique is simple but requires attention to detail.

Volar fixation of dorsally unstable distal radius fractures is a new method of treatment that provides the benefits of stable internal fixation without the complications of the dorsal approach. A new, fixed-angle fixation device, the distal volar radius (DVR) plate, (Fig. 1) has been introduced for this purpose. Experience gained by applying this technique to clinically complex cases led us to the realization that more exposure, especially in a dorsal direction, was necessary than that provided by the traditional volar approaches. The need to reduce fractures with significant articular displacement (Fig. 2) and the need to release dorsal callus in inveterate fractures or nascent malunions led us to use an extended form of the flexor carpi radialis (FCR) approach. Volar displaced distal radius fractures are commonly managed with volar buttress plates through the FCR approach. This approach goes deep to the forearm fascia through the FCR tendon sheath and is continuous with the distal part of the Henry approach. The traditional FCR approach provides access to the volar aspect of the distal radius, the volar wrist capsule, and the scaphoid. In comparison with dorsal approaches, which present a high incidence of extensor tendon problems, the FCR approach is relatively free of complications. We extend the FCR approach by releasing the radial septum, by mobilizing the proximal radial fragment, and by using the fracture plane for exposure or what is known as intrafocal technique. Therefore, understanding the anatomy of the radial septum is important. On its proximal aspect, it is a simple fascial wall separating the flexor and extensor compartments of the forearm. At the level of the radial metaphysis, the radial septum is a complex fascial structure that includes the first extensor compartment and the insertion of the brachioradialis. More distally, the radial septum forms the radial insertion of the carpal ligament and ends as the FCR tendon sheath approaches the tuberosity of the scaphoid. The proximal radial fragment has a dependable endosteal blood supply that permits its subperiosteal release and subsequent mobilization. Pronating this fragment out of the way provides wide exposure of the fracture surfaces. This allows the volar reduction and fixation of even the most complex dorsally displaced distal radius fractures. Address correspondence and reprint requests to Dr. Jorge L. Orbay, Miami Hand Center, 8905 SW 87 Ave., Suite 100, Miami, Florida 33176; e-mail: MIAHANDS@ix.netcom.com Techniques in Hand and Upper Extremity Surgery 5(4):204–211, 2001 © 2001 Lippincott Williams & Wilkins, Inc., Philadelphia

Volar fixed-angle fixation of distal radius fractures is a new method of treatment that provides the benefits of stable internal fixation without incurring the disadvantages of the dorsal approach. The DVR plate is a new fixation implant that was introduced specifically for the purpose of managing both dorsal and volar displaced fractures from the volar aspect. Experience gained applying volar fixed-angle fixation to clinically complex cases led to the description of a new surgical approach and to refinement in design of the implant. The need to reduce fractures with significant articular displacement and the need to debride dorsal organized hematoma or callus in old fractures led to the development of an extended form of the flexor carpi radialis approach that provides improved dorsal exposure by mobilizing the proximal radius out of the way and allows the use of the fracture plane for intrafocal exposure. The use of this implant in severely osteoporotic bone and in those fractures presenting severe articular fragmentation or displacement led to the improvement of its design. The plate's ability to stabilize the distal radius was optimized by taking full advantage of the principles of subchondral support and buttress fixation.

Volar fixed angle fixation may be considered as the beginning of a new era in restoring wrist function to patients with dorsally displaced distal radius fractures even in the face of comminuted or osteopenic bone. A thorough understanding of the anatomy of the wrist is a prerequisite when volarly approaching dorsally displaced distal radius fractures. The demonstration of the device theoretical and practical advantages requires an appreciation of the basics of working length, principles of plate stability, and the effect of cantilever bending. Volar fixed angle fixation successfully improves wrist function and significantly prevents the complications of the dorsal approach previously intractable to treatment. The current advantages, indications, clinical results, and complications of this new technology are being reviewed.

Purpose Increased incidence of falls and osteoporosis combine to make distal radius fractures a major cause of morbidity for the elderly patient. This report presents our experience treating distal radius fractures in the elderly population using a volar fixed-angle internal fixation plate. Methods We reviewed retrospectively all patients older than 75 years treated during a period of 4 years and 7 months at our centers for unstable distal radius fractures using a volar fixed-angle plate. Postoperative management included immediate finger motion, early functional use of the hand, and a wrist splint used for an average of 3 weeks. Standard radiographic fracture parameters were measured and final functional results where assessed by measuring finger motion, wrist motion, and grip strength. Results Of 26 patients that fit the inclusion criteria, we were able to evaluate 23 patients with 24 unstable distal radius fractures for an average of 63 weeks. Final volar tilt averaged 6° and radial tilt 20°, and radial shortening averaged less than 1 mm. The average final dorsiflexion was 58°, volar flexion 55°, pronation 80°, and supination 76°. Grip strength was 77% of the contralateral side. There were no plate failures or significant loss of reduction, although there was settling of the distal fragment in 3 patients (1–3 mm). Conclusions The treatment of unstable distal radius fractures in the elderly patient with a volar fixed-angle plate provided stable internal fixation and allowed early function. This technique minimized morbidity in the elderly population by successfully handling osteopenic bone, allowed early return to function, provided good final results, and was associated with a low complication rate.

Purpose Many skeletal traction devices have been described to treat fracture dislocations of the proximal interphalangeal (PIP) joint. Most of these techniques are technically challenging or involve cumbersome frames. We present a design modification that enhances the stability of a simple dynamic fixation system described previously and report our results with this technique. Methods A previously described simple dynamic fixator with no rubber bands was applied to 6 patients who sustained fracture dislocations of the PIP joint. The middle finger was involved in 3 patients, the ring finger in 1 patient, and the small finger in 2 patients. The average age of the patients was 27 years (range, 21–42 y). The average involvement of the base of the middle phalanx was 48% (range, 35% to 60%). The average time from the injury to the surgery was 6 days (range, 1–14 d). The average follow-up period was 24 months (range, 7–43 mo). Immediate active flexion extension was allowed and the fixator was removed after 3 to 4 weeks. Results The average range of motion of the PIP joint at the final follow-up evaluation was 5° to 89° (range, 0° to 100°). Two patients developed pin track infection that resolved with oral antibiotics. Only one patient complained of mild pain with extreme flexion. Proper reduction and congruency of the joint was noted on final anteroposterior and lateral radiographs. Conclusions A simple dynamic fixator for the treatment of unstable PIP joint fracture dislocations was used succesfully in 6 digits to maintain reduction and restore digital range of motion. The addition of modifications to the original technique not only improves the solidity of the construct but also provides satisfactory functional results. Based on our experience we recommend this easy technique to treat fracture dislocations of the PIP joint.

Using a volar approach to avoid the soft tissue problems associated with dorsal plating, we treated a consecutive series of 29 patients with 31 dorsally displaced, unstable distal radial fractures with a new fixed-angle internal fixation device. At a minimal follow-up time of 12 months the fractures had healed with highly satisfactory radiographic and functional results. The final volar tilt averaged 5 degrees; radial inclination, 21 degrees; radial shortening, 1 mm; and articular incongruity, 0 mm. Wrist motion at final follow-up examination averaged 59 degrees extension, 57 degrees flexion, 27 degrees ulnar deviation, 17 degrees radial deviation, 80 degrees pronation, and 78 degrees supination. Grip strength was 79% of the contralateral side. The overall outcome according to the Gartland and Werley scales showed 19 excellent and 12 good results. Our experience indicates that most dorsally displaced distal radius fractures can be anatomically reduced and fixed through a volar approach. The combination of stable internal fixation with the preservation of the dorsal soft tissues resulted in rapid fracture healing, reduced need for bone grafting, and low incidence of tendon problems in our study.

Stable internal fixation and early motion has not been routinely available for distal radius fractures. Difficulties with the dorsal approach discourage surgeons from internally fixing the most common fracture types. The introduction of a new volar plate with subchondral support fixation allows the treatment of most distal radius fractures with stable internal fixation and early motion while avoiding the complications inherent in the dorsal approach.