Percutaneous fixation of scaphoid fractures.

Recent advances in techniques and implants have led to renewed interest in percutaneous screw fixation of acute scaphoid fractures. The closed (cast) treatment of acute scaphoid fractures generally has good outcome, with bony union resulting; however, closed treatment can result in delayed union, nonunion, malunion, cast- induced joint stiffness, and lost time from employment and avocations. Acute percutaneous fixation of scaphoid fracture has been proposed as a means to minimize some of the complications of closed (cast) treatment. Percutaneous treatment of both nondisplaced and displaced scaphoid fractures reportedly can achieve a nearly 100% union rate with minimal complications. Fixation of scaphoid fractures with headless compression screws can be done using both volar and dorsal approaches. The fracture reduction and alignment are assessed by fluoroscopy and arthroscopy. Appropriately performed acute percutaneous internal fixation is now a standard treatment option for a selected group of patients with acute scaphoid fracture.

Avoidance and treatment of complications of distal radius fractures.

The treatment of distal radius fractures continues to be fraught with complications. The more widespread use of internal fixation and supple-mental bone grafting with external fixation has decreased the incidence of malunions from closed-cast treatment and percutaneous pinning, but increased the risk of the complications specific to surgical intervention. Careful diagnosis, surgical planning, surgical technique, and postoperative rehabilitation can help optimize outcome in these difficult fractures.

Amputations of the hand and upper extremity in the management of malignant tumors.

The primary goal of treatment for malignant bone and soft tissue tumors of the hand and upper extremity is an oncologic cure. The secondary goal is maintenance of function. Despite recent advances in chemotherapy and radiation techniques, amputation still provides a means for achieving surgical cure for some bone and soft tissue sarcomas. A well planned amputation with attention to level, soft tissue closure, muscle transfer as needed, and nerve handling combined with early fitting of modern prosthetic devices provides patients with a rapid return to normal activity. This article reviews the general principles and specific techniques of amputation in the patient with an upper extremity malignancy.

Percutaneous internal fixation of selected scaphoid nonunions with an arthroscopically assisted dorsal approach.

BACKGROUND: Preliminary reports have indicated that selected scaphoid nonunions-i.e., those that are well aligned and without extensive sclerosis or bone resorption at the nonunion site-can be treated effectively with internal fixation alone. We examined the feasibility of percutaneous fixation in a series of such nonunions. METHODS: A consecutive series of fifteen patients with fibrous union or nonunion of a carpal scaphoid fracture with minimal sclerosis or resorption at the nonunion site were treated with rigid fixation alone (without bone graft) with a headless compression screw inserted with a dorsal percutaneous technique. RESULTS: Clinical examination, standard radiographs, and computed tomography scans confirmed union in all patients at an average of fourteen weeks. Nonunions treated less than six months after the injury healed faster than those treated later (p < 0.02). According to the Mayo modified wrist score, there were twelve excellent and three good results. CONCLUSIONS: The results in our series were due to careful examination and grading of the scaphoid nonunions preoperatively. The findings in this small series support the observation in earlier reports that percutaneous repair of selected scaphoid nonunions requires only rigid fixation to achieve healing.

Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach.

Percutaneous internal fixation of scaphoid fractures allows for more predictable union and less morbidity than cast treatment or open internal fixation. A headless cannulated compression screw (standard Acutrak) is implanted by way of a dorsal percutaneous approach with the aid of fluoroscopy and arthroscopy to confirm screw position and fracture reduction. This technique is indicated in the correction of acute proximal pole fractures, acute waist fractures, and delayed unions that are not associated with avascular necrosis or collapse. The details of this technique are reviewed. In a consecutive series of twenty-seven fractures (seventeen waist fractures and ten proximal pole fractures) treated with arthroscopically assisted dorsal percutaneous fixation, computed tomographic scanning confirmed 100% union at an average of twelve weeks. Eighteen fractures were treated within one month after the injury, and nine were treated more than one month after the injury. In this series, the fractures that were treated early (less than one month after the injury) healed more quickly than those treated later.