Pronator quadratus repair after volar plate fixation in distal radial fractures: evaluation of the clinical and functional outcome and of the protective role on the flexor tendons-a randomized controlled study.

The objective was to evaluate pronator quadratus (PQ) repair following volar plating of distal radial fractures on clinical and functional outcome, as well as flexor tendon friction, during the first 12 months in ideally positioned plates (Soong 0). Confounding factors like variation in plate positioning, anatomical consolidation of the fracture and associated lesions were excluded. Eighty patients were included with distal radius fractures treated by volar locking plate in Soong grade 0 position, who were randomized to group PQ repair and group no repair. Sixty-five patients completed the 1-year follow-up: group PQ repair (n = 35) and group no repair (n = 30). Primary outcomes included range of motion, grip strength, pain level and QuickDASH. Secondary outcomes included distance between flexor pollicis longus (FPL) and volar rim and the largest distance between FPL and plate (soft tissue thickness occupied by PQ), assessed by ultrasonography. Mobility, grip strength and QuickDASH revealed no significant differences, except extension was significantly higher only in first 3 months and radial deviation was significantly higher only at 6 weeks after PQ repair. Pain level was significantly lower after PQ repair only in the first 3 months. Distance between FPL and volar rim and the largest distance between FPL and plate were significantly higher after PQ repair. No friction contact between FPL and volar rim was measured in both groups at all measurement moments. Consequently, protective flexor tendon effect of PQ repair could consequently not be concluded. In conclusion, clinical and functional short term benefits, except improved wrist extension and reduced pain in the first 3 months, were not proven in this study. In Soong grade 0, PQ repair is probably not necessary to prevent flexor tendon pathology. In Soong grade 1 or 2, this is still to be investigated. LEVEL OF EVIDENCE: 2.

A review of guidelines for collaboration in substance misuse management.

BACKGROUND: Substance misuse among the working population results in increasing economic costs. General practitioners (GPs) and occupational physicians (OPs) can play a central role in detecting and managing substance misuse in the working population. Their collaboration could be critical in coordinating care, in facilitating rehabilitation and in reducing sickness absence. AIMS: To search guidelines for evidence on collaboration between GPs and OPs in substance misuse detection and management in the working population. METHODS: International guidelines regarding collaborative care for alcohol, illicit drug, hypnotic and tranquillizer misuse were identified by a systematic search in the Guidelines International Network and US National Guidelines Clearinghouse databases. RESULTS: In total, 20 guidelines were considered of sufficient methodological quality, based on the criteria of the Appraisal of Guidelines for Research and Education II instrument. Only two guidelines reported on the OP's role in screening and intervention for alcohol misuse. CONCLUSIONS: There is a lack of guidance on the OP's role and on collaboration between GPs and OPs in this field. Further study is required on their respective roles in substance misuse management, the effectiveness of workplace interventions and the benefits of collaboration.

Osteotomies around the thumb base in CMC 1 arthritis.

The trapeziometacarpal joint (TMC) is a saddle joint that is subjected to tremendous repetitive loads through our lifetime. This joint is apparently congruent, but only a small part of the articular surface is loaded during pinch grips. This design implies a perfect bony anatomy, high quality articular cartilage and no ligament laxity. Under certain circumstances, where these different anatomical variables are imperfect, symptoms and pain can start at a very early stage in life. They are mainly acquired, but can be posttraumatic in origin. High quality radiographic views are needed: these radiographs must be done methodically by well-trained radiologists. The symptoms and radiographic changes may not match, such as when radiographic changes are minimal but functional impairment is significant. The primary goal of treatment is conservative. This cannot be stressed enough since conservative treatment can be successful with good follow-up by the hand surgeon: resting splint, good postures at work and if necessary, anti-inflammatory drugs and paracetamol. If this fails after a minimum of 6 months, different osteotomies can be proposed, combined with ligament augmentation in some cases. These osteotomies are mainly extra-articular, can be at the level of the base of the first metacarpal and the trapezium, or can be solely at the base of the first metacarpal. Isolated osteotomies of the trapezium should be avoided since they tend to close the first web space. In certain posttraumatic cases, intra-articular osteotomy of the malunion can be done to restore congruency and provide pain relief.

Spontaneous index finger extensor tendon rupture in a SNAC wrist.

We present two recent cases of spontaneous rupture of both index finger extensor digitorum communis and extensor indices proprius tendons caused by a dorsal carpus osteophyte. Both patients had a history of scaphoid fracture non-union with evolution to scaphoid non-union advanced collapse (SNAC) of the wrist. These two cases were treated surgically with a 3-corner arthrodesis, and an interposition of a fragment of one of both ruptured tendons together with a tendon transfer of a supernumerary extensor digitorum communis of the third finger. The interposed tendon fragment was sutured with a Pulvertaft weave proximally and end-to-end distally. The supernumerary tendon was added as reinforcement to this construction. At 6-month and 14-month follow-up, the patients had a slight decrease in range of motion and functionality without hindering the activities of daily living and a great improvement in strength. Isolated extension of the index finger was possible minimum 6 months postoperatively. Spontaneous tendon ruptures of the finger extensors are not common but were described earlier in literature. Recent literature described that underlying cause of a spontaneous tendon rupture should always be corrected in order to prevent or at least delay future ruptures. To our knowledge, this is a rare type of complication and this kind of treatment has never been reported in literature.

Radiological measurement of trapezial dysplasia - variation of trapezial tilt and trapezial inclination.

Trapeziometacarpal instability is a well-known condition that could lead to trapeziometacarpal osteoarthritis. With the focus in the literature being on ligament insufficiency, bony deformity has received much less attention. Although trapezial tilt is currently used to measure trapezial dysplasia, we believe trapezial inclination is a more reliable measurement. The purpose of this study is to compare these two methods for evaluating trapezial dysplasia and to define the most reproducible measurement. Fifty patients were identified who had three consecutive radiographs of the trapeziometacarpal joint. Eaton views with little to no signs of osteoarthritis (Eaton stage I or II) were used. Both trapezial tilt and trapezial inclination were measured by two independent observers on three radiographs for every patient. Intra-observer variation, absolute agreement and consistency, and intra-observer variation and consistency were assessed for both measurements. Mean trapezial tilt was 135° and mean trapezial inclination was 10°. For both observers, intra-observer variation of trapezial inclination was significantly less than for trapezial tilt. Our study shows that mean trapezial inclination in a middle-aged adult population is approximately 10°. This measurement is more reproducible than the more frequently used trapezial tilt and may be a better parameter to define trapezial dysplasia and to guide its treatment.

Scaphometacarpal arthrodesis with autologous structural bone graft as a salvage procedure after failed trapeziectomy - Surgical technique and initial results.

Painful instability due to proximal migration of the first metacarpal remains a challenging problem in patients who have undergone multiple surgeries for trapeziometacarpal osteoarthritis. The objective of this study was to investigate whether scaphometacarpal (SMC) arthrodesis with a structural bone graft is an acceptable and definitive salvage procedure for the multioperated patient. Three patients underwent SMC arthrodesis using a structural iliac crest bone graft. All patients had symptomatic instability of the thumb base and had undergone three to four surgeries prior to the arthrodesis. All patients were satisfied with the outcomes. Mean opposition decreased from 8 to 7 and mean retropulsion remained at 1. Mean grip strength increased from 3.5 to 10.5kg and mean precision pinch strength increased from 1.5 to 2.5kg. Fusion was confirmed in all patients. SMC arthrodesis with a structural bone graft is an acceptable procedure that largely preserves thumb opposition and restores stability with increased grip and pinch strength. Although far from ideal, it can be considered as a definitive salvage procedure in patients who have already had multiple surgeries to the trapeziometacarpal joint.

Ultrasonographic evaluation of the distance between the flexor pollicis longus tendon and volar prominence of the plate as a function of volar plate positioning and pronator quadratus repair - A cadaver study.

Flexor tendon injury after volar plating of distal radius fractures is due to friction against the plate. To assess this risk, the distance between the flexor pollicis longus (FPL) and the volar prominence of the plate was measured with ultrasonography under various conditions: a standard plate fixed proximal or distal to the watershed line and a low-profile volar rim plate, with and without transection of the pronator quadratus (PQ). Distance from the FPL to the volar prominence of the plate decreased significantly when the PQ was cut and when a standard plate was placed distal to the watershed line, with the tendon often bulging over the plate. No statistical difference was measured between a volar rim plate and a standard plate distal to the watershed line. Our results confirm the importance of positioning the volar plate proximal to the watershed line and of repairing the PQ.