[Treatment reality of distal radius fractures in a center]. / Versorgungsrealität distaler Radiusfrakturen in einem Zentrum.

Distal radius fractures are the third most common type of fracture in Germany after fractures of the femoral neck and peritrochanteric femoral fractures. In 2019 a total of 72,087 cases were registered with an incidence of 106 cases per 100,000 inhabitants (81,570 fractures of the femoral neck, 73,785 peritrochanteric fractures). Many of these fractures are surgically treated also in this hospital but with controversial views on the optimal treatment. Against the background of the coronavirus disease 2019 (COVID-19) pandemic, disappearing personnel resources and the political pressure to form centers and a switch to outpatient treatment, the authors ask the question what the treatment reality in this hospital looks like and whether the general changes in the framework conditions also have an affect in this context. This is not a strictly scientific study but a stocktaking without any claims of completeness and the retrospective evaluation of a larger data pool with all its weaknesses. On the contrary, the data provide interesting aspects that are explained in detail in the individual sections.

[Physiolysis with Resection of Vickers' Ligament in Adolescent Patients with Madelung's Deformity]. / Physiolyse mit Resektion des Vickers-Bandes bei adoleszenten Patienten mit Madelung-Deformität.

BACKGROUND: Madelung's deformity is a congenital or acquired growth disorder of the forearm that can lead to significant impairments in the quality of life of affected patients. Various surgical treatment options for the condition have been described in the literature. This study aimed to investigate whether physiolysis with resection of the Vickers ligament can successfully halt the progression of the disease in a cohort of young patients, as would be expected based on existing literature on this topic. MATERIAL AND METHODS: An analysis was performed on the records of all patients with Madelung's deformity who were primarily treated with physiolysis with resection of the Vickers ligament between January 2001 and June 2017. Patients were invited for follow-up examinations, and surgical outcome was assessed. Parameters evaluated included pain at rest and under load, range of motion of the wrists, and activity level. Additionally, standard X-rays and radiological measurements were performed for each operated wrist. The collected data was compared with the preoperative data from patient records. RESULTS: Nine wrists were included in the study. The average age at the time of surgery was 13.2 years, and the average follow-up period was five years. Extension and ulnar abduction showed a slight decrease from preoperative to follow-up, while flexion improved minimally, and radial abduction and forearm rotation showed noticeable improvement. The visual analogue scale score for pain at rest increased from preoperative 0.25 points to 1.88 points at follow-up. Under load, the average pain score increased from 2.00 to 4.25 points. The mean DASH score increased from 6.04 points before the surgical procedure to 12.20 points at follow-up. The average values of two out of the five measured McCarroll parameters increased, the increase being statistically significant for lunate subsidence. A follow-up procedure was required in one wrist. CONCLUSION: In our cohort, the progression of Madelung's deformity was only partially halted by physiolysis with resection of the Vickers ligament, and a significant increase in pain symptoms during the study period could not be avoided. Therefore, this procedure should be used cautiously in skeletally immature patients.

[Scaphoid fractures : Current diagnostic and treatment concepts]. / Skaphoidfrakturen : Aktuelle diagnostische und therapeutische Konzepte.

Scaphoid fractures are by far the most frequent fractures of the carpal bones of the hand and often lead to problematic healing processes if the diagnostics and treatment are inadequate. The main complication of a scaphoid fracture is pseudarthrosis, which leads to carpal collapse and degenerative arthritis of the wrist if left untreated. Early diagnosis and individualized differentiated treatment aim to achieve bony healing with restoration of the scaphoid shape and preservation of the function of the wrist. The anatomical and biomechanical characteristics of the scaphoid can impede bony healing after a fracture and, in contrast to the diagnostics and treatment, cannot be influenced. A history of trauma and typical clinical signs of a scaphoid fracture should lead to systematic imaging diagnostics with obligatory computed tomography. Only by determining the exact fracture morphology can an appropriate treatment concept be established. Conservative treatment should be restricted to stable fractures without relevant displacement. Fractures of the proximal scaphoid pole are considered unstable even if they are not displaced. Operative treatment is indicated for all unstable fractures. The favored surgical procedure is osteosynthesis with a cannulated double-threaded screw, which can be used in a retrograde or antegrade manner and in a minimally invasive or open technique, depending on the fracture type. Surgical treatment results in earlier bony healing and quicker restoration of function but can be associated with a higher complication rate. Posttraumatic osteoarthritis after healing in malalignment is usually asymptomatic.

Results of primary radial corrective osteotomy in Madelung's deformity.

INTRODUCTION: The purpose of this study was the evaluation of surgical outcomes in a series of wrists with Madelung's deformity treated with radial corrective osteotomy. We hypothesize that this surgical technique is a suitable and safe way of treatment. MATERIALS AND METHODS: A retrospective review of patients with Madelung's deformity treated with radial corrective osteotomy between January 2001 and June 2017 at a single large department of hand surgery in Germany was performed. Patients who met the inclusion criteria were invited for follow-up and outcome variables including pain, range of motion, patient-rated outcome measures, and radiographic measurements were obtained for comparison with preoperative data collected from the patients' medical records. RESULTS: 14 wrists were included. The average age at the time of surgery was 21.9 years, and the average follow-up was 7.2 years. The average visual analog pain scale at rest decreased from preoperative 2.6 points to postoperative 0.7 points. Under strain, the average VAS declined from 7.4 to 4.9 points. The mean DASH Score decreased from 42.9 before surgery to 22.0 points after surgery. Range of motion improved slightly in five out of six directions of motion, with the greatest increase seen in average supination from preoperative 68.5° to postoperative 82.0°. Averages of all five measured McCarroll's parameters and ulnar variance decreased, as expected from corrective surgery. Four wrists (26.8%) needed subsequent procedures. CONCLUSION: Radial corrective osteotomy was a suitable treatment of Madelung's deformity in our collective, although surgical outcomes are not yet fully satisfying.

[Differented Aproaches for Fracture Treatment in the Hand - when doing what?] / Differentialtherapeutische Zugänge zur Frakturversorgung an der Hand ­ Wann macht man was?

Treatment of finger fractures is demanding twice. Malunion and incongruence of the joints frequently result in severe functional restriction and should not be tolerated. On the other hand surgical access to the fracture site is frequently limited by the proximity of vulnerable structures like nerves, vessels, ligaments, and tendons.This article presents a selection of treatment options, that in the opinion of the authors have been proven beyond the background of a large institution with reference to alternative procedures and the management of special situations.

[Revision surgery after resection arthroplasty of the CMC-1 joint using the extensor carpi radialis longus muscle tendon]. / Revisionsoperation nach Resektionsarthroplastik des Daumensattelgelenkes unter Verwendung der Sehne des M. extensor carpi radialis longus.

OBJECTIVE: Resuspension of the first metacarpal bone using the extensor carpi radialis longus muscle tendon. Prevention of contact between the first metacarpal bone and adjacent bones (scaphoid, trapezoideum, second metacarpal bone). Preservation of motion. INDICATIONS: Pain after preceeding resectional arthroplasty due to proximalisation of the first ray. Radiologically demonstrated contact between the base of the first metacarpal bone and adjacent bones (scaphoid, trapezoideum, second metacarpal bone). Instability of the first ray at the site of the suspension. CONTRAINDICATIONS: Proven specific reasons: neuropathical complaints and dysaesthesia in the region supplied by the superficial branch of the radial nerve, tendinitis of the flexor carpi radialis tendon etc. SURGICAL TECHNIQUE: Distalisation of the first ray after mobilisation and debridement at the base of the first metacarpal bone with resection of scar tissue, Resection of the pre-existing tendon plasty and contouring the base of the first metacarpal bone with removal of osteophytes. Interposition of tendon material between the base of the first and second metacarpal bones. POSTOPERATIVE MANAGEMENT: Immobilisation in a forearm cast including the thumb metacarpophalangeal joint for 6 weeks. RESULTS: Of 21 patients treated using this procedure, 15 (13 women, 2 men, average age 59 (51-70) years) were evaluated retrospectively on average 4 (2-10) years postoperatively. Opposition of the thumb was nearly normal. Grip strength and strength of pinch grip did not differ significantly from the contralateral side. Pain at rest and exercise (evaluated by a visual analogue scale from 0-10) was postoperatively significantly reduced. On plain X­rays the distance between the base of the first metacarpal bone and the distal scaphoid pole was significantly increased as a sign of a successful distalisation. Ultimately, 12 patients postoperatively returned to work, 10 to their original occupation. No patient required additional procedures.

Closed continuous Irrigation for the Therapy of Pyogenic Flexor Tenosynovitis.

BACKGROUND/PURPOSE: Pyogenic flexor tenosynovitis within the flexor tendon sheath requires urgent treatment to avoid tendon necrosis and loss of the finger. Objective of this article is the treatment by revision and postoperative continuous irrigation via a closed irrigation system. PATIENTS AND METHODS: From 1.1.2007 to 31.12.2016 54 patients with a pyogenic flexor tenosynovitis were treated by revision and closed continuous irrigation. Besides the evaluation of the patient´s records with respect to the involved fingers and hand, duration of hospitalisation, and required revision surgery, 33 patients (19 males, 14 females) with an average age of 51 (8-85) years were re-examined on average after 21 (4-38) months. Re-examination included measurements of the mobility of the involved fingers and thumbs, grip and pinch strength, pain using the numeric rating scale (BRS), and DASH score. The overall result was graded according to the grading system by Buck-Gramcko for flexor tendon reconstruction. RESULTS: Hospital stay was 9 (3-26) days on average. In 11 patients revision surgery was required including 3 re-installations of the continuous irrigation system, 2 ray amputations, and 1 finger amputation at the level of the proximal interphalangeal joint. The re-examined patients averaged a grip strength of 84 (23-163) % of the unaffected side. On average pain at rest was 0,2 (0-4), pain at daily living activity 1,2 (0-8) on the NRS, the DASH score 16,8 (0-58) points. According to the rating system for flexor tendon function there were one poor, one fair, 5 good and 26 excellent results. CONCLUSIONS: Continuous irrigation by a closed irrigation system for pyogenic flexor tenosynovitis is a successful procedure with a low amputation rate. The functional results are predominantly good and excellent.

[Extensor tendon injuries at the level of the proximal interphalangeal joint]. / Strecksehnenverletzungen in Höhe des Mittelgelenks.

Closed and open injuries of the extensor mechanism at the proximal interphalangeal (PIP) joint can involve the central slip, the lateral slips or both. They are classified as zone III injuries. All open injuries on the dorsal side of the PIP joint should raise suspicion of an extensor tendon injury that is frequently overlooked. The operative strategy consists of wound revision with extensor tendon suture or refixation of the central slip. Acute closed central slip injuries are clinically diagnosed (Elson test) after ruling out bony injuries to the joint. Nondisplaced avulsions of the central slip insertion or lacerations can be treated nonoperatively by splinting. For displaced avulsions and complex injuries the treatment is surgical. In overlooked injuries a typical deformity (buttonhole/Boutonnière deformity) develops within 1-2 weeks that is characterized by an extension lag of the PIP joint and hyperextension at the distal interphalangeal joint. In early cases, when passive extension is still complete (mobile buttonhole deformity) the central slip can be immediately reconstructed. In fixed deformities complete passive extension of the PIP joint has to be restored before surgery by hand therapeutic measures or PIP joint release. Depending on the pattern of the injury and the resulting defects, a number of reconstructive techniques have been established that are summarized in this article. The functional results can be limited by tendon adhesions, imbalance within the reconstructed extensor apparatus and stiff joints that can all restrict the range of motion. Therefore, active rehabilitation protocols are mandatory for optimal results.

[Scaphoid non-union: Experience from more than 280 reconstructions using a medial femur condyle bone graft]. / Kahnbeinpseudarthrose: Erfahrungen aus mehr als 280 Rekonstruktionen mit einem vaskularisierten Knochenblock aus der medialen Femurkondyle.

BACKGROUND: Since 2008 we have been using many free vascularized medial femoral condyle grafts for reconstruction of difficult scaphoid non-unions. This article aims to report our results and experiences. PATIENTS AND METHODS: Until the end of 2019 a total of 287 patients had a microvascular scaphoid reconstruction, 158 with use of a corticocancellous, and 129 using an osseocartilaginous graft. Complete analysis of all of these patients was impossible. This manuscript is based on a retrospective analysis of 28 out of 42 patients with corticocancellous grafts operated on between 2008 and 2010 with a mean follow-up time of 6.1 years as well as another 44 out of 76 patients with an osseocartilaginous graft operated on between 2011 and 2016 with a mean follow-up time of 44 months. Follow-up included clinical parameters, conventional x-rays, a DASH-Score and a modified Mayo wrist score. Additionally, the authors report their personal experiences - necessarily without quantification. In view of this incomplete data-pool statistical analysis was not reasonable. RESULTS: In the group with corticocancellous reconstructions bony healing was achieved in 69 %, salvage operations were required in 9,5 %. The 28 patients had a mean DASH-Score of 11, a mean modified Mayo wrist score of 83 points, a mean ROM of 86° and a mean grip strength of 89 % of the contralateral side. In the group with osseocartilaginous reconstructions complete bony healing was seen in 80 %, partial healing in 5 %, and salvage procedures were required in 11 %. The remaining 39 patients had a mean DASH-Score of 15, a mean modified Mayo wrist score of 80 points, a mean ROM of 90° and a grip strength of 81 % of the contralateral hand. A specific complication was an ossification of the pedicle, but the main problem was a satisfying reconstruction of the shape of the scaphoid and reestablishment of carpal stability in far advanced cases. We could not identify factors reliable for the persisting non-unions. CONCLUSIONS: These operations combine great chances for healing with considerable risks for serious complications. So future patients have to be fully informed, so that their decision for such a procedure is based on realistic expectations.

Outcome of proximal interphalangeal joint replacement with pyrocarbon implants: a long-term longitudinal follow-up study.

INTRODUCTION: The aim of this study was to compare the short-, mid-, and long-term results of pyrocarbon PIPJ arthroplasty. MATERIALS AND METHODS: 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 (ø 19 months), mid-term (ø 54 months), and long-term follow-up (ø 9.8 years) to compare functional and radiological parameters longitudinally. RESULTS: 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. CONCLUSIONS: 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.

[Tenoarthrolysis after flexor tendon injuries]. / Tenoarthrolysen nach Beugesehnenverletzungen.

Normal function of the fingers and thumb depends on properly gliding flexor tendons and a free range of motion of the involved joints. This normal gliding function may be inhibited by adhesions due to damage of the tendon, tendon sheath and adjacent tissue. When digital function is still limited despite a long-term course of hand therapy and there are no signs of further improvement, surgical intervention should be considered. There are no absolute indications for tenoathrolysis of the flexor tendons. With respect to complications, such as secondary tendon rupture, loss of annular pulleys and scar formation, it is part of a stepwise reconstructive concept including further procedures, such as staged flexor tendon reconstruction. Important preconditions for tenoathrolysis are motivation of the patient, the possibility of readily available and frequent postoperative follow-up hand therapy, healed fractures and osteotomy, mature soft tissue, intact tendons and gliding tissue. Preoperatively, a maximum passive range of motion of the involved joints should be achieved. During the operative procedure all adhesive tissue surrounding the tendon within and outside the tendon sheath is consistently resected preserving the annular pulleys as far as possible. Therefore, extensive approaches, arthrolysis, dissolution of unfavorable scar tissue, resection of scarred lumbrical muscles and annular pulley reconstruction are frequently necessary. Salvage procedures, such as arthrodesis, amputation, ray resection or multistage flexor tendon reconstruction are recommended in failed cases and should be considered even preoperatively. In order to retain the intraoperative functional improvement hand therapy for at least 3-6 months should follow.

[Correction of Intraarticular Malunion of the Distal Radius Based on a Computer-Assisted Virtual Planning]. / Die Korrektur intraartikulärer Fehlstellungen am distalen Radius auf der Basis computergestützter virtueller Planungen.

BACKGROUND: Computer-assisted 3D-virtual planning of extraarticular corrective procedures at the distal radius and transfer of the virtually planned procedure to the radius in vivo has been recently described. In contrast to this analogue studies on intraarticular corrective procedures are still lacking. With regard to the difficulties of the technique and the potential risks a similar technique would be valuable, that overcomes the problems of the limited access and the difficulties of reposition and fixation. This study presents a technique for intraarticular corrective procedures at the distal radius based on computer assisted 3D- virtual planning and custom made patient specific instruments. PATIENTS AND METHODS: Between 2013 and 2016, 6 patients (1 female and 5 male) underwent intraarticular corrective osteotomy of the distal radius. The average age was 48 (38-60) years, the interval between injury and correction 10 (4-13) months. All patients had been previously operated externally. The computer-assisted planning was performed in cooperation with an external industrial partner ((Materialise NV, 15 Technologielaan, 3001 Leuven, Belgium). Therefore CT-scans of both wrists and forearms were performed at our institution following a special protocol from which both distal radii were virtually reconstructed. The mirror-image of the 3-D-model of the uninjured radius was superposed over the 3-D-image of the malunited radius so that the malunion was exactly visualized. The correction as well as the desired position of the implants was planned step by step via an online-conference. The stabilisation of the fragments was simulated by introducing plates and screws into the 3-D-images. Based on this plan for every step of the procedure patient-specific drilling and sawing guides were produced (Fa. Materialise) and supplied to our institution. The operative strategy and technique is demonstrated by a typical example and will vary with the individual situation of the patient. RESULTS: No complications occurred. All patients gained bony union. No additional procedures were required. Postoperative CT-scans confirmed that step offs were regularly well corrected but gaps often persisted.

[The Malunited Distal Radius Fracture - Extraarticular Correction without Bone Graft]. / Die in Fehlstellung verheilte distale Radiusfraktur ­ extraartikuläre Korrekturen ohne Knochentransplantation.

BACKGROUND: In open wedge osteotomies of the distal radius, bone grafts increase initial stability and enhance bone formation but are frequently associated with complaints and complications at the donor site. Previous studies have suggested that bone grafting may probably be unnecessary. PATIENTS AND METHODS: Between 2013 and 2016, 19 patients with symptomatic extra-articular fractures of the distal radius, malunited in extension, underwent corrective osteotomy using a palmar locking implant without an additional bone graft. 3 patients dropped out for implant related problems. One patient refused the follow-up investigation. RESULTS: 12 patients (7 male / 5 female) showed complete remodeling of the defect at 5.5 ±â€…3.5 (1.5-13) months. Palmar tilt improved significantly, from a mean of 17° to -1°, the DASH score from 41 ±â€…26 (7-94) points to 26 ±â€…25 (0-75). Radial inclination and ulnar variance and pain level showed only slight, non-significant improvement. Final range of motion and grip strength did not improve. In the modified Mayo wrist score, 5 excellent, 1 good, 3 fair and 3 unfavourable results were obtained. Three female patients showed no remodeling at 10 ±â€…3 (6-12) months. In the modified Mayo wrist score, 1 fair and two unfavourable results were obtained. One of these patients underwent reoperation with iliac crest bone grafting. Though remodeling of the distal radius only failed in female patients, no statistically significant dependence of bony healing on gender, age at the date surgery or size of the defect was found. In the healed group there was no statistical correlation between the interval from surgery to bony fusion and gender, age at the date of surgery or width of the osteotomy gap dorsally. A correlation was found between the widths of the osteotomy gap palmarly and the interval to bony fusion. CONCLUSIONS: After open wedge osteotomy of the distal radius, remodeling may occur without filling the defect by a bone graft. Since bony healing is not predictable and may require more than 12 months in single cases, we will continue bone grafting in our own practice.

[Effect of distal interphalangeal joint fusion of the index or middle finger on the grip or finger force and load distribution in the hand]. / Auswirkungen der Versteifung des Zeige- bzw. Mittelfingerendgelenkes auf Hand- und Fingerkraft sowie auf die Druckverteilung.

BACKGROUND: Due to the functional coupling of adjacent finger joints and the quadriga effect of the flexor digitorum profundus an influence of the grip pattern of the hand after fusion of a distal interphalangeal joint (DIPJ) is assumed. PATIENTS AND METHODS: Two patients with DIPJ II- fusion and 8 patients with DIPJ III- fusion due to a posttraumatic osteoarthritis, but without any other pathology of both hands were assessed on average 55 (17-121) months postoperatively by manugraphy. Using three sizes of cylinders the total grip force and the load distribution of the hand and each finger were measured. The grip pattern was analyzed by 2D-graphs. The results of the affected hand were compared to the healthy opposite side. The consolidation of the DIPJ arthrodesis was confirmed and the angle of the joint fusion measured by radiographs. Patients rated their pain in rest or under strain by a visual analogue scale. RESULTS: The total grip force of the affected hand compared to the opposite side was 93 % for the small cylinder, 97 % for the middle, and 96 % for the large cylinder. Both patients with a DIPJ II- fusion neglected the index finger considerably and had a remarkably weak grip force (68/62/68 % for the 3 cylinders respectively). The grip pattern of all fingers has changed. Eight patients with DIPJ III- fusion averaged 99/106/103 % grip force. In six of them, the affected hand was stronger than the opposite hand when using the middle cylinder. The finger force of the middle and ring finger was reduced, but of the index and little finger increased. Five patients had a striking peak of local pressure at the fused DIPJ III.The angle of the fused DIPJ averaged 6° (0-21°) for all patients. Pain was rated on average 1.4 (0-5) at rest and 2 (0-8) with strain. Both aspects were not found to influence the grip force or the load distribution. CONCLUSION: After DIPJ- fusion of the middle finger its finger force is reduced; but, the total grip force is compensated by an increased finger force of the index and little finger. Despite limitations due to the small number of patients, a DIPJ II- fusion might have a considerable effect on grip force and load distribution of the hand rather due to omitting this finger than purely biomechanical effects.

[Results of the reconstruction of the middle phalangeal base of the finger through an osteochondral autograft from the hamate bone]. / Ergebnisse der Rekonstruktion der Mittelgliedbasis am Finger durch ein osteochondrales Transplantat vom Os hamatum.

OBJECTIVE: The fractured base of the middle phalanx was reconstructed in 13 patients using an osteochondral transplant from the carpometacarpal joint surface of the hamate bone. The goal was to restore joint stability with preservation of mobility. Indications were acute and missed isolated destruction of the palmar middle phalanx base ≥ 30 %. Contraindications were destruction of the head of the proximal phalanx, advanced chondropathy of the head of the proximal phalanx, and extensive soft tissue injury with loss of skin coverage for the proximal interphalangeal joint. SURGICAL TECHNIQUE: In this procedure the fractured middle phalangeal base was debrided and the defect replaced by a size-matched autograft from the dorsal carpometacarpal osteoarticular surface of the hamate bone, which was secured in place with miniscrews. RESULTS: Bone fusion was achieved in 100 % with restoration of joint congruity in 12 of 13 cases and a slight subluxation in one case. Follow-up was possible in 9 cases after 23 (5-51) months. The average range of motion in the reconstructed joint for extension/flexion was 0/9/73°; grip strength was 82 % of the unaffected side. Five out of 9 patients developed a mild flexion contracture in the PIP joint. The DASH score was 6 (0-33) points, pain at rest was 1 (0-5), and pain at exercise 2 (0-6) on a visual analogue scale from 0-10. All patients were satisfied and willing to undergo the procedure again. According to the literature, reconstruction of the base of the middle phalanx by an osteochondral graft from the hamate bone is a reliable procedure to restore stability and mobility of the joint.

Update TFCC: histology and pathology, classification, examination and diagnostics.

The TFCC is a crucial stabilizer of the DRUJ. Based on its superficial and deep fibers, the TFCC guarantees unrestricted pronation and supination which is essential for performing sophisticated tasks. The ability to perform complex movements is of uppermost importance for hand function. Therefore, a functional intact TFCC is a prerequisite in this context. The articular disc of the TFCC is a fibrocartilaginous extension of the superficial zone of hyaline articular cartilage which arises from the radius. The peripheral 10-40 % of the TFC is vascularized. Degeneration of the articular disc is common with increasing age. Even though the central part of the articular disc is avascular, potential regeneration of lesions could be detected. The Palmer and Atzei classifications of TFCC lesions are complementary. TFCC innervation is based on different nerves. There is a high variability. A diligent clinical examination facilitates specific tests which help to allocate symptoms to the pathology. Therefore, a thorough clinical examination is not dispensable. Wrist arthroscopy remains the "gold standard" for diagnosing TFCC pathologies despite technical progress in imaging modalities. MR arthrography may have the potential to become a real alternative to wrist arthroscopy for diagnosing TFCC pathologies with technical progress in the future.

Ulnar shortening osteotomy for malunited distal radius fractures: results of a 7-year follow-up with special regard to the grade of radial displacement and post-operative ulnar variance.

INTRODUCTION: 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. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.