[Free vascularized iliac bone graft for the treatment of scaphoid nonunion with avascular proximal fragment]. / Die Rekonstruktion der Kahnbeinpseudarthrose mit avaskulärem proximalen Fragment mit freiem mikrovaskulär gestielten Beckenkammtransplantat.

OBJECTIVE: The goal of the procedure is osseous healing of the scaphoid in an anatomic position and replacement of necrotic bone at the site of the scaphoid nonunion by a vascularized iliac bone graft. INDICATIONS: Scaphoid nonunion with necrotic fragment in SNAC (scaphoid nonunion advanced collapse) < 1. Nonunion following previous surgery. CONTRAINDICATIONS: Pattern of advanced carpal collapse (SNAC > 1). Malformation, disease or previous injury of the vascular system. Poor compliance. Reduced general health. SURGICAL TECHNIQUE: Principles of the surgical technique according to Pechlaner et al.: harvesting of a corticocancellous bone graft from the anterior iliac crest with a nutrient vascular bundle from the deep circumflex iliac artery, debridement of the necrotic scaphoid, press-fit fixation of the tailored graft, pin fixation, and microvascular anastomosis to the radial artery. POSTOPERATIVE MANAGEMENT: Fixation in an upper-arm cast for 4 weeks, followed by lower-arm cast fixation including the thumb to the interphalangeal joint until week 12. Physiotherapy. Wrist splinting in patients enforced to heavy manual load. RESULTS: The described procedure has been practiced at the own institution since 1985 and evaluated in different studies. Using a free vascularized iliac bone graft, union could be achieved in 85% of patients with avascular scaphoid nonunion and in 80% with avascular proximal pole nonunion. The nonunion can be bridged in 93% following failed previous scaphoid screw fixation.

[Stabilization of perilunate and transscaphoid perilunate fracture-dislocations via a combined palmar and dorsal approach]. / Die Versorgung von perilunären Luxationen und Luxationsfrakturen über einen kombinierten palmaren und dorsalen Zugang.

OBJECTIVE: Restoration of the intercarpal alignment and the radio- and ulnocarpal joint in order to avoid the development of a carpal collapse with concomitant arthritis of the radiocarpal and midcarpal joint. INDICATIONS: All perilunate and transscaphoid perilunate fracture-dislocations. An exception is a pure ligamentous injury with anatomic carpal alignment following closed reduction (computed tomography scan). CONTRAINDICATIONS: General contraindications to an operative procedure. SURGICAL TECHNIQUE: It is crucial that all involved bony and ligamentous structures are addressed, using a bilateral approach. Depending on their location, scaphoid fractures are stabilized from proximal or distal, and bony avulsions are fixed at their origin. The typical rent across the palmar ligaments is closed, and the avulsed scapholunate ligament and the dorsal intercarpal ligament are reattached to the adjacent bones. Temporary Kirschner wire fixation is essential for healing. POSTOPERATIVE MANAGEMENT: Forearm plaster cast with short thumb for 12 weeks. Kirschner wire removal after 8 weeks. RESULTS: 25 patients (15 perilunate dislocations and ten perilunate fracture-dislocations) could be included for follow-up 5 years after the trauma. Perilunate fracture-dislocations achieved slightly better results than perilunate dislocations. The DASH Score (Disability of the Arm, Shoulder and Hand) averaged 11.3 and 14.2 points, the PRWE Score (Patient- Related Wrist Evaluation) 20.7 and 27.7 points, respectively. The Mayo Wrist Score amounted to 81.5 and 82.7 points. Active range of wrist motion was reduced by one third compared with the opposite side. Grip strength was reduced by 15-20%. The pain level ranged between 2 and 4 on a scale from 0 to 10. In pure ligamentous injuries, degenerative arthritis was more common in the midcarpal joint, whereas radiocarpal arthritis predominated in the fracture-dislocation group.

[Primary treatment of acute extensor tendon injuries of the hand]. / Primäre Behandlung von offenen Strecksehnenverletzungen der Hand.

OBJECTIVE: Reconstruction of extensor functions after extensor tendon injuries of the hand. INDICATIONS: Acute injuries of extensor mechanism with corresponding loss of function. CONTRAINDICATIONS: Complex injuries with loss of soft tissue. Limited possibility of extensor tendon reconstruction with combined injuries of the interphalangeal joints (in situations with irreparable joints: primary arthrodesis). SURGICAL TECHNIQUE: The treatment of extensor tendon injuries depends on the various levels of tendon laceration. Zones 1 and 2: in case of tendon disruption close to the base of the distal phalanx, refixation of tractus terminalis using a pull-out suture. In case of disruption more proximally, primary repair using mattress sutures. Temporary pinning of the distal interphalangeal joint in extension using a single transarticular Kirschner wire. Zone 3: mattress sutures of the tractus intermedius. Temporary pinning of the proximal interphalangeal joint in extension using a single transarticular Kirschner wire. Zone 4: reconstruction of the central slip and the lateral slip of extensor tendon using modified Becker sutures and mattress sutures. Temporary pinning of the proximal interphalangeal joint in extension using a single transarticular Kirschner wire. Zones 5 and 6: four-strand modified Becker sutures with additional epitendinous suture. Zones 7 and 8: core sutures using modified Kirchmayr techniques with additional epitendinous suture. POSTOPERATIVE MANAGEMENT: Zones 1-4: immobilization of the finger for 6 weeks with removal of the transarticular wire at 4 weeks. Zones 5-8: dynamic postoperative treatment in intrinsic-plus splint for 6 weeks. RESULTS: It is postulated that dynamic postoperative treatment leads to improved functional outcome after extensor tendon injuries. While for zones 1-4 no better final clinical results are observed using the dynamic postoperative protocol, early protected motion for zones 5-8 is superior to static post operative treatment.

Long-term results following pediatric distal forearm fractures.

INTRODUCTION: The purpose of this retrospective study was to investigate the frequency and extent of clinical and radiological late sequelae and to identify predicting factors. MATERIALS AND METHODS: A total of 220 patients of growing age with 232 closed, conservatively treated fractures were re-examined clinically and radiologically at a median follow-up time of 10 years (range 5-16 years). Clinical and radiological findings were summarised as an overall result. RESULTS: Of the total of patients, 19% reported pain in the injured wrist, and wrist mobility was limited in 5% of patients. Forearm rotation was decreased in 16%, primarily in epiphyseal separation of the ulna ( p=0.0033). Radial inclination was different in 6% of patients, palmar tilt in 2%, and ulnar variance in 37%, compared with the contralateral side. Ulnocarpal impaction syndrome was present in 75% of the patients with positive ulnar variance. Overall outcome was excellent in 72%, good in 19%, moderate in 6%, and poor in 3% of patients. The younger the children were at the time of injury, the more favourable the results were ( p=0.009). Children who were older than 10 years when they suffered a severe fracture dislocation had the poorest results ( p=0.008). Further factors having a negative influence on outcome were repeated reduction maneuvers and an additional fracture of the ulna. CONCLUSION: Our follow-up examinations showed that the majority of patients achieved good results, especially in children under 10 years old. Large dislocations at the time of fracture healing do not influence long-term results in this age group and thus can be tolerated. Patients over 10 years old, whose fractures healed with an angular deformity of more than 20 degrees and/or fragment dislocation over half the breadth of the shaft showed the poorest results. Thus, such dislocations should not be tolerated, and reduction should be attempted in this age group by only one reduction maneuver.

Remodeling capacity and functional outcome of palmarly versus dorsally displaced pediatric radius fractures in the distal one-third.

INTRODUCTION: The purpose of this retrospective study was to compare the remodeling capacity and functional outcome of palmarly and dorsally displaced pediatric radius fractures in the distal one-third. MATERIALS AND METHODS: Fifty-three children with a residual dorsal angulation of 15 degrees (range 10 degrees -28 degrees, +/-SD 5.32) and 31 children with a residual palmar angulation of 15 degrees (range 10 degrees -30 degrees, +/-SD 4.88) at fracture healing were re-examined clinically and radiologically with a median follow-up time of 10 years (range 5-15 years). RESULTS: There was no difference in the remodeling capacity, palmar tilt, radial inclination, and ulnar variance between both groups at follow-up. Pain as well as flexion/extension of the wrist and pronation showed no difference in both groups. Palmarly displaced fractures showed a significantly higher restriction of supination ( p=0.01). CONCLUSION: We conclude that remodeling of residual palmar angulation occurs to the same extent as it does in dorsal angulation. Functional outcome differs in forearm supination.

Treatment of distal radioulnar joint disorders with a modified Sauvé-Kapandji procedure: long-term outcome with special attention to the DASH Questionnaire.

INTRODUCTION: An intact distal radioulnar joint (DRUJ) is essential for normal functioning of the upper limb. Osteoarthritis of the DRUJ often leads to ulnar wrist pain, limitation of forearm rotation and reduced grip strength, all of which limit activities of daily living. Once the joint is damaged, salvage procedures are recommended. MATERIALS AND METHODS: Between 1986 and 1996 a modified Sauvé-Kapandji procedure was performed in 117 patients with painfully limited forearm rotation and osteoarthritis of the distal radioulnar joint (DRUJ). Of the 117 patients, 73 women and 32 men, whose ages at operation ranged from 22 to 74 years (average 58 years), were retrospectively reviewed clinically and radiologically 8 years (range 5-12 years) after the operation. The DASH questionnaire was used with 53 patients, 43 patients were accepted for the study, and 10 were excluded. RESULTS: Forearm rotation improved in all patients, ulnar wrist pain was reduced in 97% of the patients, and 9% had mild pain at the proximal ulnar stump. Grip strength improved from a preoperative mean of 38% to a postoperative mean of 55% compared with the contralateral side. The mean DASH score was 28 points (range 0-53 points). In all cases the arthrodesis fused within 8 weeks. The radiographs showed approximation between the proximal ulna stump and the radius compared with the preoperative situation in 74% of the patients. CONCLUSION: Our clinical and radiological findings suggest that the Sauvé-Kapandji procedure is indicated in symptomatic, non-reconstructable disorders of the DRUJ. The DASH questionnaire provides a general view of the functional outcome after the Sauvé-Kapandji procedure. The DASH questionnaire is very helpful in evaluating the effect of the Sauvé-Kapandji procedure on the entire upper limb.

Injectable calcium phosphate bone cement Norian SRS for the treatment of intra-articular compression fractures of the distal radius in osteoporotic women.

BACKGROUND: Distal radius fracture often presents a metaphyseal void which is more extended in elderly, osteoporotic patients. Bone graft and bone substitutes are reported to be beneficial in maintaining metaphyseal reduction. METHODS: We performed a prospective study on 52 menopausal, osteoporotic women with unstable intra-articular distal radius fractures to compare the outcome of percutaneous pinning and immobilisation in a cast for 6 weeks with that using injectable calcium phosphate bone cement (Norian Skeletal Repair System, SRS) to supplement pin and screw fixation and immobilisation in a cast for 3 weeks. All patients were reviewed 2 years (range 21-29 months) after surgery. RESULTS: Patients treated with SRS had better functional outcome, restoration of movement and grip strength ( p<0.001). In this group there was 1 mm loss of radial length, 3 degrees loss of radial inclination and 7 degrees loss of palmar tilt. In the control group radial length decreased 3 mm, radial inclination decreased 11 degrees and palmar tilt 12 degrees. Loss of reduction was significantly higher in the control group ( p<0.001). CONCLUSION: We conclude that the use of Norian SRS to supplement pin and screw fixation is effective in maintaining the reduction of unstable intra-articular distal radius fractures in osteoporotic patients and provides a better clinical outcome than percutaneous pinning.

Storage phosphor radiography of wrist fractures: a subjective comparison of image quality at varying exposure levels.

Image quality of storage phosphor radiographs acquired at different exposure levels was compared to define the minimal radiation dose needed to achieve images which allow for reliable detection of wrist fractures. In a study on 33 fractured anatomical wrist specimens image quality of storage phosphor radiographs was assessed on a diagnostic PACS workstation by three observers. Images were acquired at exposure levels corresponding to a speed classes 100, 200, 400 and 800. Cortical bone surface, trabecular bone, soft tissues and fracture delineation were judged on a subjective basis. Image quality was rated according to a standard protocol and statistical evaluation was performed based on an analysis of variance (ANOVA). Images at a dose reduction of 37% were rated sufficient quality without loss in diagnostic accuracy. Sufficient trabecular and cortical bone presentation was still achieved at a dose reduction of 62%. The latter images, however, were considered unacceptable for fracture detection. To achieve high-quality storage phosphor radiographs, which allow for a reliable evaluation of wrist fractures, a minimum exposure dose equivalent to a speed class of 200 is needed. For general-purpose skeletal radiography, however, a dose reduction of up to 62% can be achieved. A choice of exposure settings according to the clinical situation (ALARA principle) is recommended to achieve possible dose reductions.

Direct digital radiography versus storage phosphor radiography in the detection of wrist fractures.

AIM: To define the value of digital radiography with a clinical flat panel detector system for evaluation of wrist fractures in comparison with state of the art storage phosphor radiography. MATERIAL AND METHODS: Hard copy images of 26 fractured wrist specimens were acquired with the same exposure dose on a state of the art storage phosphor radiography system and a clinical flat panel detector. Image features like cortical bone surface, trabecular bone, soft tissues and fracture delineation were independently analysed by 4 observers using a standardised protocol. Image quality ratings were evaluated with an analysis of variance (ANOVA). RESULTS: Flat panel detector radiographs were rated superior with respect to cortical and trabecular bone representation as well as fracture evaluation, while storage phosphor radiographs produced better soft tissue detail. CONCLUSION: In some of the observed image quality aspects, the performance of caesium iodide/amorphous silicon flat panel detector exceeds state of the art storage phosphor radiography. This makes it well suited for skeletal imaging particularly in trauma as seen in the detection of wrist fractures.