The minimally invasive flexor carpi radialis approach: a new perspective for distal radius fractures.

The minimally invasive flexor carpi radialis approach can be used for volar locking plate fixation of distal radius fractures. After 15-mm incision on the lateral aspect of the FCR tendon and all structures but the radial artery are reclined ulnarly, a plate is inserted under the pronator quadratus just proximal to the "watershed line." The distal epiphyseal screws are put in place, and the proximal part of the plate is exposed by flexion of the wrist to put in place the proximal screws. No drainage or postoperative immobilization is used. It offers the advantage of preserving ligamentotaxis which facilitates the reduction, and the small size of the scar improves the esthetic result of the procedure. It is indicated for extra-articular fractures of the distal radius. In the case of an intraarticular fracture, an arthroscopy may be associated. In the case of a proximal diaphyseal extension of the fracture, a second proximal approach can be added in order to use a longer plate. Relative contraindications are comminuted articular fractures in elderly osteoporotic patients. Functional and radiological results are comparable to those obtained with the extented flexor carpi radialis approach. A conversion of the procedure for a larger incision is always possible in the case of a difficult reduction.

Treatment of hand enchondroma with injectable calcium phosphate cement: a series of eight cases.

The gold standard treatment for enchondroma in the hand is curettage and filling of the defect. The goal of this study was to evaluate the results when injectable calcium phosphate cement is used to fill the bone defect. Eight patients having a mean age of 44 years were operated through a minimally invasive skin incision. After a small bone window was made, curettage of the lesion was performed and verified by intraosseous endoscopy. The defect was filled with injectable calcium phosphate cement (JectOS/AREX®BONE, Kasios, L'Union France). The mean pain score (out of 10) decreased from 4.1 preoperatively to 1.6 postoperatively. The mean QuickDASH (out of 100) improved from 37.66 to 24.14. At the last follow-up (mean of 16 months), the range of motion in the operated hand had reached 89.3% of the contralateral hand. Based on radiographs, a mean of 69.3% calcium phosphate cement remained in the bone. There were two cases of extraosseous cement leakage, one of which required revision and resulted in a poor outcome. Overall, these results show that curettage of a hand enchondroma followed by filling of the defect with injectable calcium phosphate cement is a simple, reliable technique with no donor site morbidity, as long as cement does not leak out.

Volar Locking Plate Fixation of Distal Radius Fractures: Splint versus Immediate Mobilization.

Background The goal of this study was to demonstrate that the use of a splint after performing an osteosynthesis of the distal radius with a volar locking plate is unnecessary. The main hypothesis was that postoperative flexion of the wrist was greater without a splint. Secondary hypothesis was that patients who were allowed immediate mobilization got better results in terms of pain, Quick Disabilities of the Arm, Shoulder and Hand (DASH), Patient-Rated Wrist Evaluation (PRWE), strength, extension, pronation, and supination. Case Description Our series included 72 patients, aged 59 years in average of which 59 were female patients. All patients had been operated for a volar locking plate fixation of a distal radius fracture. The first 36 patients (group I) were immobilized by a splint at 30° of extension of the wrist for 2 weeks. The following 36 patients (group II) were not immobilized. Results At 3 months, all the average variables were better in the group without splint (group I: flexion 74.83%, extension 83.13%, pronation 92.07%, supination 88.11%, pain 1.72/10, Quick DASH 21.78/100, PRWE 22.97/100, strength 62.96%; group II: flexion 85.50%, extension 83.4%, pronation 92.96%, supination 92.96%, pain 1.28/10, Quick DASH 19.57/100, PRWE 20.56/100, strength 66.34%). No complication was reported. Conclusion Overall, our results demonstrate that wearing a splint after volar locking plate fixation of a distal radius fracture is unnecessary.

Nerve injuries to the volar aspect of the hand: A comparison of the reliability of the Weber static test versus the gauze test.

When examining lacerations to the volar aspect of the hand a gauze test may usually be performed to detect nerve injuries. However, published literature suggests that its sensitivity and specificity are lower than 100%. The aim of this study was to determine whether a Weber static (main hypothesis) and dynamic test or a Semmes-Weinstein test (secondary hypotheses) could be a more reliable test than the gauze test to rule out any nerve injury and avoid unnecessary wound explorations. Our case series included a total of 102 patients presenting with 123 palmar lacerations and 158 nerve injuries. On arrival at the emergency department, every patient was tested for epicritic sensation at the pulp of the injured and contralateral fingers with the Weber static and dynamic tests and the Semmes-Weinstein monofilament test. All lacerations underwent exploration under anesthetic to rule out nerve injury. The sensitivities of the gauze test, the Weber static test, the Weber dynamic test and the Semmes Weinstein monofilament test were proven to be 82.5%, 98.6%, 97.9% and 86.7% respectively. The specificities of the gauze test, the Weber static test, the Weber dynamic test and the Semmes Weinstein monofilament test were 79%, 79%, 79% and 78.9% respectively. Examination of lacerations to the volar aspect of the hand to rule out any nerve injuries should include a Weber static test instead of a gauze test. A negative Weber static test should not however discourage a surgical exploration of the laceration to rule out tendinous or vascular injury.

Distal Radius Isoelastic Resurfacing Prosthesis: A Preliminary Report.

Background Here we present a preliminary case series of unicompartmental isoelastic resurfacing prosthesis of the distal radius to treat comminuted articular fractures of osteoporotic elderly patients. Materials and Methods Our study included 12 patients, mean age 76 years, who presented with comminuted osteoporotic distal radius fracture. Because of the severity of injury and poor bone quality; osteosynthesis was not deemed to be a good option. Description of Technique The surgery was performed through a dorsal approach. The subchondral bone of the entire distal radial articular was excised and a unicompartmental prosthesis was applied. Results At an average follow-up of 32 months, the pain was 2.8/10, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) 37.4/100, grip strength in neutral 49.9%, in supination 59.0%, and in pronation 56.2% of the contralateral normal side. The wrist ranges of motion in flexion and extension were 56.1% and 79.3%, in supination and pronation 87.7% and 91.0% of the contralateral normal side. Two patients experienced a complex regional pain syndrome (CRPS) type II; these resolved spontaneously. One patient experienced distal radioulnar joint (DRUJ) stiffness, which improved after an ulna head resection. Finally, one patient required revision surgery after a secondary traumatic fracture. Radiographically; the average volar tilt was 9.8°; the average of radial inclination was 11.6°. Conclusion The concept of a unicompartmental isoelastic resurfacing prosthesis offers a promising option for the treatment of comminuted, osteoporotic distal radius articular fractures of elderly patients. Level of Evidence IV.