Vacuum-Assisted Therapy for Combined Volar-Dorsal Soft-Tissue Defects of the Hand: A Case Report.

ABSTRACT: Application of negative-pressure wound therapy dressings to the web spaces and small, often moist, areas of the hand can be technically demanding and time consuming. The researchers present a case report and technique for managing a devastating hand infection and soft-tissue defects by creating a self-fabricated sponge glove that is easily reproducible. Vacuum-assisted therapy for combined volar dorsal soft-tissue defects of the hand, or "Hand Vac," is a novel approach for treating extensive hand wounds. This technique was used in a patient with diabetes with a deep space infection of the hand following serial debridements and antibiotic bead therapy. A single, medium-size sponge was cut using a knife and scissors to create an easily applied glove that was then sealed with adhesive dressing and a single suction port. The patient avoided complete amputation of the hand and deep infection was eradicated. The wounds had progressive granulation and healing and were eventually covered with split-thickness skin grafts. The authors conclude that severe soft-tissue defects involving both the volar and dorsal aspects of the hand can be effectively managed with a single glove-like sponge and suction port.

Orthopedic Oncology Caseload Among Orthopedic Surgery Residents.

Despite educational focus regarding orthopedic oncology during residency, assessment of resident orthopedic oncology caseload has not been performed. The purpose of this study was to evaluate orthopedic oncology caseload trends and variation among residents. The Accreditation Council for Graduate Medical Education case log reports for orthopedic surgery residents were reviewed for graduating years 2007 to 2013. Trends in orthopedic oncology cases and variation in the median number of cases performed by residents in the 90th, 50th, and 10th percentiles of caseload were evaluated. The proportion of orthopedic oncology caseload among all cases performed by residents increased significantly (P = 0.005) from 2007 to 2013. Likewise, the mean number of adult (P = 0.002), pediatric (P = 0.003), and total orthopedic oncology cases increased significantly (P = 0.002). On average, residents in the 90th, 50th, and 10th percentiles performed 83, 28, and 3 cases, respectively. The current study demonstrates a significant increase in adult, pediatric, and total orthopedic oncology caseload. There is also evidence of substantial caseload variation among residents. Caseload variation may influence the education and technical proficiency of orthopedic residents.

Performance Outcomes After Hook of Hamate Fractures in Major League Baseball Players.

CONTEXT: Major League Baseball (MLB) players are at risk of hook of hamate fractures. There is a paucity of data assessing the effect of a hook of hamate fracture on MLB players' future athletic performance. OBJECTIVE: To determine if MLB players who sustain hook of hamate fractures demonstrate decreased performance upon return to competition when compared with their performance before injury and that of their control-matched peers. DESIGN: Retrospective case-control design. SETTING: Retrospective database study. PARTICIPANTS: 18 MLB players who sustained hook of hamate fractures. METHODS: Data for 18 MLB players with hook of hamate fractures incurred over 26 seasons (1989-2014) were obtained from injury reports, press releases, and player profiles ( www.mlb.com and www.baseballreference.com ). Player age, position, number of years in the league, mechanism of injury, and treatment were recorded. Individual season statistics for the 2 seasons immediately prior to injury and the 2 seasons after injury for the main performance variable-Wins Above Replacement-were obtained. Eighteen controls matched by player position, age, and performance statistics were identified. A performance comparison of the cohorts was performed. MAIN OUTCOME MEASURES: Postinjury performance compared with preinjury performance and matched-controls. RESULTS: Mean age at the time of injury was 25.1 years with a mean of 4.4 seasons of MLB experience prior to injury. All injuries were sustained to their nondominant batting hand. All players underwent operative intervention. There was no significant change in Wins Above Replacement or isolated power when preinjury and postinjury performance were compared. When compared with matched-controls, no significant decline in performance in Wins Above Replacement the first season and second season after injury was found. CONCLUSION: MLB players sustaining hook of hamate fractures can reasonably expect to return to their preinjury performance levels following operative treatment.

The Effect of Price on Surgeons' Choice of Implants: A Randomized Controlled Survey.

PURPOSE: Surgical costs are under scrutiny and surgeons are being held increasingly responsible for cost containment. In some instances, implants are the largest component of total procedure cost, yet previous studies reveal that surgeons' knowledge of implant prices is poor. Our study aims to (1) understand drivers behind implant selection and (2) assess whether educating surgeons about implant costs affects implant selection. METHODS: We surveyed 226 orthopedic surgeons across 6 continents. The survey presented 8 clinical cases of upper extremity fractures with history, radiographs, and implant options. Surgeons were randomized to receive either a version with each implant's average selling price ("price-aware" group), or a version without prices ("price-naïve" group). Surgeons selected a surgical implant and ranked factors affecting implant choice. Descriptive statistics and univariate, multivariable, and subgroup analyses were performed. RESULTS: For cases offering implants within the same class (eg, volar locking plates), price-awareness reduced implant cost by 9% to 11%. When offered different models of distal radius volar locking plates, 25% of price-naïve surgeons selected the most expensive plate compared with only 7% of price-aware surgeons. For cases offering different classes of implants (eg, plate vs external fixator), there was no difference in implant choice between price-aware and price-naïve surgeons. Familiarity with the implant was the most common reason for choosing an implant in both groups (35% vs 46%). Price-aware surgeons were more likely to rank cost as a factor (29% vs 21%). CONCLUSIONS: Price awareness significantly influences surgeons' choice of a specific model within the same implant class. Merely including prices with a list of implants leads surgeons to select less expensive implants. This implies that an untapped opportunity exists to reduce surgical expenditures simply by enhancing surgeons' cost awareness. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analyses I.

Trends in Arthroscopic Procedures Performed During Orthopaedic Residency: An Analysis of Accreditation Council for Graduate Medical Education Case Log Data.

PURPOSE: To analyze orthopaedic resident case log data to report temporal trends in performing arthroscopic procedures and to assess variability in arthroscopic case volume among residents. METHODS: Accreditation Council for Graduate Medical Education orthopaedic surgery resident case logs were reviewed from 2007 to 2013. The mean number of wrist, elbow, shoulder, knee, and ankle arthroscopic procedures performed by graduating residents was analyzed. The median number of arthroscopic procedures reported by the 70th and 30th percentiles of graduating residents (by arthroscopic case volume) was also recorded. Temporal trends were assessed using a linear regression model. RESULTS: From 2007 to 2013, there were significant increases in the mean number of wrist (5.8 to 6.3; P = .038), elbow (2.5 to 3.2; P < .001), shoulder (93.5 to 133.8; P < .001), knee (170.6 to 185.1; P = .011), and ankle (5.8 to 7.4; P < .001) arthroscopies performed per resident. Residents in the 70th percentile of caseload performed significantly more wrist (7 v 2; P < .001), elbow (3.3 v 1; P < .001), shoulder (134.1 v 70.6; P < .001), knee (205 v 128.7; P < .001), and ankle (7.9 v 2.9; P < .001) arthroscopies than residents in the 30th percentile. CONCLUSIONS: Our findings indicate that arthroscopic caseload is increasing among orthopaedic residents. However, resident experience performing arthroscopic procedures is substantially disparate. Although the educational implications of this disparity are not well understood, our findings may aid in efforts to optimize arthroscopic training during orthopaedic residency.

Volar-Ulnar Approach for Fixation of the Volar Lunate Facet Fragment in Distal Radius Fractures: A Technical Tip.

The volar Henry approach is most commonly used for surgical fixation of distal radius fractures. However, this approach is limited in achieving adequate exposure for the fixation of the volar-ulnar portion of the distal radius, rendering it difficult for the ideal placement of the fixation construct. We propose the use of the extensile volar-ulnar approach for fixation of distal radius fracture involving a small volar-ulnar fragment. This approach allows optimal reduction of the sigmoid notch and the volar lunate facet, which anatomically reduces both the radiocarpal joint and the sigmoid notch. In addition, extension of this approach may safely be performed if concomitant carpal tunnel release is necessary.

Risk of Injury to the Dorsal Sensory Branch of the Ulnar Nerve With Percutaneous Pinning of Ulnar-Sided Structures.

PURPOSE: To assess the risk of injury to the dorsal sensory branch of the ulnar nerve (DSBUN) with percutaneous pinning of commonly stabilized ulnar-sided structures. METHODS: Eleven fresh-frozen cadaveric upper extremities were assessed. Percutaneous pinning of the fifth metacarpal base and neck, lunotriquetral joint, ulnar styloid, and distal radioulnar joint (DRUJ) with 1.4-mm Kirschner wires was performed under fluoroscopic guidance. Each specimen was then carefully dissected and the distance from each pin to the DSBUN was measured using a digital caliper. Direct injury to the DSBUN and pins found immediately adjacent to the nerve were recorded. RESULTS: Mean distance from the pin to the DSBUN at the fifth metacarpal neck was 5.0 ± 1.5 mm; fifth metacarpal base, 2.3 ± 2.2 mm; lunotriquetral joint, 1.8 ± 1.6 mm; ulnar styloid, 0.8 ± 1.1 mm; and DRUJ, 3.1 ± 0.9 mm. Two of 11 ulnar styloid pins and 1 of 11 lunotriquetral pin directly penetrated the DSBUN, whereas 4 of 11 ulnar styloid pins, 3 of 11 fifth metacarpal base pins, and 2 of 11 lunotriquetral pins were directly adjacent to the DSBUN. There was an increased overall risk of DSBUN injury (risk of direct injury and risk of adjacent pin) with pinning of the ulnar styloid compared with fifth metacarpal neck and DRUJ pinning. CONCLUSIONS: The current study demonstrates the risk of iatrogenic injury to the DSBUN with percutaneous pinning of the ulnar styloid, lunotriquetral joint, and fifth metacarpal base. CLINICAL RELEVANCE: We recommend identifying and protecting the nerve to mitigate the risk of iatrogenic injury when performing ulnar-sided pinning of structures from the ulnar styloid to the fifth metacarpal base.

Complex proximal ulna fractures: outcomes of surgical treatment.

BACKGROUND: To review the results of plating of various fracture patterns of proximal ulna fractures including isolated olecranon fractures, olecranon fractures combined with a coronoid fracture, and olecranon fractures combined with a coronoid and radial head fracture. MATERIALS AND METHODS: The study included 38 patients with either an isolated olecranon fracture or combined injuries, all treated with open reduction and internal fixation of the olecranon. Other procedures were performed as needed, including radial head fixation or arthroplasty, fixation of the coronoid, and repair of the lateral collateral ligament complex. There were 27 men and 11 women with an average age of 49 years. Clinical and radiographic assessment was obtained at an average follow-up time of 15 and 8.4 months, respectively. RESULTS: All fractures healed within 5 months. The average arc of ulnohumeral motion was 91° (range 0°-140°); average pronation-supination arc was 128° (range 0°-180°). Subgroup analysis showed a statistically significant lower rotational motion arc in patients with associated radial head (73°) or coronoid fractures (68°) compared to isolated olecranon fractures. All other parameters including ulnohumeral motion, complication rate, and revision rate were similar among the groups. CONCLUSIONS: A stable, functional elbow can be restored in most patients with proximal ulna fractures treated with open reduction and internal fixation. Loss of full flexion is likely with high-energy trauma, complex fracture patterns, and concomitant injuries. Fracture patterns involving the coronoid and/or the radial head are associated with restricted forearm rotation. LEVEL OF EVIDENCE: III.

Fracture pattern characteristics and associated injuries of high-energy, large fragment, partial articular radial head fractures: a preliminary imaging analysis.

BACKGROUND: High-energy radial head injuries often present with a large partial articular displaced fragment with any number of surrounding injuries. The objective of the study was to determine the characteristics of large fragment, partial articular radial head fractures and determine any significant correlation with specific injury patterns. MATERIALS AND METHODS: Patients sustaining a radial head fracture from 2002-2010 were screened for participation. Twenty-five patients with documented partial articular radial head fractures were identified and completed the study. Our main outcome measurement was computed tomography (CT)-based analysis of the radial head fracture. The location of the radial head fracture fragment was evaluated from the axial CT scan in relation to the radial tuberosity used as a reference point. The fragment was characterized by location as anteromedial (AM), anterolateral (AL), posteromedial (PM) or posterolateral (PL) with the tuberosity referenced as straight posterior. All measurements were performed by a blinded, third party hand and upper extremity fellowship trained orthopedic surgeon. Fracture pattern, location, and size were then correlated with possible associated injuries obtained from prospective clinical data. RESULTS: The radial head fracture fragments were most commonly within the AL quadrant (16/25; 64 %). Seven fracture fragments were in the AM quadrant and two in the PM quadrant. The fragment size averaged 42.5 % of the articular surface and spanned an average angle of 134.4(°). Significant differences were noted between AM (49.5 %) and AL (40.3 %) fracture fragment size with the AM fragments being larger. Seventeen cases had associated coronoid fractures. Of the total 25 cases, 13 had fracture dislocations while 12 remained reduced following the injury. The rate of dislocation was highest in radial head fractures that involved the AM quadrant (6/7; 85.7 %) compared to the AL quadrant (7/16; 43.7 %). No dislocations were observed with PM fragments. Ten of the 13 (78 %) fracture dislocations had associated lateral collateral ligament (LCL)/medial collateral ligament tear. The most common associated injuries were coronoid fractures (68 %), dislocations (52 %), and LCL tears (44 %). CONCLUSION: The most common location for partial articular radial head fractures is the AL quadrant. The rate of elbow dislocation was highest in fractures involving the AM quadrant. Cases with large fragment, partial articular radial head fractures should undergo a CT scan; if associated with >30 % or >120(°) fracture arc, then the patient should be assessed closely for obvious or occult instability. These are key associations that hopefully greatly aid in the consultation and preoperative planning settings. LEVEL OF EVIDENCE: Diagnostic III.

How is forearm compliance affected by various circumferential dressings?

BACKGROUND: The forearm is the second most common location for extremity compartment syndrome. Compliance is a physical property that describes a material's ability to expand with an increasing internal volume. The effect of circumferential dressings on extremity pressures has been investigated in various animal models and in some nonphysiologic mechanical models, but the importance of this effect has not been fully investigated in the human upper extremity. In addition, the physical property of compliance has not been reported in the analysis of compartment volume-pressure relationships. QUESTIONS/PURPOSES: We created a physiologic cadaver model for acute compartment syndrome in the human forearm to determine (1) how much volume is required to reach the pressure threshold of 50 mm Hg in forearms, undressed and dressed with various circumferential dressings, (2) differences in forearm compliances that result from dressings, and (3) whether univalving or bivalving of those dressings adequately reduces compartment pressures. METHODS: A sealed inflatable bladder was placed deep in the volar compartment of seven fresh-frozen cadaveric forearms and overlying fascia and skin were closed. Compartment pressures were measured as saline was infused in the bladder, and compliance was calculated from pressure versus volume curves. This was repeated for each specimen using five external wraps, splints, and casts. At a baseline of 50 mm Hg, each dressing then was univalved (and bivalved, when appropriate for the material) and the decrease in compartment pressure was measured. For each of the seven cadaver forearms, one test was performed without dressings and then for each of five dressing conditions. RESULTS: Forearms in fiberglass casts accommodated only a mean of 19 mL (SD, 11 mL; 95% CI, 9-28 mL) before reaching the 50 mm Hg pressure threshold, which was much less than in undressed forearms (mean, 77 mL; SD, 25 mL; 95% CI, 55-98 mL; p < 0.001). Mean compliances were as follows: ACE™ wrap (1.75 mL/mm Hg; SD, 0.41 mL/mm Hg), Webril™ (1.54 mL/mm Hg; SD, 0.56 mL/mm Hg), Kling(®) (1.23 mL/mm Hg; SD, 0.52 mL/mm Hg), sugar tong splint (1.05 mL/mm Hg; SD, 0.52 mL/mm Hg), and fiberglass cast (0.38 mL/mm Hg; SD, 0.27 mL/mm Hg). Univalving of all circumferential wraps dropped the mean compartment pressure from the 50 mm Hg starting point: ACE™ (46%; SD, 14%), Webril™ (52%; SD, 20%), Kling(®) (70%; SD, 18%), sugar tong splint (52%; SD, 19%), and fiberglass cast (58%; SD, 7%), with p less than 0.001 for all dressings. CONCLUSIONS: We observed the compressive effect of various commonly used upper-extremity splints and wraps, finding the least amount of accommodation afforded by fiberglass casts. Univalve release resulted in reduction in forearm compartment pressures, even in fiberglass casts. CLINICAL RELEVANCE: A rigid circumferential dressing can have a dramatic effect on extremity compartment compliance. Contrary to common clinical teaching, univalving of forearm circumferential dressings effectively reduced compartment pressures, as shown in this physiologic model.

Biomechanical evaluation of 5 fixation devices for proximal interphalangeal joint arthrodesis.

PURPOSE: To determine in a cadaver model which, among 5 fixation methods for proximal interphalangeal (PIP) joint arthrodesis, has the greatest stiffness. METHODS: Thirty-five cadaver digits were randomly assigned to 1 of 5 fixation groups: oblique K-wire with coronal intraosseous wiring, tension-band wire (TBW), dorsal plate, intramedullary linked screw (IMS), and 90/90 wiring (90/90W). Testing was done by applying bending moments to the PIP joint in the sagittal and frontal planes. The force/displacement curves were used to estimate the stiffness of each construct. Ultimate strength was determined by loading to failure in extension. RESULTS: The IMS had significantly higher stiffness than all wiring constructs in all planes of motion and significantly greater stiffness in extension than the dorsal plate. The IMS stiffness exceeded 10 N/mm across all bending directions and showed an ultimate strength of 21 N. The plate demonstrated higher stiffness in radial bending than the oblique K-wire with coronal intraosseous wiring and TBW. There were no differences in stiffness between the IMS and plate in all modes of testing except extension. Load-to-failure testing of the devices showed the IMS device to be significantly stronger than the TBW, 90/90W, and plating constructs. CONCLUSIONS: The IMS resisted larger bending moments than all wiring constructs and showed the greatest ultimate strength when compared with 3 of the tested arthrodesis techniques. The plate was significantly better than 2 of the wiring constructs, but only in radial bending. No differences were found between the, TBW, and 90/90W when compared with each other. CLINICAL RELEVANCE: The stiffness necessary for a successful PIP joint fusion has not been quantified, but according to this study, the IMS was the most favorable biomechanical construct for initial stability.

Three-dimensional analysis of elbow soft tissue footprints and anatomy.

BACKGROUND: Tendinous and ligamentous injuries commonly occur in the elbow. This study characterized the location, surface areas, and origin and insertional footprints of major elbow capsuloligamentous and tendinous structures in relation to bony landmarks with the use of a precision 3-dimensional modeling system. METHODS: Nine unpaired cadaveric elbow specimens were dissected and mounted on a custom jig. Mapping of the medial collateral ligament (MCL), lateral ulnar collateral ligament (LUCL), triceps, biceps, brachialis, and capsular reflections was then performed with 3-dimensional digitizing technology. The location, surface areas, and footprints of the soft tissues were calculated. RESULTS: The MCL had a mean origin (humeral) footprint of 216 mm(2), insertional footprint of 154 mm(2), and surface area of 421 mm(2). The LUCL had a mean origin footprint of 136 mm(2), an insertional footprint of 142 mm(2), and a surface area of 532 mm(2). Of the tendons, the triceps maintained the largest insertional footprint, followed by the brachialis and the biceps (P < .001-.03). The MCL, LUCL, and biceps footprint locations were consistent, with little variability. The surface areas of the anterior (1251 mm(2)) and posterior (1147 mm(2)) capsular reflections were similar (P = .82), and the anterior capsule extended farther proximally. CONCLUSION: Restoring the normal anatomy of key elbow capsuloligamentous and tendinous structures is crucial for effective reconstruction after bony or soft tissue trauma. This study provides the upper extremity surgeon with information that may aid in restoring elbow biomechanics and preserving range of motion in these patients.

Outcomes of distal humerus diaphyseal injuries fixed with a single-column anatomic plate.

PURPOSE: The locking compression extra-articular distal humerus plate (EADHP) is an anatomically shaped, angular stable single-column fixation system for distal third humerus fractures. The purpose of this retrospective study was to evaluate clinical and radiographic outcomes after open reduction and internal fixation of distal humerus fractures with this device. METHODS: Twenty-one consecutive patients with distal humerus fractures were treated with the EADHP system between February 2006 and June 2012. Of these, 19 were clinically and radiographically evaluated after a mean follow-up of 10.4 months. Follow-up assessment included anteroposterior and lateral radiographs, assessment of range of motion (ROM), pain according to a visual analogue scale (VAS) and Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS: All fractures demonstrated satisfactory reduction and healing at an average of 7.3 months. One patient showed post-operative sensory ulnar neuropathy that recovered completely, and nine patients had a preoperative radial nerve palsy, which recovered spontaneously following exploration and plating. Mean post-operative ROM was as follows: flexion 126°, extension -7°, pronation 82° and supination 83°. The VAS score was zero points in eight patients, while the mean DASH score was 25.8 points. CONCLUSIONS: For extra-articular distal humerus fractures, including high-energy injuries often seen in gunshot wounds or motor vehicle injuries, the anatomically shaped angular stable single-column plate provides satisfactory clinical and radiographic results and serves as a valuable tool in the treatment of these injuries.

A Comparison of Outcomes following Plate versus Pin Fixation of Metacarpal Shaft and Neck Fractures.

The aim of this study is to compare clinical and radiographic outcomes of open reduction and internal fixation versus closed reduction and percutaneous pinning of metacarpal fractures in relation to anatomic and surgical variables. Methods: Electronic medical records at two institutions were reviewed for patients who underwent surgical intervention for metacarpal fractures. Data were collected from those who underwent reduction and internal fixation with either plates or Kirschner wires (K-wires). Inclusion criteria included minimum postoperative follow-up of 60 days and age 18 years or older. Exclusion criteria included insufficient radiographic data, previously attempted closed reduction with immobilization, pathologic fracture mechanism, history of previous trauma or surgery to the affected bone, and fixation technique other than plate or K-wire. Results: We reviewed data for patients treated over a 22-year time period. Ultimately, 81 metacarpal shaft and neck fractures in 60 patients met inclusion criteria. Among all metacarpal fractures, complications were present in 39 (48.1%) cases. There were no significant associations between complication prevalence and hardware type. Revision surgery was required in 11 (13.6%) patients; there were no significant associations between revision procedures and hardware type. Postoperatively, all patients with imaging data had radiograph follow-up to assess union status. There was no significant association between time to union and hardware type. Conclusions: Outcomes showed no significant difference between plate and pin fixation for metacarpal shaft and neck fractures. These findings suggest that surgeons may have flexibility to decide on the type of operative intervention while considering patient-specific factors, such as the need for early mobilization.

Percutaneous screw fixation without bone grafting of scaphoid non-union.

BACKGROUND: Delays in diagnosis and inadequate treatment of acute scaphoid fractures can lead to non-unions, presenting surgeons with unique challenges regarding optimal management. OBJECTIVES: To evaluate the clinical and radiographic outcome of scaphoid non-unions treated with percutaneous screw fixation. METHODS: The study group comprised 12 patients with scaphoid non-unions of an average duration of 8.7 months. There were 11 males and 1 female with an average age of 24 years (range 14-47 years). All patients were initially treated with percutaneous screw fixation without bone grafting. A volar percutaneous approach was used in eight patients and a dorsal percutaneous approach in four. Wrist range of motion (ROM) and disabilities of the arm, shoulder, and hand (DASH) questionnaires were used to assess clinical outcomes. Postoperative radiographs were reviewed to assess the fracture union, carpal alignment and screw position. RESULTS: Eleven of the 12 (92%) fractures united successfully with no additional procedures. These fractures achieved radiographic union at an average of 4 months. One patient with sickle cell anemia required revision fixation, which consisted of repeat percutaneous fixation and bone grafting. In this patient his non-union healed 3 months after the revision procedure. The average DASH score at final followup was 6 (range 0-16). Average wrist ROM was extension of 66 degrees (range 50-80) and flexion 71 degrees (range 55-90). None of the patients showed radiographic signs of osteoarthritis, osteonecrosis of the scaphoid, or hardware-related complications. CONCLUSIONS: For scaphoid waist non-unions without collapse, percutaneous fixation without supplementary bone grafting provides satisfactory results with a high union rate, early return of function and minimal complications.

Single Incision, Dual Window Approach for a Comminuted Distal Radius Fracture.

Introduction Complex distal radius fractures often involve a fragment of the volar-ulnar articular surface and the radial styloid. The volar ulnar corner of the distal radius is an important constraint to volar translation of the carpus and thus requires stable fixation to prevent wrist displacement. The traditional volar Henry approach often requires undue tension on the median nerve while retracting for access to the ulnar aspect of the radius. To protect the median nerve from iatrogenic injury and to improve exposure of the surgical site, we propose a single incision, dual window approach to the distal radius for complex bi-columnar fractures. Methods This technique combines the trans-Flexor Carpi Radialis (FCR) approach with a subcutaneous dissection to the ulnar aspect of the wrist. This window utilizes the interval between the ulnar neurovascular bundle and the carpal tunnel contents. Results This technique allows the surgeon to work through either window and thus visualize and directly fixate the various fracture fragments. We have treated complex articular distal radius fractures associated with ulnar communition with this novel technique and it has provided direct reduction with improved fragment access. The surgical technique, a case presentation and results are detailed in this report. Conclusion This case report has demonstrated that complex bi-columnar fractures of the distal radius can be effectively approached and fixated with a single incision dual window approach.

The treatment of complex fractures and fracture-dislocations of the hand.

Most fractures of the phalanges or metacarpals are amenable to closed treatment, with favorable outcomes. However, two groups of complex fractures are difficult to diagnose and treat. The first group includes unicondylar and bicondylar fractures, fracture-dislocations, and fracture-related instability of the proximal interphalangeal joint. Fracture-dislocations can be treated with splinting or surgical intervention. Microscrews and condylar plates have added considerably to the ability to securely fix small articular fractures and fracture-dislocations about the proximal interphalangeal joint. Some unstable fracture-dislocations are characterized by loss of the volar aspect of the articular surface of the base of the middle phalanx; they can be treated by using a sculpted osseous articular graft from the dorsal hamate. The second group includes displaced diaphyseal fractures associated with a soft-tissue injury, instability, or multiple fracturing. Articular fractures and fracture-dislocations at the base of the metacarpal also can be difficult to diagnose and treat.

Treatment of extra-articular distal radial malunions with an intramedullary implant.

PURPOSE: Malunited distal radius fractures pose considerable problems, especially for young, active individuals. Surgical correction with osteotomy, bone grafting, and internal fixation with plates and screws has been the treatment of choice. Locked intramedullary fixation is an alternative technique to provide bony stability while minimizing soft tissue irritation in the management of acute distal radius fractures, with acceptable clinical results. The purpose of this study was to describe our experience with the use of an intramedullary device combined with grafting to repair distal radial malunions. This fixation device is inserted through the radial styloid and obtains distal fixation with 3 fixed-angle locking screws. METHODS: Thirteen patients underwent distal radius malunion repair with an intramedullary implant and grafting. There were 6 male and 7 female participants with an average age of 51 years (range, 18-72 y). Patients were evaluated at an average follow-up of 24 months (range, 13-38 mo). Clinical outcome was measured by range of motion of the wrist and forearm, and grip strength, and by using the Disabilities of the Arm, Shoulder, and Hand questionnaire. We analyzed radiographs to determine time to union and adequacy of correction. RESULTS: All of the malunions healed, with an average time to healing of 11 weeks. Patients' average range of motion at follow-up was 56 degrees of flexion, 66 degrees extension, 85 degrees pronation, and 84 degrees supination. Mean grip strength was 83% of the unaffected side, and the average Disabilities of the Arm, Shoulder, and Hand score was 21. Radiographs taken on the latest follow-up showed correction to the following average parameters: 20.6 degrees radial inclination, 11.0 mm radial height, +1.0 mm ulnar variance, and 2.1 degrees volar tilt. CONCLUSIONS: The technique presented in this report demonstrates the effectiveness of an intramedullary nail combined with bone graft or graft substitute in repairing malunited fractures of the distal radius. The results show reliable correction of the deformity and good functional outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Elbow instability associated with bicolumnar fracture of the distal humerus: report of three cases.

Ulnohumeral subluxation or dislocation is rare after open reduction and internal fixation of a bicolumnar fracture of the distal humerus. We report 3 patients in whom detachment of the origins of the lateral collateral ligament and common extensor muscle origins from the lateral epicondyle contributed to postoperative instability after open reduction and internal fixation of a fracture of the distal humerus. This may be due to either unrecognized ligament injury or iatrogenic injury during surgical dissection.