Arthroscopically Assisted Treatment of Volar Rim Fractures

Background Arthroscopically-assisted reduction and internal fixation (AARIF) for distal radius fractures (DRF) has been extensively described. Little information is available about AARIF in AO “B3” and “C” DRF with displaced lunate facet volar rim fragment (VRF) and volar carpal subluxation. However, lunate volar rim fragment (LVRF) may be very difficult to reduce and fix under arthroscopic control using the flexor carpi radialis (FCR) or FCR extended approaches while traction is applied. Purposes The aims were to describe our surgical technique of AARIF of partial or complete DRF with VRF and provide information about how often this technique may be necessary, based on a large DRF database. Methods The dual-window volar approach for complete articular AO C DRF with volar medial fragment was described in 2012 for performing open reduction internal fixation (ORIF). Since 2015, we have used the dual-window approach for AARIF of “B3” or “C” DRF with volar carpal subluxation. We analyzed our PAF database, searching for patients treated with AARIF in “B3” and “C” fractures. Results The dual-window volar approach is very useful when using AARIF for AO “B3” and “C” DRF with displaced VRF and volar carpal subluxation. The anteromedial part of the exposure allows a direct access to reduction and fixation of the LVRF under traction and arthroscopic control. Overall, 1% of all articular DRF in this series showed a displaced LVRF amenable to the dual-window volar approach. Conclusion It is almost impossible to access and properly fix a VRF using traction and arthroscopic control through the FCR or FCR extended FCR approach because of the stretched flexor tendon mass. The use of the dual-window approach during AARIF of AO “B3” or “C” DRF has not previously been reported. Displaced VRF are rare whether they were part of “B3” or “C” fractures. If AARIF is chosen, we strongly recommend the use of the dual-window volar approach for AO “B3” and “C” fractures with VRF. A single anteromedial approach can also be used for isolated “B3” anteromedial DRF.

Percutaneous Dorsal Approach for Fractures of the Hook of the Hamate: A Less Common but Effective Option

Introduction Hook of hamate fractures are rare. The best treatment option is a source of debate; it ranges from conservative to surgical techniques, including resection of the hook or a volar approach followed by internal fixation. These techniques are not exempt from risk. Minimal invasive fixation using a dorsal percutaneous approach and a headless, cannulated mini screw is another option, although not commonly considered. We present a case series of patients who underwent this surgical technique. Methods This is a retrospective review of four patients with nondisplaced hook of hamate fractures treated with dorsal percutaneous fixation. The evaluation included symptoms, physical examination, and radiological (radiographs, magnetic resonance imaging [MRI], and computed tomography [CT]) findings, as well as pre and postoperative strength (determined with a Jamar (JLW Instruments, Chicago, USA) hydraulic dynamometer) and quick disabilities of the arm, shoulder and hand (QuickDASH) scores. Results The union rate was 100% with no associated complications. All patients resumed their preinjury activities 3 months after the surgery and reported they would undergo surgery again if needed. Conclusion This retrospective study shows that safe treatment of nondisplaced hook of hamate fractures with percutaneous dorsal fixation is feasible, with excellent clinical outcomes. In any case, our sample is limited, and further studies are required.

Intra-operative peri-articular cocktail injection in inflammatory arthritis patients undergoing total knee arthroplasty

<p class="abstract">Surgical treatment of scaphoid fractures has evolved over the years to include variety of procedures and techniques. However scaphoid middle and distal third fractures fixation with Herbert screw by means of volar approach is a safe and effective method with good functional outcome and union rates. Our study concluded that management of middle and distal third scaphoid fractures with Herbert screw by volar approach gives excellent results in terms of union and recovery to daily activities. The wrist function improvement is more satisfactory, and the incidence of complications is low with this modality of treatment.</p>

PRIMARY BONE GRAFTING AND K-WIRE FIXATION: A PREFERABLE OPTION TO TREAT ACUTE UNSTABLE SCAPHOID FRACTURE

Objective: The Objective of this study is to analyze the radiological, clinical and functional outcome of patients with acute unstable scaphoid fracture treated with primary bone grafting and K (Kirschner)-wire fixation Methods:Based on inclusion and exclusion criteria , a prospective observational study was carried out on 21 patients with acute unstable scaphoid fracture who had been treated with primary bone grafting and K-wire fixation from November 2017 to March 2020 and were followed up for a minimum of 24 weeks. The average patient age was 26.9 years. The time from injury to treatment averaged 11days. Surgery was done under Bier’s Block using volar approach. Bone graft was harvested from distal Radius. The mean operating time was 24 minutes.Clinical parameters like tenderness, grip strength and Range of Movement (ROM) at wrist was assessed. The functional outcome was evaluated using Modified Mayo wrist score. Bone union was assessed using serial plain radiographs. Results:Union was achieved in all (100%) at 12 weeks. There was no evidence of Avascular necrosis (AVN) or arthrosis at latest follow up. As per Modified Mayo wrist score, there were 15 excellent,03 good and 03 fair results at the final follow-up. Individuals resumed their routine work at 12 weeks and all were comfortable with heavy works/ sports activity by 24 weeks. Conclusion: Primary bone grafting has a definite role in the management of acute unstable scaphoid fracture by which aquicker and higher rate of union isachieved with minimal complications. Open reduction allows thorough assessment of fracture for better anatomic reduction. Although the type of fixation device hardly contributes for quicker and higher union, but then the use of K-wire for fixation is the only viable option for smaller bony fragments and is more forgiving in terms of its positioning. It has an added advantage in terms of requirement of minimal inventory and thus is a cost-effective modality. This procedure also confirms that the patients could get back to their work earlier hence decreasing economic burden.

1224 Effect of Distal Brachioradialis Release During Open Reduction and Internal Fixation of Distal Radius Fractures

Aim The study aim is to determine the impact of the brachioradialis release during the open reduction and internal fixation of distal radius fractures using a volar approach Method Total of 40 patients was treated with Open reduction and internal fixation of intra articular distal radius fractures. Distal release of Brachioradialis was performed to 19 patients, while 21 patients had no release of BR during surgery. Radiological parameters including Radial height, Inclination and volar tilt were measured 1 month post-operatively, while functional outcomes assessed with modified mayo wrist scores and Quick-dash scores Results There is no significant difference between age, gender and pre-operative conditions indicating that both the groups (BR release and without BR release) have similar demographic characteristics. Pre-operatively both groups had disturbed values for radial height, inclination, and volar tilt. Postoperatively, the mean of both groups was closer to normal ranges for radial inclination and volar tilt; however, radial height was the least adequately restored radiological parameter for both study group (11.54 ± 1.35 for BR group versus 10.21 ± 2.29 for Non-BR group). Pain, functional status, and grip strength had similar values in both groups whereas BR group showed higher ROM and DASH scores with P values of 0.048 and 0.025 respectively. Conclusions Brachioradialis release enhances the reduction and operative fixation, restoring the necessary radiological and subsequent functional parameters in distal radius fractures with reported no complications.

Correlation of clinical and radiological outcome of distal radius fractures treated with volar plating

<p class="abstract"><strong>Background:</strong> Distal radius fractures are one of the most common injuries treated by an orthopaedic surgeon, accounting for approximately one sixth of all fractures. Due to increase in incidence of high velocity trauma, the injury is seen occurring in young patients more often. A displaced fracture deranges the wrist anatomy causing deformity and loss of function at the wrist joint. Open reduction and internal fixation with plate using a volar approach allows anatomical reduction of the fracture, stable fixation aiding in early mobilization.</p><p class="abstract"><strong>Methods:</strong> Our study was a hospital-based study conducted during the period June 2016 to November 2018. A total of 30 patients with distal radius fracture were treated with ORIF with a volar plate. They were followed up for a year and clinical and radiological outcomes were evaluated.<strong></strong></p><p class="abstract"><strong>Results:</strong> Among the 30 patients studied 25 were males and 5 were females with mean age of 36.23 years. According to Gartland and Werley demerit scoring system, 15 of them had excellent result at the end of one year. 13 Of them had good and 2 of them had fair results. Radiological assessment was done by Sarmiento’s modification of the Lind storm criteria and 15 of them had excellent results. 15 patients had good radiological outcome.</p><p class="abstract"><strong>Conclusions:</strong> From this study we conclude that ORIF with volar plating can provide good clinical and functional outcome in distal radius fractures. Anatomical reduction of the fracture fragments is the key in achieving good results.</p>

Kaplan’s Lesion of the Little Finger Treated with Open Reduction by a Volar Approach: A Case Report

Kaplan’s lesions are defined as open wounds with the metacarpal head exposed in the palms, accompanied by complex dorsal dislocation of the metacarpophalangeal joint (MCPJ). Kaplan’s lesions are clinically rare because the volar side of the MCPJ is anatomically supported and reinforced by a stronger adjacent structure. Moreover, lesions in the little finger are very rarely reported because most Kaplan’s lesions occur in the index finger. The reduction of lesions and restoration of joint stability is difficult when Kaplan’s lesions occur. Various methods have been currently introduced in the treatment of Kaplan’s lesions; however, no standardized treatment has been established because of the rarity of this disease. This paper reports a case of Kaplan’s lesion of the left little finger without fracture after a fall; the case was successfully treated with open reduction using a volar approach.

The Flexor Carpi Radialis Portal for Arthroscopy-Assisted Reduction of the Dorsal Ulnar Fragment in Distal Radius Fractures

Background The importance of the dorsal ulnar fragment (DUF) for stability and articular congruence of the radius is widely recognized, and standard surgical techniques often fail to ensure its reduction. Description of Technique We describe a modification of volar wrist portals for arthroscopic management of the DUF of the distal radius. It is made in an outside-in fashion in line with the flexor carpi radialis (FCR) approach for the distal radius. Through this volar portal, we achieve wide and direct visualization of the DUF, with the advantage of protecting important anatomic structures such as the FCR tendon, the radial artery, and the median nerve; all protected with the previously made volar approach for the distal radius. In addition, easy manipulation and reduction of the DUF is obtained with instrumentation through standard dorsal portals. Patients and Methods We performed this procedure in 23 patients with distal radius fractures (DRF) with displaced DUF. Results Early and late postoperative evaluation demonstrated intraoperative reduction maintenance and adequate range of motion, compatible with the usual findings of standard volar plating, with the benefit of anatomic reduction of the DUF. Conclusion With our technique, volar plating associated with arthroscopy-assisted dorsal fragment specific fixation with dorsal standard and the FCR portals permits optimal surgical treatment of most DRFs.

Should We Repair the Pronator Quadratus in a Distal Radius Fracture with an Ulnar Styloid Base Fracture? A Biomechanical Study

Background Merits of repairing the pronator quadratus (PQ) to restore distal radioulnar joint (DRUJ) stability after a volar approach remain controversial. Distal radius fractures are often associated with ulnar styloid fractures (USF). When involving the fovea, this USF can lead to a DRUJ instability. The PQ repair may be key in reducing this DRUJ instability. Methods This study aims to assess the biomechanical role of PQ repair in a cadaveric model of USF. In 17 forearm specimens, a USF including the fovea was executed. Positional changes of the DRUJ in forearm rotation and dorso-palmar (DP) translation were measured with variable loads (0, 2.5, and 5N) applied to the PQ origin. Results Forearm rotation and DP-translation decreased significantly with PQ loading of 5N, changing on average by 5 degrees and 0.6 mm, respectively. Conclusion We found a significant decrease in forearm rotation and DP-translation comparing a fully loaded PQ to an unloaded PQ in our cadaveric model.