The treatment of complex intra-articular distal radius fractures with turning radius and distal volaris radius plate fixation

Background Although distal radius fractures (DRFs) are clinically common, intra-articular DRFs accompanied by dorsally displaced free fragments are much less so. At present, it is very difficult to fix and stabilize the intra-articular distal radius fractures accompanying dorsally displaced free fragments with a plate. Our aim was to investigate the clinical effect of DRFs with distally displaced dorsal free mass treated with distal volaris radius (DVR) combined with turning of the radius via the distal palmar approach. Methods From 2015 to 2019, 25 patients with intra-articular distal radius fractures associated with dorsally displaced free fragments were selected and treated with distal volaris radius (DVR) combined with turning of the radius via the distal palmar approach. This study involved 14 males and 11 females, with an average age of 34.5 years (ranging from 21 to 50 years). The mean follow-up period was 16.5 months (ranging from 12 to 22 months). The dorsal displacement of the free fragments was analyzed by X-ray and three-dimensional computed tomography, allowing characterization of postoperative recovery effects by radial height, volar tilt and radial inclination. For the follow-up, we evaluated effects of the surgery by analyzing range of motion (ROM); Modified Mayo Wrist Score (MMWS); and Disabilities of Arm, Shoulder and Hand (DASH) score. Postoperative wound recovery and complications were also monitored to evaluate the clinical therapeutic effects of the surgical procedures. Results X-ray showed that all patients showed reduced fractures, well-healed wounds and recovered function with no obvious complications. Based on the follow-up, patients had a mean radial height of 10.5 mm (ranging from 8.1 to 12.6 mm), mean MMWS of 78.8° (ranging from 61° to 90°), mean DASH score of 16.25 (ranging from 11 to 21), mean ROM for volar flexion of 76.5° (ranging from 62° to 81°), mean ROM for dorsiflexion of 77.1° (ranging from 59 to 83) and mean VAS score of 1.4 (ranging from 1 to 3). Conclusion Treatment of the intra-articular distal radius fractures accompanying dorsally displaced free fragments with turning of the radius and the DVR plate system via the distal palmar approach is effective and has no obvious complications.

Percutaneous Scaphoid Fixation: Experience Value among Different Approaches

Background Percutaneous scaphoid osteosynthesis is an attractive and increasingly popular option, as a treatment for acute scaphoid fractures in selected cases, and as an alternative to conservative treatment. The purpose of this study is to assess the radiographic positioning of the screw in percutaneous scaphoid fixation, taking into consideration the surgeons' experience, and the difference between volar and dorsal approaches. Methods We retrospectively assessed patients undergoing percutaneous scaphoid fixation from 2013 to 2019. Inclusion criteria are as follows: (1) scaphoid waist fractures (Herbert's B2), (2) a minimum of 18 years of age and a maximum of 55 years of age, (3) dominant hand, (4) manual work, (5) minimum follow-up time of 6 months, and (6) without associated lesions. Criteria for correct positioning are as follows: (1) on the axis or parallel to the scaphoid axis with a maximum deviation of 1.5 mm volar/dorsal, (2) without proximal/dorsal prominence, (3) correct scaphoid alignment/reduction, and (4) absence of threads in the fracture site. Radiographs were evaluated separately by a hand surgeon, a general orthopaedic surgeon, and an orthopaedic resident. Results With a total of 39 patients, a dorsal approach was performed in 10 patients and a palmar approach in 29 patients. We verified a very good interobserver reliability. The hand surgeon's team correctly positioned 15 (83.3%, 15/18), while the other team did 9 correctly (42.9%, 9/21). Comparing teams according to the approach used, the dorsal approach did not show a statistical difference, while the same was not true for the volar approach (p < 0.05). Conclusion This points to a positive impact on the team's experience in the positioning of the screws, and therefore in the benefit of treatment by teams dedicated to the area, while daring to suggest that less-experienced surgeons should utilize the dorsal approach.

FRI0041 ULTRASOUND-DETECTED SYNOVITIS AMONG INDIVIDUALS AT RISK OF RHEUMATOID ARTHRITIS INCREASES THE RISK OF DEVELOPING CLINICAL ARTHRITIS

Background:During the transition to rheumatoid arthritis (RA) patients pass through several phases. In the preclinical phase, the presence of anti citrullinated protein antibodies (ACPA) can be detected [1]. A set of clinical characteristics for patients with arthralgia who are at risk of progression to RA was established (clinically suspected arthralgia; CSA) [2]. Ultrasound (US) is more sensitive diagnostic tool in detecting synovitis than clinical assessment and was recommended to use in diagnostics of RA.Objectives:To test if ultrasound-detected synovitis among patients at risk of progression to RA increases the risk of developing clinical arthritis (CA) in the future.Methods:ACPA+ individuals with arthralgia and/or those fulfilling CSA criteria were enrolled into the study and were assessed in 3 months interval (routine clinical investigation with laboratory tests, 68-joint count, US assessment). Tender and swollen joint counts were provided by an independent investigator. Sonographer was blinded to all clinical and laboratory data. CA was defined as clinically swollen and tender joint. All US assessments were provided by a single experienced investigator. Thirty joints US score was assessed bilaterally in wrist, MCP I-V, PIP II-V (dorsal and palmar approach), MTP II-V (dorsal approach), ankle (dorsal, medial and lateral approach). US synovitis was defined according the EULAR-OMERACT and scored separately in gray-scale (GS) 0-3 (zero to severe synovitis) and Power Doppler (PD) 0-3 (zero to high activity). Scores were calculated as sum scores. For the statistical analysis, we used GraphPad Prism 8.0.0 software (Wilcoxon-Mann-Whitney test), and relative risk ratio (RR).Results:93 patients were enrolled into the study (95% female). 58 patients were ACPA+ (all of them RF+), 35 were ACPA- (10 of them RF+). Of ACPA+ individuals, 100% fulfilled the CSA criteria, all seronegative individuals met the CSA criteria. At baseline, GS≥1 was detected in 69 patients (74%), PD≥1 was in 26 (28 %) patients. Single erosion was found by US in 1 patient (0,9%) at baseline. 14 patients (15%) developed CA within 30 months, 77% of them till month 10 from the baseline. No statistical difference in US synovitis score was found between ACPA+ vs. ACPA- and CSA+ vs. CSA- groups at baseline. RR to develop CA at the joint level in patients with GS≥1 at baseline was 1.37 (95% CI 0.99-1.89; p<0.05), with PD≥1 the RR was 2.5 (95% CI 1.3-4.8; p<0.05), in GS≥2 RR was 3.8 (95% CI 2.6-5.6; p<0.0001), in PD≥2 RR was 5.3 (95% CI 2.4-11.7; p<0.0001). US-detected synovitis preceded clinical finding of arthritis by 3 months (SD 1.2).Conclusion:US-detected synovitis in patients at risk of RA further increases the risk of developing clinical arthritis in the future. US detected synovitis in joints appear about 3 months prior synovitis detected by routine clinical assessment.References:[1]Bos, W. H., Wolbink, G. J., Boers, et al. Arthritis development in patients with arthralgia is strongly associated with anti- citrullinated protein antibody status: a prospective cohort study. Annals of the Rheumatic Diseases, 2010;69(3):490-4.[2]van Steenbergen HW, Aletaha D, Beaart-van de Voorde LJJ, et al. EULAR definition of arthralgia suspicious for progression to rheumatoid arthritis. Annals of the Rheumatic Diseases 2017;76:491-6.Acknowledgments:Project AZV-17-32612ADisclosure of Interests:Petra Hanova: None declared, Klára Prajzlerová: None declared, Nora Petrovská: None declared, Monika Gregová Consultant of: Novartis, Abbvie, Paid instructor for: Novartis, Speakers bureau: Novartis, Abbvie, MSD, Heřman Mann: None declared, Karel Pavelka Consultant of: Abbvie, MSD, BMS, Egis, Roche, UCB, Medac, Pfizer, Biogen, Speakers bureau: Abbvie, MSD, BMS, Egis, Roche, UCB, Medac, Pfizer, Biogen, Jiří Vencovský: None declared, Ladislav Šenolt: None declared, Mária Filková: None declared

The treatment of distal radius fractures accompanying dorsally displaced free fragments beyond the watershed line with turning radius and distal volaris radius system plate fixation via the distal palmar approach

Background: Although distal radius fractures (DRFs) are clinically common, DRFs accompanied by dorsally displaced free fragments beyond the watershed line are much less so. At present, it is very difficult to fix and stabilize the displaced free fragments far away from the watershed line with a plate. Our aim was to investigate the clinical effect of DRFs with distally displaced dorsal free mass treated with distal volaris radius (DVR) combined with turning of the radius via the distal palmar approach. Methods: From 2015 to 2019, 25 patients with distal radius fractures associated with dorsally displaced free fragments beyond the watershed line were selected and treated with distal volaris radius (DVR) combined with turning of the radius via the distal palmar approach. This study involved 14 males and 11 females, with an average age of 34.5 years (ranging from 21 to 50 years). The mean follow-up period was 16.5 months (ranging from 12 to 22 months). The dorsal displacement of the free fragments was analyzed by X-ray and three-dimensional computed tomography, allowing characterization of postoperative recovery effects by radial height, volar tilt and radial inclination. For the follow-up, we evaluated effects of the surgery by analyzing range of motion (ROM); Modified Mayo Wrist Score (MMWS); and Disabilities of Arm, Shoulder and Hand (DASH) score. Postoperative wound recovery and complications were also monitored to evaluate the clinical therapeutic effects of the surgical procedures. Results: X-ray showed that all patients showed reduced fractures, well-healed wounds and recovered function with no obvious complications. Based on the follow-up, patients had a mean radial height of 10.5mm (ranging from 8.1 to 12.6 mm), mean MMWS of 78.8° (ranging from 61 to 90°), mean DASH score of 16.25 (ranging from 11 to 21), mean ROM for volar flexion of 76.5° (ranging from 62 to 81°), mean ROM for dorsiflexion of 77.1° (ranging from 59 to 83) and mean VAS score of 1.4 (ranging from 1 to 3). Conclusion: Treatment of distal radius fractures with accompanying dorsally displaced free fragments beyond the watershed line with turning of the radius and the DVR plate system via the distal palmar approach is effective and has no obvious complications.

Nascent Malunion of an Isolated Intraarticular Fracture of the Ulnar Head

Background Isolated fractures of the ulnar head are rare. Only few cases have been reported in literature. Case Description We report a case of a 16-year-old student who was treated for an ulnar styloid fracture conservatively. An associated displaced intraarticular fracture of the ulnar head has been overlooked. He presented late in our clinic with a symptomatic nascent malunion of the ulnar head fracture. A corrective osteotomy by a palmar approach was performed. Fixation by screws was used with an excellent result at 7-year follow-up. Literature Review The rare cases of isolated ulnar head fractures reported in literature were treated by open reduction and internal fixation only in case of fracture dislocation. Clinical Relevance The authors highlight the fact that even a nascent malunion of an isolated intraarticular fracture of the ulnar head may be treated successfully by open reduction and internal fixation.

Distal Ulnar Approach in the Palmar Artery for Coronary Angiography and Intervention: Safety, Feasibility, and Reliability in 15 Patients

Highlights The distal ulnar palmar approach for both coronary angiography and intervention was safe, feasible, and reliable in our case series of 15 consecutive patients. The distal ulnar palmar approach was not a technical limitation for coronary angiography and interventional procedures in our cohort of patients. Further studies are needed to understand the potential benefits for patients and avoid medical futility. Abstract Background: Transradial and translunar approaches, associated with fewer bleeding and vascular complications than transfemoral access, have been adopted and increasingly utilized following a “radial-first strategy.” Approaches that are innovative and more distal than standard radial approaches are available, even if their clinical utility is under debate. At the price of a more difficult puncture and risk of access failure, there are possible ergonomic advantages, with lower risk of upstream artery occlusion and shorter hemostasis. Aim: The study was aimed at proving the preliminary feasibility, safety, and reliability of the right distal ulnar palmar approach in 15 consecutive patients. Results: In 15 out of the 17 patients enrolled, the distal ulnar access in the palmar artery was feasible, safe, and reliable. The diameter of the distal ulnar artery was greater than that of the distal radial in the anatomical snuff box. There were no significant complications. Conclusion: The distal ulnar palmar approach for both coronary angiography and intervention was safe, feasible, and reliable. It was not a limitation for coronary angiography and interventional procedures in our cohort of patients

Elbow Dislocation with Ipsilateral Radial Shaft Fracture – A Case Report

Background Posterior dislocation of the elbow associated to a radial shaft fracture is a rare lesion, its treatment is difficult and complicated, and the indications, surgical options, and timing of surgery may vary. In the present case, we performed immediately after the trauma (urgent care) an open reduction internal fixation (ORIF) surgery of the radial fracture by means of a 3.5 mm locking plate, associated to closed elbow reduction and stabilization with dynamic bracing. Case Report A 26-year-old woman was seen in our service with a traumatic deformity of her right, dominant forearm and elbow after a fall from a balance board and presented with a radial shaft fracture and posterior elbow dislocation. The palmar approach was used and the shaft fracture was fixated. During the radial fracture reduction maneuver, the dislocation of the elbow was spontaneously reduced. At 1 year postoperatively, the patient showed good wrist, forearm, and elbow range of motion (ROM). Disabilities of the arm, shoulder and hand (DASH) score of 5, visual analogue scale (VAS) of 0, and grip strength of 92%, as compared with the nonaffected side. Clinical Relevance Nowadays, case reports of concomitant, ipsilateral multiple injuries that uncommonly occur together in a single traumatic episode are very rare. The awareness of this association for early recognition is of paramount significance for ideal clinical results.

Proximal row carpectomy, scaphoidectomy with midcarpal arthrodesis or midcarpal tenodesis: when and how to use

I report my personal experience over three decades in the treatment of carpal collapse due to scapholunate collapse and scaphoid nonunion. I have used the proximal carpal row resection performed through palmar approach, the scaphoidectomy and double-column midcarpal arthrodesis, and scaphoidectomy with midcarpal tenodesis. Diagnostic arthroscopy is essential for staging and surgical decision making regarding the type of treatment. The details of the surgical techniques, tips, results and possible complications are described for each method. The advantage of the proximal row carpectomy by palmar approach is the early permitted rehabilitation with better recovery of wrist motility in comparison with the traditional technique. The advantage of the double-column midcarpal arthrodesis lies in its ease of execution. The midcarpal tenodesis is an excellent intervention from the conceptual point of view even if over time there is a progressive carpal collapse even in absence of symptoms.