Editorial Comment

Abstract

Nearly a decade has passed since the publication of the first symposium on problem fractures of the hand and wrist. In those 10 years, no major change in our concept of fracture biology has occurred, but the tide of cost control through managed care and the relentless currents of technology have caused many surgeons to rechart their methods of management. This symposium details many of those changes. Rolando's article of 1910 on comminuted fractures of the base of the first metacarpal serves as an appropriate classic. He recognized these as problem fractures nearly a century ago. Our basic science understanding of fracture healing continues to grow, and Brennwald updates his overview of fracture healing first seen in the 1987 symposium. Four papers describe the particular personality of common fracture patterns. Lubahn and Hood present their methods of dealing with fractures about the small and tightly constrained distal interphalangeal joint. Husband and McPherson do the same for bony avulsion injuries at the thumb metacarpophalangeal joint, and Lipton and Wallstein cover the ubiquitous and problematic intraarticular distal radial fracture. Geissler, Fernandez, and Lamey look at a here to fore neglected aspect of distal radial fractures-injuries to the distal radioulnar joint. Three papers present straightforward techniques developed from years of experience with fractures for which there are no easy solutions. Proximal interphalangeal joint fracture dislocations can be managed by external fixation, as described by Krakauer and Stern, or by internal fixation, as described by Weiss. Foster presents his experience in dealing with injuries at the fourth and fifth metacarpal bases. Two papers champion methods that, though not new, have nevertheless not gained wide acceptance. Boulas describes his technique for harvesting autograft joint components to replace small defects in the hand. Geissler and Freeland share many pearls and pitfalls of arthroscopically assisted reduction of intraarticular fractures of the distal radius. Two other papers present their authors' experiences with orthopaedic hardware first developed for the lower extremity, now miniaturized and adapted to the hand. Oullette and Freeland expand the indications for the minicondylar plate in hand fractures, and Gonzalez and Hall introduce a locked intramedullary nail for metacarpal stabilization. This array of high technology and aggressive approach toward fracture alignment and healing inevitably exacts failures. Therefore, many of the papers in this symposium concern management strategies useful in the face of expected (or unexpected) complications. Two papers are devoted to malunions of the distal radius. Marx and Axelrod cover intraarticular malunions and Ladd and Huene offer valuable advice for managing severe extraarticular malunions. Smith and Cooney describe their experience with the scaphoid nonunion that has failed a bone grafting attempt. Throughout the symposium, authors stress the importance of careful soft tissue management as a critical factor in restoring limb function. Two important articles center on this problem. Levin and Condit describe management of the severe soft tissue injuries that can accompany any fracture of the upper extremity. Putnam details the biology of post traumatic stiffness and gives guidelines for its avoidance and treatment in conjunction with fracture management. Schneider focuses on the difficult and all too common soft tissue problems of capsular contractures and tendon adhesions after fracture healing. Under certain circumstances, fracture fixation and healing may not be possible or may not be expected to return the patient to a functional level expeditiously. Three papers recommend early arthrodesis or other salvage in these situations. Lester and Mallik do so for impending malunions at the proximal interphalangeal joint, Hanel recommends the same for fractures at the bases of the central metacarpals, and Terral and Freeland present their experience with salvage of severe distal radial fractures. The guest editors thank the authors for their enthusiasm and energy, both for confronting problem wrist and hand fractures head on and for willingly describing their experiences for us. One only has to look at the advances seen in this symposium compared with the symposium of 10 years ago to be excited about developments in the years to come. Roy A. Meals, MD; Guy D. Foulkes, MD