Volar Approach Research Articles

Outcomes of Arthroscopic Lunate Core Decompression Versus Radial Osteotomy in Treatment of Kienböck Disease

The purpose of the study was to evaluate the functional and radiographic outcomes of arthroscopic lunate decompression versus radial osteotomy in the treatment of Kienböck disease (KD). In a prospective cohort design, we enrolled 82 patients with KD with Lichtman stages I to IIIb. Participants assigned themselves to groups by choosing either arthroscopic lunate core decompression and synovectomy (group A; n= 54) or radial osteotomy (group B; n= 28). For radial osteotomy, a distal radius volar approach was used and a shortening osteotomy (in negative and neutral ulnar variance) or lateral closing wedge osteotomy (in positive ulnar variance) was performed. Arthroscopic lunate core decompression was performed under direct visualization from the 3-4 portal using a shaver (through the 6R portal) and a cutting burr (through the trans-4 portal). The shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, visual analog scale (VAS) score for pain, wrist passive flexion/extension, grip strength, and radiographic assessments (Lichtman classification, radioscaphoid angle, carpal height ratio) were recorded before surgery and at the final follow-up. Sixty-four patients were included in the final analysis (44 in group A and 20 in group B). The mean ages of participants were 33 ± 11 years in group A and 31 ± 8 years in group B. The mean follow-up periods were 44 ± 20 months in group A and 37 ± 23 months in group B. The QuickDASH score, VAS score, and passive wrist movements significantly improved in both groups. Grip strength showed a significant increase in group A only. The postoperative functional analysis between the 2 groups showed no significant difference, except for the wrist passive extension, which was higher in group A. Lichtman staging remained the same in 79.5% and 73.6% of patients in groups A and B, respectively. An arthroscopic lunate core decompression and wrist synovectomy has comparable midterm results to radial shortening osteotomy in the treatment of KD. Therapeutic II.

Dorsal locked plate fixation in dorsally unstable distal radius fractures

Introduction: Distal radius fractures are common, and internal fixation for operative management of these injuries is widely accepted. Although use of the volar approach for plate fixation has become more popular, benefits of the dorsal surgical approach include the potential for direct reduction and assessment of articular alignment, evaluation and management of concomitant intrinsic intercarpal ligament injury, and initiation of early range of motion. For certain fracture patterns, dorsal plate fixation is the preferred surgical technique. Improvements in implant design, in particular the use of low-profile dorsal plates, has decreased the rate of complications seen previously with this technique. Purpose of the study: We are trying into evaluate the functional outcome of distal radius fractures treated by open reduction internal fixation [ORIF] with precontoured low profile dorsal locking plates. Material and Methods: We performed ORIF with dorsal plating in 40 patients (16 males and 24 females) for distal radius fractures according to our inclusion and exclusion criteria. Fractures were classified by AO classification. Patients were followed up at routine intervals and the functional outcome was evaluated by the Disabilities of the Arm, Shoulder, and Hand questionnaire, the Gartland and Werley scoring system and modified Green O’ Brien score. All plates were low profile and stainless steel. Radiographic parameters, range of motion, and strength compared with the uninjured side were recorded. Results: According to the AO classification system, there were 5 type A fractures, 6 type B fractures, and 29 type C fractures. The median preoperative dorsal angulation was 30°, and the median postoperative angulation was -4° volar. Twenty-six patients with fractures had an intra-articular step-off or gap, which were all corrected to neutral by the procedure. Seven patients with the fractures showed positive ulnar variance, all corrected to neutral at time of follow-up evaluation. The median patient age at surgery was 59 years. The median follow-up period was 18 months Compared with the contralateral side, the mean extension and flexion were 88% and 81%, respectively; pronation and supination were 89% and 87%, respectively; and grip strength and thumb pinch were 78% and 94%, respectively. The mean postoperative Disabilities of the Arm, Shoulder, and Hand questionnaire score was 15 points. 38 patients had Gartland and Werley scores of good or excellent. No patients needed to have their plates removed, and no extensor tendon rupture was reported. 1 patient lost reduction; 1 patient needed a tenolysis of the extensor pollicis longus tendon. Out of 40 patients, 31 patients had excellent results, 7 patients had good results and 1 had fair and only 1 patient had poor result, according to the modified Green O’ Brien score. Average time to clinico-radiological union was 7 weeks. Average follow up time was 18 months. Conclusion: Our study has demonstrated that dorsal plating is an effective method for management of dorsally unstable distal radius fractures.

Prognostic factors for outcomes of surgical mobilisation in patients with posttraumatic limited range of motion of the proximal interphalangeal joint: a multivariate analysis

This study aimed to identify the prognostic factors for outcomes of surgical mobilisation in patients with posttraumatic limited range of motion (ROM) of the proximal interphalangeal (PIP) joint and determine which procedure actually improves the PIP joint ROM. A total of 71 fingers (57 patients: 49 men, 8 women; mean age, 41 years) with posttraumatic limited passive ROM of the PIP joint (<60°) who underwent surgical mobilisation were reviewed. Possible prognostic factors, including age, injury type, injured finger, injury in the adjacent finger, and procedure types, were assessed. We defined the PIP joint ROM improvement as the primary outcome in the linear regression analysis. To evaluate surgical efficacy, we classified the surgical treatment options into four categories (volar release, dorsal release, volar and dorsal release, and joint distraction with an external fixator) and compared their outcomes. The mean postoperative improvement in the PIP joint ROM was 12°. In the linear regression analysis, advanced age (estimate, −0.41; 95% confidence interval [CI], −0.76 to −0.06), open injury (estimate, −13.54; 95% CI −27.02 to −0.06), and skin defects (estimate, −23.22; 95% CI −34.83 to −11.61) were associated with worse outcomes; however, the volar approach was associated with favourable outcomes. Surgical mobilisation is strongly recommended when limited ROM of the PIP joint is caused by flexion site contracture. To improve the final outcome of fingers with complex injuries, a tailored treatment strategy is required to avoid dorsal release.

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.

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

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; 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.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 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.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; 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.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; 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.&lt;/p&gt;

Sliding rotational osteotomy for cases of dorsally angulated distal radius malunion: A technical note

The aim of this study was to present a novel pre-planned distal radius sliding rotational osteotomy that can address all deformities in dorsally angulated distal radius malunion through a volar approach using a locking plate. Four consecutive adult women with symptomatic dorsally angulated distal radius malunion were surgically treated with sliding rotational osteotomy. All the patients underwent preoperative Disabilities of the Arm, Shoulder and Hand (DASH) scores, a series of radiography, and a course of physiotherapy. The osteotomy was planned on 2 orthogonal radiographs, and the surgery was performed through a volar approach. A back slab was applied post-operatively for two weeks and changed to a removable splint for further four weeks. Gentle active movements out of splint were permitted at two weeks, and formal physiotherapy at six weeks post-operatively. Radiographs were taken immediately post-operatively, at three months, and with DASH scores at a mean final follow-up of 18 months. On radiographic evaluation, all the deformities were corrected within an acceptable range. The mean increase in radial inclination was 6.5 degrees. The mean gain in radial height was 2.95 mm. The mean improvement in ulnar variance was 4.25 mm. The mean change from dorsal to volar angulation was 23 degrees, and the mean improvement in the DASH score was 45.25 at a mean final follow-up of 16 months. All osteotomies achieved bony union within 3 months postoperatively. None of the patients required metalwork removal, and no complications were observed. Sliding rotational osteotomy appears to be a safe technique to correct deformity and improve function in patients with dorsally angulated, shortened, and radially deviated distal radius malunion.

Surgical approaches and applied anatomy of the wrist

A familiarity with common approaches to the wrist and their associated anatomy is essential for any surgeon operating in this area. Such knowledge reduces the likelihood of iatrogenic injury to adjacent structures; enabling the surgeon to progress purposefully and with confidence through an operation, to reveal underlying pathology. Furthermore, it is a favourite topic for the fellowship examiner. This article provides a description of the common dorsal, volar, radial and ulnar approaches to the carpus and distal radius. Safe corridors for external fixation are also considered. Additionally, clinical pearls are included for each approach, to enable the surgeon to avoid common pitfalls.

A prospective observational study to assess the functional outcome of fracture distal end of radius treated with locking compression plate by volar approach

Introduction: Distal radius fractures are one of the most common skeletal injuries in the daily orthopaedic practice. They represent approximately 16% of all adult fractures treated by orthopedic surgeons. Outcome of the displaced extra-or intra-articular fractures require a good anatomical reduction. Various treatments such as manipulation and casting, percutaneous pinning with Kirschner (K) wires, External fixators were being practiced to treat distal radius fractures. Recent advances with Locking compression plates restore anatomical alignment and allow patient to start early mobilisation. The aim of our study is to compare the advantages and disadvantages of intraarticular distal radius fractures fixed with internal fixation using locking compression plate and to analyze the functional and radiological outcomes. Methods: The present study was carried out on 52 cases of intraarticular distal radius fractures treated by open reduction and internal fixation using locking compression plating (LCP) in Department of orthopaedics, Guntur medical college, Andhra Pradesh between November 2014 and October 2015. Functional outcome of patients was evaluated using Mayo modified wrist score and Lidstrom classification score. Data was analysed using SPSS v17 Software. Results: 52 Patients with intra articular distal radius fractures who fit the inclusion criteria, were selected and operated. Follow up of patients at 10 days, 6 weeks, 3 months and 6 months were studied according to Mayo modified wrist score. 47 patients exhibited excellent results and 5 patients exhibited good results. Radiological outcome using Lidstorm classification score were measured and 29 patients exhibited excellent results, 19 patients exhibited good results and 4 patients exhibited satisfactory results. Out of 4 patients One developed infection and implant exit was done and another 2 patients developed wrist stiffness and one patient developed hypertrophic scar. Conclusion:In the present study open reduction internal fixation using locking compression plate with screws was done for intra articular distal radius fractures. This resulted in successful outcome in terms of anatomic realignment, better access with minimal surgical trauma, functional outcomes and fewer complications.

Case report: Open reduction and extension block pinning with volar plate reconstruction for 1 month PIP joint dislocation

Proximal interphalangeal (PIP) fracture-dislocation is a common injury that results from “jamming” a finger. It can be classified according to displacement of proximal phalanx over middle phalanx. For simple dislocation treatment can be closed reduction and splinting. For old cases open reduction is usually required. Following open reduction stability of the joint is checked and accordingly augmentation of stability is done. For unstable injuries, a variety of surgical interventions have been described including extension block pinning, open reduction internal fixation, volar plate arthroplasty, static or dynamic external fixation, and hemi-hamate reconstruction. For fracture dislocation treatment varies with the degree of articular surface involvement, which determines stability of the joint. We present the case of an unstable, subacute middle finger PIP dorsal fracture dislocation in a young female for which attempts of closed reduction were given elsewhere but it could not be reduced. With volar approach we reduced the joint and for augmentation of the stability we did volar plate reconstruction using z-plasty of A3 pully. For additional stability we did extension block pinning.

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.

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.

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.

Techniques for Injection of the Scaphotrapezium-Trapezoid Joint Without Image Guidance

PurposeScaphotrapezium-trapezoid (STT) joint arthritis is one of the most common forms of wrist arthritis. Conservative management often involves corticosteroid injection. Despite this, there is a scarcity of literature on palpation-guided injection techniques for the STT joint. We aimed to determine a standardized palpation-guided injection method that is easily reproducible and poses minimal risk to local anatomic structures.MethodsSix fresh-frozen cadaveric upper extremity specimens were tested. Access to the STT joint was attempted with dorsal, volar, and radial approaches. Fluoroscopy was used to confirm accurate placement within the joint. Needle placement was documented in relation to the surrounding soft tissue and bony landmarks were measured with a ruler, and the angle of the needle entry was recorded using a goniometer. The cadavers were carefully dissected to identify the surrounding neurovascular structures at risk of injury.ResultsTo access the STT joint with the dorsal approach, the needle was angled at 90º and inserted one-third of the distance from the prominence of the base of the second metacarpal to Lister tubercle. No neurovascular structures were found in the immediate vicinity of the needle. For the volar approach, the needle was angled at 65º and inserted at the distal wrist crease, 1 cm ulnar to the radial border of the wrist, in line with the second metacarpal. The volar branch of the radial artery was at risk with this approach. For the radial approach, the needle was angled at 60º and inserted immediately dorsal to the extensor pollicis brevis tendon, midway between the radial styloid and the prominence of the thumb metacarpal base. The dorsal branch of the radial artery was at risk with this approach.ConclusionsIn a clinical setting where fluoroscopy or ultrasound is not readily available, the dorsal approach may allow for safe and accurate placement of the injectate into the STT joint.Type of study/level of evidenceTherapeutic IV.

The Effect of Forearm Shortening on Forearm Range of Motion

Osseous shortening of the forearm is performed during forearm replantation; however, no large clinical reviews have discussed its effects on patient outcomes. A recent cadaver study demonstrated the progressive loss of forearm pronation/supination ranges of motion with increased shortening lengths using external fixation. Our study aimed to quantify the effects of shortening on passive forearm motion using internal fixation after 2, 4, and 6 cm of mid-forearm shortening. A volar Henry approach and direct approach to the ulna were used on 8 cadaveric specimens. The forearms were sequentially shortened by 2, 4, and 6 cm. Fixation was performed on the volar surfaces of the radius and ulna. Pronation and supination of the forearms were tested by applying 1 Nm of torque at baseline and after the fixation of both the radius and ulna using osteotomy. Radiographs and measurements were obtained at each phase to determine the maximum radial bow and radioulnar gap. Data were analyzed using a linear mixed-effects model. Greater shortening of the radius and ulna led to progressively greater reductions in both pronation and supination range of motion. Larger differences were seen in supination at 2-4 cm of shortening and in pronation at 4-6 cm of shortening. Changes in supination were found to be associated with the radial bow and radioulnar gap; changes in pronation were found to be associated with the radial bow and radial bow's location. This study demonstrates that quantifiable effects on passive forearm motion occur after osseous shortening of the forearm. This information may improve surgeons' and patients' understanding of the changes in forearm motion expected after shortening in the setting of replantation or tumor resection or in the setting of limb salvage of a mangled extremity.

Shelf Osteotomy for Madelung's Deformity in Adults: A Novel Technique.

Background Madelung's deformity (MD) comprises increased volar and ulnar tilt of the distal radius joint facet, secondary to an idiopathic physeal dysplasia. Such change causes radial shortening and a consequent distal ulnar prominence, along with wrist pain and loss of motion. Classic surgical techniques are problematic for adults, as they are specific for children and adolescents whose distal radial physis is still open. Description of Technique It is suggested a new treatment method for MD in skeletally mature patients: a distal radius osteotomy and joint realignment are performed through a volar approach to increase the support area of the lunate bone. The rotation and lengthening of the distal epiphysis of the radius generate support and cover to the lunate bone, with improvement of both radiocarpal and distal radioulnar joints. Patients and Methods We describe the technique in details and report the treatment of a 25-year-old female patient. Results Early clinical and radiographic outcomes are encouraging for the treatment of symptomatic patients. Conclusion There is a plethora on the literature about conflicting opinions on the best treatment options and surgical techniques are quite variable, although usually with good results. Besides, the technique here described is indicated during a specific stage of disease presentation, consisting of young adults without any wrist-degenerative changes. Having said that, it is possible to claim that MD treatment with shelf osteotomy is a concept change. Our main goal is to reconstruct the diseased segment and improve wrist stability.

Danger zone for screw placement in minimally invasive plate osteosynthesis (MIPO) of diaphyseal fractures of forearm: a cadaveric study.

To identify the anatomical relationship between neurovascular structures and screws and to evaluate the danger zone of screw placement during minimally invasive plate osteosynthesis (MIPO) technique following the volar approach for the radius and the subcutaneous approach for the ulna in diaphyseal forearm fractures. Sixteen cadaveric forearms were fixed with a 3.5-mm, 14-hole, locking compression plate (LCP) using the MIPO technique with a volar approach of the radius. Two locking screws were fixed at each end via two separated incisions, and the remaining ten screws were inserted percutaneously. The same MIPO technique was performed at the ulna with the subcutaneous approach. The forearms were then dissected to identify any damage to or direct contact between the screws and the radial artery (RA), the superficial branch of the radial nerve (SBRN), the posterior interosseous nerve (PIN), and the dorsal cutaneous branch of the ulnar nerve (DCBUN). The distances from the screws to the structures at risk, as well as the radial and ulnar length, were measured. The average lengths of the radius and ulna were 24.74cm and 25.93cm, respectively. On the volar aspect of the radius, the danger zones of RA and SRN were between 15.26 and 81.24% of the length of the radius from the radial styloid. The zone of PIN injury at the posterior aspect of the radius was between 41.45 and 81.24% of the length of the radius from the radial styloid. Meanwhile, the danger zone of DCBUN was between 12.21 and 27.23% of the ulnar length from the ulnar styloid. Based on our study, the percutaneous screw fixation in MIPO for the treatment of diaphyseal fractures of the forearm is a dangerous procedure, especially for the volar approach of the entire radius and the subcutaneous approach of the distal ulna.

Clinical and radiological evaluation of nonvascularized cancellous iliac bone graft for the treatment of nonunited scaphoid fracture

Purpose We evaluated the clinical and radiological outcome of pure cancellous iliac bone graft for the treatment of scaphoid nonunion. Patients and methods The subjects of this study were 30 patients who had a nonunited scaphoid fracture treated with pure cancellous iliac bone graft and casting between March 2015 and April 2019. The average follow-up period was 9 months. We performed open reduction through the volar approach with impaction of the fracture site with pure nonvascularized cancellous iliac bone graft and scaphoid cast for a period ranging from 1 1/2 to 3 months. Results Bony union was achieved in 29 of 30 patients. Nonunion occurred in only one patient.

Scaphoid Nonunion Volar Plating with Pure Nonvascularized Cancellous Autograft.

Surgical treatment of scaphoid nonunion has evolved over the years to include a variety of procedures and techniques involving a number of vascularized and nonvascularized bone grafting options and fixation strategies. Volar plating of scaphoid nonunions with use of pure cancellous nonvascularized autograft is a safe and effective treatment method with good functional outcomes and union rates1. Volar plating of the scaphoid nonunion is performed via a volar approach, with debridement and reduction of the nonunion site. A nonvascularized pure cancellous bone autograft is then harvested and impacted from the distal aspect of the ipsilateral radius or the olecranon. Finally, a low-profile volar locking plate is applied for fixation2. There is no consensus regarding the optimal treatment of scaphoid nonunion. Headless compression screws are currently popular, and advances have been made over time to include various nonvascularized and vascularized corticocancellous grafts. The advent of plate fixation of the scaphoid has enabled the surgical treatment of nonunion to better replicate scaphoid morphology, allowing for improved biomechanical stability and optimizing the biologic milieu for healing. Headless compression screws, although a reasonable option for most acute scaphoid fractures, may not be the most appropriate application for nonunions. Compression, in itself, is not required for the surgical treatment of scaphoid nonunion, and can even prove detrimental by forcing the reduction into a malunion. The stability of headless compression screws must rely on a structural graft to resist the compression and create friction. The more structural the graft, however, the less biologically active it tends to be. Further, the simple placement of a metallic screw within the fracture site is counter to orthopaedic principles because it dramatically lowers the surface area available for union. Volar locking plates address the shortcoming of headless compression screws by (1) directly buttressing the deforming forces superior to headless screws3-6; (2) utilizing the most accessible, biologically active nonvascularized bone graft, which is pure cancellous graft; (3) allowing for maximal surface area contact for union; and (4) preserving the intraosseous vascular network within the scaphoid and its vascular supply at its dorsal ridge. Volar scaphoid plating with cancellous bone grafting is a reliable technique with excellent union rates and favorable functional outcomes. A review of 34 patients with scaphoid nonunions with segmental defects treated with volar plates and pure cancellous autograft demonstrated 100% union as verified by computed tomography scans postoperatively1. Average Disabilities of the Arm, Shoulder and Hand scores and grip strengths improved by final follow-up. Another series of 13 scaphoid nonunions with osteonecrosis treated with volar plating and pure cancellous autograft showed 100% union and good patient-reported and functional outcomes, despite smokers, proximal poles, and previous failed surgical procedures in the cohort2. These favorable results are consistent with earlier reports of the modern plating systems; however, concerns for hardware-related complications have been elucidated over the years, including symptomatic hardware impingement7. This risk can be mitigated by proper surgical technique and plate placement. Clear visualization of the entire volar surface of the scaphoid is crucial. Take care not to reflect too much capsule, so as to cause ulnar translation of the carpus.Thorough debridement of nonviable bone is paramount. Using a 2.0 or 3.0-mm low-speed burr with continuous irrigation can be helpful. We have had successful unions even in cases in which the remaining proximal pole was just a cortical shell and essentially a hollow vessel for graft.Err on the side of verticalization of the scaphoid, overextending and supinating the distal pole. Overstuffing the nonunion site with cancellous autograft aids in reduction and maximizes the osteoinductive and osteoconductive properties of the graft.Impaction of the graft is crucial, and the surgeon should harvest more autograft than one might initially anticipate.Secure the plate to the proximal portion of the scaphoid first. There is less room for error on the proximal portion where plate positioning is more critical.Do not cross the scaphoid "line in the sand"; to do so will result in plate impingement on the radius. Proper placement of the plate is just distal to the point at which the convex surface of the proximal pole transitions to become the concave surface of the scaphoid waist, as viewed from a volar approach.Plate modification for proximal pole fractures and nonunions: removal of the most proximal hole in the plate allows for improved fixation despite the plate itself remaining behind the scaphoid "line in the sand." In these cases, the locking screws must be directed so that they buttress the subchondral bone of each pole, especially the proximal pole.

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.

Flexor carpi radialis brevis identified during volar approach for distal radial fracture fixation: a review of the literature and case report

Flexor carpi radialis brevis identified during volar approach for distal radial fracture fixation: a review of the literature and case report