Volar Approach Research Articles

A cadaveric study comparing the three approaches for ulnar nerve block at wrist.

Background:Ulnar nerve blockade as a component of wrist block is a promising technique for adequate anesthesia and analgesia for different surgeries of the hand. Due to anatomical variations in the location of ulnar nerve under the flexor carpi ulnaris (FCU) a technique with good results and minimal complications are required.Aim:The aim of the following study is to compare the three techniques (volar, transtendinous volar [TTV] and ulnar) for ulnar nerve block at the wrist in human cadaveric wrists.Materials and Methods:Our study was conducted using 40 cadaver wrists. After inserting standard hypodermic needles by three techniques for ulnar nerve blockade at the wrist, a detailed dissection of FCU was done. The mean distance from the tip of the needle to ulnar artery/nerve and number of instances in which the ulnar artery/nerve pierced were observed.Results:Inter-group statistical significance was observed in measurement of the mean distance (mm) from the tip of the needle to the ulnar artery (volar [0.92 ± 0.11], TTV [3.96 ± 0.14] and ulnar [7.14 ± 0.08] approaches) and ulnar nerve (volar/TTV/ulnar approaches were 0.71 ± 0.12/3.61 ± 0.10/6.31 ± 0.49, respectively) (P = 0.001). Inadvertent intra-arterial/intraneural injections was seen with volar approach in 14 (35%) and 16 (40%) of the cadaveric wrists respectively, statistically significant with transtendinous and ulnar techniques of ulnar nerve block.Conclusion:TTV approach could be a better technique of choice for ulnar nerve blockade at the wrist because of its ease to practice, safer profile and minimum chances of inadvertent intra-arterial/intraneural injection with adequate anesthesia/analgesia.

Distal radius fixation through a mini-invasive approach of 15 mm. PART 1: a series of 144 cases

The volar Henry approach is becoming the gold standard for distal radius fracture fixation. It decreases the incidence of nonunion, limits complications especially complex regional pain syndrome (CRPS) type I, and allows early mobilization of the wrist. Nonetheless, it has some disadvantages such as the size of the incision, which is not esthetically pleasing, and the loss of ligamentotaxis. This is why some authors have developed a mini-invasive approach. The aim of this work was to evaluate the feasibility of the anterior mini-invasive approach of 15 mm in a clinical series of 144 cases of distal radius fracture. All patients were operated under regional anesthesia using the same techniques by five surgeons of the same team. According to the AO classification, there were 83 type A fractures, 2 type B, and 59 type C. A volar plate (Step One(®), Newclip Technics™, Haute-Goulaine, France) was used in all cases. The 2 proximal metaphyseal screws and the 2 distal central epiphyseal screws were monoaxial locking. The 2 distal ulnar and radial epiphyseal screws were placed in polyaxial locking at 20° angulation maximum. Skin closure without drainage was performed. No postoperative immobilization was prescribed, and patients were encouraged to use their upper limb immediately postoperative. No postoperative physiotherapy was prescribed. The mean follow-up was 4.1 months. The final size of the incision was on average 16.1 mm. Mean pain score was 1.8. The Quick DASH score was average 25. Average range of motion was more than 85 %, and global force of the hand was 67 % compared with contralateral side. On X-ray, the mean radial slope was 22°, the mean radial tilt was 8.3°, and the mean radioulnar variance/index was -0.4 mm. There were nine cases of CRPS type I, which all resolved. Specific complications included two secondary displacements and nine tenosynovitis cases. No tendon rupture was noted. Two intra-articular distal radioulnar joint screws had to be removed at 3 months. One epiphyseal screw required removal 1 month postoperative due to loosening. There were no intra-articular radiocarpal screws. Distal radius fracture fixation using a mini-invasive approach is a reliable and reproducible procedure with few complications. It allows anatomical reduction in the distal radius fractures including intra-articular ones. It can be associated with arthroscopy, scaphoid screw fixation or even percutaneous pinning. Thus, most traumatic lesions of the wrist bony or soft tissue can be treated through this mini-invasive approach.

Should patients requiring scrotal exploration for testicular torsion be explored by general surgeons or urologists? Our experience in a district general hospital

Should patients requiring scrotal exploration for testicular torsion be explored by general surgeons or urologists? Our experience in a district general hospital

Volar Plate Fixation of Intra-Articular Distal Radius Fractures: A Retrospective Study

Background Intra-articular fractures of the distal radius represent a therapeutic challenge as compared with the unstable extra-articular fractures. With the recent development of specifically designed internal fixation materials for the distal radius, treatment of these fractures by fragment-specific implants using two or more incisions has been advocated. Purpose The purpose of this study was to investigate the efficacy of a fixed-angle locking plate applied through a single volar approach in maintaining the radiographic alignment of unstable intra-articular fractures as well as to report the clinical outcomes. We only excluded those with massive comminution, as is discussed in greater detail in the text. Patients and Methods This is a multicentered, retrospective study involving three hospitals situated in Spain, Switzerland, and the United States. In the period between January 2000 and March 2006, 97 patients with 101 intra-articular distal radius fractures, including 13 volarly displaced and 88 dorsally angulated fractures were analyzed. Over 80% were C2/C3 fractures, based on the AO classification. 16 open fractures were noted. Results With an average follow-up of 28 months (range 24-70 months), the range of movement of the wrist was very satisfactory, and the mean grip strength was 81% of the opposite wrist. The Disabilities of the Arm, Shoulder, and Hand (DASH) score was 8. The complications rate was < 5%, including loss of reduction in two patients. All fractures healed by 3 months postinjury. Conclusions Irrespective of the direction and amount of initial displacement, a great majority of intra-articular fractures of the distal radius can be managed with a fixed-angle volar plate through a single volar approach. Level IV retrospective case series.

Volar A1 pulley sparing technique for fixation of avulsion fractures of the base of the proximal phalanx

For open reduction and internal fixation of the displaced avulsion fractures of the base of the proximal phalanx of the fingers, the volar A1 pulley approach was introduced instead of the dorsal approach. Although this procedure is quite useful, the A1 pulley and volar plate need to be divided. As a less invasive alternative, the authors developed the volar A1 pulley sparing technique and treated six patients with the median follow-up period of 14 months. All fractures healed without displacement, and all patients regained full range of motion without any evidence of instability. The volar A1 pulley sparing technique is minimally invasive and provides good visualization of the fracture site without damage to the metacarpophalangeal joint and flexor tendon structure.

AB1285 Ultrasound of MCP- and PIP-joints in rheumatoid arthritis: Increased value of the dorsal approach compared to the volar approach

BackgroundUltrasound is more sensitive for the detection of synovitis than clinical examination in patients with rheumatoid arthritis (RA). However, different examination techniques may result in different sensitivities and specificities of...

Transscaphoid–transtriquetral–transhamate perilunate fracture–dislocation: case report

A transscaphoid–transtriquetral–transhamate perilunate fracture–dislocation is a very rare pattern of injury among the known spectrum of perilunate dislocations and perilunate fracture–dislocations, and the details of the initial treatment and outcome of this injury have never been reported. We present the case of a 24-year-old, right-handed man, who presented in the emergency department with acute fracture at the waist of the scaphoid, fracture avulsion at the proximal pole of the triquetrum, and fracture of the hamate body with an associated dorsal perilunate dislocation after a fall from 3 m onto his outstretched left hand. Under general anesthesia, closed reduction was attempted with axial traction. After anatomical reduction was achieved, osteosynthesis of the scaphoid was performed using a cannulated screw, and after this was done, percutaneous pinning of the hamate with a K-wire and reconstruction of the scapholunate ligament was performed using an anchor for reinforcement of the scapholunate ligament through a minimally invasive volar approach. A short arm thumb cast splint was applied for 4 weeks, and part-time splinting was continued for another additional 4 weeks. The patient subsequently underwent 3 months of intensive range-of-motion and muscle-strengthening exercises. At the final follow-up examination, 60 months after the initial operation, the range of motion of the left wrist was 145° (extension plus flexion arc), and grip strength, 47 kg, were 91 and 98 % of the values for the unaffected wrist, respectively. Radiographs showed a bony union of the scaphoid, triquetrum, and hamate, and no sign of avascular necrosis in the proximal scaphoid fragment, as well as other carpal bones. No midcarpal or radiocarpal degenerative arthritis was observed, and the normal carpal bone relationships were still maintained, with a scapholunate angle of 49° and a scapholunate distance of 1.5 mm. We recommend closed reduction and minimally invasive volar approach for screw fixation of the scaphoid, as well as percutaneous pinning of the hamate in this case and reconstruction of the disrupted carpal ligaments to minimize the interruption of the blood supply to the carpus and also to obtain rigid fixation during the procedure.

Comparison of Volar and Dorsal approaches for surgical treatment in fracture of proximal half of the radius

Fracture of the proximal half of the radius shaft can be exposed by either one of volar or dorsal approaches. The aim of this study was to compare the results of volar and dorsal approach for surgical treatment of proximal half fracture of the radius. This prospective study was performed from April 2008 to March 2012 in two teaching hospitals. Seventy adults patients with closed fracture in proximal half of the radius or radius and ulna were operated on and fixed using small plate and screw by volar approach (VA) (39 patients) and dorsal approach (DA) (31 patients). Comparison of the results in both surgical approach were the primary measurement outcome. Duration and time of procedure, rate and time of fracture union and motion of the forearm were assessed at 4 months after operation. Mean age of the patients with VA and DA was 25.3 and 26.5 years respectively. There was 26 male and 13 female in VD and 22 male and 9 female in DA patients. Radial nerve injury in VA and DA occurred in three and two patients, infection in one and nonunion in one other patient was seen in each group. There was no significant difference in duration of procedure or time of union after both approaches =0.643. Mean rotation of forearm was 135 deg. in VA, and 138 deg. in DA patients at 4 months post surgery. There was no significant difference in term of fracture union, early complications, and range of forearm rotation between volar and dorsal approach for the fixation of radius fractures in its proximal half.

Proximal Interphalangeal Joint Injection Through a Volar Approach: Anatomic Feasibility and Cadaveric Assessment of Success

The proximal interphalangeal (PIP) joint is a challenging joint to access reliably for corticosteroid injection. Literature has confirmed both a relatively high failure rate for injections performed with the traditional dorsal approach and an improved clinical response rate for confirmed intra-articular injections. We describe a technique for injecting the PIP joint through a volar approach, assess its reliability through cadaveric dissection, and determine its reproducibility by comparing success rates with the dorsal approach in a cadaver model. We dissected the PIP joint of 10 cadaveric digits to document necessary anatomic landmarks for this technique. We then used 20 matched pairs of cadaver hands for the remainder of our study. Four PIP joints on each hand (thumb excluded) were injected with a solution of saline and radio-opaque dye using the dorsal approach. We injected each joint on the contralateral matched hand through the volar approach. We obtained standardized fluoroscopic images of each joint immediately after injection, which were reviewed by an independent observer who was blinded to the technique and who rated outcomes as success, failure, or mixed. Success rates were evaluated based on approach used, digit injected, and degree of pre-existing arthritis. We found reproducible anatomic landmarks that justified our injection technique. The rates of absolute failure were similar in the 2 cohorts. The volar approach demonstrated a higher percentage of successful injections with a smaller percentage of mixed results, although results did not reach statistical significance. There was no statistically significant difference in success rates based on digit injected or grade of arthritis in either cohort. The volar approach to injecting the PIP joint demonstrated success similar to that of the traditional dorsal approach. Reproducible surface landmarks exist to guide practitioners using this technique. Further study is needed to determine the potential complications and clinical outcomes of the volar approach. Therapeutic IV.

Anterolateral Surgical Approach to the Malunited Distal Radius Fracture for Corrective Osteotomy and Bone-graft Harvest

The most common complication after distal radius fractures is union with deformity. When symptomatic, distal radial malunions may require operative intervention. Numerous approaches to the distal radius have been described. Most volar approaches involve sectioning the brachioradialis and opening the first extensor compartment to permit adequate exposure. When bone graft is required, this may necessitate a separate incision and further add to the morbidity. We present an alternative anterolateral surgical approach to the distal radius, which allows for excellent exposure, and minimal trauma to the tendons while permitting harvest of local bone graft through the same incision.

The pronator quadratus muscle after plating of distal radius fractures: is the muscle still working?

The purpose of this study is to define the function of the pronator quadratus muscle after plating of a distal radius fracture using anterior (volar) approach. Fourteen cases with volar plating after for a distal radius fracture were included in the study. Sixteen healthy volunteers were selected to determine the effect of dominant arm on pronation torque of the forearm for the control group. Biodex System 4 PRO (Biodex Medical Systems Inc., New York) torque meter was used for pronation torque measurement. In healthy volunteer group, there was no statistically significant difference in mean pronation torque values between the dominant arm and nondominant arms. The mean loss of pronator strength was 18.5% and the mean loss of pronator durability was 12.9% indicating a pronator insufficiency in the cases operated by a volar approach compared to uninjured forearm. Two patients among the operated group, who had further strengthening exercises beyond their own rehabilitation regimes, had improved pronator torque compared to uninjured forearm. In conclusion, the results of this study indicate that following volar plating of distal radius fractures, there is a significant loss in pronator strength of the forearm. As the two of the patients had improved pronator strength of their operated forearm, further rehabilitation regimes should be considered to prevent pronator weakness following volar plating for distal radius fractures.

Complications following dorsal versus volar plate fixation of distal radius fracture: A meta-analysis

A meta-analysis to compare complication rates following volar or dorsal surgical fixation of distal radius fracture. A detailed search of PubMed®/MEDLINE® was undertaken to identify randomized and nonrandomized controlled trials published before 25 August 2012 that compared volar with dorsal fixation, in patients with distal radius fracture. A quantitative meta-analysis of 12 trials (952 patients) was performed. There was no between-group difference in the overall rate of complications. Volar fixation was associated with significant increases in neuropathy (relative risk [RR] 2.19; 95% confidence intervals [CI] 1.27, 3.76) and carpal tunnel syndrome (RR 4.56; 95% CI 1.02, 20.44), and a reduction in tendon irritation, compared with the dorsal approach (RR 0.38; 95% CI 0.17, 0.86). Dorsal fixation offers a lower risk of neuropathy and carpal tunnel syndrome than the volar approach, but a higher risk of tendon irritation. Patients with a distal radius fracture can expect similar outcomes after volar or dorsal surgery.

Fracture articulaire du radius distal avec fragment de fossette lunarienne retourné, à propos de 4 cas : intérêt du traitement chirurgical par voie antéro-médiale

IntroductionIntra-articular distal radial fractures in young subjects occur in severe trauma. Articular reduction needs to be anatomical. We report four cases with the particularity of having a 90° or 180° rotated lunate fossa. Our goal is to bring out the positive aspects of surgical procedure by volar medial approach and to assess long-term functionnal and radiological results. Material and methodsOur study focused on four men whose average age was 27 (age range from 19 to 43). The fractures were type IV according to Melone's classification. The associated lesions included: one fracture of the base of the ulnar styloid, one fracture of the distal quarter of the ulnar diaphysis and one scapho-lunate diastasis. We used a volar medial approach between the flexors tendons and the ulnar bundle in order to pin the fragment of lunate fossa. The rest of the radial epiphysis was pinned after a 5mm skin incision. In two cases, this pinning was complemented with a brachial-antebrachial-palmar cast and in the other two cases with an external fixator. ResultsThe follow-up period averaged 68.8 (18 to 115) months, all the patients were clinically examined through antero-posterior, lateral and dynamic X-rays. The objective results assessed according to Green and O’Brien's criteria, later modified by Cooney, were as follows: two very good, one good, one average. The X-rays showed consolidated fractures. According to Knirk and Jupiter's classification of arthritis, we had three grades 0, one of which showed a subchondral sclerosis of the lunate fossa, and one grade 3. Discussion and conclusionImaging with simple radiographs is not sufficient and needs to be complemented with CT scan. Our approach allows for direct access to the fragment of the lunate fossa and easier visualization of the distal radioulnar, compared to Henry's approach, thereby avoiding excessive traction of the median nerve. Type d’étudeNiveau IV.

New Technique for Dorsal Fragment Reduction in Distal Radius Fractures by Using Volar Bone Fenestration.

Introduction:For intra-articular distal radius fractures (AO Classification, type B2) with a displaced dorsal fragment, there remains much discussion on the fixation method for the dorsal fragment. To reduce the displaced dorsal fragment, we developed a new technique consisting of fenestration of the volar bone cortex, reduction using an intramedullary procedure, and fixation using a volar plate. This avoids necessity of dorsal approach.Technical Note:We performed this surgical technique in 2 patients and achieved a good reduced position without much injury to the bone cortex at the site of volar plate placement. This surgical technique allows reduction of the dorsal fragment using an intramedullary procedure by only a volar approach, and, therefore, does not affect the dorsal soft tissue (extensor tendon). For intra-articular distal radius fractures, complete reduction of the articular surface is extremely difficult, and, in patients with a remaining gap on the articular surface, a variable angle locking screw system may be useful. In the 2 patients, the angle of the locking screw was adjusted to catch the displaced dorsal fragment, and adequate reduction and fixation could be achieved.Conclusion:This technique using fenestration of the volar bone cortex allows reduction and fixation of the displaced dorsal fragment in distal radius fractures and thus avoids the necessity of a dorsal approach.

A novel method of treating isolated unicondylar fracture of the head of the proximal phalanx: A case report

The phalangeal fractures are common hand injuries. The unicondylar fractures of proximal phalanx are unique. They need prompt and accurate treatment to have a good functional outcome. We present a technique for managing a volar displaced (type 4) unicondylar fracture of the proximal phalanx. This provides accurate reduction and stabilization until fracture union, with minimal soft tissue tethering to allow early movement. A 26-years-old male sustained an injury to the right index finger while playing cricket. He attended fracture clinic complaining of pain and difficulty in moving the proximal interphalangeal (PIP) joint of the index finger. The X-ray showed a unicondylar fracture of the proximal phalanx in the coronal plane, with a displaced volar fragment. The patient was treated with open reduction and internal fixation with a single Kirschner wire (K-wire) passed from volar to dorsal aspect through the fragment. The patient commenced hand physiotherapy straight away and regained full range of movements. We report the technique of fixing the displaced unicondylar fractures of the proximal phalanx using single K-wire passed from the volar to dorsal aspect after open reduction of the fragment through a volar approach. This technique will allow early mobilization with very minimal soft tissue dissection thus preventing stiffness.

Trans-scaphoid dislocation of the proximal row: a case report

This report is of a 32 year old man who presented with complains of pain, swelling and deformity of right wrist of four weeks duration. He gave history of road traffic accident four weeks back leading to injury to right wrist; Preoperative radiographs and C.T. scan images were suggestive of trans-scaphoid dislocation of the proximal row of wrist. A volar and dorsal approach were used to reduce this complex dislocation but was not successful. Wrist arthodesis was performed after doing proximal row carpectomy. One year follow-up of the patient showed fair result with grip strength of 85% to contralateral side and modified Mayo wrist score of 65 at one year.

SESAMOIDECTOMY AND VOLAR PLATE REPAIR USING SUTURE ANCHOR FOR HYPEREXTENSION INJURY OF THE METACARPOPHALANGEAL JOINT OF THE THUMB

A retrospective study for the combination of suture anchor and selective sesamoidectomy for treating volar instability of the metacarpophalangeal joint (MCPJ) of the thumb. Eleven patients with hyperextension of the MCPJ of the thumb underwent volar plate repair using a volar or voloradial approach. All the patients were reviewed radiologically and clinically using both objective and subjective criteria. The patients presented with sesamoid fractures (n = 2), sesamoid subluxation (n = 1), isolated volar plate laxity (n = 4), isolated sesamoid fracture (n = 4), and metacarpal condyle fracture (n = 2). The inner intersesamoid distance was 4.6 mm and the outer intersesamoid distance was 14.2 mm. The Disabilities of the Arm Shoulder and Hand and Michigan Hand Outcomes Questionnaire scores showed improvement. Volar plate repair using a suture anchor and selective sesamoidectomy is effective with regard to pain relief and stabilisation of volar instability of the thumb.

Treatment of Dorsal Perilunate Dislocations and Fracture–Dislocations Using a Standardized Protocol

The aims of this study were to evaluate the associated injuries occurring with acute perilunate instability and to assess the clinical and radiographic outcomes of perilunate dislocations and fracture-dislocations treated with a combined dorsal and volar approach. A total of 45 patients (46 wrist injuries) with perilunate dislocations and fracture-dislocations were prospectively evaluated. The size of the mid-carpal ligament tear, the location of the scapholunate ligament tear, and the presence of osteochondral fragments and of the dorsal radiocarpal ligament avulsions were recorded at injury. Final clinical and radiographic outcomes were evaluated in 25 cases (25 wrists) with a minimum of 6months of follow-up. Intraoperative examination of the 46 cases with operative treatment showed the volar carpal ligament tear to be present 100% of the time and to be an average length of 3.4cm. Complete avulsion of the dorsal extrinsic radiocarpal ligaments was found in 65.2% of cases. The scapholunate ligament was torn in 35 cases. Osteochondral fragments were found either volarly or dorsally in 74% of the cases. The average flexion-extension arc was 82°, forearm rotation was 155°, and grip strength averaged 59% of the uninjured hand. The average final scapholunate angle was 55° and the scapholunate gap was 2.2mm. Treatment of perilunate fracture-dislocations with a combined volar and dorsal approach results in reasonable and functional clinical results. The incidence of associated injuries with these carpal dislocations is high. Although the perilunate fracture-dislocations have a slightly better radiologic alignment than the dislocation group, the clinical outcome is similar.

Chronic Exertional Compartment Syndrome in Adductor Pollicis Muscle: Case Report

We report a case of chronic exertional compartment syndrome in the adductor pollicis that was confirmed by measuring elevated compartment pressure. Specific finding of magnetic resonance imaging, increased T2 signal intensity in the involved compartment, was also useful for the diagnosis. Pain was relieved by fasciotomy through a volar approach.

Transseptal dorsal approaches to the wrist

The dorsal approach to the wrist is the exposure of choice for most of the surgical procedures on the radiocarpal and intercarpal joints. Contrary to the volar approach, it encounters neither the main arteries nor the motor nerve branch. However, the dorsal approach goes necessarily through the extensor retinaculum. We describe two transseptal dorsal approaches that pass through the extensor retinaculum in the thickness of a septum between two compartments. A virtual space was developed beneath the infratendinous retinaculum (which is a deep layer covering the floor of the extensor compartments) to expose the periosteum, the ligaments and the joint capsule without opening the extensor compartments. Twenty cadaveric wrists have been dissected to study the feasibility of the two transseptal approaches. Ten wrists were exposed through a 3-4 transseptal approach, passing through the extensor retinaculum in the thickness of the septum between the third and fourth compartments. Ten wrists were exposed through a 4-5 transseptal approach, passing through the extensor retinaculum in the thickness of the septum between the fourth and fifth compartments. The extent of violations of extensor compartments and joint capsule, and the exposed anatomical structures were noted. At the end of each dissection, the whole extensor system was outrightly removed for histological study. The feasibility of the transseptal approaches was demonstrated for all the dissected wrists. The dissection plane beneath the infratendinous retinaculum was macroscopically and microscopically highlighted. The transseptal approaches provide a good exposure to the dorsal side of the wrist joint, without opening the extensor tendon compartments.