Metacarpal Fractures

Introduction The metacarpal bones make up the bony arch connecting the phalanges to the carpus and are one of the most commonly fractured bone in the hand. Knowledge of the unique metacarpal anatomy, musculotendinous attachments, and surrounding neurovascular structures can allow surgeons to select the most effective and safe treatment individualized to each fracture. Several deforming forces act on the metacarpal head, neck, shaft, and base…

Technique Spotlight: Open Reduction and Repair of Perilunate Injuries

Treatment of perilunate injuries may be accomplished via a number of different approaches. Open repair of perilunate injuries can be accomplished via an all-dorsal, all-volar, or combined dorsal and volar approach. Due to the complexity of some ligamentous disruptions and the carpal relationships, many recommend a combined two-incision approach. In the combined volar-dorsal technique, the volar approach is used for reduction of the lunate, carpal tunnel…

Perilunate and Lunate Dislocations

Introduction Perilunate injuries represent a challenge to the hand and wrist surgeon. Complex anatomy and kinematics, coupled with missed diagnoses and oft-delayed presentation, make the achievement of excellent outcomes difficult. It is our goal to present the essential information—anatomy, pathoanatomy, treatment options, surgical approaches, and expected outcomes—necessary for the hand and wrist surgeon to successfully identify and treat perilunate injuries. Anatomy Knowledge of the ligamentous and…

Technique Spotlight: Scaphoid Fractures—Volar vs. Dorsal, Open vs. Percutaneous; Bone Graft Options

Volar Percutaneous Technique Indications The indications for volar percutaneous fixation of scaphoid fractures include nondisplaced scaphoid fractures, or minimally displaced fractures that can be reduced using K-wires as joysticks. In particular, the volar approach is useful for more distal fractures which can be more challenging to manage from a dorsal approach. Preoperative Evaluation Standard radiographic imaging including posteroanterior (PA), oblique, lateral, and scaphoid views should be…

Scaphoid Fractures

Relevant Anatomy The scaphoid bone functions as a link between the proximal and the distal carpal rows through ligamentous attachments and articular mechanics. It has a fairly complex and certainly unique anatomy. It is often described as having a peanut shell shape. The scaphoid articulates with the distal radius proximally and the lunate ulnarly. It also articulates with the trapezium, trapezoid, and capitate of the distal…

Technique Spotlight: Dumontier Type 1 vs. Type 2; When and How to Fix the Radial Styloid Fragment; Neutralization Device Options

The surgical approaches for treating radiocarpal dislocations and fracture-dislocations are variable, dependent on the specific injury pattern. It is not unusual for these injuries to require multiple surgical approaches to address all the fracture fragments and achieve ligamentous stability. In a series of patients with dorsal articular rim fractures with radiocarpal fracture-dislocation, 7 of 19 patients required both a dorsal and volar incision to address distal…

Radiocarpal Dislocations and Fracture Dislocation

Introduction Radiocarpal dislocations are rare injuries that occur as a result of a high-energy mechanism. The initial descriptions of this injury were prior to the advent of radiographs, at which time the clinical deformity of a distal radius fracture was presumed to be a dislocation of the joint. The advent of radiography naturally elucidated the bony injuries underlying clinical deformities and allowed better comprehension of the…

Technique Spotlight : Tips and Tricks for Predicting Which Radial Shaft Fractures Will Be Unstable; Repair Options for the DRUJ/TFCC After Radial Fixation

Indications Persistent distal radioulnar joint (DRUJ) instability or an irreducible DRUJ after anatomic fixation of a radial shaft fracture requires further evaluation and management. The following scenarios are typically encountered after radial shaft fixation: 1. Reduced and stable DRUJ 2. Reduced and DRUJ stable only in specific forearm positions (supination or pronation) 3. Reduced but unstable DRUJ with concomitant large ulnar styloid fracture 4. Reduced but…

Technique Spotlight : ORIF of Galeazzi Fracture-Dislocations

Indications The decision between surgical and nonsurgical management is largely guided by patient age. In children, closed reduction and casting is the mainstay of treatment if an adequate reduction of both the radius fracture and the distal radioulnar joint (DRUJ) dislocation can be maintained. In adults, a fracture of the radial shaft with concomitant DRUJ dislocation has been termed “a fracture of necessity,” referring to the…

Distal Radioulnar Joint Instability and Galeazzi Fractures

Introduction The Galeazzi fracture-dislocation is a fracture of the distal one-third of the radial shaft with an associated distal radioulnar joint (DRUJ) dislocation. This injury was described first by Astley Cooper in 1826 and later named after Riccardo Galeazzi who published his series of cases in 1934. , The Galeazzi fracture has been given the name the “fracture of necessity,” referring to its need for anatomic…

Technique Spotlight: Bridge Plating for Distal Radius Fractures

Indications Initially described by Burke and Singer as an alternative to wrist-spanning external fixation, dorsal bridge plate fixation has proven to be a versatile option for the management of fractures of the distal radius. Bridge plate fixation is most frequently utilized in the treatment of distal radius fractures with significant articular or metadiaphyseal comminution which would be suboptimally treated with a conventional locked volar plate construct.…

Technique Spotlight: Fragment Specific Options for Distal Radius Fractures

Introduction The last two decades have seen the introduction of new implants and techniques revolutionize the capacity to successfully stabilize displaced and unstable distal radius fractures. The advent and sweeping adoption of volar locked plating in the new millennium quickly broadened indications for surgery. , The demonstrated success and versatility of volar locked plating have led to its adoption as the most common method of fixation…

Technique Spotlight: Dorsal Plating for Distal Radius Fractures

Indications Open reduction with internal fixation has become the preferred treatment for most unstable intra-articular and periarticular fractures; however, there is no consensus regarding optimal treatment algorithms and predicted outcomes with various surgical options. Like any fixation technique, each has advantages and disadvantages. Volar locked plating, for example, although popular for most fractures that are dorsally displaced, relies on locking screws to buttress the subchondral bone…

Technique Spotlight: ORIF of Intra-Articular Distal Radius Fractures—Volar Approach

Introduction It is important to try and achieve as close as an anatomic reduction of the articular surface as possible, especially in a young patient, in the management of intra-articular distal radius fractures to reduce the chance of posttraumatic radiocarpal arthritis. , Visualization of the radiocarpal articular surface was historically performed through a dorsal approach to the distal radius fracture via a dorsal capsulotomy. With the…

Distal Radius Fractures

Introduction Distal radius fractures are the most common upper extremity fracture in patients in the United States, accounting for 0.7%–2.5% of emergency department visits. , Worldwide, the incidence of distal radius fractures has increased over the past 40–50 years, almost doubling in certain populations. , Distal radius fractures occur in a bimodal distribution with the highest frequency in youths under the age of 18 years and…

Technique Spotlight: ORIF of Both Bones Forearm Fractures—Approaches

Indications Surgical indications for both bones forearm fractures include the following: (1) nondisplaced or minimally displaced both bones forearm fractures with a propensity for instability (comminution, initial displacement prior to reduction, and polytrauma patients) and (2) significantly displaced or angulated radius or ulna or both bones forearm fractures. You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership…

Radial and Ulnar Shaft Fractures: Choice of Approach, Nails vs. Plates, Compression Tips and Tricks

Relevant Anatomy The diaphyseal forearm functions to provide a stable platform upon which the hand can be positioned in space, as well as to facilitate forearm rotation. The ulna functions as the dominant load-bearing structure, with the radius rotating about it in pronation and supination. The soft tissue envelope about the diaphysis of the forearm is composed of the superficial and deep volar compartments, the extensor…

Technique Spotlight: Interosseous Membrane Reconstruction

Indications The primary indication to reconstruct the interosseous membrane (IOM) is a longitudinal radioulnar dissociation also known as an Essex-Lopresti injury (ELI). An ELI is an injury triad involving fracture of the radial head, rupture of the interosseous ligaments, and instability of the distal radioulnar joint (DRUJ). Early diagnosis is paramount for a favorable outcome, as timing affects the strategy of treatment. In the acute setting,…

Essex-Lopresti—When Do All Three Levels Require Attention?

History Although the eponym for forearm longitudinal instability is known as Essex-Lopresti, Dr. Peter Essex-Lopresti was not the first person who reported the injury. It was first described by Brockman in 1931. Curr and Coe later reported on a case of a dislocation “on both ends of the radius” 15 years later in 1946. However, in a case report by Dr. Essex-Lopresti in 1951, he correctly…

Technique Spotlight: ORIF Monteggia Fractures

Introduction A Monteggia fracture-dislocation, defined as a proximal ulna fracture with a concurrent proximal radioulnar joint dislocation, is a rare but complex injury of the forearm and elbow. Monteggia fracture-dislocations account for 1%–2% of forearm fractures and are commonly secondary to a direct force to the forearm while the elbow is extended and the forearm is pronated. Several classification systems have been proposed to describe these…