The increasing incidence of civilian firearm-related injuries has placed a growing burden on hand surgeons to manage complex ballistic trauma. Periarticular hand fractures caused by firearms present a particularly difficult treatment challenge, characterized by articular comminution, bone loss, and concurrent soft tissue injury. These features frequently render standard fixation options, including plate fixation, wire pinning, and external fixation, either technically infeasible or prone to complication. This manuscript describes our technique of dorsal trans-articular bridge plating as a salvage option for gunshot-related periarticular fractures at the metacarpophalangeal and proximal interphalangeal joints of the hand. Originally developed for severely comminuted intra-articular distal radius fractures, bridge plating achieves relative reduction through ligamentotaxis while providing a robust, length-stable construct with minimal additional soft tissue disruption. We present a retrospective case series of 14 patients treated at a level 1 urban trauma center between 2021 and 2023. Nine underwent trans-articular bridge plating at the MCP joint and 5 at the PIP joint. Of the 11 patients with available postoperative data, 91% achieved radiographic fracture union. Mean pain scores improved from 5.6 of 10 at initial follow-up to 1.4 of 10 at final follow-up (mean 6.7 mo after hardware placement). Postoperative stiffness was encountered in all patients, reflecting the severity of the underlying injury. Trans-articular bridge plating is a technically reproducible salvage option for severely comminuted gunshot-related periarticular hand fractures, offering reliable restoration of digital length, alignment, and rotation with acceptable early outcomes.
BACKGROUND:Carpometacarpal (CMC) joint instability can arise from multiple factors, including rheumatoid arthritis, congenital abnormalities, connective tissue disorders, and acute or cumulative trauma. Early detection is crucial, as ligamentous laxity leads to joint incongruence, which, if left untreated, may progress to osteoarthritis(45) First-line treatment consists of immobilization with a splint combined with physical therapy. However, when conservative management fails, surgical stabilization of the CMC-1 joint becomes necessary. Traditional open techniques typically require bone tunnels and tendon harvesting. Technique: We present a novel arthroscopic technique that is less invasive and reinforces the dorsal capsule and dorsal ligaments complex. This approach, inspired by the Birman open procedure, is based on the concept that the dorsal ligament complex is the primary stabilizer of the CMC-1 joint. Results: Seven cases were followed for an average of 24 months. The mean visual analog scale (VAS) pain score was 0. The Kapandji score was 10. Grip strength reached 95% and pinch strength 92.5% of the contralateral hand. One complication was observed: transient irritation of the dorsal radial nerve. CONCLUSION:Arthroscopy is a viable option for capsuloplasty of the dorsal carpometacarpal ligament of the CMC-1 joint. It offers a minimally invasive alternative with fewer risks and less tissue damage while providing improved visualization of the joint, bone, and soft tissues and avoiding the need for complex joint reconstructions.
Reconstruction of large shoulder defects may not be possible with standard pedicled flap designs. Here, we describe a technique for coverage of a wide shoulder defect using the “Kiss” latissimus dorsi pedicled flap. This concept utilizes 2 or more skin paddles in series and combines these in parallel to permit coverage of a wider shoulder defect while permitting primary closure of the back donor site.
