Even today, the treatment of scaphoid nonunions remains challenging for the treating hand surgeon. Considering the biomechanical principles of wrist kinematics, especially the three-dimensional movement of the scaphoid, it is evident that a single headless compression screw does not provide sufficient stability to counteract all these forces, particularly rotational forces. Palmar plate fixation was initially introduced as a salvage procedure after failed screw fixation. It ensures very high rotational stability but also supports correction of the humpback deformity, reconstruction of scaphoid length, and prevents bone graft extrusion. However, indications have since been extended to include primary nonunion treatment in cases with humpback deformity or comminuted fractures. Even in recalcitrant cases (substantial bone loss, prior surgery failure, avascular necrosis, or durations exceeding 2 years), high union rates and favorable functional outcomes have been reported. This article attempts to summarize the biomechanical principles, indications, surgical techniques, and results following palmar angular stable plate fixation in scaphoid nonunions.

Introduction Over the past years, different fixation techniques focused on rotational stability in order to increase stability and stimulate union rates. Additionally, extracorporeal shockwave therapy (ESWT) has gained importance in the treatment of delayed and nonunions. Purpose of this study was to compare the radiological and clinical outcome of two headless compression screws (HCS) and plate fixation in scaphoid nonunions, in combination with intraoperative high energy ESWT. Materials and methods Thirty-eight patients with scaphoid nonunions were treated by using a nonvascularized bone graft from the iliac crest and stabilization with either two HCS or a volar angular stable scaphoid plate. All patients received one ESWT session with 3000 impulses and energy flux per pulse of 0.41 mJ/mm 2 intraoperatively. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O’Brien (Mayo) Wrist Score. To confirm union, a CT scan of the wrist was performed. Results Thirty-two patients returned for clinical and radiological examination. Out of these, 29 (91%) showed bony union. All patients treated with two HCS compared to 16 out of 19 (84%) patients treated by plate showed bony union on the CT scans. The difference was not statistically significant. However, at a mean follow-up interval of 34 months, no significant differences could be found in ROM, pain, grip strength and patient-reported outcome measurements between the two HCS and plate group. Height-to-length ratio and capitolunate angle improved significantly in both groups compared to preoperative. Conclusions Scaphoid nonunion stabilization by using two HCS or angular stable volar plate fixation and intraoperative ESWT results in comparable high union rates and good functional outcome. Due to the higher rate for a secondary intervention (plate removal), HCS might be preferable as first choice, whereas the scaphoid plate fixation should be reserved for recalcitrant (substantial bone loss, humpback deformity or failed prior surgical intervention) scaphoid nonunions.

Objective: To evaluate the impact of immediate (first day after surgery) mobilization compared to standard five weeks cast immobilization on the functional outcome after volar locking plate fixation of distal radius fractures. Design: Prospective randomized parallel group comparative trial. Setting: Trauma Hospital, Austria. Participants: Patients with isolated unstable distal radius fractures, stabilized with volar angular stable locking plate. Interventions: The immediate mobilization group received a removable forearm splint for one week and active supervised group physiotherapy and home exercises for the shoulder, elbow, wrist, and fingers from the first postoperative day. The cast immobilization group received a non-removable cast for five weeks. In the first five weeks supervised group physiotherapy and home exercises were performed for shoulder, elbow, and fingers. Thereafter additional supervised and home exercises for the wrist were started. Main measures: At regular intervals of six and nine weeks, three and six months, and one year post surgery range of motion, grip strength, and x-rays were evaluated. Additionally, the shortened disabilities of the arm, shoulder and hand ( QuickDASH) score, Patient-rated Wrist Evaluation, Mayo Wrist score, and pain according to the Visual Analog Scale score were analyzed. Results: One hundred and sixteen patients were prospectively randomized into two study groups. At the one-year follow-up, patients in the immediate mobilization group showed a significantly higher range of motion in extension/flexion (mean difference 10.2°, 99% confidence interval 0.6–19.8), grip strength (mean difference 5.1 kg, 99% confidence interval −0.5 to 10.7), and Mayo Wrist score (mean difference 7.9 points, 99% confidence interval 2.3–13.5) than the cast immobilization group. Range of motion in supination/pronation (mean difference 13.4°, 99% confidence interval 1.5–25.3) and in radial/ulnar deviation (mean difference 6.3°, 99% confidence interval 0.9–11.7) differed significantly up to nine weeks favoring the immediate mobilization group. The Patient-rated Wrist Evaluation revealed significantly better scores after three months (mean difference 9.3 points, 99% confidence interval 0.5–18.1) and QuickDASH after six months (mean difference 7.3 points, 99% confidence interval 0.3–14.3) in the immediate mobilization group. All other subsequent follow-up examinations indicated no significant differences in respect of pain, range of motion, and patient-reported outcome measurements between the study groups. There were no significant differences in respect of radiological loss of reduction and complications between the groups. Conclusions: Immediate mobilization in combination with supervised physiotherapy of the wrist after volar locking plate fixation of unstable distal radius fractures results in a significantly improved range of motion and grip strength after one year compared to cast immobilization. No increased risk for loss of reduction and other complications was observed.

Although the literature generally agrees that displaced distal radius fractures require surgery, no single consensus exists concerning the length of immobilization and type of post-operative physiotherapeutic rehabilitation program. Palmar locking plate fixation represents a very stable fixation of the distal radius, and was assessed biomechanically in various studies. Surprisingly, most authors report additional immobilization after plate fixation. One reason might be due to the pain caused during active wrist mobilization in the early post-operative stages or secondly to protect the osteosynthesis in the early healing stages preventing secondary loss of reduction. This article addresses the biomechanical principles, current available evidence for early mobilization/immobilization and impact of physiotherapy after operatively treated distal radius fractures.

INTRODUCTION:Distal radius fractures (DRF) are the most common fractures of the upper extremities and incidence is expected to continue rising as life expectancy increases. Palmar locking plate stabilizing has since become the standard treatment for dorsally displaced DRF. Main aim of this study was to investigate correlation between radiological and clinical outcome in patients stabilized by palmar locking plate with a minimum follow-up of one year. METHODS:A total of 524 patients with DRF, stabilized using palmar angular stable locking plate fixation were included in the study. Of these, 117 patients had to be excluded and another 177 were not accessible. The study group thus compromised 230 patients who returned for the follow-up investigation and were followed-up clinically and radiologically with a mean follow-up interval of 20 months. Outcome was evaluated using pain, range of motion (ROM) and grip strength parameters. In addition, self-assessment by patients was registered on the QuickDASH, PRWE and Mayo Score. The immediate postoperative and final checkup radiographs were scrutinized for alignment and intra-articular step-off. RESULTS:Bivariant correlation analysis showed a significant correlation between ulnar variance and QuickDASH (r = 0.18, p = 0.01), grip strength (r = - 0.18, p = 0.04) and Mayo Score (r = - 0.23, p = 0.001). No significant differences could be found between an unacceptable (> 2 mm) and acceptable (< 2 mm) ulnar variance in respect of pain, ROM, grip strength and patient-reported outcome measurements. Age, gender, additional fracture to the ulnar styloid, or type of postoperative immobilization showed no significant or clinical important impact on the final patient-reported outcome. No significant differences in incidence of complications, ROM or loss of reduction could be found in any patients over or under 65 years of age. CONCLUSIONS:Stabilization of DRF by palmar angular stable locking plate is a safe form of treatment and results in a good clinical and radiological outcome with low complication rate. Ulnar variance showed a significant correlation to grip strength, QuickDASH and Mayo Score, but an unacceptable ulnar variance (> 2 mm) was not associated with a worse clinical important outcome. Age (< 65/> 65 years), gender and type of immobilization had no impact on the complication rate or in the final functional or radiological outcome.

A wide range of different classifications exist for distal radius fractures (DRF). Most of them are based on plane X-rays and do not give us any information on how to treat these fractures. A biomechanical understanding of the mechanical forces underlying each fracture type is important to treat each injury specifically and ensure the optimal choice for stabilization. The main cause of DRFs are forces acting on the carpus and the radius as well as the position of the wrist in relation to the radius. Reconstructing the mechanism of the injury gives insight into which structures are involved, such as ruptured ligaments, bone fragments as well as the dislocated osteoligamentous units. This article attempts to define certain key fragments, which seem crucial to reduce and stabilize each type of DRF. Once the definition is established, an ideal implant can be selected to sufficiently maintain reduction of these key fragments. Additionally, the perfect approach is selected. By applying the following principles, the surgeon may be assisted in choosing the ideal form of treatment approach and implant selection.

Indications for surgical treatment of distal radius fractures (DRF) remain controversial in the literature, especially in elderly patients. Complication rates after operatively treated DRF are low and well documented. These include malunion, degenerative osteoarthritis in the radiocarpal joint and subsequently pain and impaired hand function. If conservative treatment fails then salvage procedures are necessary. This review summarizes the therapeutic options available to treat degenerative osteoarthritis after malunited distal radius fractures, regardless of the initial operative or conservative treatment.

OBJECTIVE:Radioscapholunate (RSL) arthrodesis with distal scaphoidectomy using an angular stable plate and palmar access in post-traumatic or degenerative osteoarthritis limited to the radiocarpal joint. INDICATIONS:Osteoarthritis limited to the radiocarpal joint with intact mediocarpal joint after malunited intra-articular distal radius fractures, rheumatoid osteoarthritis, scapholunate advanced collapse (SLAC) up to stage II. CONTRAINDICATIONS:Mediocarpal osteoarthritis, poor patient compliance, SLAC from stage III, osteitis. SURGICAL TECHNIQUE:The palmar RSL arthrodesis is performed using the palmar approach between the flexor carpi radialis tendon and the radial artery. After releasing the pronator quadratus muscle, a longitudinal capsulotomy is performed and the radiocarpal joint is inspected. After correction of a volar or dorsal intercalated segmental instability of the lunate, the lunate is temporarily fixed to the scaphoid using a K-wire. The distal quarter of the scaphoid and the palmar rim of the distal radius is resected and the cartilage between the scaphoid, lunate and distal radius is removed. The scaphoid and lunate are temporarily fixed to the distal radius using K‑wires. Under image intensifier control the angular stable low-profile plate (e.g., volar 2.5 Trilock RSL Fusion plate [Medartis® Aptus® Basel, Switzerland]) is fixed to the distal radius in the long-leg hole. The scaphoid and lunate are fixed distally with two screws each. The carpus is pushed distally using a Codeman distractor and the cancellous bone graft is impacted. Finally, the shaft is fixed with angular stable screws. POSTOPERATIVE MANAGEMENT:Immobilization using a plaster cast or thermoplastic short-arm orthosis for 5 weeks. After 2 weeks, the orthosis can be removed during hand therapy with active wrist and finger exercises. Normal activities permitted after 12 weeks. RESULTS:Palmar RSL arthrodesis and distal scaphoidectomy using angular stable plate fixation shows a high union rate and pain relief while maintaining good residual mobility of the wrist.

In the recent years, treatment of distal radius fractures (DRF) has advanced considerably. Surgical fixation with palmar angular stable plate has gained popularity, due to a reported lower complication rate when compared to dorsal fixation. The type of trauma or injury, surgical procedure and impaired bone quality are all contributors to complications in DRF. The main aim of this review is to summarize the most common complications and possible therapeutic solutions. In addition, strategies for minimizing these complications will be discussed.

Distal Radius fractures (DRF) are one of the most common injuries in the upper extremity and incidence is expected to rise due to a growing elderly population. The complex decision to treat patients operatively or conservatively depends on a large variety of parameters which have to be considered. No unanimous consensus has been reached yet, which operative approach and fixation technique would produce the best postoperative functional results with lowest complication rates. This article addresses the available evidence for indications, approaches, reduction, and fixation techniques in treating DRF.

Arthrodese zwischen Skaphoid, Lunatum und Radius mittels winkelstabiler Platte und Entfernung des distalen Skaphoidpols von palmar zur Behandlung einer posttraumatischen oder degenerativen radiokarpalen Arthrose. Isolierte radiokarpale Arthrose, bei intaktem Mediokarpalgelenk nach fehlverheilten distalen Speichenfrakturen, rheumatoider Arthritis und „scapholunate advanced collapse“ (SLAC) bis Stadium II. Mediokarpalarthrose, fehlende Compliance des Patienten, SLAC ab Stadium III, Osteitis. Der distale Speichenabschnitt und das Skaphoid werden durch einen beugeseitigen Zugang zwischen Flexor carpi radialis Sehne und A. radialis dargestellt. Nach Ablösen des M. pronator quadratus, Eröffnen der Gelenkkapsel und Korrektur einer evtl. vorhandenen Fehlstellung des Lunatums wird das Skaphoid mit dem Lunatum temporär mit einem Bohrdraht fixiert. Das distale Skaphoidviertel wird mit dem Meißel osteotomiert und entfernt, die palmare Lippe der distalen Speiche abgemeißelt und anschließend der Knorpel zwischen Skaphoid, Lunatum und Radius abgetragen. Nach temporärer Bohrdrahtarthrodese zwischen Radius, Lunatum und Skaphoid wird die winkelstabile Low-profil-Platte (z. B. palmare 2.5 TriLock RSL Fusion Platte [Medartis® Aptus®, Basel, Schweiz]) unter Bildwandlerkontrolle positioniert und im Gleitloch fixiert. Das Skaphoid und Lunatum werden mit je 2 Schrauben in der Platte distal fixiert, der Carpus wird mit einem Codman-Distraktor nach distal geschoben und die Spongiosa eingebracht. Abschließend wird die Platte am Schaft mit winkelstabilen Schrauben fixiert. Ruhigstellung in einer Unterarm(‑Kunststoff)-Schiene für 5 Wochen. Nach 2 Wochen Nahtentfernung und Beginn mit aktiver Handtherapie für das Handgelenk. Normale Belastung des Handgelenkes nach 12 Wochen. Durch die radioskapholunäre (RSL) Arthrodese kann bei Vorliegen einer isolierten Radiokarpalarthrose eine deutliche Reduktion der Schmerzsymptomatik bei erhaltener Restbeweglichkeit des Handgelenkes erreicht werden.

Since March 2011, the microbial collagenase of Clostridium histolyticum (Xiapex®, Swedish Orphan Biovitrum AB, Stockholm, Sweden) has become available in the European Union for treatment of Dupuytren’s disease. The purpose of this study was to evaluate potential safety risks of Xiapex® and to contribute to a better understanding for its use. A prospective, non-interventional, observational study using Xiapex® for Dupuytren’s disease named XIANIS was conducted between 1.10.2011 and 01.10.2017. Treatment was conducted in accordance to the manufacturer information. Patients were invited for follow-up after 1 week, 1 month, 3 months and 1 year. Demographic data, treatment data, pain levels, anaesthetic application during passive manipulation, subjective function improvement, subjective satisfaction and adverse events were recorded. 788 patients with 814 treatments were included who suffered from Dupuytren’s contracture for a mean of 64 months. The metacarpophalangeal joint was affected in 57% of cases and the PIP joint in 40.8% with a mean contracture of 39° and 56°, respectively. A change in the contracture down to 0°–5° was reported in 66.5% of cases, while 25.5% achieved a partial improvement. The pain during the injection was rated 4.5 and 3.3 during passive manipulation. Adverse events were reported in the majority of treated patients with skin tears being one main common event (26%). Further adverse outcomes were bleeding/hematoma, joint swelling, injection-site swelling, pressure sensitivity, erythema, injection-site pain, peripheral edema, blood blisters, blisters, painless lymphadenopathy, painful lymphadenopathy, axillary pain, arthralgia and sensory abnormality. There were no reported tendon ruptures, anaphylactic reactions or ligament injuries. On 1-year follow-up, 29% showed an increased contracture of a mean of 24° with the need for surgical treatment in 2% of patients. 74% of patients were very satisfied and 72% showed a high functional improvement. The injectable collagenase Clostridium histolyticum (Xiapex®) proved to be effective and safe in patients with Dupuytren’s disease. Minor adverse events disappeared within 30 days and the need for surgical treatment within 1 year was very low (2%). No major complications or rare side effects were seen in this prospective observational study.

Reposition und Stabilisierung von Impressions- und Luxationsfrakturen der Gelenkfläche an der Basis des Mittelglieds durch gedeckte Reposition (über streckseitiges Knochenfenster im sehnenfreien Dreieck) und Stabilisierung mittels gitterartig konfigurierten Bohrdrähten. Impressionsfrakturen an der Basis des Mittelglieds (mit oder ohne Luxation). Ausgedehnte Frakturen des Schafts am Mittelglied. Durch ein kleines kortikales Fenster streckseitig am Mittelglied, im sehnenfreien Dreieck, wird die imprimierte Gelenkfläche vom Markraum aus mit einem gekrümmten Bohrdraht reponiert. Anschließend erfolgt die Sicherung der Reposition durch Unterfütterung der Gelenkfläche mit Bohrdrähten, die in einer gitterartigen Konstruktion eingebracht werden. Ruhigstellung in thermoplastischer Fingerschiene für 6 Wochen. Anschließend Bohrdrahtentfernung und aktive Bewegungsübungen sowie Handtherapie. In zwei bisher veröffentlichten Fallserien konnten gute klinische und radiologische Ergebnisse dokumentiert werden. Komplikationen wurden in beiden Serien nicht beobachtet.

OBJECTIVE: Reconstruction of intra-articular impression fractures of the middle phalanx by percutaneous reduction over a small dorsal cortical window. Stabilization by lattice-like arranged K‑wires. INDICATIONS: Impression fractures of the base of the middle phalanx with or without dislocation in the proximal interphalangeal joint. CONTRAINDICATIONS: Fractures extending to the shaft of the middle phalanx. SURGICAL TECHNIQUE: By a cortical window at the dorsum of the middle phalanx (through the tendon free triangle) the impression fracture is reduced from the medullary cavity. Reduction is secured and the articular surface is supported by lattice-like arranged K‑wires. POSTOPERATIVE MANAGEMENT: Thermoplastic splint for the finger for 6 weeks, subsequently K‑wire removal, active range of motion exercises and hand occupational therapy. RESULTS: In two case series already published, good clinical and radiological results were reported. No complications were detected in either series.

Stabilisierung von Kahnbeinpseudarthrosen/Trümmerfrakturen mit palmarer winkelstabiler „Low-profile“-Skaphoidplatte. Kahnbeinpseudarthrose mit großer beugeseitiger Defektzone, Zweit‑/Dritteingriff nach vorheriger Stabilisierung mittels Headless Compression Screw (HCS). Trümmerfrakturen des Kahnbeins, die mit einer HCS nicht ausreichend stabilisiert werden können. Fortgeschrittene Radio- oder Mediokarpalarthrose, kleine proximale Polfragmente, Mehrfachfragmentierung des proximalen Pols. Über einen beugeseitigen Zugang wird die Kahnbeinpseudarthrose dargestellt. Nach Korrektur der DISI-Fehlstellung („dorsal intercalated segment instability“) des Lunatums sowie der Humpback-Deformität des Kahnbeins wird die Reposition mit temporären Bohrdrähten fixiert. Die Pseudarthrose wird angefrischt und der Knochendefekt mit Spongiosa aufgefüllt. Anschließend erfolgt die Platzierung der Platte und die Fixierung mit winkelstabilen Schrauben über je drei Schrauben im proximalen und distalen Fragment des Kahnbeins. Die Plattenanlage bei Trümmerfrakturen des Kahnbeins erfolgt analog zur Pseudarthrose nach vorheriger Reposition und temporärer Bohrdrahtfixation. Ruhigstellung im Unterarmgips oder Kunststoffverband mit Einschluss des Daumengrundgelenks für 8 Wochen (sowohl Trümmerfrakturen als auch Pseudarthrosen). Keine schweren manuellen Tätigkeiten und Risiko‑/Kontaktsportarten für 12 Wochen. Plattenentfernung nach 6 Monaten bzw. knöcherner Heilung empfohlen. Durch die Stabilisierung mit der winkelstabilen palmaren Skaphoidplatte können – bei richtiger Indikationsstellung – hohe Heilungsraten mit guten funktionellen Ergebnissen erzielt werden.

Introduction Scaphoid nonunion remains challenging for hand surgeons. Several treatment options are available such as: non-vascularized or vascularized bone grafting, with or without additional stabilization. In the last few decades, extracorporeal shockwave therapy (ESWT) has become an established procedure for treating delayed and nonunions. Purpose of this retrospective follow-up study was (a) to investigate union rate and clinical outcome of the different implants [either one/two headless compression screws (HCS) or a plate] and (b) union rate and clinical outcome using only surgery, or a combination of surgery and ESWT. Materials and methods The study included 42 patients with scaphoid nonunions of the waist with a mean follow-up of 52 months. All patients received a non-vascularized bone graft from the iliac crest and stabilization was achieved by using one, two HCS or a plate. ESWT was performed with 3000 impulses, energy flux density per pulse 0.41 mJ/mm 2 within 2 weeks after surgery. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, Disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O’Brien (Mayo) Wrist Score. In addition, each patient had a CT scan of the wrist. Results A total of 33/42 (79%) patients showed union at the follow-up investigation. Patients treated with additional ESWT showed bony healing in 21/26 (81%) and without ESWT in 12/16 (75%). Patients that were stabilized using one HCS showed bony healing in 6/10 (60%), with two HCS 10/12 (83%) and by plate 17/20 (85%). The ESWT group had a significantly lower pain score according to the VAS and better modified Green O’Brien (Mayo) Score. No differences could be found in respect of ROM, grip strength, functional outcome score depending of which stabilization method was used. Conclusions Stabilization of scaphoid waist nonunions with two HCS or plate showed higher union rates than a stabilization using only one HCS. In addition, ESWT combined with a nonvascularized bone graft from the iliac crest seems a suitable option for treating scaphoid nonunions.

Distal radius fractures (DRF) are the most common fractures of the upper extremities. The incidence is expected to continue rising in the next years due to the increased life expectancy. Palmar locking plate stabilizing has since become the standard treatment for dorsally displaced DRF with a complication rate of 8–39% reported in the literature. Main aim of this study was to investigate the incidence of complications after DRF stabilization using palmar angular stable locking plate.