Comparing treatment of proximal phalangeal fractures with intramedullary screws versus plating.

PURPOSE Phalangeal fractures are the most common injuries in humans and account for approximately 10% of all fractures. With plate fixation, anatomic reduction is achievable in most cases, but extension lag is seen in up to 67%. Intramedullary headless screw offers treatment of unstable proximal phalangeal fractures using a minimally invasive procedure with very few complications. One of the major disadvantages of this technique is the transarticular screw position, damaging the articular surface and thus preventing very proximal fractures from being treated with a distally inserted screw. In this study, we present a modified approach to the fixation of the proximal phalangeal fractures and compare outcomes with plate osteosynthesis. MATERIALS AND METHODS Twenty-nine patients with 31 comparable fractures of the proximal phalanx were treated either with a plate (14) or with minimal invasive cannulated compression screw (17). Pain, strength, range of motion (ROM), work disability and QuickDASH score were assessed. RESULTS TAM was significantly better in the screw group. The extension lag was worse in the plate group. Plate removal had to be performed in 13 of 14 the cases, while the screw had to be removed in only 3 cases. The average duration of work disability was 9.9 weeks in the plate group, compared to 5.6 weeks in the screw group. CONCLUSION Minimally invasive screw osteosynthesis not only has the advantage of significantly shorter work disabilities, but also shows remarkably improved postoperative range of motion. In contrast to plate osteosynthesis, removal of the screw is only necessary in exceptional cases. With the antegrade screws position, even difficult fractures close to the base can be treated without destroying any articular surface. In proximal phalanx fractures with both options of plate or single-screw osteosynthesis, we recommend minimal invasive cannulated screw osteosynthesis

Radio-luno-triquetral bone-ligament transfer as an additional stabilizer in scapholunate-instability.

INTRODUCTION Reconstruction of the scapho-lunate (SL) ligament is still challenging. Many different techniques, such as capsulodesis, tendon graft and bone-ligament-bone graft have been described to stabilize reducible SL dissociation. If primary ligament repair alone is not possible, an additional stabilizer is needed to achieve scapho-lunate stability. A new local bone-ligament transfer using half of the radio-luno-triquetral ligament is performed. The direction of traction of the transposed ligament is very similar to the original ligament. Ideal tension can be attained by fixation of the bone block at the dorsal ridge of the scaphoid. The biomechanical stability of this bone-ligament transfer shall be examined biomechanically. MATERIAL AND METHODS Computed tomography imaging was performed using eight cadaveric forearms with a defined position of the wrist. Axial load was accomplished with tension springs attached to the extensor and flexor tendons. Three series ([a] native, [b] divided SL ligament and [c]) after reconstruction with bone-ligament transfer] were reconstructed three-dimensionally to determine the angles between radius, scaphoid and lunate. The radial distal part including a bone fragment of the radio-luno-triquetral ligament was transferred from its insertion at the distal edge of the radius to be attached to the dorsal ridge of the scaphoid. RESULTS SL gap was widened after its transection. Average SL distance was 6.6 ± 1.6 mm. After ligament reconstruction, the gap could be narrowed significantly to 4.2 mm (± 0.7 mm). The movement of the scaphoid and lunate showed significant changes, especially in wrist flexion, fist closure and radial deviation. These deviations could be corrected by the bone ligament transfer. CONCLUSION Reconstruction of a transected SL ligament with a bone-ligament transfer from the radio-luno-triquetral ligament reduces SL dissociation under axial load. The described surgical technique causes low donor-side morbidity and can be considered in addition to improve stability if SL ligament suture alone does not appear sufficient. LEVEL OF EVIDENCE Level II, therapeutic investigating experimental study