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Five cases with an avulsion fracture of the thumb metacarpophalangeal joint treated by a simple method of internal fixation are described. This method is designed as a form of modified tension band wiring using the combination of a single Kirschner wire and a pull-out wire, and is technically easy.

Hamate hook non-union is a relatively rare, but on the increase. We encountered a 25-year-old male baseball instructor with hamate hook non-union, and treated it with debridement of the fractured region and osteosynthesis using a break-away screw. Splint fixation was applied for three weeks after surgery, and active/passive range of motion exercises were actively performed thereafter. Bone union was noted three months after surgery. Transient ulnar paralysis resolved, and the patient could return to the same sports activity as that before injury six months after surgery. Since break-away screws are capable of loading a strong pressure on the fractured region and these screws can be inserted by preparing only a surgical field for guide wire insertion, requiring no soft tissue dissection to prepare a region for applying fixation materials, break-away screws are useful for the fixation of small bone fragments and osteosynthesis in a deep surgical field.

Background: Distal radius fractures in elderly patients are now commonly treated with a volar locking plate, but flexor pollicis longus dysfunction caused by stripping of the muscle and tendon irritation and rupture caused by prominence of the implant have been reported. Intramedullary implants can stabilize distal radius fractures while minimally affecting the flexor and extensor tendons and muscles around the site, but osteoporosis in elderly patients might affect the radiographic and functional results of distal radius fractures treated by intramedullary implants. We investigated the radiographic and functional results of intramedullary implants for distal radius fractures in patients ≥65 years of age.

Methods: We reviewed medical records of 40 patients with extra-articular or simple intra-articular fractures with the sagittal fracture line treated by an intramedullary implant.

Results: All fractures achieved bony union, with an average radial inclination of 24.9 degrees, volar tilt of 9.2 degrees, and ulnar variance of 0.7 mm. We encountered one case of postoperative volar displacement of the distal fragment due to the small size of the intramedullary implant. The average range of motion was 69.8 and 59.9 degrees for dorsal and palmar wrist flexion, respectively. Average percentile grip strength of the uninjured side was 97%. The average Mayo modified wrist score at final follow-up was 91.9 points, with 20 patients graded as excellent, 16 as good, and 4 as fair.

Conclusions: The findings of this study indicate that intramedullary implants for dorsally displaced extra-articular or simple intraarticular distal radius fractures may offer good radiological and functional outcomes without hardware irritation in elderly patients. Distal radius fractures with an osteoporotic, large medullary canal should be stabilized by implants of an appropriate size.

Background: A three-dimensional (3D) digital pre-operative planning system for the osteosynthesis of distal radius fracture was developed. The objective of this study was to evaluate screw choices for three-dimensional (3D) digital pre-operative planning of osteosynthesis of distal radius fractures and to compare with the screw choices for the conventional method.

Methods: Distal radius fracture patients who underwent osteosynthesis using volar locking plates were evaluated. Thirty wrists in the plan group utilized 3D preoperative planning, and nineteen wrists in the control group utilized conventional preoperative assessment. In the plan group, the 3D preoperative planning was performed prior to surgery. The reduction was simulated with 3D image, and the implant choice/placement also simulated on the 3D image. In the control group, standard preoperative planning was performed using posterior-anterior and lateral view radiographs, and CT scan. After the planning, osteosynthesis was performed. During the surgery, the operator performed the reduction and the placement of the plate while comparing images between the pre-operative plan and fluoroscopy. The distal screw lengths and the anteroposterior diameter of the radius along the axis of the distal screws were measured. The ratios of the screw length and radius diameter were evaluated. The screw/radius ratios within the range of 0.75–1.00 were considered appropriate. The screw choices less than 0.75, or greater than 1.00 were considered inappropriate. The rate of appropriate screw choices were compared between plan and control groups.

Results: The results of appropriate screw choices were 86.1% and 74.8% in the plan group and the control group, respectively. The inappropriate screw choices were 14.0% and 25.2% in the plan group and the control group, respectively. The three-dimensional planning significantly increased appropriate screw choices compared to the conventional planning (p < 0.05).

Conclusions: Three-dimensional digital preoperative planning is useful for the optimization of screw lengths in osteosynthesis of distal radius fractures.

Background: To assess the usefulness of three-dimensional (3D) digital pre-operative planning, we compared the radiographic parameters of the distal radius from 3D planning and conventional planning after osteosynthesis of distal radius fractures. We hypothesized that the use of 3D digital planning may improve radiographic outcomes for reduction and decrease the risk of correction loss.

Methods: Sixty wrists of 60 distal radius fracture patients were randomly divided into two groups according to the order of hospital visits. Thirty wrists were treated with 3D preoperative planning as the plan group. Another thirty wrists were treated with conventional preoperative planning as the control group. Both groups were treated with volar locking plates. In the plan group, 3D digital preoperative planning and a surgical simulation were performed in order to determine the reduction and placement of the implants in addition to the plate/screw size prior to surgery. In the control group, conventional preoperative planning was performed. Ulnar variance, volar tilt, and radial inclination were measured at one week, three and six months after surgery. Difference of the measurement of radiographic parameters between operated and healthy side wrists were compared between plan and control groups at one week after surgery. Loss of corrections for radiographic parameters were compared between plan and control groups.

Results: The differences between the operated and healthy side wrists were significantly smaller in the plan group compared to the control group for the volar tilt and radial inclination (p < 0.05).The loss of corrections for ulnar variance and volar tilt were significantly smaller in the plan group compared to the control group at six months after surgery (p < 0.05).

Conclusions: 3D preoperative planning offers better reduction accuracy and reduces correction loss in the osteosynthesis of distal radius fractures.

Background: There are many options to treat post osteomyelitic gaps in forearm bones. We report a pediatric series with postosteomyelitic forearm segmental defects reconstructed with fibular only graft: the non vascular fibular intramedullary bridging bone and additional grafting (FIBBAG) and the results thereof.

Methods: Outcomes in 8 patients treated with fibular strut and overlay matchstick grafts were retrospectively assessed. The clinical results were expressed as forearm shortening, range of motion at elbow and wrist joint. The radiological evaluation included time to union, presence of fractures and recurrence of infection, if any.

Results: The average patient age was 6 years (range, 3–12 years). The radius was involved in 6 and ulna in 2. Union occurred in all patients. The average intraoperative gap to be spanned was 5.86 cm (range, 3–14 cm). The average time for union was 6.63 months (range, 2–14 months). Two patients required additional bone grafting procedures. No graft fatigues/fractures were noted in available follow up. There was no recurrence of infection in any case. A positive ulnar variance was seen in 3 patients at follow up. Forearm shortening was a major cosmetic limitation following the procedure.

Conclusions: Fibular strut and additional bone grafting (FIBBAG) is one of the viable options for reconstruction of post osteomyelitic forearm defects in children with low procedural complication rate.

Background: The objective of this study was to clarify whether anteroposterior dimension of the radius along the screw axis of a fixed angle volar locking plate (VLP) can be predicted from the width of the radius on the VLP.

Methods: Sixty-nine wrists in 68 patients with distal radius fractures that underwent fixation with a fixed angle VLPs were evaluated. All patients underwent pre- and postoperative computed tomographic scans of the distal radius. The transverse width of the radius was measured at the position of the third screw hole from the proximal edge. The anteroposterior dimension of the radius (R) was measured along the axes of the distal screws. The distal row screw holes were defined as R1, R2, R3, and R4 from the radial to the ulnar side. Correlation analysis between the width and the anteroposterior dimension, and single regression analysis were performed for each screw hole. The correlations amongst the R values for the different distal row screws were also assessed.

Results: The correlation coefficients between the transverse width and anteroposterior dimensions were 0.54, 0.58, 0.55, and 0.42 for R1, R2, R3, and R4 respectively (p < 0.05). The regression equations were R1 = 0.49W + 7.99, R2 = 0.47W + 11.8, R3 = 0.52W + 10.8, and R4 = 0.41W + 11.5 respectively. The correlation coefficients among anteroposterior dimensions were 0.85, 0.64, 0.59, 0.70, 0.61, and 0.80 for R1/R2, R1/R3, R1/R4, R2/R3, R2/R4, and R3/R4 respectively (p < 0.01).

Conclusions: There were significant correlations in the anteroposterior dimensions amongst the distal row screw lengths. The regression equations used in this study may be helpful to predict the length of distal row screw and prevent complications due to inappropriate screw choices.

Level of Evidence: Level III (Therapeutic)

Tension band wiring (TBW) is a standard surgical technique for treating olecranon fractures (OFs). We devised a hybrid TBW (HTBW) combining TBW using wires with eyelets and cerclage wiring. Twenty-six patients with isolated OFs with Colton classification groups 1–2C were subjected to HTBW, and the data was compared with those treated with conventional TBW (38 patients). The mean operation time and hardware removal rate were 51 versus 67 minutes (p < 0.001) and 42% versus 74% (p < 0.012), respectively. The HTBW group had one patient (4%) with surgical wire breakage. The conventional TBW group had 14 patients (37%) with symptomatic backout of Kirschner wires, three patients (8%) with loss of reduction, two patients (5%) with surgical site infection and one patient (3%) with ulnar nerve palsy. The motion and functional score ranges of the elbow were not significantly different. Therefore, this procedure may be a feasible alternative.

Level of Evidence: Level V (Therapeutic)

Background: A high incidence of ulnar nerve-related complications has been reported in open reduction and internal fixation for distal humerus fractures (DHFs). To minimise ulnar nerve damage, we used a percutaneous medial screw combined with a posterolateral plate in the elderly. The aim of this study was to evaluate the postoperative complications and functional outcomes of this method.

Methods: Data from patients aged over 65 who underwent this surgical procedure for DHFs at a single Level I trauma centre from 2013 to 2021 were extracted. Postoperative complications, reoperations, mean range of motion, Mayo Elbow Performance Index (MEPI) scores and Hand20 scores were retrospectively evaluated. All patients in this study received postoperative rehabilitation by hand therapists at our hospital.

Results: We identified 28 patients treated with this method. The mean follow-up period was 8.6 ± 3.7 months. The median intraoperative time was 125 minutes (interquartile range: 105–157 minutes). None of the patients developed ulnar nerve neuropathy, but one patient (3.7%) experienced radial nerve dysfunction. Two patients (7.4%) had nonunion. Implant failure occurred in three patients (11.1%) due to migration of the medial screw. One patient (3.7%) amongst them underwent reoperation. The mean flexion to extension arc was 97 ± 18°, 116 ± 19°, and 116 ± 19° at 1-, 3- and 6-month follow-ups, respectively. According to the MEPI, 20 patients achieved excellent results, seven patients achieved good results and one patient achieved a fair result at the last follow-up. The median Hand20 score was 4.3 (interquartile range: 2.1–14.0) at the 6-month follow-up.

Conclusions: The posterolateral plate and medial screw method showed good functional outcomes and few nerve-related complications. This modified method might be a better option for DHFs in elderly patients.

Level of Evidence: Level IV (Therapeutic)