|Year : 2013 | Volume
| Issue : 1 | Page : 95-105
Acute trauma to the upper extremity ( what to do and when to do it)
Jennifer M Wolf, George S Athwal, Alexander Y Shin, David G Dennison
|Date of Web Publication||19-Jul-2014|
Source of Support: None, Conflict of Interest: None
The management of acute trauma to the upper extremity includes the urgent treatment of injuries and the timing and choice of surgical stabilization and reconstruction. To evaluate and treat severe upper extremity trauma, the orthopedic surgeon should understand the principles of the emergency department and operating theater management of commonly seen traumatic injuries to the distal humerus, elbow, forearm, wrist, and hand. A review of the principles for treating these complex injuries, including principles of soft tissue coverage, will aid surgeons in achieving the goal of providing optimal treatment for their patients.
|How to cite this article:|
Wolf JM, Athwal GS, Shin AY, Dennison DG. Acute trauma to the upper extremity ( what to do and when to do it). Egypt Orthop J 2013;48:95-105
|How to cite this URL:|
Wolf JM, Athwal GS, Shin AY, Dennison DG. Acute trauma to the upper extremity ( what to do and when to do it). Egypt Orthop J [serial online] 2013 [cited 2017 Jun 23];48:95-105. Available from: http://www.eoj.eg.net/text.asp?2013/48/1/95/137111
| Introduction|| |
The management of any trauma patient begins with the standard trauma survey [ABODE: airway, breathing, and circulation, followed by evaluation of the disability (assessed using the Glasgow Coma Scale) and exposure for adequate examination while prevention of hypothermia is maintained]. The purpose of the primary survey is the control and stabilization of life-threatening injuries 1. The secondary trauma survey, consisting of a detailed examination of each body region for possible injury, is then conducted. Standard recommendations for identification of orthopedic injuries include plain radiographs of the injured region and the joints proximal and distal to it.
Debridement coupled with intravenous antibiotics and administration of tetanus toxoid is the most important initial treatment of severe open injuries. Debridement includes copious irrigation and removal of skin, subcutaneous tissue, muscle, fascia, and bone. It should be completed with careful inspection of the entire wound and the medullary canals and an evaluation of muscle viability. In severe situations, such as forearm and wrist amputations, skeletal shortening may facilitate revascularization or replantation.
| Acute trauma to the humerus and elbow|| |
Humeral shaft fractures
Fractures of the humeral shaft account for 1–3% of all fractures 2. Indications for surgical treatment of such fractures include polytrauma, vascular injuries requiring surgery, open or segmental fractures, bilateral humeral fractures, floating elbow injuries, and most pathological fractures. Methods of fixation include plate osteosynthesis, intramedullary nailing, and external fixation. The management of open fractures of the humeral shaft is similar to that of open fractures of other long bones. Prompt surgical debridement, irrigation, intravenous antibiotics, and stabilization are the mainstay. There is controversy about the ideal form of fixation, with advocates of plate fixation and of intramedullary nailing 3–6.
Open reduction and internal fixation is the most acceptable form of surgical treatment. The surgical approach can be anterior, posterior, lateral, or medial. The anterior approach to the humerus is useful for the treatment of fractures of the proximal third of the humeral shaft, as well as for polytraumatized patients, because it is extensile and allows supine patient positioning for concurrent procedures with good access to the airway. The disadvantages of the anterior approach include limited access to the radial nerve if microscopic repair is required and difficult access to the distal part of the humerus. The posterior approach described by Gerwin et al. 7 allows good access to the middle and distal parts of the humerus with nearly full exposure of the radial nerve [Figure 1]. The limitations include the need for the lateral decubitus position and limited access to the humeral head and neck. In general, open reduction and internal fixation should be performed with a broad 4.5-mm dynamic compression plate with engagement of a minimum of six cortices, and ideally eight cortices, both proximal and distal to the fracture site.
|Figure 1. (a) An anteroposterior radiograph of a 45-year-old man who fell off a ladder and sustained a midshaft humeral fracture in association with a distal humeral intra-articular fracture. (b–d) A paratricipital approach extended to a posterior Gerwin approach allowed fixation of the distal humeral fracture with orthogonal 3.5-mm limited-contact dynamic compression plates and fixation of the humeral shaft with a 4.5-mm plate.|
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Intramedullary nail fixation is also a viable option for treating acute humeral shaft fractures. The nail can be inserted antegrade through the proximal part of the humerus or retrograde through the apex of the olecranon fossa. Indications include burns, soft tissue compromise, highly comminuted fractures, obesity, and pathological fractures. The complication rate associated with intramedullary nails is slightly higher than that associated with plate osteosynthesis. These complications include nonunion, shoulder pain (after antegrade insertion), radial nerve injury, elbow stiffness (after retrograde insertion), and heterotopic ossification.
External fixation is not generally recommended as definitive treatment and is usually reserved for severely contaminated wounds or wounds with excessive soft tissue loss 8,9. External fixation may be used to stabilize a humeral fracture rapidly, if required for vascular repair. The insertion of distal half pins should be carried out through a mini-open approach to protect the radial nerve against injury.
Concurrent injury to the radial nerve is frequently associated with humeral shaft fractures. The reported prevalence ranges between 2 and 17%, and management is controversial 2,10–14. In general, when there is no indication for surgical intervention, the patient can be observed, with an expectation that more than 70% of radial nerve injuries will resolve. When there is an indication for surgical fixation of the humeral fracture, nerve exploration should be carried out in association with open reduction and internal fixation. When a patient can tolerate a lateral decubitus position, the posterior approach to the humerus and radial nerve, as described by Gerwin et al. 7, should be used. When there is a high risk of a nerve transection, such as in a patient with penetrating injuries or severe soft tissue loss, early nerve exploration is recommended. If the nerve is transected, a primary microscopic repair should be performed. When there is loss of a nerve segment, the humerus can be shortened for primary nerve repair. If the nerve is deemed irreparable, the ends should be tagged so that they can be found if nerve grafting is performed later.
Distal humeral fractures
Distal humeral fractures remain one of the most challenging injuries to manage because they are commonly multifragmented, occur in osteopenic bones, and have a complex anatomy with limited options for internal fixation. In younger adults, these fractures are usually caused by higher-energy mechanisms. Although standard radiographs of the elbow are usually sufficient for diagnosis, a computed tomography (CT) with three-dimensional reconstructions improves the identification and visualization of fracture fragments.
Several surgical approaches have been described for exposure and fixation of distal humeral fractures. The available types of posterior approaches include olecranon osteotomy 15–17 and the paratricipital (triceps-on), triceps-splitting, triceps-reflecting, and triceps-dividing approaches 18–23. The selection of the approach depends on how much articular visualization is required, the bone quality, the demand level of the patient, associated injuries such as triceps laceration, and whether the intraoperative decision is to proceed with arthroplasty as opposed to fixation.
Anatomical reduction and rigid internal fixation of displaced intra-articular distal humeral fractures provides stability for early range of motion. Patients who are medically fit and whose soft tissues are healthy may have surgery within 48–72 h after the injury 24. A closed distal humeral fracture in a multiply injured patient is splinted and treated after primary stabilization. Most surgeons prefer to perform definitive fixation within 2 or 3 weeks, but there are no data supporting this recommendation. When open reduction and internal fixation cannot be performed for several weeks, external fixation is recommended to stabilize the extremity to improve pain control and facilitate transfers, hygiene, and wound care. External fixator pins should be placed as far as possible from the planned internal fixation site to decrease the likelihood of infection.
Rigid fixation is obtained with orthogonal, parallel, or triple plates [Figure 2] 25–28. Under usual circumstances, devascularized bone is debrided, but large segments that include articular cartilage are not necessarily removed. The risk of infection associated with retention of the fragments must be weighed against the risk of post-traumatic arthritis, and all attempts should be made to preserve the articular cartilage.
|Figure 2. Parallel plate fixation of an intra-articular distal humeral fracture through an olecranon osteotomy. Preoperative (a) and postoperative (b) radiographs.|
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Rigid fixation of the distal humeral fracture may not be possible in elderly patients with osteopenia, comminution, and/or articular fragmentation or in patients with a pre-existing elbow disorder such as rheumatoid arthritis. In these situations, total elbow arthroplasty is a viable treatment option 29–33.
Fracture-dislocations of the elbow
Fracture-dislocations of the elbow remain one of the most difficult and technically complex injuries to manage. These are loosely classified into three broad categories: terrible triad, Monteggia, and varus posteromedial injuries. The primary goal in managing these injuries is to stabilize the elbow to allow early motion. Failure to recognize complex elbow instability or to adequately stabilize the elbow leads to chronic instability, accelerated post-traumatic arthritis, or stiffness 34–41.
The ulnohumeral joint, the anterior bundle of the medial collateral ligament, and the lateral ulnar collateral ligament are the primary stabilizers of the elbow. The secondary stabilizers include the radial head, the joint capsule, and the common flexor and extensor origins. Imaging should include anteroposterior and lateral radiographs with CT to better identify fracture patterns, comminution, and displacement. The initial management of an elbow fracture-dislocation is closed reduction; this reduces pain and soft tissue swelling and allows more accurate radiographical interpretation. After the reduction, a repeat neurological and vascular examination is documented. The management of open elbow fracture-dislocations is similar to that of open distal humeral fractures. The definitive surgical management of terrible triad, Monteggia, and varus posteromedial injuries varies. Most elbow fracture-dislocations require surgical management. When a patient has multiple traumatic injuries that include a closed elbow fracture-dislocation, the elbow fracture-dislocation should be reduced provisionally, followed serially to ensure continued alignment, and treated after the patient’s condition has stabilized. When definitive stabilization will be delayed for several weeks, static external fixation is recommended if the elbow displays instability.
Surgical management of an elbow dislocation with associated fractures of the radial head and coronoid, the so-called terrible triad, requires fixation of the osseous structures and repair of the ligaments. Fractures of the radial head should be internally fixed or the head should be replaced, depending on the specific characteristics of the fragments. All coronoid fractures, other than small tip fragments, require open reduction and internal fixation or suture fixation if they are comminuted. After osseous stability is achieved, the lateral ulnar collateral ligament is repaired, and the elbow is examined for stability. If the elbow remains unstable, the anterior bundle of the medial collateral ligament is repaired. In the exceedingly rare circumstance that the elbow remains unstable after anatomical open reduction and internal fixation and ligament repair, a temporary dynamic or static external fixator may be used.
The ulnar fracture of the Monteggia injury is treated with rigid open reduction and internal fixation, which usually stabilizes the radiocapitellar joint. When there is a fracture of the radial head, it is treated with open reduction and internal fixation, radial head arthroplasty, or partial excision, depending on the characteristics of the fracture. If there is a coronoid fracture, anatomical and rigid fixation is required to recreate the anterior buttress of the ulnohumeral joint.
Varus posteromedial instability is caused by a coronoid fracture with an avulsion of the lateral collateral ligament. Repair of these injuries usually requires both a medial and a lateral approach to the elbow: a posterior skin incision can be used to achieve both medial and lateral exposure. The medial approach is used to repair a fracture that involves the anteromedial aspect of the coronoid, and the lateral approach is used to repair the lateral collateral ligament.
| Acute trauma to the forearm, distal part of the radius, and distal radioulnar joint|| |
Adult forearm fractures
Adult forearm fractures include a fracture of the radius or ulna alone or a fracture of both these bones. The accepted treatment of fracture-dislocations such as a Monteggia fracture-dislocation (fracture of the ulna and dislocation of the radial head) and a Galeazzi fracture-dislocation (fracture of the radius and dislocation of the distal radioulnar joint) is open reduction and internal fixation 42–46. Nonsurgical treatment is rare, but it can be used for a closed, minimally displaced (middle-to-distal) ulnar shaft fracture 47,48.
As is the case for all fractures, treatment of forearm fractures includes management of the soft tissue injury and restoration of skeletal alignment. If there is an open wound after debridement, open reduction and internal fixation of the radius and ulna is performed either through the traumatic wound or through a separate incision. A separate exposure for each bone is recommended to minimize the risk of radioulnar synostosis 49,50. External fixation should be considered when the wound is contaminated or the soft tissue injury is extensive [Figure 3]. When there is an arterial injury with ischemia, stabilization (ideally definitive fixation) should be performed quickly, with temporary arterial shunting used to perfuse the distal part of the limb if necessary.
|Figure 3. (a) A radiograph of open radial and ulnar fractures with ischemia and severe soft tissue injury. (b) Debridement of the injury. (c) Provisional external fixation to allow revascularization.|
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The volar (Henry) approach is used to expose the flat surface of the radius 51. The dorsal Thompson approach allows exposure but is associated with a risk of injury to the posterior interosseous nerve 52. The ulna is exposed through the interval between the extensor carpi ulnaris and the flexor carpi ulnaris. Attention to the radial length and radial bow (which should be ∼12°) and the proximal ulnar varus bow (which should be ∼9°) and ulnar variance is key 53. Rotational malalignment is avoided by reduction and provisional fixation, followed by an examination of the forearm rotation 53–55. Open reduction and internal fixation with a 3.5-mm limited-contact dynamic compression plate provides balanced fixation with compression across the fracture with three bicortical screws on either side of the fracture. Locking plate fixation is recommended for osteoporotic bones, periarticular fractures, and fractures with segmental bone loss. Malleable reconstruction plates and partial tubular plates should not be used for diaphyseal forearm fractures because they routinely fail and break. The bones with the more easily reduced fractures should be reduced and fixed first. This makes the complex fracture easier to reduce. Radiographs of the contralateral extremity may provide a helpful ‘intact’ template for reference when one is dealing with severely comminuted fractures.
When a patient has a distal radial or ulnar shaft fracture, stable fixation of the smaller periarticular fragments may be obtained with the use of locking plates, nonlocked minifragment (2.7-mm) plates, or combination plates. Segmental fractures and comminution may be managed with bridge plate or locking plate techniques. Segmental fractures may be treated with two plates placed at 90° to one another, ideally with the plates overlapping by a minimum of two screw holes, with interdigitating screws.
When an incision is not prudent, particularly at the distal diaphyseal (or metaphyseal–diaphyseal) area of the ulna, percutaneous intramedullary fixation is considered to provide stability with minimal dissection of the soft tissues 56. Finally, external fixation may be used temporarily, or definitively, when needed for a severely contaminated wound 57,58.
Bone defects may be treated using a cancellous or corticocancellous iliac crest bone graft alone if they are less than 6 cm in length and are located within a vascularized and clean wound 17,59. Larger defects should be filled with autogenous or allogenic cancellous bone grafts. When the soft tissues are compromised, as a result of trauma, prior irradiation, or infection, a vascularized cortical graft is preferred 60. Acute bone grafting of simple or comminuted fractures remains controversial because it has not been shown to increase the rate of union 44,61. Delayed grafting is preferable if the soft tissues are compromised. Space for a subsequent graft may be maintained by using antibiotic-impregnated bone cement 62. Synostosis is a risk after the bone graft is used, and the graft needs to be kept away from the interosseous membrane to reduce this risk. When the injury is severe because of ischemia or crush, particularly with a segmental injury about the wrist, forearm, or elbow, amputation should be considered. Replantation or revascularization can often be performed but may not be appropriate if there is poor myotendinous function, joint contractures, or an insensate extremity. When a forearm-level amputation is necessary, every attempt should be made to preserve the elbow joint and sufficient forearm length and tissue to facilitate the use of prosthesis.
Distal radioulnar joint
Stability of the distal radioulnar joint results from osseous, ligamentous (dorsal and volar radioulnar ligaments), and capsular constraints 63–69. When the patient has a fracture with an associated distal radioulnar joint injury, the radius and/or ulna are stabilized first, then the distal radioulnar joint is evaluated 46,70. When the distal radioulnar joint is reduced and stable, it is treated with a splint, with the forearm in either neutral rotation or in supination. When the distal radioulnar joint is unstable, several types of treatments have been recommended 46,71–73. These include fixation with two 0.062-inch (0.16-cm) Kirschner wires placed just proximal to the distal radioulnar joint across all four cortices (to facilitate removal if they break), external fixation cross-bridging the radius and ulna, or suture repair of the foveal insertion of the distal radioulnar ligaments 74.
Ulnar styloid fixation and foveal repair may be completed at the same time through an ulnar incision using a Kirschner wire and tension band, cannulated screws, or a simple suture technique. In general, ulnar styloid fractures do not require fixation unless the distal radioulnar joint is unstable 75,76. When the distal radioulnar joint is unstable in the setting of an intra-articular distal radial fracture, the volar and dorsal lunate facet fragments must be reduced because they are attached to the radioulnar ligaments. The most common reason why the distal radioulnar joint cannot be reduced (provided that the radial fracture is reduced) is entrapment of the extensor carpi ulnaris, the triangular fibrocartilage complex, the extensor tendons, and the ulnar styloid 77–81.
High-energy distal radial fractures
High-energy distal radial fractures include extra-articular and intra-articular fractures caused by impaction, shearing, or bending loads. Although, in the past, shortening of up to 5 mm and articular displacement of up to 2 mm have been accepted in the alignment of distal radial fractures, Ruch 82 recommended a more anatomical goal for young, active adults, with an articular step-off of less than 2 mm, radial shortening of less than 2–3 mm, and neutral tilt. CT imaging of intra-articular fractures provides a better understanding of fragment size and position to aid in treatment decisions.
There are several options for stabilizing these fractures, but there are insufficient data to indicate that one type of fixation is superior. Combined external fixation and percutaneous pin fixation has advantages, but its precise role is not clear. Associated complications include pin site infection, complex regional pain syndrome, stiffness, and malunion 83–89. The best anatomical results are possible with open reduction and internal fixation, and an early return to function may follow 90. The current trend of volar plate fixation (with distal locking screws or pegs) is supported by numerous reports of good outcomes, but most studies have not substantiated if the overall long-term function is improved 91–95. Complications include flexor and extensor tendon ruptures and subchondral screw penetration 91,95. Dorsal plates are quite stable but their use is associated with many complications 96. Fragment-specific fixation with the use of separate pin–plate constructs for the volar, radial, and dorsal aspects of the fracture are powerful tools for reduction and stabilization. Finally, combinations of these techniques based on the fracture type and comminution may be required. Volar plates take advantage of an anatomical recess at the pronator quadratus fossa for plate placement, minimizing the approach to the area of comminution dorsally 92,93. During the reduction of these displaced fractures, the brachioradialis tendon may be released through the flexor carpi radialis approach 94, which removes a deforming force and thus improves the reduction. Reduction of intra-articular fractures proceeds with reduction of the volar ulnar cortex, and then the dorsal lunate facet and the radial styloid. Subchondral Kirschner wires may be placed through Kirschner wire holes in the plate to maintain the reduction. They are later replaced with locking pegs to secure the articular reduction. Limitations of this approach include an inability to visualize the interosseous ligament injuries and articular surfaces. Distal and ulnar fracture fragments are also difficult to stabilize because the plate and peg construct does not support or penetrate these small fragments. The volar marginal fracture occurs at the volar ulnar aspect of the distal part of the radius. It is important to identify and treat this intra-articular fracture because the radiocarpal ligaments are attached to the fragment, and the lunate will subluxate or dislocate volarly if the fracture is displaced 97. Fragment-specific fixation works well for these relatively small fragments, as do Kirschner wire fixation and tension band techniques 98,99. Severely comminuted fractures or those with volar and dorsal comminution may require adjunctive external fixation.
When an unstable distal ulnar fracture accompanies a distal radial fracture and remains unstable after fixation of the distal part of the radius, the ulnar fracture should be stabilized with a condylar blade plate or a locking plate 17,100. For severely comminuted and unstable distal radial fractures (especially those associated with multiple trauma), a 3.5-mm distraction plate may be used as an ‘internal external fixator’ to stabilize the wrist with a temporary ‘wrist fusion’; this plate, spanning from the radius to the long finger metacarpal, is used to distract the severely injured and comminuted metaphyseal–diaphyseal area of the radius 101. The plate is removed after fracture healing, or at ∼12–16 weeks.
Distal radial fractures and soft tissue injuries may be so severe that acute salvage with a wrist arthrodesis or arthroplasty may be the best treatment 102. Kafury et al. 103 and Richards and Roth 104 recommended that proximal row carpectomy, with provision of bone graft, decompression of the ulnocarpal joint, and shortening, be used to facilitate fusion in patients with severe injuries, such as those involving tendon, nerve, or arterial injury.
| Acute trauma to the wrist and hand perilunate dislocations and acute carpal tunnel syndrome|| |
Perilunate fracture-dislocations are generally caused by a high-energy injury 105. However, there is a subset of these injuries that involves primarily ligamentous disruption, which is often missed without a high index of suspicion 106. Perilunate dislocations usually involve a combination of osseous and soft tissue injuries, with subtypes rated using the Mayfield classification 107. Perilunate injury follows a predictable pattern, beginning on the radial side of the wrist with either the scaphoid or the scapholunate ligament, proceeding in an ulnar direction through either the carpal bones or the intercarpal ligaments, and culminating with Mayfield stage IV (complete volar dislocation of the lunate).
A perilunate fracture-dislocation requires urgent reduction, either open or closed, because of the risk of acute carpal tunnel syndrome. Reduction of the dislocation relieves pain and allows a more accurate radiographical assessment. Reduction is usually obtained in the emergency department with the use of finger traps, with 10 Ib (4.5 kg) of traction applied for 10–15 min. The authors of this chapter recommend this type of reduction even for an open injury, unless the patient can be taken to the operating room urgently. The wrist is gently dorsiflexed while the physician’s thumb maintains pressure on the lunate. Volar flexion should then allow the capitate to be reduced onto the lunate, and a palpable clunk should be felt with reduction. If the lunate is dislocated, it must first be reduced back onto the radius before the intercarpal reduction is performed 107.
Acute carpal tunnel syndrome is a substantial risk, particularly in a patient with a volar dislocated lunate type of perilunate injury in whom carpal tunnel compression is caused by direct pressure on the nerve. Fractures of the distal part of the radius are the most common cause of acute carpal tunnel syndrome, and differentiating median nerve contusion from acute carpal tunnel syndrome is critical when deciding whether acute carpal tunnel release in a patient with a traumatic injury to the wrist is necessary. A patient with a median nerve contusion generally develops nonprogressive sensory changes immediately after the injury, whereas the sensory changes in a patient with acute carpal tunnel syndrome develop later and are associated with worsening pain 108,109. Although Semmes–Weinstein monofilament tests and measurements of intracarpal canal pressure can be used to diagnose acute carpal tunnel syndrome, the diagnosis is usually based on the history. When an acute carpal tunnel syndrome is diagnosed, immediate surgical release of the transverse carpal ligament is indicated, with an extensile volar incision crossing the wrist crease, allowing full visualization of the nerve during decompression 108.
If a perilunate fracture-dislocation is associated with acute carpal tunnel syndrome, decompression of the carpal canal is the first surgical priority and should be performed urgently. Definitive stabilization of the perilunate injury can be performed at the same time, or provisional pinning can be performed with surgery planned later (optimally within 3–5 days) for definitive stabilization. Definitive surgery for a perilunate injury includes fixation of the scaphoid and other carpal bones if necessary, fixation of the radial styloid if indicated, and ligament repair. Some advocate a single dorsal approach for definitive treatment, with repair of the scapholunate ligament, the lunotriquetral ligament, and the torn dorsal capsular ligaments 110,111. Others recommend a combined dorsal and volar approach to directly repair the stout volar ligaments 106,112–114. Perilunate injuries represent substantial trauma to the articular cartilage of the carpus and wrist, and sequelae of stiffness and subsequent arthritic changes are not uncommon 112,115.
| Radiocarpal dislocation|| |
Another type of high-energy injury is dislocation of the radiocarpal joint, which is mainly a ligamentous injury. Commonly, this is a dorsal dislocation, usually with avulsion of the cortical margin of the distal part of the radius 116–118. Moneim et al. 119 classified these injuries on the basis of the presence or absence of intercarpal instability, whereas Dumontier and associates 117 subdivided radiocarpal dislocations on the basis of the size of the associated radial styloid fracture.
Initially, these injuries can be treated with closed reduction and splinting. Six of the 12 patients in the study by Mudgal et al. 118 had sensory impairment at presentation, and these resolved after reduction. Radiocarpal dislocations are often open and require acute stabilization but even a closed injury should be stabilized within 7 days. The radial styloid fracture is reduced and fixed. Mudgal et al. 118 treated their patients with an elevation of the articular rim fragments, a bone graft to fill any defect, a buttress plate fixation in some cases, repair of the ulnar styloid, suture repair of the palmar radiocarpal capsule, and scapholunate repair, as needed.
| High-energy axial carpal, carpometacarpal, and metacarpophalangeal joint fracture-dislocations|| |
Severe traumatic injuries to the carpus and hand involve both soft tissue and bone. One of the most dramatic of these injuries is axial carpal dislocation, which is caused by a force of injury transmitted through the hand, splitting it into the radial and ulnar columns 120. Treatment of this type of ‘exploded hand’ often requires several surgeries, with initial debridement of open wounds and provisional pinning of the carpus and metacarpals. An external fixator placed across the wrist can be used if needed to obtain stability. This is followed by repair of the fractures; reconstruction of the intercarpal and intermetacarpal ligaments, with supportive pinning, and soft tissue reconstruction 121.
Injuries of the carpometacarpal joints are divided into two groups: those of the thumb carpometacarpal joint and those of the other carpometacarpal joints. An isolated thumb carpometacarpal joint dislocation without a fracture is rare and generally is caused by a high-energy injury or occurs in an individual with hyperlaxity. When this injury is acute, it can be reduced and then temporarily held in a splint, but it often requires the reconstruction of the anterior oblique ligament as described by Eaton and Littler to achieve definitive stability 122,123. A Bennett-type fracture-dislocation of the thumb carpometacarpal joint is more common and can be treated with closed methods, if it is minimally displaced, percutaneous Kirschner wire pinning, or miniscrews to fix the metacarpal shaft to the volar ulnar fragment 124.
Injuries to the other carpometacarpal joints of the hand are most common at the bases of the fourth and fifth metacarpals as these joints are less intrinsically stable compared with the second and third carpometacarpal joints. Dislocations are usually dorsal and are sometimes associated with fractures of the articular base of the metacarpal. These dislocations are easily missed on standard radiographs, especially when there is a small amount of subluxation. A pronated oblique radiograph of the hand should be obtained if an ulnar-sided hand injury is suspected. When acute, these injuries can be reduced and splinted and then treated within 7–10 days with percutaneous Kirschner wire fixation or application of small screws and plates as needed 125,126.
Metacarpophalangeal joint dislocations are seen after high-energy injuries and often occur in the index finger. A single attempt at a closed reduction is recommended, but these injuries are often irreducible and generally require open reduction. Closed manipulation is performed with the wrist flexed to relax the flexor tendons. The metacarpophalangeal joint is then flexed, whereas the proximal phalanx is pushed dorsally. Metacarpophalangeal joint dislocations are frequently irreducible because of interposition of the volar plate between the proximal phalanx and the metacarpal head, and open reduction is performed through a dorsal incision, with incision of the extensor hood and capsule to expose the volar plate tented over the metacarpal head. The volar plate is released, and the joint is then reduced. The fractures are fixed as needed. Approximately 50% of these injuries are associated with an osteoarticular fracture fragment 127.
| Management of soft tissue injuries of the upper extremity|| |
The spectrum of traumatic soft tissue injuries of the upper extremity is vast, ranging from closed soft tissue injuries (such as compartment syndrome) to composite soft tissue and bone loss (amputations and segmental defects) to soft tissue loss alone (degloving and avulsion-type injuries). Discussion of the management of every type of soft tissue injury of the upper extremity is nearly impossible because of the tremendous variations in the types of injuries, the varying degrees of energy imparted to the injured arm, and the numerous mechanisms of injury. However, a key understanding of the principles of treatment of soft tissue injuries can guide a surgeon in choosing the optimal treatment of such injuries of the upper extremity. An outline of the eight basic principles of soft tissue reconstruction that can be applied to upper extremity injuries follows.
Principle 1: prevent further injury
Further injury to the upper extremity must be prevented. After determining the mechanism of injury, it is necessary to ascertain whether compartment syndrome may be an issue or whether a chemical burn must be neutralized 128. Treating burns or frostbite injuries may be necessary.
Principle 2: achieve adequate debridement
An aggressive tumor-like debridement of all necrotic and nonviable tissue, including bone, is essential 129. This is often considered the most important single step in the management of soft tissue injuries related to trauma. Appropriate cultures of contaminated tissue should be performed to guide the antibiotic treatment. Reconstructive plans should not impede an adequate soft tissue debridement. Repeat debridements should be performed every 24–48 h, as dictated by the wound and the patient’s medical status.
Principle 3: stabilize bone
Once adequate debridement of soft tissue and bone has been accomplished, bone stability should be achieved. This can be performed using external fixation or internal fixation, or both. External fixation is often preferred for highly contaminated wounds or wounds that have poor soft tissue coverage. Internal fixation can be used for adequately debrided wounds that have good soft tissue coverage of bone.
Principle 4: achieve soft tissue coverage
When soft tissue coverage is needed, acute coverage should be considered. Levin’s reconstructive ladder identifies the simplest type of soft tissue reconstruction procedure needed to cover a wound, with the procedures increasing in complexity as needed 130,131. At the lowest level of the reconstructive ladder is healing by secondary intention, whereas free tissue transfer is at the highest level [Figure 4]. When the wound is evaluated to determine the possible options for coverage, it is imperative to consider patient factors; the genesis of the defect; the location, size, and depth of the defect; the exposed structures; the structures needing reconstruction; the degree of contamination; and the quality of the surrounding tissues. All of these factors play a role in the decision.
Godina 129 popularized the concept of covering wounds within 72 h. However, with advances in wound management with vacuum-assisted closure devices and antibiotic bead pouches, wound coverage can be performed more than 72 h after the injury without untoward complications 132.
Principle 5: determine possible secondary reconstructive procedures
It is necessary to determine what secondary reconstructions will be needed before the time of the soft tissue coverage and the initial reconstructive procedure. If nerve grafts will be needed, the vascular pedicle of the free flap should be placed as far away from the nerve graft sites as possible. If bone grafting (vascularized or conventional) or tendon procedures are to be performed, it must be decided how these will be accomplished so that the pedicle is properly placed.
Principle 6: consider composite soft tissue reconstruction
Composite soft tissue reconstruction should be considered when there is soft tissue loss [Figure 5]. A toe-to-thumb transfer is one such composite flap.
|Figure 5. A composite flap reconstruction of the dorsal part of the hand with a combination of the latissimus dorsi, the serratus anterior, and two ribs on a combined thoracodorsal pedicle. (a) The soft tissue and bone defect; (b) the free composite flap; (c) placement of the flap.|
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Principle 7: evaluate amputation versus limb salvage
An amputation may be better than limb salvage. This is especially true in patients requiring a high amputation in whom replantation is potentially associated with myoglobinuria, reperfusion injury, and systemic sequelae, all of which can place the patient at great risk. Although technically feasible, heroic efforts to reconstruct parts can lead to long recovery times with a prolonged loss of gainful employment and manifestation of psychological problems.
Principle 8: seek advice
One should not hesitate to get assistance and advice. This is the most humbling of the principles but can be one of the most important. Collaboration with other surgeons may be extremely helpful in difficult cases.
| Summary|| |
The treatment of severe upper extremity injuries begins with standard trauma algorithms and debridement of devitalized soft tissue. The timing of osseous stabilization varies and is dependent on the quality and integrity of the soft tissue envelope. A collaborative approach often represents the best care for the traumatized patient.
Conflicts of interest
Dr Wolf or an immediate family member serves as a board member, owner, officer, or committee member of the Rocky Mountain Hand Surgery Society. Dr Athwal or an immediate family member has received research or institutional support from Wright Medical Technology and Tornier. Dr Shin or an immediate family member has received, research or institutional support from the Mayo Foundation and Stryker. Dr Dennison or an immediate family member has received research or institutional support from Aircast-DJ Orthopedics and DePuy.
| References|| |
|1.||Thomson CB, Greaves I. Missed injury and the tertiary trauma survey. Injury. 2008;39:107–114 |
|2.||Ekholm R, Adami J, Tidermark J, Hansson K, Tornkvist H, Ponzer S. Fractures of the shaft of the humerus. An epidemiological study of 401 fractures. J Bone Joint Surg Br. 2006;88:1469–1473 |
|3.||Bell MJ, Beauchamp CG, Kellam JK, McMurtry RY. The results of plating humeral shaft fractures in patients with multiple injuries. The Sunnybrook experience. J Bone Joint Surg Br. 1985;67:293–296 |
|4.||Heim D, Herkert F, Hess P, Regazzoni P. Surgical treatment of humeral shaft fractures: the Basel experience. J Trauma. 1993;35:226–232 |
|5.||Schoots IG, Simons MP, Nork SE, Chapman JR, Henley MB. Antegrade locked nailing of open humeral shaft fractures. Orthopedics. 2007;30:49–54 |
|6.||Vander Griend R, Tomasin J, Ward EF. Open reduction and internal fixation of humeral shaft fractures. Results using AO plating techniques. J Bone Joint Surg Am. 1986;68:430–433 |
|7.||Gerwin M, Griffith A, Weiland AJ, Hotchkiss RN, McCormack RR. Ligament reconstruction basal joint arthroplasty without tendon interposition. Clin Orthop Relat Res. 1997;342:42–45 |
|8.||Marsh JL, Mahoney CR, Steinbronn D. External fixation of open humerus fractures. Iowa Orthop J. 1999;19:35–42 |
|9.||Mostafavi HR, Tornetta PIII. Open fractures of the humerus treated with external fixation. Clin Orthop Relat Res. 1997;337:187–197 |
|10.||Amillo S, Barrios RH, Martinez-Peric R, Losada JI. Surgical treatment of the radial nerve lesions associated with fractures of the humerus. J Orthop Trauma. 1993;7:211–215 |
|11.||DeFranco MJ, Lawton JN. Radial nerve injuries associated with humeral fractures. J Hand Surg Am. 2006;31:655–663 |
|12.||Holstein A, Lewis GM. Fractures of the humerus with radial-nerve paralysis. J Bone Joint Surg Am. 1963;45:1382–1388 |
|13.||Pollock FH, Drake D, Bovill EG, Day L, Trafton PG. Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am. 1981;63:239–243 |
|14.||Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005;87:1647–1652 |
|15.||Cassebaum WH. Open reduction of T & Y fractures of the lower end of the humerus. J Trauma. 1969;9:915–925 |
|16.||Gainor BJ, Moussa F, Schott T. Healing rate of transverse osteotomies of the olecranon used in reconstruction of distal humerus fractures. J South Orthop Assoc. 1995;4:263–268 |
|17.||Hewins EA, Gofton WT, Dubberly J, MacDermid JC, Faber KJ, King GJ. Plate fixation of olecranon osteotomies. J Orthop Trauma. 2007;21:58–62 |
|18.||Alonso-Llames M. Bilaterotricipital approach to the elbow. Its application in the osteosynthesis of supracondylar fractures of the humerus in children. Acta Orthop Scand. 1972;43:479–490 |
|19.||Schildhauer TA, Nork SE, Mills WJ, Henley MB. Extensor mechanism-sparing paratricipital posterior approach to the distal humerus. J Orthop Trauma. 2003;17:374–378 |
|20.||Campbell WC. Incision for exposure of the elbow joint. Am J Surg. 1932;15:65–67 |
|21.||Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin Orthop Relat Res. 1982;166:188–192 |
|22.||O’Driscoll SWMorrey BF. Elbow dislocations. The elbow and its disorders. 2000 Philadelphia, PA Saunders:409–420 |
|23.||Van Gorder GW. Surgical approach in supracondylar ‘T’ fractures of the humerus requiring open reduction. J Bone Joint Surg Am. 1940;22:278–292 |
|24.||Ilahi OA, Strausser DW, Gabel GT. Post-traumatic heterotopic ossification about the elbow. Orthopedics. 1998;21:265–268 |
|25.||Helfet DL, Schmeling GJ. Bicondylar intraarticular fractures of the distal humerus in adults. Clin Orthop Relat Res. 1993;292:26–36 |
|26.||Jupiter JB, Neff U, Holzach P, All-gower M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am. 1985;67:226–239 |
|27.||Self J, Viegas SF, Buford WL Jr, Patterson RM. A comparison of double-plate fixation methods for complex distal humerus fractures. J Shoulder Elbow Surg. 1995;4:10–16 |
|28.||Gofton WT, Macdermid JC, Patterson SD, Faber KJ, King GJ. Functional outcome of AO type C distal humeral fractures. J Hand Surg Am. 2003;28:294–308 |
|29.||Frankle MA, D Herscovici Jr, Di Pasquale TG, Vasey MB, Sanders RW. A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma. 2003;17:473–480 |
|30.||Kalogrianitis S, Sinopidis C, El Meligy M, Rawal A, Frostick SP. Unlinked elbow arthroplasty as primary treatment for fractures of the distal humerus. J Shoulder Elbow Surg. 2008;17:287–292 |
|31.||Kamineni S, Morrey BF. Distal humeral fractures treated with noncustom total elbow replacement. Surgical technique. J Bone Joint Surg Am. 2005;87:41–50 |
|32.||Morrey BF. Fractures of the distal humerus: role of elbow replacement. Orthop Clin North Am. 2000;31:145–154 |
|33.||Prasad N, Dent C. Outcome of total elbow replacement for distal humeral fractures in the elderly: a comparison of primary surgery and surgery after failed internal fixation or conservative treatment. J Bone Joint Surg Br. 2008;90:343–348 |
|34.||Beingessner DM, Stacpoole RA, Dunning CE, Johnson JA, King GJ. The effect of suture fixation of type I coronoid fractures on the kinematics and stability of the elbow with and without medial collateral ligament repair. J Shoulder Elbow Surg. 2007;16:213–217 |
|35.||Closkey RF, Goode JR, Kirschenbaum D, Cody RP. The role of the coronoid process in elbow stability. A biomechanical analysis of axial loading. J Bone Joint Surg Am. 2000;82:1749–1753 |
|36.||McKee MD, Pugh DM, Wild LM, Schemitsch EH, King GJ. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Surgical technique. J Bone Joint Surg Am. 2005;87:22–32 |
|37.||Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am. 2004;86:1122–1130 |
|38.||Ring D. Fractures of the coronoid process of the ulna. J Hand Surg Am. 2006;31:1679–1689 |
|39.||Ring D, Doornberg JN. Fracture of the anteromedial facet of the coronoid process. Surgical technique. J Bone Joint Surg Am. 2007;89:267–283 |
|40.||Ring D, Jupiter JB, Simpson NS. Monteggia fractures in adults. J Bone Joint Surg Am. 1998;80:1733–1744 |
|41.||Sotereanos DG, Darlis NA, Wright TW, Goitz RJ, King GJ. Unstable fracture-dislocations of the elbow. Instr Course Lect. 2007;56:369–376 |
|42.||Sauter SL, Chapman LJ, Knutson SJ, Anderson HA. Case example of wrist trauma in keyboard use. Appl Ergon. 1987;18:183–186 |
|43.||Wilson FC, Dirschl DR, Bynum DK. Fractures of the radius and ulna in adults: an analysis of factors affecting outcome. Iowa Orthop J. 1997;17:14–19 |
|44.||Wright RR, Schmeling GJ, Schwab JP. The necessity of acute bone grafting in diaphyseal forearm fractures: a retrospective review. J Orthop Trauma. 1997;11:288–294 |
|45.||Moed BR, Kellam JF, Foster RJ, Tile M, Hansen ST Jr. Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am. 1986;68:1008–1017 |
|46.||Mikic Z. The blood supply of the human distal radioulnar joint and the microvasculature of its articular disk. Clin Orthop Relat Res. 1992;275:19–28 |
|47.||Szabo RM, Skinner M. Isolated ulnar shaft fractures. Retrospective study of 46 cases. Acta Orthop Scand. 1990;61:350–352 |
|48.||Sarmiento A, Latta LL, Zych G, Mc-Keever P, Zagorski JP. Isolated ulnar shaft fractures treated with functional braces. J Orthop Trauma. 1998;12:420–424 |
|49.||Bauer G, Worsdorfer O, Braun K. Radio-ulnar bridge callus following osteosynthesis of forearm fractures. Aktuelle Traumatol. 1990;20:194–198 |
|50.||Stern PJ, Drury WJ. Complications of plate fixation of forearm fractures. Clin Orthop Relat Res. 1983;175:25–29 |
|51.||Henry AK Extensile exposure. 1973 Edinburgh, UK Churchill Livingstone |
|52.||Spinner RJ, Berger RA, Carmichael SW, Dyck PJ, Nunley JA. Isolated paralysis of the extensor digitorum communis associated with the posterior (Thompson) approach to the proximal radius. J Hand Surg Am. 1998;23:135–141 |
|53.||Yasutomi T, Nakatsuchi Y, Koike H, Uchiyama S. Mechanism of limitation of pronation/supination of the forearm in geometric models of deformities of the forearm bones. Clin Biomech (Bristol, Avon). 2002;17:456–463 |
|54.||Dumont CE, Thalmann R, Macy JC. The effect of rotational malunion of the radius and the ulna on supination and pronation. J Bone Joint Surg Br. 2002;84:1070–1074 |
|55.||Tynan MC, Fornalski S, McMahon PJ, Utkan A, Green SA, Lee TQ. The effects of ulnar axial malalignment on supination and pronation. J Bone Joint Surg Am. 2000;82:1726–1731 |
|56.||Walz M, Kolbow B, Mollenhoff G. Fracture of the distal ulna accompanying fractures of the distal radius. Minimally invasive treatment with elastic stable intramedullary nailing (ESIN). Unfallchirurg. 2006;109:1058–1063 |
|57.||Jackson RP, Jacobs RR, Neff JR. External skeletal fixation in severe limb trauma. J Trauma. 1978;18:201–205 |
|58.||Putnam MD, Walsh TMIV. External fixation for open fractures of the upper extremity. Hand Clin. 1993;9:613–623 |
|59.||Barbieri PG, Colombini D, Occhipinti E, Vigasio A, Poli R. Epidemics of musculotendinous pathologies of the upper limbs (cumulative trauma disorders) in a group of assembly line workers. Med Lav. 1993;84:487–500 |
|60.||Ring D, Jupiter JB, Brennwald J, Buchler U, Hastings H II. Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg Am. 1997;22:777–784 |
|61.||Ring D, Rhim R, Carpenter C, Jupiter JB. Comminuted diaphyseal fractures of the radius and ulna: does bone grafting affect nonunion rate? J Trauma. 2005;59:438–442 |
|62.||Georgiadis GM, DeSilva SP. Reconstruction of skeletal defects in the forearm after trauma: treatment with cement spacer and delayed cancellous bone grafting. J Trauma. 1995;38:910–914 |
|63.||Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res. 1984;187:26–35 |
|64.||Tay SC, Berger RA, Tomita K, Tan ETKK, Amrami KK, An KN. In vivo three-dimensional displacement of the distal radioulnar joint during resisted forearm rotation. J Hand Surg Am. 2007;32:450–458 |
|65.||Haugstvedt JR, Berger RA, Nakamura T, Neale P, Berglund L, An KN. Relative contributions of the ulnar attachments of the triangular fibrocartilage complex to the dynamic stability of the distal radioulnar joint. J Hand Surg Am. 2006;31:445–451 |
|66.||Watanabe H, Berger RA, An KN, Berglund LJ, Zobitz ME. Stability of the distal radioulnar joint contributed by the joint capsule. J Hand Surg Am. 2004;29:1114–1120 |
|67.||Stuart PR, Berger RA, Linscheid RL, An KN. The dorsopalmar stability of the distal radioulnar joint. J Hand Surg Am. 2000;25:689–699 |
|68.||Palmer AK. The distal radioulnar joint. Orthop Clin North Am. 1984;15:321–335 |
|69.||Palmer AK. The distal radioulnar joint. Anatomy, biomechanics, and triangular fibrocartilage complex abnormalities. Hand Clin. 1987;3:31–40 |
|70.||Rettig ME, Raskin KB. Galeazzi fracture-dislocation: a new treatment-oriented classification. J Hand Surg Am. 2001;26:228–235 |
|71.||Nicolaidis SC, Hildreth DH, Lichtman DM. Acute injuries of the distal radioulnar joint. Hand Clin. 2000;16:449–459 |
|72.||Cheng SL, Axelrod TS. Management of complex dislocations of the distal radioulnar joint. Clin Orthop Relat Res. 1997;341:183–191 |
|73.||Giannoulis FS, Sotereanos DG. Galeazzi fractures and dislocations. Hand Clin. 2007;23:153–163 |
|74.||Mestdagh H, Duquennoy A, Letendart J, Sensey JJ, Fontaine C. Long-term results in the treatment of fracture-dislocations of Galeazzi in adults. Report on twenty-nine cases. Ann Chir Main. 1983;2:125–133 |
|75.||Lindau T, Adlercreutz C, Aspenberg P. Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radial fractures. J Hand Surg Am. 2000;25:464–468 |
|76.||Nakamura R, Horii E, Imaeda T, Nakao E, Shionoya K, Kato H. Ulnar styloid malunion with dislocation of the distal radioulnar joint. J Hand Surg Br. 1998;23:173–175 |
|77.||Bruckner JD, Lichtman DM, Alexander AH. Complex dislocations of the distal radioulnar joint. Recognition and management. Clin Orthop Relat Res. 1992;275:90–103 |
|78.||Paley D, Rubenstein J, McMurtry RY. Irreducible dislocation of distal radial ulnar joint. Orthop Rev. 1986;15:228–231 |
|79.||Kikuchi Y, Nakamura T. Irreducible Galeazzi fracture-dislocation due to an avulsion fracture of the fovea of the ulna. J Hand Surg Br. 1999;24:379–381 |
|80.||Jenkins SA. Osteoarthritis of the pisiform-triquetral joint: report of three cases. J Bone Joint Surg Br. 1951;33:532–534 |
|81.||Alexander AH, Lichtman DM. Irreducible distal radioulnar joint occurring in a Galeazzi fracture: case report. J Hand Surg Am. 1981;6:258–261 |
|82.||Ruch DSBucholz RW, Heckman JD, Court-Brown C. Fractures of the distal radius and ulna. Rockwood and Green’s fractures in adults. 20066 ed. Philadelphia, PA Lippincott Williams and Wilkins:909–964 |
|83.||Handoll HH, Huntley JS, Madhok R. External fixation versus conservative treatment for distal radial fractures in adults. Cochrane Database Syst Rev. 2007 3:CD006194 |
|84.||Handoll HH, Huntley JS, Madhok R. Different methods of external fixation for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2008;1:CD006522 |
|85.||Handoll HH, Madhok R. Surgical interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003;3:CD003209 |
|86.||Handoll HH, Vaghela MV, Madhok R. Percutaneous pinning for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2007;3:CD006080 |
|87.||Chiou-Tan FY, Reno SB, Magee KN, Krouskop TA. Electromyographic localization of the palmaris brevis muscle. Am J Phys Med Rehabil. 1998;77:243–246 |
|88.||Cooney WP. Distal radius fractures: external fixation proves best. J Hand Surg Am. 1998;23:1119–1121 |
|89.||Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to management. Clin Orthop Relat Res. 1980;149:90–97 |
|90.||Chung KC, Kotsis SV, Kirn HM. Predictors of functional outcome after surgical treatment of distal radius fractures. J Hand Surg Am. 2007;32:76–83 |
|91.||Arora R, Lutz M, Hennerbichler A, Krappinger D, Espen D, Gabl M. Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate. J Orthop Trauma. 2007;21:316–322 |
|92.||Orbay JL. The treatment of unstable distal radius fractures with volar fixation. Hand Surg. 2000;5:103–112 |
|93.||Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg Am. 2002;27:205–215 |
|94.||Orbay JL, Fernandez DL. Volar fixed angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg Am. 2004;29:96–102 |
|95.||Rozental TD, Blazar PE. Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius. J Hand Surg Am. 2006;31:359–365 |
|96.||Kambouroglou GK, Axelrod TS. Complications of the AO/ASIF titanium distal radius plate system (pi plate) in internal fixation of the distal radius: A brief report. J Hand Surg Am. 1998;23:737–741 |
|97.||Jupiter JB, Fernandez DL, Toh CL, Fellman T, Ring D. Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am. 1996;78:1817–1828 |
|98.||Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. J Bone Joint Surg Am. 2004;86:1900–1908 |
|99.||Bae DS, Koris MJ. Fragment-specific internal fixation of distal radius fractures. Hand Clin. 2005;21:355–362 |
|100.||Dennison DG. Open reduction and internal locked fixation of unstable distal ulna fractures with concomitant distal radius fracture. J Hand Surg Am. 2007;32:801–805 |
|101.||Shen J, Papadonikolakis A, Garrett JP, Davis SM, Ruch DS. Ulnar-positive variance as a predictor of distal radioulnar joint ligament disruption. J Hand Surg Am. 2005;30:1172–1177 |
|102.||Terral TG, Freeland AE. Early salvage reconstruction of severe distal radial fractures. Clin Orthop Relat Res. 1996;327:147–151 |
|103.||Kafury AA, Freeland AE, Barbieri RA. Primary wrist arthrodesis in a severe intra-articular distal radial fracture. Orthopedics. 1998;21:803–805 |
|104.||Richards RS, Roth JH. Simultaneous proximal row carpectomy and radius to distal carpal row arthrodesis. J Hand Surg Am. 1994;19:728–732 |
|105.||Sauder DJ, Athwal GS, Faber KJ, Roth JH. Perilunate injuries. Orthop Clin North Am. 2007;38:279–288 |
|106.||Simic PM, Robison J, Gardner MJ, Gelberman RH, Weiland AJ, Boyer MI. Treatment of distal radius fractures with a low-profile dorsal plating system: an outcomes assessment. J Hand Surg Am. 2006;31:382–386 |
|107.||Mayfield JK. Mechanism of carpal injuries. Clin Orthop Relat Res. 1980;149:45–54 |
|108.||Szabo RM. Acute carpal tunnel syndrome. Hand Clin. 1998;14:419–429 |
|109.||Schnetzler KA. Acute carpal tunnel syndrome. J Am Acad Orthop Surg. 2008;16:276–282 |
|110.||Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg Am. 1993;18:768–779 |
|111.||Knoll VD, Allan C, Trumble TE. Trans-scaphoid perilunate fracture dislocations: results of screw fixation of the scaphoid and lunotriquetral repair with a dorsal approach. J Hand Surg Am. 2005;30:1145–1152 |
|112.||Hildebrand KA, Ross DC, Patterson SD, Roth JH, MacDermid JC, King GJ. Dorsal perilunate dislocations and fracture-dislocations: questionnaire, clinical, and radiographic evaluation. J Hand Surg Am. 2000;25:1069–1079 |
|113.||Apergis E, Maris J, Theodoratos G, Pavlakis D, Antoniou N. Perilunate dislocations and fracture-dislocations. Closed and early open reduction compared in 28 cases. Acta Orthop Scand Suppl. 1997;275:55–59 |
|114.||Blazar PE, Murray P. Treatment of perilunate dislocations by combined dorsal and palmar approaches. Tech Hand Up Extrem Surg. 2001;5:2–7 |
|115.||Sotereanos DG, Mitsionis GJ, Giannakopoulos PN, Tomaino MM, Herndon JH. Perilunate dislocation and fracture dislocation: a critical analysis of the volar-dorsal approach. J Hand Surg Am. 1997;22:49–56 |
|116.||Arslan H, Tokmak M. Isolated ulnar radiocarpal dislocation. Arch Orthop Trauma Surg. 2002;122:179–181 |
|117.||Dumontier C, Meyer zu Reckendorf G, Sautet A, Lenoble E, Saffar P, Allieu Y. Radiocarpal dislocations: classification and proposal for treatment. A review of twenty-seven cases. J Bone Joint Surg Am. 2001;83:212–218 |
|118.||Mudgal CS, Psenica J, Jupiter JB. Radiocarpal fracture-dislocation. J Hand Surg Br. 1999;24:92–98 |
|119.||Moneim MS, Bolger JT, Omer GE. Radiocarpal dislocation: classification and rationale for management. Clin Orthop Relat Res. 1985;192:199–209 |
|120.||Garcia-Elias M, Dobyns JH, Cooney WP III, Linscheid RL. Traumatic axial dislocations of the carpus. J Hand Surg Am. 1989;14:446–457 |
|121.||Graham TJ. The exploded hand syndrome: logical evaluation and comprehensive treatment of the severely crushed hand. J Hand Surg Am. 2006;31:1012–1023 |
|122.||Van Giffen N, Van Ransbeeck H, De Smet L. Stabilization of the pre-arthritic trapeziometacarpal joint using ligament reconstruction. Chir Main. 2002;21:277–281 |
|123.||Marcotte AL, Trzeciak MA. Non-operative treatment for a double dislocation of the thumb metacarpal: a case report. Arch Orthop Trauma Surg. 2008;128:281–284 |
|124.||Lutz M, Sailer R, Zimmermann R, Gabl M, Ulmer H, Pechlaner S. Closed reduction transarticular Kirschner wire fixation versus open reduction internal fixation in the treatment of Bennett’s fracture dislocation. J Hand Surg Br. 2003;28:142–147 |
|125.||Lawlis JF III, Gunther SF. Carpometacarpal dislocations. Long-term follow-up. J Bone Joint Surg Am. 1991;73:52–59 |
|126.||Stern PJGreen DP, Hotchkiss RN, Pederson WC, Wolfe SW. Fractures of the metacarpals and phalanges. Green’s operative hand surgery. 20055 ed. Philadelphia, PA Churchill Livingstone:277–341 |
|127.||Becton JL, Christian JD Jr, Goodwin HN, Jackson JG III. A simplified technique for treating the complex dislocation of the index metacarpophalangeal joint. J Bone Joint Surg Am. 1975;57:698–700 |
|128.||Friedrich JB, Shin AY. Management of forearm compartment syndrome. Hand Clin. 2007;23:245–254 |
|129.||Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78:285–292 |
|130.||Levin LS. The reconstructive ladder. An orthoplastic approach. Orthop Clin North Am. 1993;24:393–409 |
|131.||Levin LS, Condit DP. Combined injuries: soft tissue management. Clin Orthop Relat Res. 1996;327:172–181 |
|132.||Geiger S, McCormick F, Chou R, Wandel AG. War wounds: lessons learned from Operation Iraqi Freedom. Plast Reconstr Surg. 2008;122:146–153 |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]