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The Journal of Bone and Joint Surgery (American). 2008;90:453-458. doi:10.2106/JBJS.G.01470 © 2008 The Journal of Bone and Joint Surgery, Inc.
What's New in Hand Surgery1 The Department of Orthopedic Surgery, Mayo Clinic, 200 First Street, S.W., Rochester MN 55905. E-mail address: amadio.peter{at}mayo.edu
Specialty Update has been developed in collaboration with the Council of Musculoskeletal Specialty Societies (COMSS) of the American Academy of Orthopaedic Surgeons.
This update reviews material presented at the 2007 annual meetings of the American Society for Surgery of the Hand (ASSH), American Association for Hand Surgery (AAHS), and the American Academy of Orthopaedic Surgeons (AAOS) as well as articles published in the field of hand surgery (other than those published in this journal) between August 2006 and July 2007. Over the years, as with other maturing organizations, the trend at meetings has been for fewer free papers and more symposia and hands-on workshops, including many non-CME-credit industry-sponsored workshops in facilities adjacent to the accredited scientific meeting. In addition, both hand surgery organizations feature presentations on shoulder and elbow surgery and general microsurgery beyond the scope of this review. In 2007, however, the ASSH reversed its trend and accepted nearly twice as many free papers as it had in 2006. In addition, there was a clear focus on the evidence base, and authors were encouraged to discuss the level of evidence for the data presented, both in free papers and in invited symposia. Meeting abstracts for the ASSH and AAOS annual meetings are maintained online at www.assh.org and www.aaos.org, respectively.
Screening for osteoporosis after distal radial fracture is an important consideration, especially in postmenopausal women. In a study of 298 consecutive patients that was presented to the AAOS, however, only 52% of patients were evaluated for osteoporosis either before (30%) or within six months after (22%) the fracture. The authors concluded that much more can and should be done to screen patients who are at risk for osteoporosis in the context of distal radial fracture treatment. It is often claimed that plate fixation of distal radial fractures results in better wrist motion because the procedure permits earlier mobilization. This hypothesis was evaluated in a prospective randomized study, presented to the AAOS, in which forty-two patients were randomized to early motion (at the time of suture removal) or six weeks of cast immobilization after surgery. At both three and six months postoperatively, there were no differences in motion, pain, strength, or function between the two groups. The authors concluded that while plate fixation may allow early motion, initiating motion early does not result in a better outcome at either three or six months after surgery. Complications after the treatment of distal radial fractures were the subject of a prospective study that was presented to the AAOS. Over a two-year period, 338 consecutive patients were followed. Treatments included casting for 169 patients, external fixation for fifty-seven, locked volar plating for 108, and miscellaneous treatments for the rest. The complication rate was 11% in the casting group, 31% in the plate fixation group (with seven unplanned returns to the operating room), and 37% in the external fixation group. While the indications for these treatments, and thus the types of injuries, were different in each group, the authors concluded that patients who are managed surgically for distal radial fractures have more complications than are generally appreciated. While vascularized bone grafts are commonly used to help scaphoid nonunions to heal, especially when there is evidence of osteonecrosis in the proximal pole, there is little consensus on the specific type of vascularized graft to use. In a study that was presented to the ASSH, the results associated with dorsal radial vascularized pedicle grafts (ten patients), iliac crest grafts with an implanted vascular bundle (three patients), and free vascularized grafts using bone from the medial femoral condyle (eleven patients) were compared. Only four of ten radial grafts healed. While all grafts healed in both of the other groups, healing was significantly faster (mean, 3.5 compared with 6.3 months) in the medial femoral condyle group. On the basis of these data, it would appear that a new option, free grafting from the medial femoral condyle, has been added to the surgical armamentarium for scaphoid nonunion in the presence of osteonecrosis of the proximal pole. Most hand surgeons agree that thumb replantation should be performed whenever it is technically possible. The results of such a policy were reviewed in a study, presented to the ASSH, involving a consecutive series of twenty-nine thumb amputations in patients who presented to a single center. While all but three replantations resulted in a viable thumb, 46% of the viable replantations required additional surgical procedures and, at the time of the most recent follow-up, pinch and grip strength averaged 59% and 70%, respectively, of the values on the uninjured side. Patients should be aware that while thumb replantations are often successful in terms of viability, complications requiring additional surgery and diminished strength are common sequelae. While it is heretical to consider the possibility, a recent study suggested that it may not be necessary to treat fractures of the fifth metacarpal neck (boxer's factures)1. In that study of eighty such fractures, half of the patients were managed with reduction and casting whereas the other half were managed with buddy-taping of the fingers and were told to return only if there were problems. When all patients were assessed at twelve weeks after the fracture, there was no difference between the groups with regard to Disabilities of the Arm, Shoulder and Hand (DASH) score. The untreated group went back to work significantly (two weeks) sooner (at three weeks as compared with five weeks) and were also significantly more satisfied with their "care." The bottom line is that, for some hand problems, less may be more.
Pain on the ulnar side of the wrist is often compared with low back pain: it is common, it is difficult to sort out functional from organic etiologies, and it is often frustrating to treat. A recent article2 may provide critical insight into how to improve the care of these challenging patients. On the basis of anecdotal observations, a hypothesis was developed and subsequently tested. Specifically, this hypothesis stated that tenderness on the ulnar side of the triquetrum (the hollow just distal to the ulnar styloid on the ulnar side of the wrist, sometimes called the "ulnar snuffbox" or the ulnar "fovea"), is sensitive and specific for the detection of two ulnar-sided wrist conditions: (1) instability of the distal radioulnar ligaments and (2) ulnotriquetral ligament injuries. A review of 272 patients who had had subsequent arthroscopy showed that the fovea sign was positive in 156 patients, while arthroscopy showed that there were ninety distal radioulnar ligament tears and eighty-eight ulnotriquetral ligament injuries. The sensitivity of the fovea sign in detecting these injuries was 95.2%, with a specificity of 86.5%. The fovea sign may be a useful tool for identifying patients with ulnar-sided wrist pain who may benefit from arthroscopic evaluation and treatment. When the distal radioulnar joint is arthritic, traditional options have included resection arthroplasty (the Darrach procedure and its variants) arthrodesis with proximal resection (the Sauve-Kapandji procedure), and resection of the ulnar articular surface with preservation of the styloid (matched resection or hemiresection interposition procedures). Another alternative, implant arthroplasty, is now enjoying a resurgence. Although initial experience four decades ago with silicone ulnar head implants was, in general, disappointing, a new metallic device has shown promise3. In a review of seventeen patients (nineteen implants) who were followed for two years, pain was reduced and function was significantly increased, although most of the patients had had multiple failed previous attempts at surgical reconstruction. At the time of the most recent follow-up, all but two implants were stable and functioning well. Why do patients with rheumatoid arthritis request surgery? Why do doctors recommend it? The authors of a recent study evaluated these questions and came up with interesting answers4. In that study, a survey of 126 patients and 500 rheumatologists and hand surgeons showed that male and female patients were very similar in terms of their willingness to undergo hand surgery and that they placed equal value on hand appearance, function, and pain in making a decision for surgery. Women were, however, more risk-averse than men were: for a given degree of pain, loss of function, or appearance, they were less likely than men to choose surgery as an option. In contrast, the surgeons and rheumatologists thought that appearance was almost exclusively a concern of women. It is clear that these different attitudes might result in physicians mistakenly downplaying cosmesis in men and overplaying it in women or recommending surgery to a woman who prefers nonsurgical options. The authors concluded that, for patients with rheumatoid arthritis, doctors' notions about patients are not always accurate. A report that was presented to the ASSH reviewed the results of sixty-two revision silicone metacarpophalangeal joint arthroplasties in twenty patients with rheumatoid arthritis. At an average of five years of follow-up (minimum, one year) the mean postoperative motion was an arc from 20° to 54°, unchanged from the preoperative level, whereas ulnar drift decreased significantly from 24° to 13°. Although a third of the revised implants had fractured at the time of the most recent follow-up, 80% of the patients were satisfied with the results of the revision procedure. The authors concluded that, while patient satisfaction is high, the objective results of revision silicone implant arthroplasty are less impressive.
Both silicone and pyrolytic carbon implants are used to treat arthritic disorders of the proximal interphalangeal joints. A recent case series compared the results of the two procedures in the practice of a single surgeon5. Thirteen patients (twenty-two joints) in the silicone implant group were followed for a mean of forty-five months, and nine patients (nineteen joints) in the pyrolytic carbon implant group were followed for a mean of nineteen months. At the time of follow-up, the mean arc of motion was 49° for the silicone implants and 53° for the carbon implants. Eleven silicone implants and four carbon implants were angulated The results of hemiarthroplasties with pyrolytic carbon implants for the treatment of thumb carpometacarpal osteoarthritis in a series of fifty-four thumbs, most of which had osteoarthritis, were also presented to the ASSH. After a mean duration of follow-up of fourteen months, fifteen reoperations had been performed and only 70% of the patients were satisfied. These results compared poorly with those of another series, presented at the same meeting, in which patients who had undergone simple trapezium excision without reconstruction reported no reoperations and an 80% rate of satisfaction at seven years postoperatively. Another option for the treatment of thumb carpometacarpal arthritis is arthrodesis of the trapeziometacarpal joint. One report that was presented to the AAHS reviewed the results of 178 such procedures that had been performed between 1970 and 2003. Similar to the overall findings related to trapeziometacarpal arthritis, two-thirds of the patients were women and the mean age of the patients was fifty-one years. The most common diagnosis was osteoarthritis; Kirschner wires without graft were used in most cases. The minimum duration of follow-up was more than two years (mean, twelve years). At the time of the most recent follow-up, there were twenty-seven nonunions and forty-seven cases in which scaphotrapezial arthritis had developed postoperatively, but only twelve nonunions and two cases of scaphotrapezial arthritis had led to additional surgery. The mean final pinch strength was 6 kg, and the mean final grip strength was 22 kg. The mean pain score improved from 6 of 10 to 1 of 10. The authors concluded that, despite some complications, trapeziometacarpal arthrodesis is a procedure that can provide good results in a variety of patients with thumb carpometacarpal arthritis.
While some hand surgeons prefer a soluble corticosteroid such as dexamethasone for injections in the hand, others prefer a longer-lasting insoluble agent, such as triamcinolone. These two treatment options were compared in a prospective randomized study of sixty-three patients with trigger finger that was presented to the AAOS. After three months, the patients who had been managed with triamcinolone had fewer symptoms of triggering and were less likely to have needed surgery, but final function and satisfaction were similar in the patient groups. The treatment of severe flexion contractures in the finger is a major challenge for the hand surgeon. A recent report described a method of tenolysis and joint release through a lateral finger incision in which the tendon sheath and volar capsule are raised from the phalanges as a large flap (total anterior tenoarthrolysis, or TATA)6. In fifty patients with an average combined preoperative flexion contracture of the proximal and distal interphalangeal joints of 131°, the mean correction of the flexion contracture was 90°. All but five patients had improvement in terms of motion, and none had worsening. The total anterior tenoarthrolysis procedure seems to be one that is worth remembering when treating a severe finger contracture.
Does the duration of symptoms affect the outcome of carpal tunnel release? This interesting question was the subject of a recent investigation in which the outcomes of 523 carpal tunnel releases were studied7. The duration of symptoms varied from less than one year to more than five years. At six months postoperatively, function and symptoms, as measured with the Levine questionnaire, were unrelated to the duration of symptoms but did correlate with the severity of preoperative symptoms. The authors concluded that the wait before surgery was not a significant factor in determining the surgical outcome.
Congenital trigger thumbs are common. A report that was presented to the ASSH emphasized that an initial period of observation is worthwhile before recommending surgery for such patients. In a report from one institution, forty-five of seventy-one trigger thumbs resolved spontaneously. Most patients showed steady improvement over time. Follow-up at six-month intervals was recommended, with surgery reserved for patients who showed no improvement.
A report that was presented to the AAOS reviewed the results of surgical treatment for aggressive tumors of the distal part of the radius, including twenty-one giant-cell tumors of bone, four other aggressive but benign lesions, and eight sarcomas. Initially, seventeen patients had wide excision and arthrodesis whereas sixteen had joint-sparing procedures. Local recurrence occurred in the cases of six benign lesions, five of which had been treated with joint-sparing procedures. At the time of the most recent follow-up, one to eleven years later, six joint-sparing procedures had been converted to arthrodeses. All of the arthrodeses resulted in union. All patients were disease-free at the time of the most recent follow-up. Final assessment showed higher DASH scores, indicating more disability, in the arthrodesis group, but the joint-sparing group had more pain and weaker grip and showed evidence of early wrist arthritis. The authors concluded that joint salvage resulted in better function but also in higher rates of recurrence, pain, and arthritis. Dupuytren contracture is a frustrating condition both for hand surgeons, because the surgery can be difficult, and for patients, because the rehabilitation can be lengthy. Both surgeons and patients are often frustrated by complications and poor results, with fingers that remain contracted even after multiple attempts at correction. Among alternatives to surgery, the injection of collagenase into the affected cords has been shown to offer the hope of similar or improved outcomes with less risk than surgery. Within a day after injection, the collagenase-injected cords often can be manually ruptured, extending the finger and avoiding the need for surgery. Badalamente et al.8 reviewed thirty-five patients who were prospectively randomized to treatment with either placebo or collagenase injection. Patients could have one joint injected per month, up to a total of six injections. After 1.6 years, twenty-one of the twenty-three patients in the collagenase group and none of the twelve patients in the placebo group had had correction of the contracture to within 5° of normal. There were no significant adverse events in either group. An open-label trial of this treatment is now under way. Another novel treatment is being piloted for patients with Dupuytren disease. Percutaneous needle fasciotomy is a procedure in which a needle is used in an up-and-down motion to rupture the diseased cords so that, as with the collagenase treatment, the affected finger can then be manually extended. There is now level-1 evidence, in the form of a prospective randomized trial, to demonstrate the effectiveness of the procedure in comparison with open fasciectomy9, at least in the short term. A total of 113 hands were randomized to one of the two procedures, for a total of 166 operatively treated rays. All degrees of severity of contracture were included, from very mild contractures to extension deficits of >135°. The results showed that the percutaneous procedure improved contractures of <90° by about 70%, whereas the open procedure resulted in an 80% improvement. This difference was not significant. For larger deficits, however, there was a significant difference, with the open procedure resulting in a 75% improvement whereas the needle procedure provided <50% improvement. While the open procedure provided better motion, especially for more severely affected digits, the benefit came at a cost. Disability as measured on the basis of the DASH score was identical and low (16 points, with 0 points representing no disability and 100 points representing maximum disability) in the two groups preoperatively. In the first weeks postoperatively, it increased significantly to 49 points in the open group whereas it decreased to 9 points in the needle group. There were also major complications (including nerve injury, wound infection, and hematoma) in the open group, whereas there were no major complications in the needle group. Pain was significantly greater after open surgery than after the needle procedure. Perhaps unsurprisingly, the level of satisfaction was significantly higher among the patients managed with needle fasciotomy. The authors concluded that, in the short term, the percutaneous needle fasciotomy is a reasonable alternative for the treatment of symptomatic Dupuytren contracture in patients with an extension deficit of <90°.
Hand surgeons have used tourniquets for nearly a century, but are tourniquets really necessary? Sterling Bunnell, the father of American hand surgery, famously compared operating without a tourniquet to operating in an inkwell, but it may be possible to obtain the salutary effect of a tourniquet in a different way. The authors of a recent article reviewing the data for and against the use of local anesthesia with epinephrine in the hand10 found that the data against the use of epinephrine were limited and were based primarily on case reports of ischemic necrosis of fingers following the use of procaine and epinephrine, without consideration of the possibility of phentolamine "rescue" of a vascularly compromised digit. In contrast, a large contemporary series involving the use of lidocaine and epinephrine showed few problems and many benefits. Investigators from the same group recently reported one of the benefits of operating without a tourniquet, namely, the ability of a wide-awake patient to move a tendon transfer immediately after suture, without pain or tourniquet palsy, to help the surgeon to set proper tension11. The same principle can be used with tendon repairs to test repair strength and tendon gliding intraoperatively. Truly what was old is new again.
Hand surgery has not been touched specifically by the current pay-for-performance measures proposed by the Centers for Medicare and Medicaid Services (CMS), but hand surgeons have nonetheless been active in evidence-based practice initiatives. Indeed, it was possible to use an evidence-based approach to exempt carpal tunnel surgery from the need for routine perioperative antibiotics. Now the AAOS and ASSH have teamed up to develop evidence-based guidelines for the diagnosis of carpal tunnel syndrome (see http://www.aaos.org/Research/guidelines/CTS_guideline.pdf). Additional guidelines on treatment of carpal tunnel syndrome are in development. While the issue of maintenance of certification affects all orthopaedists, hand surgeons in the past have been able to recertify in orthopaedics as well as hand surgery simply by passing an examination in hand surgery. Now, hand surgeons who choose this recertification pathway must take a combined computer-based examination consisting of approximately 160 hand surgery questions and eighty general orthopaedic surgery questions. In addition, of course, they must fulfill the requirement of 120 hours of CME credit within the three years preceding recertification. To address the CME requirement, the ASSH is developing a program of review articles with CME credit to be provided through the Journal of Hand Surgery, designed to review the scope of hand surgery over a three-year cycle, and also is preparing a core curriculum in hand surgery that may be of interest to residency program directors.
The Sixty-third Annual Meeting of the American Society for Surgery of the Hand will be held in Chicago, Illinois, on September 18 through 20, 2008. The ASSH will also sponsor a Comprehensive Review in Hand and Upper Extremity Surgery, to be held in Chicago, Illinois, on July 11 and 12, 2008. The Thirty-ninth Annual Meeting of the American Association for Hand Surgery will be held in Wailea, Hawaii, from January 7 through 10, 2009. The annual meetings of the AAHS are always held in combination with the annual meetings of the American Society for Reconstructive Microsurgery and the American Society for Peripheral Nerve. These three organizations also share certain management functions, permitting closer integration of their meetings, even offering a combined registration option. They will meet together again in 2010. All of these meetings are open to all interested parties. Further details will be forthcoming on the society web sites, listed below. Both annual meetings accept free papers and also feature a wide variety of instructional courses and symposia, many with hands-on sessions.
Membership in the two hand surgery societies is restricted to those who have had specific hand surgery training and, in the case of the American Society for Surgery of the Hand, those who have received the Certificate of Added Qualification in Hand Surgery offered by the American Boards of Orthopaedic Surgery, Plastic Surgery, and Surgery. Further information on membership as well as any of the above meetings can be obtained by contacting the organizations directly. Finally, both organizations maintain active web sites, with educational and informational content directed to the public and interested medical professionals as well as members. American Society for Surgery of the Hand 6300 North River Road, Suite 600 Rosemont, IL 60018 Phone: (847) 384-8300 American Association for Hand Surgery 20 North Michigan Avenue, Suite 700 Chicago, IL 60602 Phone: (312) 236-3307
The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a Level of Evidence grade of I. Over 100 medical journals were reviewed to identify these articles, which all have high-quality study design. In addition to articles published previously in this journal or cited already in this Update, eight level-I articles were identified that were relevant to hand surgery. A list of those titles is appended to this review after the standard bibliography. We have provided a brief commentary about each of the articles to help to guide your further reading, in an evidence-based fashion, in this subspecialty area.
Zhang W, Doherty M, Leeb BF, Alekseeva L, Arden NK, Bijlsma JW, Dinçer F, Dziedzic K, Häuselmann HJ, Herrero-Beaumont G, Kaklamanis P, Lohmander S, Maheu E, Martin-Mola E, Pavelka K, Punzi L, Reiter S, Sautner J, Smolen J, Verbruggen G, Zimmermann-Górska I. EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2007;66:377-88. Sixteen European rheumatologists were joined by a physiatrist, an orthopaedist, two allied health professionals, and a methodology expert to review the evidence supporting treatment recommendations for hand arthritis. The three strongest recommendations were as follows. First, local treatments are preferred over systemic treatments, especially for mild to moderate pain and when only a few joints are affected. Topical nonsteroidal anti-inflammatory drugs and capsaicin are effective and safe for the treatment of hand osteoarthritis. (Level of evidence: I.) Second, oral nonsteroidal anti-inflammatory drugs should be used at the lowest effective dose and for the shortest duration in patients who respond inadequately to acetaminophen. The patient's requirements and response to treatment should be reevaluated periodically. In patients with increased gastrointestinal risk, nonselective nonsteroidal anti-inflammatory drugs plus a gastroprotective agent or a selective COX-2 inhibitor should be used. In patients with increased cardiovascular risk, COX-2 inhibitors are contraindicated and nonselective nonsteroidal anti-inflammatory drugs should be used with caution. (Level of evidence: I.) Third, surgery (for example, interposition arthroplasty, osteotomy, or arthrodesis) is an effective treatment for severe thumb base osteoarthritis and should be considered for patients with marked pain and/or disability when conservative treatments have failed. (Level of evidence: III.) Eight other recommendations were made on the basis of lower levels of evidence or expert opinion. Rosén B, Lundborg G. Enhanced sensory recovery after median nerve repair using cortical audio-tactile interaction. A randomised multicentre study. J Hand Surg Eur Vol. 2007;32:31-7. The Sensor Glove System consists of a glove with miniature microphones on the dorsal aspects of the fingertips. When an object is touched, the friction sound is relayed to stereo headphones. As different surfaces create different sounds and the microphones in the fingertips are represented differently in the stereo system, both spatial localization and tactile differentiation are possible with use of the auditory stimuli created by the glove. This glove was used in a prospective randomized trial of twenty-six patients with a median nerve laceration. Fourteen patients used the sensor glove in the first three months postoperatively, whereas the other twelve did not. At one year, tactile gnosis was better in the Sensor Glove group. Siegmeth AW, Hopkinson-Woolley JA. Standard open decompression in carpal tunnel syndrome compared with a modified open technique preserving the superficial skin nerves: a prospective randomized study. J Hand Surg [Am]. 2006;31:1483-9. Scar tenderness is a common problem after carpal tunnel release. Some have suggested that the symptoms might be related to the injury of small palmar cutaneous nerves that might be transected during the surgical exposure. In this prospective study of forty-two patients with bilateral carpal tunnel syndrome, one hand was randomized to treatment with a technique in which the surgeon made a specific effort to avoid injury to palmar cutaneous nerves whereas the contralateral hand was randomized to treatment with a technique in which no special effort was made. Patients were followed at six, twelve, and twenty-six weeks postoperatively. There was no difference in palmar pain between the two groups at any time-point. Zyluk A, Strychar J. A comparison of two limited open techniques for carpal tunnel release. J Hand Surg [Br]. 2006;31:466-72. Sixty-five patients (seventy-three hands) were randomized to have a limited open carpal tunnel release through either a single or double incision. Patients were reevaluated at one, two, six, and twelve months with regard to strength, sensibility, symptoms, and function. The single incision method was associated with significantly better grip strength (16 compared with 15 kg) at one month, but there was no difference in recovery of sensibility, symptoms, or function as measured with the Levine carpal tunnel syndrome questionnaire. Nalamachu S, Crockett RS, Mathur D. Lidocaine patch 5 for carpal tunnel syndrome: how it compares with injections: a pilot study. J Fam Pract. 2006;55:209-14. In this study, forty patients with carpal tunnel syndrome were randomized to treatment with either a dermal 5% lidocaine patch or the injection of 0.5 mL of 1% lidocaine and 40 mg of Depo-Medrol into the carpal tunnel. Pain relief was similar in the two groups at one, three, and six weeks. The authors concluded that topical lidocaine was an effective modality for the treatment of hand pain in patients with carpal tunnel syndrome. Remarkably, improvement in terms of sensory symptoms was not reported. Thus, unfortunately, the effect on the carpal tunnel syndrome itself was not assessed. Benson LS, Bare AA, Nagle DJ, Harder VS, Williams CS, Visotsky JL. Complications of endoscopic and open carpal tunnel release. Arthroscopy. 2006;22:919-24. The authors of this study reviewed the literature on open and endoscopic carpal tunnel release for reports of injuries to nerves, arteries, and tendons. Overall, studies involving a total of 22,327 endoscopic and 5669 open carpal tunnel releases were reviewed. The prevalence of injury was 0.49% for the open series and 0.19% for the endoscopic series. On the basis of these data, the authors concluded that the risk of structural injury during either open or endoscopic carpal tunnel release is very low and that the selection of an open or endoscopic approach on the basis of a perceived difference in risk of structural injury is not supported by the published case series. Handoll HH, Madhok R, Howe TE. Rehabilitation for distal radius fractures in adults. Cochrane Database Syst Rev. 2006;3:CD003324. Randomized or quasi-randomized studies of fractures of the distal part of the radius were reviewed for evidence regarding the effect of rehabilitation interventions. Fifteen trials involving 746 patients were identified. The patients were mostly female and elderly. All but twenty-seven of the patients in these trials were managed without surgery. While these studies did provide weak evidence to support a short-term (one-month) clinical benefit to hand therapy, in general the studies demonstrated no difference between supervised and unsupervised therapy and demonstrated only weak evidence of a short-term benefit to modalities such as continuous passive motion, ultrasound, or intermittent pneumatic compression. The authors concluded that the available evidence is insufficient to establish a benefit for rehabilitation interventions in patients with distal radial fractures. Atroshi I, Brogren E, Larsson GU, Kloow J, Hofer M, Berggren AM. Wrist-bridging versus non-bridging external fixation for displaced distal radius fractures: a randomized assessor-blind clinical trial of 38 patients followed for 1 year. Acta Orthop. 2006;77:445-53. In this study, bridging fixation was compared with nonbridging fixation for the treatment of displaced distal radial fractures. Women with an age of more than fifty years and men with an age of more than sixty years were enrolled. Both intra-articular and extra-articular fractures were included. All fractures had at least 20° of dorsal angulation or 5 mm of radial shortening. Patients were followed for one year. Outcome measures included the DASH score, pain, wrist range of motion, and grip strength. At the time of the most recent follow-up, there were few differences between the two groups. Shortening was slightly (1.4 mm) less in the nonbridging fixation group (p = 0.04), whereas operative time was ten minutes less in the bridging fixation group. The data supported the use of nonbridging fixation as an alternative to bridging fixation for moderately or severely displaced distal radial fractures.
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10° in the radioulnar plane, with an average angulation of 12° in the silicone group and just 2° in the carbon group; this difference was significant. Three silicone implants were removed subsequently. While none of the carbon implants were removed during the course of the study, eight joints had an audible squeak, two dislocated, and two were loose radiographically. The authors concluded that the pyrolytic implants showed promise for the treatment of proximal interphalangeal joint arthritis but that the available data did not show a conclusive superiority over the silicone implants. | home | CME | help | feedback | subscriptions | archive | site index |
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