The effect of brachioradialis release during distal radius fracture fixation on elbow flexion strength and wrist function

Evaluation of sparing the pronator quadratus for volar plating of distal radius fractures: a retrospective clinical study

BACKGROUND

The most commonly used approach for distal radius fractures is the traditional Henry approach. However, it requires an intraoperative incision of the pronator quadratus (PQ) muscle, which results in a series of complications if the repair of the PQ fails.

AIM

The objective of this study was to investigate the efficacy of sparing the pronator quadratus for volar plating of the distal radius fractures.

METHODS

Seventy-six patients who suffered from distal radius fractures of types 23-B, 23-C1, and 23-C2 as per the AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification were treated with volar locking plate fixation using either the PQ muscle incision and repair (group A, n = 39) or the PQ muscle preservation approach (group B, n = 37). Intraoperative index, postoperative efficacy and complications of patients were recorded and evaluated.

RESULTS

All patients were followed up for more than one year after surgery. All fractures achieved union. There were significant differences in mean operative time, mean intraoperative blood loss, and mean fracture healing time between the two groups. Still, there were no significant differences in limb function scores between the two groups at the 12-month postoperative follow-up. Outcomes assessed at 1 week, 1 month, and 3 months after surgery demonstrated significant differences in the mean range of motion and pain-related visual analog scale (VAS) between the two groups. As the range of motion and grip strength increased, the VAS scores decreased, and there was no significant difference between the two groups at 12 months postoperatively. Although tendon irritation and delayed carpal tunnel syndrome were more common in group A than in group B (7.6% vs. 0% and 5.1% vs. 0%, respectively), the differences were not statistically significant.

CONCLUSION

The modified Henry approach with sparing pronator quadratus muscle has no significant advantage in the range of wrist motion and upper limb function in the late stage. Nevertheless, the intraoperative placement of the plate under the pronator quadratus muscle can shorten the operation time, reduce intraoperative bleeding, reduce early postoperative pain, promote early activity, and improve the patient's quality of life. It is recommended that the pronator be preserved at the time of surgery.

Radiation necrosis of the pharyngeal soft tissue: Unique clinical entity reconstructed with a previously unreported composite brachioradialis and flexor digitorum superficialis radial forearm flap

BACKGROUND

The radial forearm free flap (RFFF) is a versatile flap commonly used in head and neck reconstructive surgery. We describe the use of a composite RFFF that includes muscle for reconstruction of a hostile wound of the posterior pharyngeal wall.

METHODS

A 54-year-old male with a history of recurrent right palatine tonsil HPV+ squamous cell carcinoma developed severe soft tissue necrosis of the posterior pharyngeal wall secondary to reirradiation. The defect was reconstructed with a composite RFFF that included the brachioradialis (BR) muscle and the flexor digitorum superficialis (FDS) muscle.

RESULTS

Restoration of this complex defect was successfully accomplished with minimal donor site functional deficits and satisfactory functional outcomes including decannulation and resumption of oral intake.

CONCLUSION

This composite RFFF can be effectively used to reconstruct a hostile wound of the posterior pharyngeal wall. Incorporation of muscle in the reconstruction of complex wounds with soft tissue necrosis is beneficial.

The Measurement Methods of Movement and Grip Strength in Children with a Previous Upper Extremity Fracture: A Comparative, Prospective Research

BACKGROUND AND AIMS

Decreased range of motion of the elbow and forearm and decreased grip strength are potential findings following a childhood upper extremity fracture. Clinical follow-up is essential because spontaneous improvement is seen several months after the injury. Freehand measuring with a goniometer and hydraulic dynamometer is used to evaluate clinical result. The new methods are justified in avoiding human typewriting errors, thus improving patient safety. Nevertheless, their feasibility in child patients is unknown. This study aimed to evaluate congruence between the computer-assisted and the free-hand measuring methods.

MATERIALS AND METHODS

A total of 59 children with a previous supracondylar humerus fracture were clinically examined by means of free-hand (transparent goniometer and hydraulic dynamometer; Jamar, Lafayette Ltd.) and computer-assisted (E-Link System Packages, Biometrics Ltd.) methods. The range of motion and grip strength were measured separately using both methods. Agreement between the measurements was evaluated using the Bland-Altman method.

RESULTS

The results between the two methods were incongruent and the differences between measurements increased along with the mean of measurements in all categories except elbow extension. Rotational range of motions were smaller and grip strength was weaker while measuring with the computer-assisted method. The mean discrepancy was 0.97° (95% confidence interval = -2.46 to 0.53) for elbow extension and 7.97° (95% confidence interval = 6.60-9.33) for elbow flexion.

CONCLUSIONS

Grip strength is used to evaluate impairment of hand function. The study method showed slightly lower results in grip strength. Range of motion is essential when evaluating the outcome of supracondylar humerus fracture, while >10° of change in elbow range of motion associate with impaired function. As compared with the gold-standard goniometer, the methods were not congruent. However, all differences were under 10° and probably beyond clinical importance. Because of its advantages in recording the outcomes to electronical charts, the computer-assisted method is recommended option in performing the follow-up of complicated pediatric supracondylar humerus fractures.

Forearm-Based Turnover Muscle Flaps for Elbow Soft-Tissue Reconstruction: A Comparison of Regional Coverage Based on Distal Flap Perfusion

BACKGROUND

Elbow wounds pose a reconstructive challenge. Prior studies have described the vascular anatomy of both the brachioradialis and flexor carpi ulnaris muscle flaps. The goal of this study was to describe the distal flap perfusion of the flexor carpi radialis, with a direct comparison of the brachioradialis, flexor carpi ulnaris, and flexor carpi radialis muscle flaps for coverage around the elbow.

METHODS

Six fresh-frozen upper extremity specimens were dissected for brachioradialis, flexor carpi radialis, and flexor carpi ulnaris flaps. Vascular data from prior studies were combined with our anatomical measurements to determine the area of perfused coverage around the elbow for the brachioradialis and flexor carpi ulnaris. The flexor carpi radialis flap distal vascular perfusion was examined separately with transverse sections at 1-cm intervals after India ink injections to determine distal flap perfusion and elbow coverage. Perfusion data were plotted on x and y axes over the posterior elbow.

RESULTS

The brachioradialis muscle covered an average of 56 percent of the x axis and 7.4 percent of the y axis. The flexor carpi ulnaris muscle covered an average of 90 percent of the elbow along the x axis and 23.3 percent of elbow along the y axis. The flexor carpi radialis covered an average of 34 percent of the x axis and 4.8 percent of the y axis.

CONCLUSION

The flexor carpi ulnaris muscle provides the most versatile and robust coverage over the posterior elbow, followed by the brachioradialis muscle, which consistently provides coverage over the lateral epicondyle.

The role of brachioradialis release during AO type C distal radius fracture fixation

INTRODUCTION

Open reduction and internal fixation of distal radius fractures often necessitates release of the brachioradialis from the radial styloid. However, whether this common procedure makes the reduction and fixation easier and affects the elbow function has not been fully understood.

HYPOTHESIS

Brachioradialis (BR) release during volar plate fixation for type C distal radius fractures makes internal reduction and fixation easier, and it does not adversely affect wrist or elbow function.

MATERIAL AND METHODS

A total of 74 patients treated with 2.4mm volar locking compression column plate (VCP) were analyzed for type C distal radius fractures prospectively. The patients were divided into two groups, group A with BR release and group B without BR release. The two groups were compared in terms of "internal reduction and fixation time" during the operation, wrist and elbow function including the scores of Gartland and Werley (G-W), Patient-related wrist evaluation score (PRWE), Mayo Elbow Performance Score (MEPS), the Disabilities of the arm, shoulder, and hand (DASH) and a Visual analog scale (VAS) for pain at 6 and 12 months postoperatively. The radial inclination angle, palmar tilt angle and ulnar variance were also measured from the radiographs.

RESULTS

According to the follow-up of the 74 patients, no significant differences were observed between the two groups on MEPS, DASH, G-W, PRWE, VAS and radiological outcomes at 6 and 12 months postoperatively. Mean time of reduction and internal fixation was significantly shorter in group A than that in group B.

CONCLUSION

Release of the BR for type C distal radius fractures facilitated the surgical procedure and did not adversely affect elbow and wrist function.

LEVEL OF EVIDENCE

II, prospective comparative study.

Intraarticular Distal Radius Fracture Open Reduction Internal Fixation

PURPOSE

Intraarticular distal radius fractures are often treated with open reduction and internal fixation (ORIF) through a volar approach. This common approach, however, is technically demanding to restore the articular surface of the radiocarpal joint while respecting soft tissue integrity. The purpose of this video is to demonstrate the surgical technique of volar plate fixation of an intraarticular distal radius fracture.

METHODS

A 32-year-old patient who sustained multiple injuries including an intraarticular distal radius fracture was treated with ORIF by a volar approach.

RESULTS

Exposure is performed through a standard flexor carpi radialis approach. The intraarticular fracture of the distal radius is reduced, and a volar plate is applied. Careful measurement of screw length is described in detail to minimize postoperative tendon irritation. Closure of the soft tissues is completed and early postoperative rehabilitation is emphasized.

DISCUSSION

Multiple, varied techniques for fixation of intraarticular distal radius fractures are described in the literature. As demonstrated in this video of ORIF with a volar plate, attention to articular reduction, soft-tissue protection, and postoperative rehabilitation are key components used to achieve good clinical outcomes.

Current Trends in the Management of Distal Radius Fractures

This article discusses recent reports on distal radius fractures. The keyword "distal radius fracture" was used to query the PubMed database of the US National Library of Medicine. From the resulting list, articles published in the Journal of Hand Surgery (American Volume), the Journal of Hand Surgery (European Volume), and the Journal of Orthopaedic Trauma from April 2014 through December 2015 were reviewed. Related commentaries were also evaluated. Case series of fewer than 5 patients were excluded. The 65 studies and commentaries identified are categorized and summarized. [Orthopedics. 2017; 40(3):145-152.].

Complex Distal Radius Fractures: An Anatomic Algorithm for Surgical Management

Most distal radius fractures result from low-energy mechanisms and can be successfully treated nonsurgically or with a variety of surgical techniques if indicated. High-energy distal radius fractures can involve extensive comminution or bone loss with concomitant ligament, soft-tissue, and neurovascular injuries. In patients with complex distal radius fractures, reconstruction of the distal radius, ulna, and triangular fibrocartilage complex can be challenging. Effective restoration of the bony architecture requires intimate knowledge of the anatomy of the distal radius, a thorough understanding of the goals of treatment, versatility in surgical approaches, and familiarity with multiple fixation options.

[Descriptive, radiographic, topographic and functional anatomy applied to distal radius fractures]

Extensive anatomical knowledge is needed in order to correctly treat distal radius fractures: normal and pathological osteology of the distal radius, distal radio-ulnar joint and radiocarpal joint-both on the descriptive and functional level-the neurovascular and muscular environments of the distal radius-which are essential to the surgical approaches-and the angles that need to be restored during the reduction. All of these concepts are broached in this article.