Neuroanatomical correlates of the assessment of facial attractiveness

In a randomized prospective trial, closed reduction and plaster application was compared with Kapandji pinning. Closed reduction and plaster cast application was performed in 50 patients, Kapandji pinning in 48 patients. According to the Cooney score, good and excellent results were found in 74% of patients in the closed reduction and plaster cast group compared with 75% of patients in the Kapandji-pinning group. In terms of maintenance of reduction and functional outcome at 1-year follow-up, no statistically significant differences were found between the two groups. We conclude, therefore, that both techniques can be applied to extra-articular fractures of the distal radius according to the characteristics of the forearm and the surgeon's or the patient's need.     

Fasciculated intramedullary pinning of metacarpal fractures

We reviewed 20 patients with 23 displaced extraarticular fractures of the distal end of the long metacarpals, treated by fasciculated pinning. At a mean follow-up of 5 years, all the patients were subjectively satisfied with the result. All the patients but one, who fractured four metacarpals, had a normal range of motion. The average grip strength was 43.4 kg for the operated side compared to 43.4 kg for the uninjured hand. Radiologically, the fractured fifth metacarpal had a shortening of 2.2 mm compared to a control group, whereas the volar angulation was 16.6 degrees (13.2 degrees for the control group). The technique of intramedullary fasciculated pinning is a reliable alternative when conservative treatment of fractures of the metacarpal neck has failed or is inappropriate. The procedure provides sufficient stability to allow early mobilization and a good functional result.     

The role of arthroscopy in the treatment of wrist injuries in the athlete

Wrist arthroscopy provides an ideal means of evaluating intraarticular soft-tissue injuries of the wrist. Many lesions such as tears of the triangular fibrocartilage complex can be treated by arthroscopic means as well. Reduction of articular fractures of the distal radius and pin fixation, reduction of scaphoid fractures and intramedullary fixation, and arthroscopic reduction and transcutaneous pin stabilization of acute carpal dissociation patterns can all be accomplished with minimally invasive techniques under arthroscopic control. These measures often provide the athlete with shorter periods of immobilization and earlier return to athletic competition. Wrist arthroscopy provides a very useful adjunct to the treatment armamentarium of all sports medicine physicians.     

Management of comminuted fractures of the distal radius in the adult. Conservative or surgical?

Displaced fractures of the distal radius are difficult to treat successfully by traditional nonoperative methods. The goal in the management of these fractures is to achieve extraarticular alignment and an articular step off of less than 2 mm. Cast immobilization has been supplemented with pins and plaster technique and external fixators. Percutaneous are limited open reduction techniques, combined with wrist arthroscopy, have been shown to be useful in the management of intraarticular distal radius fractures. Despite these advances, there are still a significant number of fractures in which the articular surface cannot be reconstructed without open reduction and internal fixation. The main objective is to restore articular integrity as perfectly as possible. Attention to meticulous surgical technique will facilitate good results. When articular restoration cannot be accomplished, early arthrodesis or arthroplasty should be indicated. In the absence of osteoarthritis, intraarticular osteotomy can be used for intraarticular malunions with a step off greater than 2 mm. Radius malalignment usually requires a dorsal opening wedge osteotomy, insertion of a corticocancellous graft, and a dorsal buttress plate. Early recognition and treatment of distal radioulnar joint injuries associated with fractures of the distal radius are paramount to reduce the incidence of painful sequelae and functional deficits.     

Dynamic external fixation for distal radius fractures

Thirty adult patients with closed comminuted and mostly intraarticular fractures of the distal radius were treated by closed reduction and immobilization with a dynamic external wrist fixator during a 2-year period. In 13 patients with severely comminuted and unstable fractures, additional Kirschner wires were used. After 10 to 14 days of rigid fixation in neutral position, the motion element was unlocked to allow up to 30 degrees flexion. Six weeks later, the fixator was removed. The patients then were observed for an average of 24 weeks. An excellent functional outcome was seen in 6 patients (20%), a good outcome in 20 patients (67%), and a fair outcome in 4 patients (13%). Anatomically, 15 patients (50%) had an excellent result, 14 (47%) a good outcome, and 1 (3%) a fair outcome. Only minimal loss of reduction averaging 1 degree palmar tilt was seen during mobilization. There were 2 major complications: 1 deep Kirschner wire tract infection and 1 index metacarpal fracture. Minor complications such as sensory disturbances and pin tenderness were present but recovered completely after removal of the fixator. This study provides promising data and offers an alternative method in the treatment of distal radius fractures with severe comminution. In cases with postreductive unstable fragments, additional Kirschner wires should be used to allow early mobilization of the wrist.     

Noninvasive measurement of distal radius instability

Except for subjective clinical criteria, there is no formal definition of distal radius fracture instability in the literature. The purposes of this ex vivo biomechanical study were (1) to provide an objective mechanical definition of fracture instability and (2) to demonstrate a noninvasive method that allows for direct measurement of instability. The following 3 questions are addressed: (1) Can the stability of distal radius fractures be measured using computed tomography (CT)? (2) Are the stability measurements reproducible? (3) How does external fixation change stability? A CT technique is described that was used to measure displacement of fracture fragments and measure the compliance of ex vivo distal radius fractures before and after external fixation. Validation studies of the CT technique revealed a mean coefficient of variation of 0.38. There was a linear relationship between measured and known displacements for all 3 orthogonal planes (coefficient of determination 0.99; p < .01). There was significant fracture displacement with loads as small as 20 N. The slope of the load-displacement curve (structural compliance) provided a quantitative measure of fracture instability. Fracture compliance decreased up to 69% after application of an external fixator.     

Recent progress in orthopaedic managements of osteoporosis-related fractures

Recent progress in orthopaedic treatment of osteoporosis-related fractures was reviewed. In the femoral neck fractures, the bipolar prosthesis reduces acetabular erosion or central migration, and press-fit stem or cemented stem lowers the incedence of the stem sinking. In thorocanteric fractures, compression hip screws are most commonly used, however, in the cases of unstable fractures with severe osteoporosis, it is difficult to start weight-bearing within a few weeks of surgery because varus deformites or translations at the fracture site sometimes occur. To avoid this disadvantage, the gamma nail has been found to be more effective. In paralysis due to burst fractures of the osteoporotic spine, surgical decompression and spinal instrumentation is the established response. A special orthosis named 'rucksack type orthosis' has been devised and is used for patients who have back pain due to anterior bending posture of the trunk. In distal radius fractures, external fixators are now more frequently used.     

Intra-articular fractures of the distal end of the radius treated with an adjustable fixator system

Twenty-five wrists with comminuted, displaced, intra-articular fractures of the distal radius were prospectively treated with an adjustable external fixator for an average of 51 days. Twenty fractures (80% [20 of 25] were available for follow-up) in 16 adults (mean age, 34 years) were treated with the Wrist Jack external fixator system (Hand Biomechanics Lab, Sacramento, CA) and evaluated at a mean follow-up period of 25 months. Ten patients (12 fractures) sustained high-energy trauma with multiple injuries, while 6 patients (8 fractures) sustained isolated distal radius fractures. Percutaneous pins supplemented the fixation in 6 fractures. All fractures were reduced to restore articular congruity to within 1 mm. At follow-up, 5% were excellent, 75% good, 20% fair, and none as poor using the demerit point system of Gartland and Werley as modified by Sarmiento. Grip strength averaged 80% of the unaffected limb. Seventeen of the 20 fractures showed some evidence of articular incongruity at follow-up evaluation. Restoration of palmar tilt, radial inclination, radial length, and range of motion were at acceptable values. Subjective analysis confirmed 85% of the patients to have only occasional pain or none at all and 15% to have some pain with weakness or limitation of motion. Two patients required additional surgery: 1 underwent a Darrach procedure and the other a tendon transfer for a rupture of the extensor pollicis longus tendon. Results suggest that an external fixator system provides an additional alternative to the surgical armamentarium for an otherwise difficult fracture fixation problem.     

Activities of cefepime and five other antibiotics against nosocomial PER-1-type and/or OXA-10-type beta-lactamase-producing Pseudomonas aeruginosa and Acinetobacter spp

A dislocated pisiform associated with type II Salter-Harris fractures of the distal radius and ulna in a 9-year-old child is described. Closed reduction followed by immobilization achieved good radiological and clinical results. The current literature on dislocation of the pisiform is reviewed.     

Intraarticular lesions in distal fractures of the radius in young adults. A descriptive arthroscopic study in 50 patients

We examined the frequency of associated chondral and ligament lesions in distal fractures of the radius in young adults (men 20-60 years, women 20-50 years). Fifty initially displaced fractures were examined arthroscopically. Chondral lesions were found in 16 patients (32%). All patients but one were found to have a ligamentous injury in the wrist. No major instability was found. The most frequent ligament tear was the triangular fibrocartilage complex in 39 cases (78%), with a statistical correlation to ulnar styloid fractures. The scapholunate ligament was partially or totally torn in 27 cases (54%). No correlation was found between specific fracture type and pattern of ligament injury. Chondral and ligamentous lesions were frequent and may explain poor outcomes after seemingly well-healed distal fractures of the radius. The ligament lesions should also be kept in mind when early mobilization of the distal fracture of the radius is considered.     

Intracranial androgenic activation of male-typical behaviours in house mice: concurrent stimulation of the medial preoptic area and medial nucleus of the amygdala

OBJECTIVE: The goal of this study was to develop a reliable and valid tool for quantifying patient-rated wrist pain and disability. DESIGN: Survey, tool development, reliability, and validity study. SETTING: Upper extremity unit. PARTICIPANTS: One hundred members of the International Wrist Investigators were surveyed by mail to assist in development of the scale. Patients with distal radius (n = 64) or scaphoid (n = 35) fractures were enrolled in a reliability study, and 101 patients with distal radius fractures were enrolled in a validity study. INTERVENTION: Information from the expert survey, biomechanical literature, and patient interviews was used as a basis for item generation and definition of structural limitations for a scale that would be practical in the clinic. Patients with distal radius or scaphoid fractures completed the Patient-Rated Wrist Evaluation (PRWE) on two occasions to determine test-retest reliability. Patients with distal radius fractures (n = 101) completed the PRWE and the SF-36 and were tested with traditional impairment measures at baseline and at two, three, and six months after fracture to determine construct and criterion validity. MAIN OUTCOME MEASURES: Reliability coefficients (ICCs) and validity correlations (Pearson product moment correlations). RESULTS: Patient opinions on pain and on ability to do activities of daily living and work were thought to be the most important dimensions to include in subjective outcome tools. Brevity and simplicity were seen as essential in the clinic environment. A fifteen-item questionnaire (the PRWE) was designed to measure wrist pain and disability. Test-retest reliability was excellent (ICCs > 0.90). Validity assessment demonstrated that the instrument detected significant differences over time (p < 0.01) and was appropriately correlated with alternate forms of assessing parameters of pain and disability. CONCLUSIONS: The PRWE provides a brief, reliable, and valid measure of patient-rated pain and disability.     

Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age

Current knowledge regarding the basic epidemiology of fractures is largely limited to a few fracture sites, notably those of the hip and distal forearm. To clarify the patterns of incidence of limb fractures in the elderly, we used data from a 5% sample of the U.S. Medicare population over age 65 years during the years 1986-1990. We identified incident fractures of the proximal humerus, other parts of the humerus, proximal radius/ ulna, shaft of the radius/ulna, distal radius/ulna, pelvis, hip, other parts of the femur, patella, ankle, and other parts of the tibia/fibula from diagnoses and procedures coded on claims for inpatient services, outpatient facility use, and physician services. We used Poisson regression to investigate the relation between demographic factors and fracture risk at these sites. Fractures at the hip were the most common, accounting for 38% of the fractures identified. The proximal humerus, distal radius/ulna, and ankle also were common fracture sites. A pattern of rapidly rising rates with age was seen for fractures of the pelvis, hip, and other parts of the femur among women. Fractures distal to the elbow or knee, however, had, at most, modest increases in incidence with age over 65 years. For each of the fractures studied, women had higher rates than men of the same race, and whites generally had higher rates than blacks of the same gender. Gender-related differences in risk were larger among whites than among blacks, and racial differences in risk were more marked among women than among men.     

Small changes in essential amino acid concentrations alter diet selection in amino acid-deficient rats

A new plate designed specifically to address complex wrist pathology was used for the internal fixation of 22 complex fractures of the distal radius in 22 patients in a prospective multicenter trial. The majority of fractures were group C2- and C3-type fractures according to the Comprehensive Classification of Fractures. No plate failures, loss of reduction, nonunions, or infections occurred. Within the average follow-up time of 14 months, the functional results (including an average motion of 76% and an average grip strength of 56% of the contralateral side) were comparable to those reported for similar fractures in previous investigations. Five patients had irritation of the tendons in the second dorsal compartment. This trial serves both as a verification of the safety and efficacy of this distal radius plate as well as a demonstration of its utility in the treatment of complex fractures of the distal radius.     

Responses of the skin over the dorsum to sunlight in hairless descendants of Mexican hairless dogs

18 consecutive cases of delayed rupture of the extensor pollicis longus tendon were recorded during 5 years; 4 were spontaneous, and 14 after distal radius fracture, most of which were undisplaced or only slightly displaced. 15 cases were operated upon with tendon transfers: 13 had extensor indicis proprius transfer, 1 transfer of the extensor carpi radialis longus, and 1 reoperated with the extensor communis to the little finger as a motor unit. Subjectively, nearly complete satisfaction was reported; all patients were able to elevate the thumb to the level of the palm and full independent index finger movements were noted. In this 5-year-period 4,400 patients with distal radius fractures were treated, giving an incidence of delayed tendon rupture after distal radius fracture of 0.3 percent.     

Is the static external fixator a suitable method in the treatment of multi-fragmented fractures of the distal radius?

We present a retrospective study of 21 patients treated with an external fixator for comminuted fractures of the distal radius from May 1993 until May 1994. Mean follow-up was 14.5 months after operation. The 21 patients were on average 59 years old. The distal radius fractures were classified according to the AO: Type A2 (four times), Type A3 (two times), Type C1 (one time), C2 (nine times), C3 (five times). We mounted the external fixator generally in a static way. After two weeks it was dynamized. The fixator was removed after four to at least six weeks. An additional osteosynthesis with Kirschner wires was performed in twenty cases. Three times we added a primary cancellous bone graft, in one case an implantation of Endobone was used.     

The management of acute fractures involving the distal radio-ulnar joint and distal ulna

The acute management of fractures involving the distal radio-ulnar joint and distal ulna is controversial. The primary goal is recognition and differentiation between stable and unstable fracture patterns. Although an operative approach is adopted in the treatment of these injuries, the optimal management protocol awaits good prospective randomized studies.     

Fractures of the wrist and hand

The hands are extremely vulnerable to injury because of their constant use. This chapter features analyses of the evaluation, treatment, rehabilitation, and complications of fractures of the distal radius, carpus, metacarpals, and phalanges.     

Vertical transarticular pin fixation for unstable ankle fractures: impressions after 16 years of experience

The usage of vertical transarticular pin fixation combined with plaster immobilization for severe ankle injuries has been reviewed in 92 consecutive cases over a period of 16 years. Moderately simple in application and without a skin incision, the procedure has been found to provide efficient and reliable short-term stabilization of the ankle and subtalar joints with minimal complications. A new technique is described for accurate placement of the pin and the prevention of its migration. It is a reasonable alternative treatment for certain unstable distal tibial and ankle fractures when open reduction with conventional internal fixation cannot be done. In particular, the method is recommended in treating displaced fractures at the ankle and deltoid ligament ruptures in geriatric patients. It is often useful as a salvage or last-resort procedure in unusually severe ankle injuries with circulatory or neural deficits. In many instances additional trauma to the head, thorax or abdomen may have been sustained. Thus total patient care is essential and priorities must be recognized. The treatment of ankle trauma, furthermore, in a physiologically-aged diabetic patient is often not the same as that for similar injuries in a young healthy adult. The clinical judgement and experience of the operator is the basis for selection of the procedure. The simplest method is often the best. Pin fixation, however, is not for everyone. It should be done only by surgeons qualified to treat bone and joint trauma and even then only for those situations in which its usage is specifically indicated.