Correcting a malunited distal radial fracture usually requires osteosynthetic material applied on the dorsal side of the radius. However, contact of the material with the extensor tendons often produces irritation and rupture problems. The aim of this study is to evaluate the effectiveness of the specific osteosynthetic material (Trimed) in treating malunion of intra- or extra-articular fractures of the distal radius, after a corrective osteotomy.

We examined 11 patients (7 females, 4 males), with average age of 42 years (ranging from 21 to 69 years old), 10 of which presented with symptomatic malunited distal radial fracture of a mean duration of 2.85 months (2–7 months). In one patient the malunited fracture was 30 years old. In 7 patients the malunited fracture was extra articular whereas in 4 patients it was intra articular. A corrective osteotomy was performed in all cases, followed by application of the special osteo-synthetic material by Trimed on the dorsal side of the radius. In seven patients iliac crest bone graft was used, whereas in four allografts were applied. Furthermore, five patients had to undergo additional surgical procedures. More specifically, shortening osteotomy of the ulna in 3 patients, radio-scapho-lunate fusion in 1 and excision of scaphoid with carpal tenodesis in 1 patient.

After a mean follow-up of 15 months (6–27 months) the results were evaluated based on (Fernadez 2001), pain, range of motion, and grip strength. Excellent results (18–20 points) were observed in three patients, good results (15–17 points) in five patients and fair results (12–14 points) in two patients.

We conclude that the use of this particular material provides satisfactory stability on the corrective osteotomy and because of its low profile it can be applied on the dorsal side on the radius without interfering with the extensor tendons.

In Essex-Lopresti injuries, the prevailing concept, according to which the stability of the forearm can be restored after fixation of the fracture or replacement of the radial head by a metallic implant, is disputable. The aim of this study is to evaluate the midterm results in 12 patients with an Essex-Lopresti injury who were treated operatively.

We studied 12 patients, with comminuted fracture of the radial head, either isolated (4 patients) or with injury of the ipsilateral (4 patients) or the contralateral (4 patients) arm. Initially, 10 patients were treated with excision of the radial head whereas 2 underwent internal fixation of the radial head and pinning of the DRUJ. Eventually, everyone developed a subluxation of DRUJ and had to be treated for an established Essex-Lopresti injury, 1–7 months after the initial injury. Six patients were treated with equalization of the radioulnar length (ulnar shortening osteotomy with or without a distractor-external fixator) and restoration of the TFC, while six patients underwent replacement of the radial head with a titanium implant, equalization of the radioulnar length and restoration of the TFC.

The results were evaluated after a mean follow-up of 4 years (1–12 years), based on radiological and clinical criteria. The six patients in whom the titanium radial head implant was used presented with good results, even though two of them reported forearm pain during activity. On the contrary, in the rest of the patients the radioulnar incongruity reappeared in varying degrees. However the poor radiological result was not consistent to the clinical one.

We conclude that in cases of complete rupture of the interosseous membrane, internal fixation or replacement of the radial head with a metallic implant will not probably provide us with a good long-term functional result.

Wrist malalignment, in cases of malunited fractures of the distal radius, is not always a consequence of adaptation of the wrist to new conditions, but an expression of non-diagnosed ligamentous injuries. The aim of our study is to examine if the wrist malalignment is correctable with radius osteotomy.

Twenty nine patients (17 female, 12 male) of mean age 51 years, with symptomatic malunited fracture of the distal radius with dorsal angulation, of duration 3 months -47 years, were examined. Twenty seven patients underwent corrective radius osteotomy (open dorsally in 26 cases and closed palmarly in 1 case). Fixation material (plate and screws) was placed on the dorsal side in 23 cases and on the volar side in 4 cases. In all patients measurements on the lateral X-ray view, concerning the reversal of the normal palmar tilt of the radius, the radiolunate and lunocapitate angles, were performed before and after surgery. Based on those measurements patients were divided in two groups:

a) In group A (23 patients) the malalignment concerned the midcarpal joint, and

The radiographic element of evaluation was the radiolunate angle. Radiolunate angle greater than 25° indicated malalignment at the radiocarpal level while radiolunate angle less than 25° indicated malalignment at the mid-carpal level. In 5 patients post-operative measurements were not performed because in addition to the radial osteotomy they were subjected to operative correction of wrist malalignment.

Results estimated immediately postoperative and at the final follow-up, 6 months later. In patients with midcarpal malalignment, correction was possible, under the condition of a sufficient radius osteotomy and a non fixed midcarpal deformity. In patients with radiocarpal malalignment the deformity persisted despite the correction of the radial osteotomy.

We conclude that correction of wrist malalignment is not always achieved with corrective osteotomy of the radius and that preoperative radiological control may be indicative of the possibility of correcting the deformity.

Fracture of the volar rim of the distal radius could be an isolated fracture or part of a complex type of fracture. Frequently it is displaced and rotated because of the attachment of the volar radio-carpal ligaments. Fixation of this fragment is mandatory to preserve integrity of radio-carpal and distal radio-ulnar joints. Given the difficulty of manipulation of this osteochondral fragment we studied the efficiency of a wire-loop as a method of fixation of this fragment.

Eleven patients were examined (8 male, 3 female) mean age 42,6 years (21–72 years) who had various type of fractures of the distal radius but had in common the presence of an osteochondral fracture of the volar radial rim in the ulnar side (7 patients), in the radial side (3 patients) or on both sides (1 patient). Distal radius fracture was type B3.1 (1 patient), B3.3 (4 patients), C3.1 (3 patients), C1.3 (1 patient) and radiocarpal fracture-dislocation in 2 cases. All patients were treated operatively. Eight of them had early (1 – 10 days post-injury) and three had delayed treatment (1 month post-injury). The rim fragment was found displaced in all patients and rotated 45°-180° in 5 patients. Different types of fixation of the distal radius fractures were used, while in all patients the rim fragment was fixed using a wire loop.

Results were estimated after a mean follow-up of 1 year (6 months- 4 years) using clinical (pain, function, range of motion, grip strength) (Cooney 1987) and radiological (articular congruence, arthritis) criteria. Results were evaluated as excellent (4 patients), good (5 patients) fair (1 patient) and poor (1 patient), while in two cases there was loss of fragment reduction.

In conclusion, although intraarticular fractures are often associated with injury of the interosseous ligaments, probably they have no effect on the integrity of the volar radiocarpal ligaments, the origins of which could influence the volar rim fracture displacement. Wire loop is a valid method for fixation of osteochondral fracture of the volar radial rim, giving stability and avoiding comminution and necrosis of the fragment.

It is known that the delayed diagnosis of Essex-Lopresti injury can lead to devastating results concerning the function of the upper extremity. The aim of our study is to suggest methods of early diagnosis and treatment based on our experience on ten patients who were treated for this rare injury.

We studied 10 patients (9 male and 1 female), average 36,5 years old (25–53) who sustained comminuted fracture of the radial head, isolated (3 patients) or with concomitant injury of the ipsilateral (3 patients) or the contralateral upper extremity (4 patients). Initially, 8 patients were treated with excision and 2 with internal fixation of the radial head and radioulnar transfixing pin. Gradually, they all developed subluxation of the DRUJ and they were treated for established Essex-Lopresti injury, 1–7 months after initial injury. Six patients were treated with reduction of radioulnar length (ulnar shortening osteotomy, with or without distraction with an external fixator) and TFC suturing. In 4 patients the radial head was replaced with a metallic implant, joint levelling and TFC suturing.

The results were estimated after an average follow-up of 67 months (1–10 years) based on radiological (radioulnar equivalence) and clinical criteria (wrist and elbow range of motion, forearm rotation and grip strength). Excellent results were achieved in 4 patients who underwent metallic radial head replacement. Conversely, in the rest patients the radioulnar discrepancy relapsed in various degrees but the radiological result does not correlate with the clinical picture.

We concluded that early diagnosis is necessary but not the only prerequisite for a good long-term result. Replacement of the radial head with titanium implant, offers good result at least in the short and mid-term period.

Nonunion of the distal radius is a rare complication (0.2%) which gradually can lead to deformity, pain and dysfunction of the hand. We examined 7 patients who developed nonunion of the distal radius after surgical intervention and we try to rationalize this complication.

Our material consisted of 7 patients (2 male and 5 female) average 51 years old (31–75). Two patients with distal radial malunion, developed nonunion after corrective osteotomy. Four patients with comminuted metaphyseal radial fracture and concomitant distal ulna fracture, developed nonunion after application of an external fixator alone or in combination with internal fixation. Finally one patient with isolated fracture of the distal metaphysis developed nonunion after internal fixation. All patients after the confirmation of the nonunion and until radiological union underwent 1–3 operations. The index procedures for final union were wrist arthrodesis (1 patient) radioscapholunate fusion with excision of the distal scaphoid (2 patients) and internal fixation (4 patients). Additionally, in 6 patients a supplementary method for DRUJ asymmetry was needed.

Results were estimated after a mean follow-up of 30,8 months (1–4 years) based on radiological and clinical criteria. There were 1 excellent, 5 good and 1 fair result.

Despite the existence of predisposing factors (comminution, associated fracture of the distal ulna, metabolic disease, osteoporosis, distraction through external fixator), the contribution of the surgeon to the development of the nonunion is undeniable.

Aim : We investigated the combination of closed reduction, percutaneous osteosynthesis with screws and external fixation in the treatment of high-energy fractures of the tibial condyles with severe soft-tissue lesions.

Method : We studied 35 fractures (11 open) of the tibial condyles. Twenty-eight were Schatzker type VI, 5 type V and 2 type I. The fracture was reduced under fluoroscopic control and the articular surface was fixed with cannulated lag screws. In 23 patients (group A) a unilateral external fixation was applied with the proximal pins placed in the tibial condyles. In 12 patients (group B) an external fixation crossing the knee was used for 6 weeks followed by a knee brace. The follow-up period was 8–45 months

Results: All fractures united in a mean time of 15 weeks except for two in group A that needed conversion to internal fixation. Ten knees developed pintract infection. All knees had range of motion of at least 1000 except for one in group B that developed osteoarththritis. A collapse of the articular surface of more than 5mm and malalignment of more than 60 were observed in 7 and 5 patients in group A and B respectively.

Conclusions: Limited internal and external fixation are a satisfactory technique for selected fractures of the tibial plateau, particularly with poor soft-tissue envelope. Crossing the knee with the external fixator does not necessarily lead to significant stiffness.

Introduction: Isolated compressive fractures of the scaphoid and lunate fossa of the distal radius are rare injuries and their closed reduction is almost impossible. Frequently the displacement becomes accepted and conservative treatment was applied which in the long-term could have catastrophic consequences concerning the fate of articular cartilage.

Material and Methods: Seven patients (6 males and 1 female) of mean age 30 years old (range 18–42) were studied with compressive fracture of scaphoid (4 patients) or lunate (3 patients) fossa. All patients (except one with compressive fracture of the lunate fossa who was treated early), were initially treated conservatively. Mean delay of surgical treatment was 36 days (3 patients) while two patients were operated 2 and 2, 5 years postinjury. One patient with fractured lunate fossa had concomitant fracture of the lunate. The vast majority of the patients underwent supplementary imaging techniques (CT scan, MRI, 3D-CT scan). The majority of patients were approached both intraarticularly and extraarticularly.

Results: Results were estimated after an average follow-up of 12 months (range, 6 months – 3 years) according to clinical and radiological criteria. Six patients revealed excellent or good result while one had a fair result.

Conclusion: In conclusion, operative treatment of these intraarticular fractures should be attempted independently of the time elapsed from injury on the premise that there are no arthritic changes and an adequate pre-operative planning has done.

Introduction: Internal fixation of distal radius fractures with dorsal plates (when needed) comprise two potential problems: efficacy of stabilization and the high frequency of tendonitis which forced us to early removal of the hardware. Our purpose is to study the efficacy of the method of stabilization with 2 plates (2mm) the central and radial columns of distal radius according to the technique presented by Regazzoni (1993).

Material and Methods: Eight patients (5 males and 3 females), average 35 years old (range, 20–52 years) were treated with comminuted intraarticular fracture type C (6 patients) or malunion of distal radius (2 patients). A combined approach was used in 4 patients and only dorsal approach in the rest 4 patients. In all patients with recent comminuted fractures a supplementary fixation method with allograft were used. In patients with mal-united fractures the technique with two plates together with iliac graft were applied.

Results: Results estimated after mean follow-up of 14 months (range 9–18 months) according to clinical (pain, range of motion, and grip strength) and radiological (articular congruency, radial height, radial inclination and palmar tilt) criteria. Six patients revealed excellent or good result although two patients with loss of reduction needed a second operation.

Conclusion: We concluded, that when the technique with 2 plates was applied correctly the stability of fixation enhanced because the detrimental rotational forces were cancelled while the frequency of tendon irritation decreased.

Only a few cases of palmar carpal subluxation associated with an ulnovolar fragment from the distal radius have been reported previously. We report a case which was treated operatively six months after the injury.