Case #1 May 10-11 2013 Edward Diao, M.D. Professor Emeritus of - - PowerPoint PPT Presentation

5/11/2013 1

Symposium: Upper Extremity Trauma

58th Annual Leroy C. Abbott Society Scientific Program 34th Annual Verne T. Inman Lectureship May 10-11 2013

Edward Diao, M.D. Professor Emeritus of Orthopaedic Surgery & NeuroSurgery University of California, San Francisco

Case #1 History

• 69 year old man
• ESRD, dialysis, DM II
• Fell in his backyard onto his bilateral wrists
• Bilateral distal radius ORIF at another hospital
• Presentation: pain and deformity 6 mos later
• Left side healed uneventfully
• Right side resulted in nonunion
• Hardware removal

Physical Exam

• Good finger motion
• Supple fracture motion, with moderate

pain

• No sign of carpal tunnel syndrome
• Normal vascular exam
• No tendonitis (trigger fingers, de

quervain's etc)

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Wrist Deformity Initial Films Initial Closed Treatment ORIF: Hardware Failure

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Hardware Removed Extreme Loss of Reduction Distal Radius Nonunion

• Traditionally, nonunion has been a rare complication
• f treatment of distal radius fractures
• Reported incidence 0.02% in reviews of thousands of

cases, historically1

• Recent trend toward open treatment may be

increasing the incidence

• Most literature pre-dates modern methods of internal

fixation

• 1 Bacorn R.W., Kurtzke J.F. A study of two thousand cases from the New

York State Workmens Compensation Board. J Bone Joint Surg. 1953; 38A, 643-58.

Distal Radius Nonunion

• Largest reported series of distal radius nonunion:

Diego Fernandez, series of 23 patients.

• These authors advocated attempt at ORIF even

when distal fragment was “small”

• This experience mostly predates modern internal

fixation devices.

• Prommersberger KJ, Fernandez DL. CORR 2004 Feb;(419):51-6.

Nonunion of distal radius fractures. Clinic of Hand Surgery, Rhön-Klinikum, Bad Neustadt, Germany.

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CT Scan

Plan

• To repeat the same thing and expect a

different result would be unwise

• Would need to address ulnar positivity
• Articular surface is spared, so revision
• pen reduction and internal fixation might

be rewarding, with ICBG

• Ulnar shortening performed at the same

time as revision ORIF

Initial Post-Op

2 year follow up

• Functional
• Painless
• Stable wrist
• Flex/Ext Arc 120deg
• Pron 75 deg
• Sup 70 deg
• DRUJ stable
• Right side has better
• Motion than left

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Case #2

Case Presentation

• 37-year-old woman s/p R elbow fracture 24

years ago.

• Status-post excision of radial head

– Subsequent arthrosis of radial head – Proximal migration of the radius

• DRUJ dysfunction and ulnocarpal abutment
• Loss of supination

Case Presentation

• C/O Chronic right elbow pain.
• C/O Chronic wrist pain as well
• Limited ROM:

– Good pronation to 90 degrees – But, supination approximately 60 degrees.

• Tenderness over the ulnar side of the wrist

when the wrist was in full extension and ulnar deviation.

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Diagnosis?:Essex-Lopresti Treatment?:

• Ulna Shortening
• Radial Lengthening
• One Bone Forearm
• Other

Valgus stability

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Proximal Migration

• The principal deformity after proximal translation is at

the wrist:

– The distal ulna sits dorsal and distal to the carpus, blocking supination and extension of the wrist. – Essex-Lopresti P: Fractures of the radial head with distal radio-ulnar dislocation: Report of 2 cases. J Bone Joint Surg Br 1951;33:244-247.

• “the optimal solution to acute forearm dissociation would be internal

fixation of the radial head.”

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Post-Op Xrays

Details of Radiocapitellar Joint

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Final Result

• Elbow room: 0/1400
• Pronation: 900
• Supination: 900
• Pain is significantly diminished

Case #3 G.B.

• 81 yo male, elite golfer
• Severe OA on Right Elbow
• Has a leg prosthesis
• Golfs 18 holes daily

DOS: 02/11/2009

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DOS: 01/14/2009

Choices

• 1. TEA
• 2. Fascial Interposition Arthroplasty
• 3. Fusion
• 4. ???

OR: 2/11/2009

• Scope R elbow
• Complete loss of articular cartilage
• Open Kocher approach, radial head excision
• Push-pull test negative for radius migration
• Annular ligament reconstruction

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G.B. – Post-Op

F/U: 11/10/2010 (1 ½ yr P/O)

• Recovery took 6 months
• Plays 18 holes every other day
• No swelling

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5/11/2013 13

FU: 1/11/12 (3 yrs P/O) Case #4 V.B. - DOB:1962

• College basketball player – Forward
• Right wrist scaphoid injury 30 years ago
• Now a 51 y.o. recreational athlete, still 6’8”

and FIT

• He can’t shoot the basketball without pain
• He is having increasing trouble as an

adult…can’t shoot the basketball anymore

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Diagnosis?: SNAC Wrist Treatment?:

• Wrist Fusion
• Scaphoid Excision/Four

Corner Fusion

• Anything more conservative?

V.B. OR 9/14/2009

• Arthroscopic synovectomy, TFCC debridement
• Proximal row radiolunate and radioscaphoid joints

preserved

• Scaphoid partial excision distal radial portion (gross

degeneration)

• Radial styloidectomy
• Scapholunate ligament degeneration noted
• Chronic scaphoid nounion pseudoarthrosis noted

Post-op 9.23.09 V.B. Follow-up 5 ½ yrs

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V.B. Follow-up 5 ½ yrs

• No symptoms…I saw him when he brought his

son in

• Playing basketball, doing push ups, no pain
• ROM is good 80% of normal
• Fluoroscans did not show progression of

disease

OV 3.12.13

Case #5 C.G.

• 32 yo male, R hand dominant.
• R chronic scaphoid non-union.
• OR #1: Volar approach + bone graft in distant past,
• OR #2: 12/16/2009 – ORIF dorsal approach screw.
• OR #3: 5/17/2010 – Revision with screw removal +

Bone graft substitute

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OV: 5/6/2010

Post ORIF OR #2 – screw backed out OV: 5/17/2010 More Deformity! OV: 10/18/2010 Post OR #3

S/P 2 operations with conventional fixations with bone substitutes.

?Now what should be done?

Judgement Call

• Screw
• Screw plus bone graft
• Vascularized bone graft +/- fixation
• Salvage procedure

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Vascular Anatomy of the dorsal distal radius

• A. Shin & A. Bishop; JAAOS 2002
• A. Shin & A. Bishop; JAAOS 2002

The arc of reach of various distal radius pedicled bone grafts 1,2 ICSRA Fourth ECA

• A. Shin & A. Bishop; JAAOS 2002
• A. Vascularized bone graft

donor site. 1,2 ICSRA is identified

• B. Dashed lines =

incisions of the first and second extensor compartments

• A. Shin & A. Bishop; JAAOS 2002

Vascularized bone graft mobilization and insertion into scaphoid nonunion

5/11/2013 18 PRE-OP #4: 10/18/2010

OR #4 (10/18/2010)

Post-Op OR #4: 2/1/11

1, 2, IMA Vascularized Bone Graft

Scaphoid Fx - Advancements

• Better implants – cannulated compression

headless screws

• Better surgical techniques – dorsal and volar

approaches

• Local vascularized pedicled bone grafts for

malunions and nonunions

• Faster rehab, reduced immobilization, better

results

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Case #6 O.L. – OR #1 2.3.10

• Severe rheumatoid arthritis of R thumb
• Complete synovectomy of T thumb IP
• Complete release of medial and ulnar collateral

ligaments

• Osteectome
• Arthrodesis

O.L. – 2.3.10 3.17.10

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O.L. – OR #2 6.29.11

• Rheumatoid arthritis/CREST syndrome w/

MCP jt arthritis, deformity and contracture

• Tenolysis of flexor tendons x2
• Volar plate release MCP joint
• Collateral ligament release MCP joint
• Intrinsic release of 3rd finger
• MCP joint arthroplasty with implant

Pre-Op 2.69.11 Intra-Op 6.29.11

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Post-op 2.12.13 O.L. – OR #3 2.22.13

• Right hand Rheumatoid arthritis and scleroderma

with PIP 2nd and 3rd joint severe arthropathies status post prior reconstructive surgery

• 2nd PIP joint resection arthroplasty and implant

arthroplasty

• 3rd PIP joint resection arthroplasty and implant

arthroplasty

• Rebalancing of Boutonniere/swan neck deformity, 2nd

and 3rd fingers

• Reconstruction radial collateral ligament, 2nd and 3rd

finger with local tissue

Post-op 3.5.13 Post-op 4.9.13

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Post-op 5.9.13 Post-op 5.9.13

Thank you!