The American Society for Surgery of the Hand and the American Association for Hand Surgery held a series of teaching sessions as part of the 2007 Specialty Day at the AAOS Annual Meeting. Presenters reviewed a wide variety of topics, ranging from new viewpoints on classic treatments to cutting-edge surgical techniques, with a focus on evidence-based care for trauma and reconstruction in the upper extremity.
Advantages of clavicle fixation
In a presentation titled “Fractures of the Clavicle: What Evidence Supports Fixation in 2007?” Edward J. Harvey, MD, examined why classic treatments for clavicle fractures may not meet patients’ or physicians’ standards, given the capability of modern technology.
“Traditionally, we were told that treating clavicle fractures nonoperatively would result in an instance of nonunion less than 1 percent,” Dr. Harvey said. “The belief that all clavicles heal well is just not true anymore. It probably never was true—we just didn’t know how to look at the patients properly.” Dr. Harvey cited the results of a meta-analysis of 2,144 clavicle fractures that found the instance of nonunion to be greater than 15 percent.
In comparison, complications of fixation are usually nothing more than local plate irritation and possibly a numb area that gradually shrinks to the size of a quarter, according to Dr. Harvey.
As for the type of fixation (plates versus pins), Dr. Harvey prefers to use a plate. “There have been one or two papers on complications of plate fixation,” he admitted. “I must note, however, that these are older-technique plate fixations. I think the plate technique now, with the lower profile plates, leaves a smaller scar. You can make incisions along the skin folds, there’s minimal stripping, and it works on almost everyone.”
Changing techniques in proximal humerus fractures
In “Operative Management of Proximal Humerus Fractures—Have New Fixation Techniques Changed Recommended Treatment?” A. Lee Osterman, MD, discussed whether evidence-based studies were being employed to determine the benefits of new technology.
In Dr. Osterman’s opinion, the recommended treatment has indeed been changing, but the changes have been driven more by device innovation and patient expectation than by evidence-based studies. “Has the new locking technology improved my treatment?” he asked. “Probably, yes. Do I use it in some cases? Yes. Is it evidence versus advertising? Unfortunately, it’s advertising, and we all know that there’s not necessarily truth in advertising.”
Advertising aside, Dr. Osterman believes that there are encouraging aspects in using the new fixation techniques. “There’s no question that these new plates can solve nonunion and malunion problems,” he said. “Proximal humerus fracture management is evolving; it’s still challenging. We do have an improved understanding of proximal humeral characteristics. There are some innovations out there, and for displaced fractures, locked and pressure plating creates a stable construct with preservation of periosteal blood supply.”
Dr. Osterman expressed a desire to see future evidence-based studies done to quantify the value of the new fixation techniques. “The most important question I can ask about a locking plate and the new osteobiologic technology is whether open reduction/internal fixation will produce better results than hemiarthroplasty, particularly in the more complex fractures,” he said.
Plates and forearm fractures
In his presentation “Pitfalls in the Management of Forearm Fractures and How to Avoid Them,” Douglas P. Hanel, MD, discussed the advantages of using low contact dynamic compression (LCDC) plates in the treatment of forearm fractures. He emphasized that the best results are obtained with anatomic reduction and internal fixation that is stable enough for early motion.
“Fixed angle plates or locking plates are now the rage within the orthopaedic literature,” he said. “I think that they are an adjunct to severe comminution and osteoporosis, but there is no evidence that they are really better than using LCDC plates. The gold standard remains the 3.5-mm equivalent of a dynamic compression plate or an LCDC plate.”
“The supposed, but unrealized, advantage of LCDC plates is that they have less bone-on-plate surface-to-surface contact—that they have better biology, but so what?” he continued. “The [real] advantage is that they are easier to contour; they provide a better anatomic fit. That means it’s easier to contour them, and they are less prone to fatigue.”
Dr. Hanel also addressed the supposed advantages of titanium plates over steel plates. “I would argue that there is absolutely no evidence in our literature that demonstrates that titanium implants in the upper extremity are of any benefit over stainless steel,” he asserted. “There’s not a single article that can tell you that.”
Finally, Dr. Hanel discussed bone grafts. “If there is no cortical contact, a bone graft is appropriate. As long as there is cortical contact at any one segment and rigid fixation, grafting is not indicated.”
Percutaneous scaphoid repair
Joseph F. Slade III, MD, reviewed the finer points of percutaneous scaphoid repair in “Technical Pearls and Pitfalls on Scaphoid Fixation.” According to Dr. Slade, “Rigid fixation—whether you’re using arthroscopic or percutaneous techniques—really depends on five different variables: bone quality, fragment geometry, fracture reduction, choice of implant, and implant placement.”
He advocated approaching scaphoid fixation with percutaneous surgery, using arthroscopy as an adjunct to assist in the repair. “Can you reduce fractures?” he continued. “The answer is yes. You can percutaneously introduce joysticks, and if you’re unhappy with your initial wire position, you can back the wire out and play with it a bit, and then you can advance the wire down. If you have a significant displacement, you need to use two wires or the wire will bend.”
In reviewing the results of several studies on screw placement, Dr. Slade noted that when screws were eccentrically placed, the fracture had a delayed healing rate. When screws were put down the central axis, the fractures tended to heal more quickly. “The central axis is simply the longest, straightest path through the scaphoid, which allows us to use the longest screw we can place,” he said.
Positioning a pin in the scaphoid is a matter of using wires to provide a reference point. His personal technique is to put two wires in the distal scaphoid, at 90 degrees so they are perpendicular. “When you take an X-ray, you’ll have a chart. If you know where you’ll start the pin,” he said, “you can reference the two wires to put the pin down the central axis of the scaphoid.”
Treating the metacarpal
In his presentation “Fractures of the Metacarpal—Technical Pearls for Treatment,” Scott W. Wolfe, MD, discussed what he called the “third most common fracture of the upper extremity.” He pointed out that although hundreds of papers have been written on the subject of the metacarpal, there is very little level 1 evidence available.
“Indications for surgery certainly include open fractures,” Dr. Wolfe said, “accompanied by bone loss, multiple trauma, and importantly, nerve, vessel, and tendon injury. The soft-tissue component is what is going to determine the patient’s outcome.”
“In closed fractures,” he continued, “our enemy is malrotation, irreducible angulation of the fractures, and marked shortening. Malrotation will lead to crossover of digits. It’s been said that about 5 degrees of rotation at the metacarpal leads to about 1.5 centimeters of overlap. This is definitely something you want to identify and address.”
Dr. Wolfe recommended “working your way up the operative ladder” when considering operative treatment options. “Try percutaneous fixation whenever you can,” he advised. “I think this is the mainstay of treatment. The next step up is open reduction, followed by intramedullary pinning, either percutaneous or open, and finally plates. Only go to the plates if you really need them.”
In his summary, Dr. Wolfe stressed the need to “understand your indications for surgery, use a stepwise algorithm for treatment, be careful not to overtreat, know that your severity of soft-tissue injury is likely to predict your outcome, and—if you’re going to choose open reduction, make sure it’s rigid enough to begin early range of motion.”