SECTION I: SYMPOSIUM: Problem Fractures of the Hand and Wrist
In 1987 and again in 1996, at the time of the first and second publications of the symposium Problem Fractures of the Hand and Wrist, the focus was on injuries of the hand with little attention devoted to the wrist. In 1996, the latest advance at that time for treatment of distal radius fractures was the arthroscopically aided reduction of intraarticular fractures. The current symposium's classic article on the internal splinting of metacarpal fractures illustrates the innovative thinking of Bosworth in 1937 and is a reminder that some things haven't changed dramatically in the treatment of hand injuries during the last half century.
This greatly contrasts with the innovation that has occurred in the treatment of distal radius fractures. For the last 10 years, much of the energy and innovation in hand surgery has focused on distal radius fractures. The development of stronger, lower-profile locking plates has revolutionized the treatment of these injuries. Although the current symposium presents new information on the treatment of problem fractures of the hand and wrist, the advances in wrist operative treatment clearly have the most to offer the practicing surgeon. As guest editors, we have provided a history of the treatment of fractures of the hand and wrist to put the most recent surgical advances in perspective.
During the last six years the treatment of distal radius fractures has been dominated by the concept of volar plating; however, other innovative approaches have just become available. Brooks et al describe their experience with the use of two new intramedullary implants for minimally invasive treatment of distal radius fractures. Capo et al also remind us not to forget the usefulness of the external fixator and provides their experience on how to avoid common complications. Schnall et al provide a compelling argument for fragment-specific fixation of distal radius fractures with an outcome study on its use in the United States and in Sweden. Orbay and Touhami provide new insight into the concept of volar fixation, focusing on the unique anatomy of the volar surface of the distal radius and the biomechanics involved in volar plating.
The biomechanics of plate design and the effects of implant metallurgy on soft tissues are covered in two papers. Mudgal and Jupiter provide an up-to-date analysis of the current state of affairs in plate and screw design for hand and wrist applications, and Cohen et al report an animal study looking at the impact of implant metallurgy and design on tendon function.
Two papers focus on the complex issues faced by surgeons who care for injuries of the wrist. The concept of bridge plating of complex distal radius fractures is presented by Hanel et al in their Harborview Method. Fernandez et al present their unique concept for treating failed Sauvé-Kapandji procedures with spherical ulnar head prosthesis.
The challenges of treating fractures of the scaphoid, scaphoid nonunions, and associated perilunate injuries are described in three papers. Slade and Dodds dare us to “think outside the box” in treating scaphoid nonunions. Weil et al then provide an outstanding introduction to new concepts in the treatment of perilunate injuries with open and arthroscopic approaches.
The most recent advances in the treatment of fractures of the hand are covered in depth by Freeland and Orbay and potential pitfalls in the treatment of pediatric phalangeal fractures are described in detail by Cornwall and Ricchetti. Tuttle et al review the current concepts in dealing with difficult avulsion fractures of the distal phalanx. Finally, Hughes provides a timely update on the use of bioabsorbable implants in the treatment of hand fractures.
The guest editors thank all of the authors for their invaluable addition to this body of knowledge on the treatment of problem fractures of the hand and wrist. All of the authors are among the leading thinkers in our field and truly deserve our respect and admiration for their innovations and honest assessment of their results. When we analyze the rapid advances in the treatment of distal radius fractures during the last 10 years, it is our hope that we can follow this lead with further improvements in the treatment of other injuries of the upper extremity. With the continued contributions of our authors and others like them this is not just a possibility but a certainty.
Neil Harness, MD
Southern California Permanente Medical Group, Orange County Orthopaedics, Yorba Linda, CA; and
Roy A. Meals, MD
UCLA School of Medicine, Division of Orthopaedic Surgery, Los Angeles, CA