Scaffold fixation aims to insert a VA locked plate (as a scaffold, subchondral screws) over the reduced fracture, making use of the radiolucent bone clamp for fracture retention, without looking for perfect bone purchase into each one of the main fragments; considering that soft tissues are important to achieve fracture reduction, and to increase construct strength.
Another unique advantage of this bone reduction forceps is that did enhance the ability to get back to normal volar tilt. And the important thing to stress in this study is not only the usefulness of this bone reduction forceps but also the fact that every patient is documented with a postoperative CT scan, which is really the only way to accurately determine determine the quality of the reduction.
This study raises the question clinically of is there truly a SL ligament tear as it would in a perilunar dislocation or an isolated traumatic SL lesion when you see it in conjunction with a distal radius fracture?
The distal radius volar shearing fracture is called a Barton’s fracture, this is clear. The volar part of the radius is disrupted, the dorsal cortex is intact, the dorsal metaphysis is intact and so, when repositioning this fragment, we are pushing up against an intact dorsal cortex. The real question is: are we able to find similar types of fractures but in reverse, that is involving the dorsal sheared component with the volar radius cortex intact?
Among the 125 comminuted distal radius fractures (DRFs) treated with VAP in the ICUCTAGS.net cohort, 61 cases had associated ulnar styloid fractures. Of these, 23 progressed to nonunion. Outcomes were as follows: 2 patients were lost to follow-up; none had a poor or fair outcome. The remaining 24 patients achieved good or very good outcomes. We found no poor outcomes related to ulnar styloid nonunion following volar plating.
We found one case out of 12 with a very poor outcome, which was related to a large positive ulnar variance and ulnar styloid–pisiform impingement. However, a large positive ulnar variance does not necessarily result in a poor outcome. No cases with significant positive ulnar variance were observed among the operated patients.
Although malunion with a residual tilt > 20° is traditionally considered a risk factor, our findings suggest that it does not necessarily lead to persistent ulnar-sided wrist pain. In the ICUC series, most disrupted distal radioulnar joints were well reduced after volar plating. While a few cases remained malreduced, the vast majority of these patients achieved very good functional outcomes.
Despite having screws initially placed in the important subchondral zone, where there’s a substantial metaphyseal defect in osteopenic patients, there is a chance of settling overtime. The results may or may not affect overall radiocarpal motion but may affect overall strength because the carpal radius alignment may be off in a more difficult situation. The screws may then penetrate the articular surface, so it’s actually very important to follow patients post op.
Surgical treatment for Volar Barton’s fracture is widely accepted. Is a non-locking buttress plate enough? Are all volar Barton’s fractures alike? Does patient’s age matter?
We found 42 cases of dorsal articular impacted fractures, out of 177 Distal radius fracture cases in the ICUC database, with massive intraarticular comminuted successfully treated by volar plating alone.
Overall there is not enough evidence to support routine operative treatment of all patients with displaced mid-clavicular fractures. These young, active, highly motivated patients with very displaced fractures, in contrast to what has been considered, may be treated non-operatively, and requires a shared decision.
We have to aim for function not for a perfect X-ray. When we oppos e anatomical reduction versus function I prefer function.
We present the analysis of the 3 patients who were treated nonoperatively. For most surgeons, the ideal treatment would have been a reverse shoulder prosthesis. Nevertheless, all three patients did well with non-operative treatment. This study suggests the possibility of a non-operative treatment trial for burst fractures, with reverse prosthesis considered as a rescue surgery if needed.
Based on the analyzed data, it cannot be conclusively determined whether reduction of the greater tuberosity is mandatory for achieving a good outcome. Detailed case analysis, potentially facilitated by Artificial Experience, could aid surgeons in making more informed decisions.
Rockwood, the champion of prosthesis said in Argentina he not longer operated humeral head in the elderly because they achieve good function without surgery, and there is no need to look at radiological images. We may see in fractures not operated, deformity but with good function, not only in shoulder, it may be the same in the elbow the wrist or the fingers. Good radiology is not a synonymous of the patient being well , without counting the many complications implants and prosthesis may have.
Intra-operative supervision of young surgeons by experienced colleagues/mentors might not always be possible. We present encouraging results of a remote mentorship concept, where in- presence mentoring was not possible and young surgeons were obliged to perform surgeries alone after receiving suggestions from an experienced mentor. Interactive 3D colored models and access to exhaustive data of similar cases from large case series of the ICUC database have proven to be advantageous. The results of 32 tibial plateau fractures treated by young surgeons with the described help of a remote mentor are encouraging.