Background  Several volar plating techniques exist to treat distal radial fractures. Question  We investigated minimally invasive plate osteosynthesis (MIPO) with pronator quadratus (PQ) sparing versus conventional flexor carpi radialis approach for volar plating with PQ repair after distal radial fractures during the first postoperative year. Patients and Methods  Prospective data of two consecutive cohorts were compared: 62 patients in MIPO group with an average age of 61.2 years and 66 patients in PQ repair group with an average age of 61.4 years completed the entire follow-up period. Results  Range of motion was not significantly different, except flexion-extension that was significantly higher in the MIPO group. Quick Disabilities of the Arm, Shoulder and Hand was significantly lower in the MIPO group. Pain visual analogue scale was only significantly lower at 6 weeks. Grip strength measurements and patient satisfaction were not significantly different. Conclusions  MIPO volar plating with PQ sparing is a surgical technique that can be chosen according to surgeon's preference and expertise, resulting in a better flexion-extension mobility and function score according to our study. Level of evidence  This is a Level 3 study.

Minimally Invasive Pronator Quadratus Sparing Approach versus Extended Flexor Carpi Radialis Approach with Pronator Quadratus Repair for Volar Plating in Distal Radial Fractures

Distal radius fractures are the most common type of upper extremity fractures, and their incidence is increasing. There has been a rise in the surgical treatment of distal radius fractures, primarily with volar locking plate fixation. Although this procedure is commonly done among orthopaedic surgeons, the role of pronator quadratus repair after fixation remains controversial. The pronator quadratus serves as a secondary forearm pronator and a dynamic stabilizer of the distal radioulnar joint. Aside from a functional role, repair of the pronator quadratus has been proposed to serve as a biologic barrier between the volar locking plate and the flexor tendons to minimize tendon irritation. In this narrative review, we discuss the current treatment trends, the surgical approach for volar locking plate treatment of distal radius fractures, and the anatomy and function of the pronator quadratus. We discuss the case for and against the repair of the pronator quadratus, both for function and prevention of flexor tendon irritation and rupture. The preponderance of high-level evidence demonstrates no benefit to pronator quadratus repair for pain relief or function. The current evidence does not conclusively support or refute pronator quadratus repair as a biologic barrier from the flexor tendons. 

Role of Pronator Quadratus Repair in Volar Locking Plate Treatment of Distal Radius Fractures

Bone morphological changes of the trapezium and first metacarpal with early thumb osteoarthritis progression

Palmar plate fixation of the distal radius fracture involves dissecting the pronator quadratus (PQ). This is regardless of whether the approach is radial or ulnar to the flexor carpi radialis (FCR) tendon. It is not yet clear whether and to what extent this dissection leads to a functional loss of pronation or pronation strength. The aim of this study was to investigate the functional recovery of pronation and pronation strength after dissection of the PQ without suturing.From October 2010 to November 2011, patients aged over 65 with fracture were prospectively enrolled in this study. Fracture stabilisation was performed via the FCR approach without suturing the PQ. Follow-up examinations took place 8 weeks and 12 months postoperatively, and pronation and supination strength were analysed by means of an especially developed measuring device.212 patients were initially screened and 107 were enrolled. The range of motion compared to the healthy opposite side was Ext/Flex 75/66% 8 weeks postoperatively. Pronation was 97% with a pronation strength of 59%. After 1 year, the scores improved to Ext/Flex 83/80%. Pronation recovered to 99% and pronation strength to 78%.The present study can show a recovery of pronation as well as pronation strength in a large patient population. At the same time, the pronation strength is still significantly lower 1 year after the operation than on the opposing healthy side. As the pronation strength recovers as the grip strength and is at all times on a par with the supination strength, we believe that we can continue to refrain from re-fixating the pronator quadratus. 

/pdf/does-access-through-the-pronator-quadratus-influence-30makc5m.pdf

Does access through the pronator quadratus influence pronation strength in palmar plate fixation of distal radius fractures in elderly patients?

In this prospective, randomized comparative study in patients with distal radial fractures, we aimed to determine whether surgical repair of the superficial head after anterior locking plate fixation of the radius improves clinical or functional outcomes or both, and distal radioulnar joint stability. One hundred patients were randomized to undergo distal radial fixation with or without repair of the superficial head. Twenty-one patients were lost to follow-up, leaving a final sample of 79 patients. No differences were observed between the groups in functional scores or complication after operation. Surgical repair of the superficial head of the pronator quadratus muscle after osteosynthesis with an anterior locking plate for distal radial fractures does not appear to substantially contribute to preserving distal radioulnar joint stability or improving the consolidation process.Level of evidence: II. 

Is pronator quadratus muscle repair required after anterior plate fixation for distal radial fractures? A prospective randomized comparative study

The objective was to evaluate pronator quadratus (PQ) repair following volar plating of distal radial fractures on clinical and functional outcome, as well as flexor tendon friction, during the first 12 months in ideally positioned plates (Soong 0). Confounding factors like variation in plate positioning, anatomical consolidation of the fracture and associated lesions were excluded. Eighty patients were included with distal radius fractures treated by volar locking plate in Soong grade 0 position, who were randomized to group PQ repair and group no repair. Sixty-five patients completed the 1-year follow-up: group PQ repair (n = 35) and group no repair (n = 30). Primary outcomes included range of motion, grip strength, pain level and QuickDASH. Secondary outcomes included distance between flexor pollicis longus (FPL) and volar rim and the largest distance between FPL and plate (soft tissue thickness occupied by PQ), assessed by ultrasonography. Mobility, grip strength and QuickDASH revealed no significant differences, except extension was significantly higher only in first 3 months and radial deviation was significantly higher only at 6 weeks after PQ repair. Pain level was significantly lower after PQ repair only in the first 3 months. Distance between FPL and volar rim and the largest distance between FPL and plate were significantly higher after PQ repair. No friction contact between FPL and volar rim was measured in both groups at all measurement moments. Consequently, protective flexor tendon effect of PQ repair could consequently not be concluded. In conclusion, clinical and functional short term benefits, except improved wrist extension and reduced pain in the first 3 months, were not proven in this study. In Soong grade 0, PQ repair is probably not necessary to prevent flexor tendon pathology. In Soong grade 1 or 2, this is still to be investigated. 2.

Pronator quadratus repair after volar plate fixation in distal radial fractures: evaluation of the clinical and functional outcome and of the protective role on the flexor tendons—a randomized controlled study

We assess the distribution of trapezial inclination in a young population in order to propose a threshold for trapezial dysplasia. One hundred peritrapezial views were reconstructed from wrist computed tomography scan datasets to measure trapezial inclination. Seventy peritrapezial views were constructed from 10 datasets to assess the influence of radiograph rotation. Mean trapezial inclination in our population was 8° (range 0.2–17.9). Fifteen degrees of radiographic pronation or supination did not alter trapezial inclination significantly. Intra-rater consistency and absolute agreement had an interclass correlation (ICC) of 0.95. Inter-rater consistency and absolute agreement had an ICC of 0.88. Trapezial inclination is a reliable measurement for trapezial dysplasia with an excellent intra-rater and good inter-rater reliability and does not change significantly with 15° of radiographic pronation or supination. These normal values can be used to propose a threshold for trapezial dysplasia in the management of trapeziometacarpal joint instability in the younger population. Level of evidence: IV

Defining trapezial dysplasia – analysis of trapezial inclination in a normal population

Traumatic lesions around the base of the thumb have special features due to the location and structure of the joint and its inherent potential instability. This causes different fracture patterns, which are mostly isolated around the metacarpal base but can also involve just the trapezium or both. Exceptionally, there may be isolated dislocation. Fracture patterns are variable and influence the type of surgery. The most common fracture is Bennett's fracture accounting for 4% of all hand fractures and sometimes associated with trapezium fracture, usually in male subjects. Different fracture mechanisms have been proposed. Apart from intra-articular fractures of the metacarpal base and the trapezium, proximal metaphyseal fractures can exceptionally be treated conservatively by immobilization. All other fractures require open or closed reduction combined with different types of temporary pinning or open reduction and internal fixation with screws or locking plate in case of comminution. Immobilization depends on the type of surgical treatment and can be removable or non-removable. Close follow-up is mandatory to avoid the inconveniences of secondary swelling with non-removable plaster and resin casts. Extra-articular malunion may be tolerated, but articular malunion must be corrected surgically by intra-articular osteotomy to restore the joint. In case of posttraumatic joint degeneration, treatment will focus on a case-by-case basis on the patient's complaints. Arthrodesis or prosthetic surgery can be proposed in case of severe problems caused by osteoarthritis. 

Traumatic lesions at the thumb base: treatment options.

Atypical presentation of a subungual intraosseous epidermoid cyst of the thumb: A case report.

Primary articular synovial chondromatosis of the fifth metacarpophalangeal joint in a child.

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