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Regarding “The Effect of Brachioradialis Release During Distal Radius Fracture Fixation on Elbow Flexion Strength and Wrist Function”
862
LETTERS TO THE EDITOR
2. Strauch RJ. Extensor tendon injury. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative Hand Surgery. 6th ed. Philadelphia, PA: Churchill Livingstone; 2011:159e188.
3. Meadows SE, Schneider LH, Sherwyn JH. Treatment of the chronic boutonniere deformity by extensor tenotomy. Hand Clin. 1995;11(3): 441e447.
Regarding “The Effect of Brachioradialis Release During Distal Radius Fracture Fixation on Elbow Flexion Strength and Wrist Function” BR insertion to act as a septum between the flexor tendons and the plate. If the BR insertion were not repaired, should we still suture the pronator quadratus with it? We look forward to the authors presenting further clinical data on cases of the proximal portion of the BR that was released and not repaired.
To the Editor: With great interest, we have read the article by Kim et al.1 Their conclusion that “Release of the BR [brachioradialis] during a volar approach for a distal radius fracture did not adversely affect elbow flexion strength and wrist function” is attractive, because it means that we could save time and simplify the surgical procedure for distal radius fractures. We usually perform the extended flexor carpi radialis approach for a volar buttress plate in treating distal radius fractures. For debridement to reduce intra-articular fragments, it is necessary to release the radial septum and pronate the proximal stump of the radius. According to guidelines from some documents and the American Society for Surgery of the Hand instructional course2 (Kakar et al, presented at the 69th Annual Meeting of the American Society for Surgery of the Hand, 2014), the BR rigid insertion was released in a sharp step-cut fashion at the level of the fracture line, with its distal portion attached to the distal fragment and its proximal portion elevated about 3 cm off to facilitate pronating the proximal fragment to give sufficient room to debride the fracture site and reducing intra-articular fragments. After the hardware inset, the BR cut was repaired and served as an anchor to reattach sutures of the pronator quadratus. However, the authors’ description of “released the portion of the BR that was attached to the distal fracture fragment” contradicts this maneuver. If the portion of the BR that was attached to the proximal fracture fragment were not released, it would be much more difficult to rotate the radius palmarly. Although some authors documented that releasing the BR tendon from its insertion had minor effects on its ability to transmit force to the distal radius based on a cadaver study,3 we still repair the severed (released) BR insertion in practice, to avoid an adverse functional effect of pronation and flexion on the wrist and elbow. Moreover, the pronator quadratus muscle was released from the radius to facilitate reducing the metaphyseal fractures and setting the hardware. After osteosynthesis, the pronator quadratus muscle was sutured to the repaired J Hand Surg Am.
Ren-Guo Xie, MD, PhD Department of Hand Surgery Affiliated Hospital of Nantong University Nantong, Jiangsu, China http://dx.doi.org/10.1016/j.jhsa.2015.01.045 REFERENCES 1. Kim JK, Park JS, Shin SJ, Bae H, Kim S-Y. The effect of brachioradialis release during distal radius fracture fixation on elbow flexion strength and wrist function. J Hand Surg Am. 2014;39(11): 2246e2250. 2. Obay JL, Touhami A. Current concepts in volar fixed-angle fixation of unstable distal radius fractures. Clin Orthop Relat Res. 2006;445: 58e67. 3. Tirrell TF, Franko OI, Bhola S, Hentzen ER, Abrams RA, Lieber RL. Functional consequence of distal brachioradialis tendon release: a biomechanical study. J Hand Surg Am. 2013;38(5):920e926.
In Reply: We would like to thank the author for his interest and the comments made concerning our article.1 The author commented that repairing brachioradialis (BR) during volar plate fixation of distal radius fracture (DRF) would be better than the method we described (releasing the BR without repair) in 3 respects. First, the author raised a concern that we did not release the BR attached to the proximal fracture fragment. However, this is the result of a misunderstanding. We do release the BR attached to the proximal fracture fragment and have experienced no difficulty elevating the BR in the proximal fragment, although we release the BR tendon transversely. Second, the author pointed out that releasing the BR without repair would adversely affect elbow flexion strength. However, previous biomechanical studies showed that BR attachment to the distal fracture fragment contributes little to total elbow r
Vol. 40, April 2015
LETTERS TO THE EDITOR
2. Strauch RJ. Extensor tendon injury. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative Hand Surgery. 6th ed. Philadelphia, PA: Churchill Livingstone; 2011:159e188.
3. Meadows SE, Schneider LH, Sherwyn JH. Treatment of the chronic boutonniere deformity by extensor tenotomy. Hand Clin. 1995;11(3): 441e447.
Regarding “The Effect of Brachioradialis Release During Distal Radius Fracture Fixation on Elbow Flexion Strength and Wrist Function” BR insertion to act as a septum between the flexor tendons and the plate. If the BR insertion were not repaired, should we still suture the pronator quadratus with it? We look forward to the authors presenting further clinical data on cases of the proximal portion of the BR that was released and not repaired.
To the Editor: With great interest, we have read the article by Kim et al.1 Their conclusion that “Release of the BR [brachioradialis] during a volar approach for a distal radius fracture did not adversely affect elbow flexion strength and wrist function” is attractive, because it means that we could save time and simplify the surgical procedure for distal radius fractures. We usually perform the extended flexor carpi radialis approach for a volar buttress plate in treating distal radius fractures. For debridement to reduce intra-articular fragments, it is necessary to release the radial septum and pronate the proximal stump of the radius. According to guidelines from some documents and the American Society for Surgery of the Hand instructional course2 (Kakar et al, presented at the 69th Annual Meeting of the American Society for Surgery of the Hand, 2014), the BR rigid insertion was released in a sharp step-cut fashion at the level of the fracture line, with its distal portion attached to the distal fragment and its proximal portion elevated about 3 cm off to facilitate pronating the proximal fragment to give sufficient room to debride the fracture site and reducing intra-articular fragments. After the hardware inset, the BR cut was repaired and served as an anchor to reattach sutures of the pronator quadratus. However, the authors’ description of “released the portion of the BR that was attached to the distal fracture fragment” contradicts this maneuver. If the portion of the BR that was attached to the proximal fracture fragment were not released, it would be much more difficult to rotate the radius palmarly. Although some authors documented that releasing the BR tendon from its insertion had minor effects on its ability to transmit force to the distal radius based on a cadaver study,3 we still repair the severed (released) BR insertion in practice, to avoid an adverse functional effect of pronation and flexion on the wrist and elbow. Moreover, the pronator quadratus muscle was released from the radius to facilitate reducing the metaphyseal fractures and setting the hardware. After osteosynthesis, the pronator quadratus muscle was sutured to the repaired J Hand Surg Am.
Ren-Guo Xie, MD, PhD Department of Hand Surgery Affiliated Hospital of Nantong University Nantong, Jiangsu, China http://dx.doi.org/10.1016/j.jhsa.2015.01.045 REFERENCES 1. Kim JK, Park JS, Shin SJ, Bae H, Kim S-Y. The effect of brachioradialis release during distal radius fracture fixation on elbow flexion strength and wrist function. J Hand Surg Am. 2014;39(11): 2246e2250. 2. Obay JL, Touhami A. Current concepts in volar fixed-angle fixation of unstable distal radius fractures. Clin Orthop Relat Res. 2006;445: 58e67. 3. Tirrell TF, Franko OI, Bhola S, Hentzen ER, Abrams RA, Lieber RL. Functional consequence of distal brachioradialis tendon release: a biomechanical study. J Hand Surg Am. 2013;38(5):920e926.
In Reply: We would like to thank the author for his interest and the comments made concerning our article.1 The author commented that repairing brachioradialis (BR) during volar plate fixation of distal radius fracture (DRF) would be better than the method we described (releasing the BR without repair) in 3 respects. First, the author raised a concern that we did not release the BR attached to the proximal fracture fragment. However, this is the result of a misunderstanding. We do release the BR attached to the proximal fracture fragment and have experienced no difficulty elevating the BR in the proximal fragment, although we release the BR tendon transversely. Second, the author pointed out that releasing the BR without repair would adversely affect elbow flexion strength. However, previous biomechanical studies showed that BR attachment to the distal fracture fragment contributes little to total elbow r
Vol. 40, April 2015