Tendon injuries after distal radius fractures Introduction: Tendon injuries after distal radius fractures are a well-documented complication that can occur in fractures managed both operatively and non-operatively. The extensor tendons, in particular the extensor pollicis longus (EPL) tendon, can be damaged and present late after initial management in a cast, or by long prominent screws that penetrate the dorsal cortex and cause attrition. Similarly, a prominent or distally placed volar plate can damage the flexor pollicis longus tendon (FPL). The aim of our study was to evaluate the incidence of tendon injuries associated with distal radius fractures. We conducted a single centre prospective observational study. Patients aged 18–99 who presented with a distal radius fracture between May 2018 to April 2020 were enrolled and followed-up for 24 months. Tendon injuries in the group were prospectively evaluated. Results: 199 patients with distal radius fractures were enrolled. 119 fractures (59.8%) had fixation and 80 (40.2%) were managed incast. In the non-operative group, 2 (2.5%) had EPL ruptures at approximately 4 weeks post injury. There were no extensor tendon ruptures in the operative group. In the operative group, there were 6 (5%) patients that required removal of metalware for FPL irritation. At the time of operation, there were no tendon ruptures noted. Within the operative group we evaluated plate prominence using a previously described classification (Soong et al.). 5 of the 6 patients (83%) with FPL irritation had Grade 3 prominence. The incidence of both flexor and extensor tendon injury in our cohort was 4%, extensor tendon rupture was 1% and flexor tendon rupture was avoided by early metalware removal. This study demonstrates tendon injuries are not uncommon after distal radius fractures, and close examination and follow-up are necessary to prevent eventual rupture. Plate prominence at the time of fixation should be minimised to reduce the risk of rupture

Background. Patients with hand injuries frequently present to Emergency Departments. The ability of junior doctors to perform an accurate clinical assessment is crucial in initiating appropriate management. Objectives. To assess the adequacy of junior doctor hand examination skills and to establish whether further training and education is required. Methods. A double-centre study was conducted using an anonymous survey assessing hand examination completed by junior doctors (Foundation year 1 and Senior House Officer grades) working in Trauma & Orthopaedics or Emergency Departments. The survey covered all aspects of hand examination including assessment of: Flexor and Extensor tendons, Nerves (motor and sensory) and Vascular status. Surveys were marked against answers pre-agreed with a Consultant hand surgeon. Results. 32 doctors completed the survey. Tendons: 59% could accurately examine extensor digitorum, 41% extensor pollicis longus, 38% flexor digitorum profundus and 28% flexor digitorum superficialis. Nerves – Motor: 53% could accurately examine the radial nerve, 37% the ulnar nerve, 22% the median nerve and 9% the anterior interosseous nerve. Nerves – Sensory: 88% could accurately examine the radial nerve, 81% the ulnar nerve, 84% the median nerve and 18.8% digital nerves. Vascular: 93% could describe 3 methods of assessing vascularity. Conclusions. Tendon and neurological aspects of hand clinical examination were poorly executed at junior doctor level in this pragmatic survey. This highlights the need for targeted education and training to improve the accuracy of junior doctor hand injury assessment and subsequent improving patient treatment and safety. Recommendations include dedicated hand examination teaching early in Orthopaedic/A&E placements and introduction of an illustrated Hand Trauma Examination Proforma. Level of evidence. III - Evidence from case, correlation, and comparative studies

Myotome values for the upper limb appear to have been established in the early twentieth century based on historical work. Supraclavicular brachial plexus injuries present with a pattern of neurological loss consistent to the nerve roots affected. Recent advances in radiological imaging and intraoperative nerve stimulation have allowed confirmation of the affected nerve roots. The records of 43 patients with partial injuries to the supraclavicular brachial plexus were reviewed. The injuries covered the full range of injury patterns including those affecting C5, C5-6, C5-7, C5-8, C7-T1 and C8-T1 roots. All cases with upper plexus injuries had surgical exploration of the brachial plexus with the injury pattern being classified on the basis of whether the roots were in continuity, ruptured, or avulsed, and, if seen in continuity, the presence or absence of a response to stimulation. For lower plexus injuries the classification relied on identification of avulsed roots on Magnetic Resonance Imaging. Muscle powers recorded on clinical examination using the MRC grading system. In upper plexus injuries paralysis of flexor carpi radialis indicated involvement of C7 in addition to C5-6, and paralysis of triceps and pectoralis major suggested loss of C8 function. A major input from T1 was confirmed for flexor digitorum superficialis, flexor digitorum profundus (FDP) to the radial digits, and extensor pollicis longus. C8 was the predominant innervation to the ulnar side of FDP and intrinsic muscles innervated by the ulnar nerve with some contribution from C7. A revised myotome chart for the upper limb is proposed

Introduction: Various variants of the extensor indicis (EI) have be described in the literature. We wanted to detect whether there exist any variants of the EI that may cause restricted mobility of the thumb following EI transposition to the extensor pollicis longus (EPL). Patients & method: Intraoperatively the function of the extensor tendons of 168 hands (98 right / 70 left) of 159 patients (96 female / 63 male) were examined. The function of the muscles was simulated using a tendon-hook. For ethical reasons the approach was not extended for the study. Results: In 34 of 168 hands 39 accessory tendons were found: 8 were localized between EPL and EI (1 from the EPL to the index; 3 extensor pollicis et indicis; 1 from the EI-muscle to the thumb; 3 to the radial extensor hood of the index). 31 accessory tendon were found ulnar to the EI (2 to the ulnar extensor hood of the index; 25 to the middle finger; 3 to the ring finger; 1 to the little finger). The EI was missing in only one hand, were a strong extensor anularis-tendon was found, which would have been suitable for EPL-reconstruction. 8 of these variants would hinder the thumb from isolated extension following EPL-reconstruction with the EI-tendon. Conclusion: The extensor tendons should be inspected carefully through EI-transposition for reconstruction of EPL to ensure a free function of the thumb postoperatively. Small accessory tendons that may cause trouble should be cut, strong tendons should be transposed together with the EI-tendon

Introduction Kirschner wire (K-wire) pinning is a widely accepted technique for fixation of distal radius fractures. Potential exists for injury to the soft tissues. This cadaveric study evaluates the safety of percutaneous pinning of distal radius fractures using a technique of intrafocal placement of K-wires. Methods Three K-wires (1.6 mm diameter) were inserted percutaneously into 18 cadaveric wrists 18 mm proximal to the radial styloid. A radial wire was placed between the first and second extensor compartments. A dorso-radial wire was placed proximal to Lister’s tubercle. A dorsoulnar wire was placed between the fourth and fifth compartments. The wrists were dissected along the wires to the bone. Results The superficial radial nerve (SRN) was pierced twice (11%), the abductor pollicis longus six times (33%), the extensor pollicis brevis and the extensor carpiradialis brevis once (6%). Extensor pollicis longus (EPL) was entered five times (28%), the fourth compartment four times (22%) and the fifth compartment once (6%). Only four wrists (22%) escaped injury to any important structure. Conclusions The incidence of SRN injury by percutaneous insertion of K-wires is similar to that reported for the mini-open approach of around 12%. Rupture of EPL has been reported at around two percent. Aetiology of rupture is unclear and a K-wire that is subsequently removed may not increase the risk of rupture

Purpose: The retrospective evaluation of long-term results after reconstructive radial osteotomy for mal-united distal radius fractures. Material-Method: Twenty-eight patients (21 male and 7 female, average aged 46 years) with 23 dorsal and 5 palmar angulated malunited distal radius fractures were operatively treated during 1994–2002 in our department. The main indications were pain and functional impairment. Dorsal or palmar approach was used in proportion to the site of angulation. The preoperative average radial inclination, radial length and volar or dorsal tilt were 13.5 degrees, 6.3 mm and 23.5 degrees respectively. An open wedge radial osteotomy followed by interposition of trapezoidal iliac crest bone graft and fixation with plate ands crews was performed in all patients four months at least after the initial surgery. An ulnar leveling procedure was considered necessary in 2 patients. Results: All patients were available in the last follow up evaluation (mean 3.7 years). The functional result according to Mayo wrist score was rated as very good in 15 patients, good in 7 and poor in 6. The average improvement in radial inclination was 14 degrees, in radial length 6.5 mm and in volar or dorsal tilt 21 degrees. The complication rate was 22.7%, including 2 material failures, 1 extensor pollicis longus rupture, 1 nonunion and 3 recurrences of the deformity. Conclusion: Surgical reconstruction for malunion is technically demanding and may not completely restore the anatomy. Patient satisfaction, however, in terms of increased function, decreased pain and decreased deformity is sufficient high to warrant reconstructive treatment

External fixation of distal radius fractures usually involves the use of a bridging fixator. However, immobilisation of the wrist can be associated with various complications and therefore dynamic external fixators were developed to allow wrist mobilisation with the fixator in place. But dynamic fixators themselves are not without complications and more recently interest has been rekindled in non-bridging external fixators (otherwise called metaphyseal or radial-radial fixators). Following a pilot study using a non-bridging external fixator (Delta frame) in the treatment of intra-articular distal radius fractures, our aim in this study was to compare the functional and radiological outcome of the Delta frame and a standard wrist-bridging static external fixator in the treatment of such fractures. Sixty patients with intra-articular distal radius fractures were randomly allocated to receive either a static bridging Hoffman external fixator or a non-bridging Delta frame. All patients had the fixator removed at six weeks. Clinical and radiographic assessment was performed regularly up to a maximum of twelve months with the clinical results being expressed in terms of range of movement, pain, grip strength and ability to perform certain activities of daily living. Radiological assessment was performed by an independent radiologist. Mean follow-up was ten months. The only sustained significant difference in function was a greater range of flexion in the Hoffman group. No significant difference could be detected between the two groups in terms of the radiological outcome. Complications included pin-site infection, paraesthesia, extensor pollicis longus tendon rupture and chronic regional pain syndrome. Three patients underwent further surgery. We did not demonstrate any advantage in the use of a non-bridging fixator in the treatment of intra-articular distal radius fractures

Pediatric hand surgery in general requires special considerations and this is even more true when planning surgery in children with CP. It is important for the surgeon to realize that the functional problems these children exhibit have their cause in a brain damage which is not amenable to hand surgical treatment. Therefore it is crucial to carefully analyze each child’s impairment including the voluntary motor control and the child’s specific needs before endeavoring into surgery. Associated impairments, such as mental retardation, nutritional problems, epilepsy, dystonia or severe sensory deficits may influence decision-making, but the crucial factor is often the child’s own wish for an improved function. A child that completely neglects his or her extremity is usually not helped by surgery, at least not in an attempt to get a better hand function. Hand surgery in CP mainly comes down to three techniques: 1. Reducing strength in spastic muscles by release operation, either at the origin of the muscle, at the insertion or as a fractional lengthening at the musculo-tendinous junction, 2. Increasing strength in weak antagonists by tendon transfer or 3. Stabilizing joints through an arthrodesis or a tenodesis. Most often a combination of these techniques is used. Almost all hand surgeons in this field have acquired their personal choice of procedures and scientific support for the benefits of the different techniques is scarce. My personal arsenal will be described in the panel but includes biceps-brachialis muscle release at the elbow, pronator teres rerouting, flexor carpi ulnaris to extensor carpi radialis brevis (Green’s) transfer and adductor pollicis muscle release in the palm combined with extensor pollicis longus rerouting for the thumb-in-palm deformity. In my mind, it is not most important which tendon transfer that is selected, but the choice of which child to operate and at what age. It is also important to tension the tendon transfers exactly right and to plan the postoperative treatment properly. The surgeon should, of course, also make sure that the child’s and the parent’s expectations on the results are realistic. Botulinum toxin A has now been used for several years in the treatment of children with cerebral palsy and the drug has been shown to be safe and effective in reducing muscle tone both in the lower and the upper extremities. It has been more difficult to show effects on hand function especially in the long-term perspective. I will present our treatment protocol for botulinum toxin injections. In 1994, a population-based health care program for children with CP was started in Lund in southern Sweden. All children in our region with a diagnosis of CP, born after Jan 1st 1990 are invited to follow the program which includes regular measurements of range of motion in extremity joints, standardized radiographic examinations of the hip joints and registration of surgery and spasticity treatments. The program, called CPUP has been very successful in the prevention of spastic hip dislocation, wind swept position and contractures. Some early results from the upper extremity part of CPUP will be presented. We believe that the program in time will give us valuable information on the natural course of joint motion and impairment of hand function in children with CP

Complications of distal radius fractures range from 20 to 30% and are consequence of injury or of treatment. Management of these complications must be individualised and the multitude of proposal treatments prove that this problem is controversial. Complications may involve soft tissue (tendon, nerve, arterial or fascial complication, reflex symphatetic distrophy) or bone and joint (malunion, nonunion, osteoarthritis). Tendon complications following distal radius fractures, range from minor adhesions to complete rupture. Peritendinous adhesions will become apparent after cast removal. Diagnosis is based on the limitation of the range of movement for individual fingers.This complication can be avoided with a proper cast technique allowing full range of motion to the digits. Treatment consists of rehabilitation techniques and only rarely, in severe cases, operative tenolysis may be a treatment of choice. Tendons may be entrapped either in the fracture site or in the distal radioulnar joint. Most common tendon entrapment are for extensor carpi ulnaris and extensor digiti minimi. If early recognition is made, open reduction with freeing the tendon must be the choice. Late diagnosis will require more complex tenolysis procedures. Tendon rupture may occur at the time of injury due to sharp fracture fragments. Diagnosis is based on identification of functional loss and, whenever possible, primary tendon suture is recommended. If the diagnosis is late the treatment is free tendon graft or tendon transfer. The late rupture of extensor pollicis longus is the most common possibility. Since it is not related with comminution or displacement of fracture it is possible that an ischemic mechanism is involved. Solutions are free tendon graft or the transfer of extensor indicis proprius. Direct tendon repair is not recommended after few weeks. Nerve complications. Careful neurological investigations demonstrated that nerve injuries associated with distal radius fractures are more common than it is believed. Median nerve is most frequently involved. Primary mechanisms of injury are: direct lesions due to fracture fragments, lesions related to forced manipulation and nonanatomical position of immobilization. Late injuries, occurring a long time after the fracture are more frequent and are related to carpal tunnel syndrome or paraneural adhesions. Carpal tunnel pressure could be measured and ethiologic factors must be identificated in order to establish the proper treatment, usually based on relise of carpal tunnel. Ulnar and radial neuropathy are less common and treatment may vary from cast removal to relise of Guyon’s canal. Vascular complications are uncommon, arise usually in relation with high energy trauma and the treatment is complex, involving different speciality surgeons. Some authors presented rare cases of entrapment of vasculare structures or radial artery pseudoaneurism after the use a volar plate. Compartment syndrome after distal radius fracture is rare and is likely to occur in young adults suffering a high energy trauma. Clinical diagnosis is based on the classical 5 “P’s” (pain, pallor, paresthesias, paralysis, and pulselessness) but treatment must start before all symptoms are present. Anytime when compartment syndrome is suspected, intracompartimental pressure must be measured. The treatment must start immediately and consist in removal of constrictive devices (bandage, cast) and fasciotomy. Indications for fasciotomy are intracompartmental pressure of 15–25mmHg in presence of clinical signs or over 25mmHg in absence of clinical signs. If there is doubt, it is better to perform an unnecessary fasciotomy than to wait until lesions becomes irreversible. Reflex sympathetic distrophy is described with many terms such as algodistrophy, cauzalgia, Sûdeck’s atrophy, shoulder-hand syndrome. Recently, the term complex regional pain syndrome was proposed to replace all the exiting synonyms. Despite many theories, the pathogeny of this disease is uncertain. The diagnosis is mainly clinical, based on presence of pain, trophic changes (atrophy, stiffness, edema) and functional impairment but plain x-ray demonstrating osteopenia and bone scintigraphy showing abnormal bone turnover may be helpful. Since the patogeny is unclear, the treatment is targeting the symptoms rather then the disease. Treatment must be individualized and may consist of: physical therapy of the hand, pain control with general or local drugs, corticosteroids, and symphatectomy. Prevention of reflex symphatetic dystrophy in the first days of a distal radial fracture is very important and include: prevention of the edema (elevation of the hand, early mobilization of fingers), decrease of pain, cast removal to relive pression, non-traumatic surgery. Malunion is the most common complication of distal radius fracture and it usually occurs after close treatment. The malalignament may be extraarticular or it may involve the joint (radiocarpal or distal radioulnar joint). Axial shortening and dorsal or radial malalignament are the most common. Clinical signs are wrist pain, loss of grip strength, limitation of wrist mobility. Osteoarthritis is likely to develop in both types of malunions. For extraarticular nonunions osteotomy is usually the treatment of choice. Many types of osteotomies have been proposed but the most commonly used are opening wedge osteotomy and Watson osteotomy. Intraarticular malunion is more difficult to treat and many surgical solutions have been proposed: intraarticular osteotomy, bone resections (styloid, anterior or posterior rim, radiolunate or radioscapholunate limited arthrodesis, proximal row carpectomy, wrist denervation, wrist arthroplasty, total wrist arthrodesis). Salvage procedures on the distal radioulnar joint may be resection of distal cubitus (Darrach) or Sauve-Kapandji technique. Nonunion is an extremely rare complication and is likely to occur in patients with multiple comorbid conditions such as diabetes, peripheral vascular disease or alcoholism. In most cases the initial treatment was close reduction and cast immobilization or external fixation. Diagnosis is based on the absence of radiographic signs of union at 6 months. Treatment must be individualized but basic options are reconstructive procedures or wrist arthrodesis. Reconstructive procedures consist of debridement of nonunion site, realignment with distractor, plate and screw fixation and iliac crest bone grafting. Since the bone is of poor-quality, new implants providing fixation in orthogonal planes may be useful. Usually, malalignement is present, so some authors recommend to take in to consideration the possibility to associate reconstructive procedures with additional techniques such as: dividing brachioradialis tendon, incision of the dorsal or volar joint capsule or Darrach operation in presence of severe shortening of the radius. Wrist arthrodesis should be chosen when the distal fragment has less then 5 millimeters of subchondral bone supporting the articular surface

Aims

Giant cell tumour of bone (GCTB) treatment changed since the introduction of denosumab from purely surgical towards a multidisciplinary approach, with recent concerns of higher recurrence rates after denosumab. We evaluated oncological, surgical, and functional outcomes for distal radius GCTB, with a critically appraised systematic literature review.