Proximal Row Carpectomy (PRO has been used as an alternative treatment for advanced radiocarpal arthrosis and carpal collapse. Its use has been recommended for Kienbock’s disease, chronic scaphoid nonunion and scapholunate advanced collapse (SLAC) deformity. Materials – Methods: Twenty-three patients were divided into two groups: group 1, consisting of patients with Kienbock’s disease (10 patients), and group 2, consisting of patients with scapholunate advanced collapse (13 patients). The average age was 51 years (range 27–69) for group 1, and 45 years (range 29–57) for group 2. The average follow-up was 30 months for Kienbock’s disease (range, 23–49 months) and 31 months for SLAC deformity of the wrist (range, 24–51 months). Pre-operative staging was performed on all patients utilizing Lichtmann’s (Lichtmann and Degnan, 1993) classification for Kienbock’s disease and Watson’s (Watson and Ballet, 1984) classification for scapholunate advanced collapse. The procedure was performed as described by Jorgansen (1969) utilizing a dorsal midline approach between the third and fourth dorsal compartments. Styloidectomy, preserving the radiocapitate ligament was performed in 7 out of the 23 patients (5 Kienbock’s and 2 SLAC wrist’s patients). Posterior Interosseous Nerve neurectomy was performed in 2 out of the 10 patients with Kienbock’s disease. Results: Statistically significant differences were noted between the Kienbock’s disease group and the SLAC wrist group (p=0.0023). Of the patients who underwent PRC for Kienbock’s disease 9 of 10 patients reported moderate to severe pain at the final follow-up visits. In the scapholunate advanced collapse group, 2 out of 13 patients demonstrated moderate or severe pain. It was noted that the patients in the SLAC wrist group lost less motion overall than those in the Kienbock’s dis ease group (p=0.00l 5). It was noted in the Kienbock’s disease group that at final follow-up the operated hand was weaker than preoperative (p=0.022). In the scapholunate advanced collapse group there was improvement of postoperative grip strength. Conclusion: We currently recommend the use of wrist arthroscopy as an adjunct to determine the status of the lunate articular surface in Kienbock’s disease, before performing a proximal row carpectomy. Our results indicate that despite only minor chondromalacia of the capitate articular surface and lunate facet of the radius, the use of PRC in Kienbock’s has not been rewarding

Twenty four patients who had a Proximal Row Carpectomy (PRC) were reviewed 9 months to 9 years post surgery (average 5 yrs). The initial cohort of 14 patients was previously reported to the society in a review encompassing 12 months to five years follow-up post surgery. No patients were lost to follow-up. Primary pathology involved wrists with scapholunate advanced collapse, long-standing scaphoid non-unions and fragmented Kienbock’s disease. All patients had painful wrists limiting function preoperatively. Twenty wrists continue to function well with their PRC. They are comfortable and strong. Mass power grip was 77% of the non-injured side. A functional flexion/extension arc of 65 % of the non-injured side was obtained. No patients with functioning PRCs have had to change their work or recreational activities primarily because of their wrist. Rapid return to work and sport was achieved in the twenty patients with a well functioning PRC. Four wrists (from the first cohort) were converted to wrist fusion for unresolved pain all around a year post PRC. Three patients developed major reflex sympathy dystrophy requiring intensive therapy. Three patients developed carpal tunnel syndrome requiring decompression. PRC is appealing in its surgical simplicity as a motion preserving procedure for the painful wrist. In the majority of circumstances it is both reliable and durable providing a comfortable strong wrist with a functional range of movement. Rehabilitation is uncomplicated and function is rapidly recovered. Patients with ongoing pain can be salvaged with a wrist fusion

Pathologies such as Scapho-Lunate Advanced Collapse (SLAC), Scaphoid Non-union Advanced Collapse (SNAC) and Kienbock's disease can lead to arthritis in the wrist. Depending on the articular surfaces that are involved, motion preserving surgical procedures can be performed. Proximal Row Carpectomy (PRC) and Four Corner Fusion (4CF) are tried and tested surgical options. However, prospective studies comparing the two methods looking at sufficient sample sizes are limited in the literature. The purpose of this study was to prospectively compare the early results of PRC vs 4CF performed in a single centre. Patients with wrist arthritis were prospectively enrolled (2015 to 2021) in a single centre in Vancouver, Canada. Thirty-six patients and a total of 39 wrists underwent either a PRC (n=18) or 4CF (n=21) according to pre-operative clinical, radiographical, and intra-operative assessment. Patient-Rated Wrist Evaluation (PRWE) scores were obtained preoperatively, as well as at six months and one year post operatively. Secondary outcomes were range of motion (ROM) of the wrist, grip strength, reoperation and complication rates. Statistical significance was set at p=0.05. Respectively for PRC and 4CF, the average PRWE scores at baseline were 61.64 (SD=19.62) and 63.67 (SD=20.85). There was significant improvement at the six-month mark to 38.81 (SD=22.95) (p=0.031) and 41.33 (SD=26.61) (p=0.007), then further improvement at the 12month mark to 33.11 (SD=23.42) (p=0.007) and 36.29 (SD=27.25) (p=0.002). There was no statistical difference between the two groups at any time point. Regarding ROM, statistical difference was seen in pronation for the PRC group at the 6month mark from an average of 72.18 deg to 61.56 deg and in flexion at the 12 month mark from 47.89 deg to 33.50 deg. All other parameters did not show statistically significant difference post operatively. For ROM of the 4CF group, only flexion at the 12month mark showed statistically significant change from an average of 48.81 deg to 38.03 deg. There was no statistical difference in pre-operative ROM between the two groups. One patient in the 4CF group required a revision for delayed union, and three patients ended up with ulnar sided wrist pain. Patients undergoing PRC and 4CF showed significant improvement in post operative PRWE scores, this reflects existing literature. For 4CF care must be taken to minimise ulnar sided wrist pain by relatively shortening the unar sided carpal column mass. ROM analysis showed that patients lost some wrist flexion ROM post-operatively at the 12month mark with both PRC and 4CF. However, other ROM parameters were unchanged

Surgical results following proximal row carpectomy modified with proximal capitate resection and dorsal capsule interposition are presented. A consecutive cohort of thirteen patients was operated upon, and outcomes measured by radiograph, physical examination and DASH questionnaire. AROM values of 50° to 105° for the flexion/extension arc, restoration of grip strength to 72% of the contralateral extremity, and an improved functional outcome can be expected; and patients’ perceptions of functional outcome, as measured by the DASH, are significantly improved as early as six weeks. The results of PRC with interposition for stages II and III SLAC wrist were uniformly favorable. Eaton has described two modifications to the proximal row carpectomy (PRC) procedure: partial capitate resection and dorsal capsular interpositional arthroplasty. The objective is to enlarge the radiocarpal interface to form a broad mobile pseudoarthrosis that would disperse compressive forces across the wrist more effectively. We present the first consecutive cohort of patients (n=13) who have undergone this procedure,. We extend the indications for PRC in this series to include those wrists with stage III SLAC deformity; approximately 67% of wrists had capitolunate arthritis. AROM values of 50° to 105° for the flexion/extension arc, restoration of grip strength to 72% of the contralateral extremity, and an improved functional outcome can be expected from PRC with dorsal capsular interpositional arthroplasty. Patients’ perceptions of functional outcome, as measured by the DASH, are significantly improved as early as six weeks following the procedure. Mean flexion/extension arc achieved was 86° (range, 50° to 105°). Radial deviation averaged 13° (range, 10° to 20°), and ulnar deviation averaged 21° (range, 15° to 25°). Grip strength averaged 72% of the contralateral extremity. The mean decline in the revised carpal height ratio was 24%. The mean DASH score was 20.8 (range, 10 to 29). Visual analog pain improved from 9.25 to 2.67 on average, with one patient reporting no pain with heavy exertion. Patients were evaluated by active range of motion ; grip and pinch strength; radiographs; subjective analog pain; and DASH questionnaire

Four-Corner Fusions (4CF) and Proximal Row Carpectomies (PRC) are common procedures utilized to treat carpal pathologies and radial sided wrist pain. Usually, the range of motion (ROM) and grip strength (GS) is affected by such conditions. Literature quotes significant reduction in ROM (50–60%) and grip strength (GS) (80% of normal) with PRC and 4CF. This study aims to determine the correlation between pre-operative ROM and GS and post-operative ROM and GS for patients with wrist pain undergoing PRC or 4CF. We hypothesize that ROM between pre-operative and post-operative patients does not change, but GS improves.

Data from a prospective database of patients with wrist pain was searched to identify patients who have undergone PRC or 4CF with one year follow-up completed in the past two years. 17 such participants were identified. The diagnosis, pre-operative ROM in flexion, extension, radial deviation, ulnar deviation, pronation and supination, as well as GS at time of surgery and at six months and one year follow up were identified and assessed. The data was analysed to determine correlation between pre-and postoperative ROM and GS. The analysis was subdivided to compare patients treated with PRC versus patients with 4CF.

No significant difference between pre- and post-operative ROM was detected, except in flexion at 6 months post-operatively. The average flexion was significantly lower at 6 months (p=0.0251) compared to pre-operative levels. Average flexion pre-operatively and at 6 and 12 months was found to be 46.6 (SD=15), 34.3 (SD=13.3), 51.2 (SD=21.5) respectively. Extension was at 41.4 (SD=15.3) pre-operatively and at 33.4 (SD=12.8) and 42.1 (SD=15.5) at 6 and 12 months post-operatively. Similarly, radial and ulnar deviation averages pre-operatively and at 6 and 12 months post-operatively were found to be 11.33 (SD=5.9), 11.9 (SD=4.5), 16 (SD=8.2) [radial deviation] and 24.1 (SD=8.3), 21.4 (SD=7.3), 26 (SD=12.8) [ulnar deviation].

No significant difference was found in GS at 6 months post-operative. However, significant difference at 12 months post-operatively was observed with an average GS of 28.4 kg (SD=12.8) [p=0.0385]. Average GS pre-operatively and at 6 months was 15.8 kg (SD=9.7) and 17.3 kg (SD=8.9) respectively.

This study provides an insight on ROM and GS after PRC and 4CF. It shows that patients do not gain or lose ROM after surgery. As expected, GS improves with treatment as the pain diminishes. It is interesting to note that flexion gets worse at 6 months post-operatively before it bounces back to pre-operative levels.

The December 2013 Wrist & Hand Roundup. 360 . looks at: Scapholunate instability; three-ligament tenodesis; Pronator quadratus; Proximal row carpectomy; FPL dysfunction after volar plate fixation; Locating the thenar branch of the median nerve; Metallosis CMCJ arthroplasties; and timing of flap reconstruction

The August 2015 Wrist & Hand Roundup360 looks at: Scaphoid screws out?; Stiff fingers under the spotlight; Trigger finger: is complexity needed?; Do we really need to replace the base of the thumb?; Scapholunate ligament injuries and their treatment: a missed research opportunity?; Proximal row carpectomy versus four-corner arthrodesis

Introduction. Transscaphoid perilunate dislocation is a rare injury and therefore it is easily missed at the initial treatment. Once ignored, an alternative treatment such as proximal row carpectomy is indicated, but surgical outcome is not as good as that of an early reduction. Also late reduction (> 3 months) is not possible and needs extensive dissection. We present an alternative technique of staged reduction with better outcome. Material & Methods. 16 cases (14 males & 2 females) with neglected Transscaphoid perilunate dislocation (> 3 month old) were treated with staged reduction. In first stage an external fixator was applied across the wrist and distraction was done at 1mm/day. Second surgery was done through dorsal approach and we were able to reduce all the fractures & dislocations. Herbert screws and K wires were used for fixation. Results. The mean duration between two surgeries was 2.4 weeks (range 2–4 weeks). 13 cases had excellent results, one had fair result. Two patients developed reflex sympathetic dystrophy and had poor results. Conclusion. Staged reduction should be considered for neglected Transscaphoid perilunate dislocations. If properly executed, a good functional pain free range of motion is the usual outcome

Complex carpal injuries can be difficult to assess and manage. They usually occur following high energy injuries to the wrist. Imaging in the form of traction views and a CT scan can help understand the detail of the fracture dislocation pattern. Perilunate dislocations and perilunate fracture dislocations are commonly managed with a dorsal approach to provide an anatomic reduction. A volar approach can be used is median nerve entrapment and allows a surgical repair of the volar aspect of the lunotriquetral ligament. Perilunate dislocations are often classified into greater and lesser arc injuries. The greater arc injuries include fractures which go through the radial styloid, scaphoid, capitate or triquetrum. Lesser arc injuries are through the scapholunate ligament and lunotriquetral ligament. It is common for there to be a combination of greater and lesser arc injuries. We have also identified a complex injury which is a lunate intra-arc injury. This is a fracture through the lunate. With this translunate perilunate dislocation it is important to stabilise the lunate prior to stabilising the remainder of the carpus. The authors have reviewed a series of complex injuries and developed a classification system based on the above findings. In complex cases where reconstruction is difficult then salvage procedures can be performed. SLAC wrist procedure, proximal row carpectomy and full wrist fusion can be performed particularly in highly comminuted cases or cases with a delayed presentation

50 consecutive cases of Scaphoid non-union were treated by open reduction and internal fixation. Average age of non-union was 2.8 yrs ranging fron 6 months to 6 years. Most common approach used was volar. Herbert screw was used to fix 48 non-unions while K wires were used in 2 cases. Bone graft was harvested from patient’s iliac crest and was used in nearly all cases. Wrist was immobilised in a plaster for an average duration of 12 weeks post operatively. All the cases were done by a single surgeon and the cases were recorded by an independent observer. The average follow up was 2 years ranging from 1 year to 6 years. Radiographic union was achieved in 45(80%) cases. Failure of union was seen in 10 cases out of which 5 were proximal pole fractures of which 2 went into avascular necrosis. Denervation of wrist, proximal row carpectomy and four corner fusion was used in 5 cases to salvage the wrist. This modest study carried out at a district general hospital of South East England suggests that scaphoid bone continues to be a challenge for general orthopaedic surgeon as some of these fractures are missed initially. Open reduction and internal fixation of Scaphoid non-union continues to give a predictable outcome

Different techniques were proposed for reconstruction after distal radial resection for bone tumors. When not dealing with heavy workers or complex revision cases, a motility preserving procedure can be used. From 1999 to 2007 we performed a reconstruction with an ostearticular allograft in 18 patients. Age of the patients ranged from 13 to 56 years. Histotypes were: giant cell tumor in 16 patients, Ewing sarcoma in 1, osteosarcoma in 1. Neadjuvant chemotherapy was used in Ewing and osteosarcoma patients. Length of resection ranged from 5 to 13 cm. An accurate host-graft capsulorraphy was performed to reestablish joint stability; no adjunctive distal radioulnar stabilization procedures were used. In one case the procedure was performed after a failed previous graft-arthrodesis; in this case also a proximal row carpectomy was performed. Non-union of the allograft occurred in 2 cases. In one case autologous cancellous bone grafting from the iliac crest was performed. In the second case the patient due to mild symptoms has till now refused further surgery. No septic complications occurred. One patient presented a fracture of the allograft; a revision procedure was performed with a new allograft but also the second graft failed and an arthrodesis was performed. This was the only complete failure of our series. Follow-up ranged from 20 to 103 months. No recurrences (local or distant) were observed. The patients were evaluated with radiographic and clinical examination. Functional evaluation was performed using ISOLS-MSTS score and a wrist-specific functional score (PRWE). The oncological and functional results in our series highlight that a functional wrist can be restored with an osteoarticular allograft after distal radial resection for bone tumors. Deterioration of the results could occur in the long-term and thus further monitoring with a longer follow-up is needed

Different techniques were proposed for reconstruction after distal radial resection for bone tumors. When not dealing with heavy workers or complex revision cases, a motility preserving procedure can be used. From 1999 to 2007 we performed a reconstruction with an ostearticular allograft in 18 patients. Age of the patients ranged from 13 to 56 years. Histotypes were: giant cell tumor in 16 patients, Ewing sarcoma in 1, osteosarcoma in 1. Neadjuvant chemotherapy was used in Ewing and osteosarcoma patients. Length of resection ranged from 5 to 13 cm. An accurate host-graft capsulorraphy was performed to reestablish joint stability; no adjunctive distal radioulnar stabilization procedures were used. In one case the procedure was performed after a failed previous graft-arthrodesis; in this case also a proximal row carpectomy was performed. Non-union of the allograft occurred in 2 cases. In one case autologous cancellous bone grafting from the iliac crest was performed. In the second case the patient due to mild symptoms has till now refused further surgery. No septic complications occurred. One patient presented a fracture of the allograft; a revision procedure was performed with a new allograft but also the second graft failed and an arthrodesis was performed. This was the only complete failure of our series. Follow-up ranged from 20 to 103 months. No recurrences (local or distant) were observed. The patients were evaluated with radiographic and clinical examination. Functional evaluation was performed using ISOLS-MSTS score, a wrist-specific functional score (PRWE) and a comprehensive evaluation of upper arm function score (DASH). The oncological and functional results in our series highlight that a functional wrist can be restored with an osteoarticular allograft after distal radial resection for bone tumors. Deterioration of the results could occur in the long-term and thus further monitoring with a longer follow-up is needed

Introduction: The literature gives ample evidence to discourage sub-optimal reductions of perilunate fracture/dislocations. These, inevitably, lead to poor long-term results. Aim: To evaluate critically the results of open reduction, fracture stabilisation and ligament repair in a cohort of greater and lesser arc perilunate dislocations treated by one surgeon at a single institution. Method: Ten patients who underwent reconstructive surgery for perilunate wrist injuries were reviewed at least 18 months following their surgery. The pathology included three pure perilunate dislocations (PD), three trans-scaphoid perilunate fracture-dislocations (TSPD), one TSPD with a lunate fracture, one trans-scaphoid PD, and two trans radial styloid PDs. Each patient was assessed at a single clinic visit. A clinical rating based on the modified Mayo Wrist Scoring Chart was applied noting pain, satisfaction, range of motion and grip strength. Radiographic analysis was also performed. Results: Nine out of 10 patients had returned to their preoperative employment. Overall, 70% of the patients were satisfied with their wrist function and 50% had mild pain only on vigorous activities. There were five ‘fair’ results and five ‘poor’ results. The range of scores was 30 to 75 (average = 55). Average arc of motion was 78 degrees. Three patients showed evidence of wrist arthritis. One patient had a pin site infection. Two patients still had mild nerve symptoms – one ulnar and one median nerve. One patient needed a proximal row carpectomy. Conclusions: Greater and lesser arc injuries of the wrist are associated with high energy trauma. These injuries result in significantly reduced wrist function, however they are treated. Open reduction and ligament repair with fracture stabilisation lead to a high degree of patient satisfaction and pain relief. In this study the clinical wrist score did not support this

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

The underlying natural history of suspected scaphoid fractures (SSFs) is unclear and assumed poor. There is an urgent requirement to develop the literature around SSFs to quantify the actual prevalence of intervention following SSF. Defining the risk of intervention following SSF may influence the need for widespread surveillance and screening of SSF injuries, and could influence medicolegal actions around missed scaphoid fractures.

The February 2015 Wrist & Hand Roundup360 looks at: Toes, feet, hands and transfers… FCR Tendonitis after Trapeziectomy and suspension, Motion sparing surgery for SLAC/SNAC wrists under the spotlight, Instability following distal radius fractures, Bilateral wrist arthrodesis a good idea?, Sodium Hyaluronate improves hand recovery following flexor tendon repair, Ultrasound treatments for de Quervain’s, Strategies for treating metacarpal neck fractures.