Objectives. This review aims to summarize the outcomes used to describe effectiveness of treatments for paediatric wrist fractures within existing literature. Method. We searched the Cochrane Library, Scopus, and Ovid Medline for studies pertaining to paediatric wrist fractures. Three authors independently identified and reviewed eligible studies. This resulted in a list of outcome domains and outcomes measures used within clinical research. Outcomes were mapped onto domains defined by the COMET collaborative. Results. Our search terms identified 4,262 different papers. Screening of titles excluded 2,975, leaving 1,287 papers to be assessed for eligibility. Of this 1,287, 30 studies were included for full analysis. Overall, five outcome domains, 16 outcome measures, and 28 measurement instruments were identified as outcomes within these studies. 24 studies used at least one measurement pertaining to the physiological/clinical outcome domain. The technical, life impact, and adverse effect domains were recorded in 23, 20, and 11 of the studies respectively. Within each domain it was common for different measurement instruments to be used to assess each outcome measure. The most commonly reported outcome measures were range of movement, a broad array of “radiological measures” and pain intensity, which were used in 24, 23, and 12 of the 30 studies. Conclusion. This study highlights the heterogeneity in outcomes reported within clinical effectiveness studies of paediatric wrist fractures. We provided an overview of the types of outcomes reported in paediatric wrist fracture studies and identified a list of potentially relevant outcomes required for the development of a core outcome set

Background. Despite the known multifactorial nature of scaphoid wrist fracture non-union, a possible genetic predisposition for the development of this complication remains unknown. This pilot study aimed to address this issue by performing Single Nucleotide Polymorphisms (SNPs) analysis of specific genes known to regulate fracture healing. Materials and Methods. We reviewed 120 patients in a retrospective case-control study from the Hand Surgery Department of Asepeyo Hospital. The case group comprised 60 patients with confirmed scaphoid wrist non-union, diagnosed by Magnetic Resonance Imaging (MRI) and Computed Tomography (CT). The control group comprised 60 patients with scaphoid fracture and complete bone consolidation. Sampling was carried out with a puncture of a finger pad using a sterile, single-use lancet. SNPs were determined by real-time polymerase chain reaction (PCR) using specific, unique probes with the analysis of the melting temperature of hybrids. The X2 test compared genotypes between groups. Multivariate logistic regression analysed the significance of many covariates and the incidence of scaphoid wrist non-union. Results. We found significant differences in subjects who had a smoking habit (p=0.001), high blood pressure (p<0.001), and surgical treatment (p=0.002) in patients with scaphoid non-union. There were more Caucasians (p=0.04) and males (p=0.001) in the case group. Falls were the main mechanism of fracture. The CC genotype in GDF5 (rs143383) was more frequent in patients with scaphoid non-union compared to the controls (p=0.02). CT was prevalent in the controls (p=0.02). T allele in GDF5 was more frequent in patients without non-union (p=0.001). Conclusions. Individuals who were carriers of the CC genotype in GDF5 showed higher susceptibility to suffering scaphoid wrist non-union. Furthermore, being a carrier of CT and T allele suggests that this could be behave as a protection factor against non-union. This is the first clinical study to investigate the potential existence of genetic susceptibility to scaphoid wrist fracture non-union. Level of evidence. Level III, Cross Sectional Study, Epidemiology Study

Aims

The aim of this study was to explore parents’ experience of their child’s recovery, and their thoughts about their decision to enrol their child in a randomized controlled trial (RCT) of surgery versus non-surgical casting for a displaced distal radius fracture.

Aims

The aim of this study was to develop a core outcome set of what to measure in all future clinical research on hand fractures and joint injuries in adults.

Introduction: Previously, we noticed loss of initial reduction with conventional palmar plate osteosynthesis for dorsally displaced distal radius fractures. Locking Compression T plate may provide more stable fixation and we report our early experience.

Materials and methods: Between November 2002 and April 2003, 23 patients (15 women, 8 men), mean age 55, (17–80) underwent open reduction and internal fixation using 3.5 mm locking compression oblique T plate (SYNTHES) through a Henry ‘s approach and a 2 weeks plaster cast immobilisation. All fractures were dorsally displaced. According to AO classification there were 15 A3 and 8 C1 and C2 fracture. 18 patients could be reviewed with a mean follow up of 16 months (6 to 30) Pre operatively, radial inclination was 11.7 ° (0–20), dorsal angulation 25.9 ° (8–48) and ulnar variance:4 mm (0–10)

Results: Post-operatively, radial inclination was 23,2. ulnar variance: 1,2 mm and ventral angulation 4,6 °. At one year follow-up, there was no loss of post-operative reduction. According to SOFCOT ‘s criteria, there were 13 anatomical results and 5 moderate malunion. According to Green and O ‘Brien’s criteria, there were 9 excellent, 6 good, 3 fair and no poor results. Mean DASH score was 22.8 (5.8 – 62.5). Strengh and pinch were respectively 95 % and 91 % when compared with the opposite side. There were 6 complications concerning 4 reflex sympathetic dystrophy, one carpal tunnel syndrome and one hypertrophic scar.

Discussion: In our experience, classic palmar plate fixation showed inability for maintaining reduction during time. Locking Compression 3,5 T plate by a palmar approach which is a demanding technique, avoids loss of post-operative recution

Conclusion Locking Compression 3.5 T Plate by palmar approach is an effective treatment for dorsally displaced distal radius fracture but the plate itself and ancillary tools have to be improved to reduce operatively difficulty.

Introduction. With advances in artificial intelligence, the use of computer-aided detection and diagnosis in clinical imaging is gaining traction. Typically, very large datasets are required to train machine-learning models, potentially limiting use of this technology when only small datasets are available. This study investigated whether pretraining of fracture detection models on large, existing datasets could improve the performance of the model when locating and classifying wrist fractures in a small X-ray image dataset. This concept is termed “transfer learning”. Method. Firstly, three detection models, namely, the faster region-based convolutional neural network (faster R-CNN), you only look once version eight (YOLOv8), and RetinaNet, were pretrained using the large, freely available dataset, common objects in context (COCO) (330000 images). Secondly, these models were pretrained using an open-source wrist X-ray dataset called “Graz Paediatric Wrist Digital X-rays” (GRAZPEDWRI-DX) on a (1) fracture detection dataset (20327 images) and (2) fracture location and classification dataset (14390 images). An orthopaedic surgeon classified the small available dataset of 776 distal radius X-rays (Arbeidsgmeischaft für Osteosynthesefragen Foundation / Orthopaedic Trauma Association; AO/OTA), on which the models were tested. Result. Detection models without pre-training on the large datasets were the least precise when tested on the small distal radius dataset. The model with the best accuracy to detect and classify wrist fractures was the YOLOv8 model pretrained on the GRAZPEDWRI-DX fracture detection dataset (mean average precision at intersection over union of 50=59.7%). This model showed up to 33.6% improved detection precision compared to the same models with no pre-training. Conclusion. Optimisation of machine-learning models can be challenging when only relatively small datasets are available. The findings of this study support the potential of transfer learning from large datasets to improve model performance in smaller datasets. This is encouraging for wider application of machine-learning technology in medical imaging evaluation, including less common orthopaedic pathologies

In-office surgeries have the potential to offer high quality medical care in a more efficient, cost-effective setting than outpatient surgical centers for certain procedures. The primary concerns with operating on patients in the office setting are insufficient sterility and lack of appropriate resources in case of excessive bleeding or other surgical complications. This study serves to investigate these concerns and determine whether in-office hand surgeries are safe and clinically effective. A retrospective review of patients who underwent minor hand operations in the office setting between December 2020 and December 2021 was performed. The surgical procedures included in this analysis are needle aponeurotomy, trigger finger release, mass/foreign body removal and reduction of hand/wrist fracture with or without percutaneous pinning. No major complications requiring extended observation or hospital admission occurred. 122 of the 132 patients (92.4%) were successfully treated with no complications and only mild symptoms within one month of surgery. Five patients (3.8%) returned to the office for pain, inflammation and/or stiffness of the affected finger, with two of the five returning due to osteoarthritis and/or pseudogout flare-ups. Five additional patients returned due to incomplete treatment with continued presence of Dupuytren's contracture (3), trigger finger (1) or infected foreign body (1). One patient (0.8%) developed infection, due to incomplete removal of an infected foreign body, which was subsequently treated with antibiotics and complete foreign body removal. The absence of major complications and high success rate for minor hand procedures shows the high degree of safety and efficacy which can be achieved via the in-office setting for select procedures. While proper patient selection is key, our result shows the in-office procedure room setting can offer the necessary elements of sterility and hemostatic support for several common hand surgeries

Aims:. 1) To determine the predictive value of a simple stability test in children’s wrist fractures treated with simple manipulation and plaster of Paris (PoP) cast immobilisation. 2) To determine the effect of cast quality as reflected in the skin cast distance (distance between the cast and the skin in the plane of major displacement or angulation) and the cast index (the inside diameter of the cast in the sagittal plane divided by the inside diameter in the coronal plane) on re-displacement rates in children’s wrist fractures treated with simple manipulation and plaster of Paris (PoP) cast immobilisation. Methods: This is a prospective study of 57 children aged 4 to 15 with metaphyseal and Salter-Harris II wrist fractures treated with simple manipulation. Under fluoroscopic imaging, a simple stability test involving moving the hand at the wrist in the dorsopalmar, and radioulnar planes was performed following reduction, and x-ray images were saved. We recorded and compared the displacement and angulation on the initial x-rays, during the test, and at one-and 6-week follow-up. We also recorded the skin-cast distance (SCD), and the cast index (CI). Results: 38 patients had isolated radius fractures and 19 had radius and ulna fractures. Four patients needed remanipulation with K-wire fixation. Multiple regression analysis revealed significant correlation between percentage loss of reduction on testing and subsequent re-displacement (relationship between the two sets of values r = 0.6167, (p< 0.001)). This indicates that instability on testing (seen as a significant percentage loss of reduction) is likely to be associated with some loss of reduction on follow-up. There was a significant relationship between the skin cast distance and the cast index, and loss of reduction on one week follow-up. (p=0.006). Isolated radius fractures had a higher risk of re-displacement than radius and ulna fractures (3.9% and 0.9% respectively; p< 0.05%). Conclusion: Stable reduction on stability testing in wrist fractures in children immobilised in a good cast (reflected in a low SCD, and CI) is associated with a good outcome. Isolated radius and ulna fractures are more likely to re-displace than radius and ulna fractures. There is a relationship between instability and loss of position at the 1-week follow-up. Potentially unstable fractures can be prevented from slipping by a good cast. A stable fracture on our stability test rarely slips. We therefore feel that stability test is a useful adjunct in decision-making

Outcome following wrist fractures is difficult to assess. There are many methods used to assess outcome following distal radius fractures, but may be that simply asking the patient for their level of satisfaction may be enough. We looked at 50 wrist fractures at 12 weeks post injury and compared their level of satisfaction with various respected outcome measures (Gartland and Verley, Sarmiento, Cooney, Patient-Rated Wrist Evaluation, Hand Function Score, and Disability of Arm Shoulder and Hand Score) to determine whether there was a correlation with their level of satisfaction. The aim was to determine which wrist scoring system best correlates with patient satisfaction and functional outcome and which individual variables predict a good outcome. Forty-five females and 5 males with a mean age of 66 years (range 19 to 93 years) were included in the study. Multivariate regression analysis was carried out using SPSS 17. Patient satisfaction correlated best with the MacDermid, Watts and DASH scores. The variables in these scoring systems that best accounted for hand function were pain, ability to perform household chores or usual occupation, open packets and cut meat. The McDermid, Watts and DASH scores provide a better measure of patient satisfaction than the Gartland and Verley, Sarmiento and Cooney scores, however they are all time consuming, complicated and may indeed not be necessary. The four most important questions to ask in the clinic following wrist fractures are about severity of pain, ability to open packets, cut meat and perform household chores or usual occupation. This may provide a simple and more concise means of assessing outcome after distal radial fractures

Distal radius fractures (DRF) are very common injuries. National recommendations (British Orthopaedic Association, National Institute for Health and Care Excellence (NICE)) exist in the UK to guide the management of these injuries. These guidelines provide recommendations about several aspects of care including which type of injuries to treat non-operatively and surgically, timing of surgery and routine follow-up. In particular, current recommendations include considering immobilizing patients for 4 weeks in plaster for those managed conservatively, and operating on fractures within 72 hours for intra-articular injuries and 7 days for extra-articular fractures. With increased demands for services and an ageing population, prompt surgery for those presenting with distal radius fractures is not always possible. A key factor is the need for prompt surgery for hip fracture patients. This study is an audit of the current standard of care at a busy level 2 trauma unit against national guidelines for the management of DRFs. This retrospective audit includes all patients presenting to our emergency department from June to September 2018. Patients over 18 years of age with a diagnosis of a closed distal radius fracture and follow-up in our department were included in the study. Those with open fractures were excluded. Data was retrieved from clinical coding, electronic patient records, and IMPAX Client (Picture archiving and communication system). The following data was collected on patients treated conservatively and those managed surgically:- (1)Time to surgery for surgical management; (2)Period of immobilization for both conservative and operative groups. 45 patients (13 male, 32 female) with 49 distal radius fractures (2 patients had bilateral injuries) were included. Patients had mean age 63 years (range 19 to 92 years) 30 wrists were treated non-operatively and 19 wrists treated surgically (8 K-wires, 10 ORIF, 1 MUA). Mean time to surgery in the operative group was 8 days (range 1 – 21 days, median 7 days). Mean time to surgery for intra-articular fractures was 7 days (range 1 – 21) and 12 days for extra-articular fractures (range 4 – 20). Mean immobilization period in those treated in plaster is 6 weeks (range 4 – 13 weeks, median 5.6 weeks). At busy level 2 trauma units with limited theatre capacity and a high volume of hip fracture admissions, time to surgery for less urgent injuries such as wrist fractures is often delayed. National guidelines are useful in helping to guide management however their standards are often difficult to achieve in the context of increasing populations in urban areas and an ageing population

The December 2012 Wrist & Hand Roundup. 360. looks at: the imaging of scaphoid fractures; splinting to help Dupuytren’s disease; quality of life after nerve transfers; early failure of Moje thumbs; electra CMCJ arthroplasty; proximal interphalangeal joint replacement; pronator quadratus repair in distal radius fractures; and osteoporosis and wrist fractures

Aims. Elective operating was halted during the COVID-19 pandemic to increase the capacity to provide care to an unprecedented volume of critically unwell patients. During the pandemic, the orthopaedic department at the Aneurin Bevan University Health Board restructured the trauma service, relocating semi-urgent ambulatory trauma operating to the isolated clean elective centre (St. Woolos’ Hospital) from the main hospital receiving COVID-19 patients (Royal Gwent Hospital). This study presents our experience of providing semi-urgent trauma care in a COVID-19-free surgical unit as a safe way to treat trauma patients during the pandemic and a potential model for restarting an elective orthopaedic service. Methods. All patients undergoing surgery during the COVID-19 pandemic at the orthopaedic surgical unit (OSU) in St. Woolos’ Hospital from 23 March 2020 to 24 April 2020 were included. All patients that were operated on had a telephone follow-up two weeks after surgery to assess if they had experienced COVID-19 symptoms or had been tested for COVID-19. The nature of admission, operative details, and patient demographics were obtained from the health board’s electronic record. Staff were assessed for sickness, self-isolation, and COVID-19 status. Results. A total of 58 surgical procedures were undertaken at the OSU during the study period; 93% (n = 54) of patients completed the telephone follow-up. Open reduction and internal fixation of ankle and wrist fractures were the most common procedures. None of the patients nor members of their households had developed symptoms suggestive of COVID-19 or required testing. No staff members reported sick days or were advised by occupational health to undergo viral testing. Conclusion. This study provides optimism that orthopaedic patients planned for surgery can be protected from COVID-19 nosocomial transmission at separate COVID-19-free sites. Cite this article: Bone Joint Open 2020;1-6:302–308

Aim. Fixation of distal radial fractures via the volar approach has become a commonly performed procedure over the past few years. This study is to highlight potential pitfalls with this ‘everyday’ procedure and to perhaps temper over-enthusiasm for plating all wrist fractures. Method and materials. 164 consecutive cases of wrist fracture treated by means of fixed angle volar fixation were looked at. In each case any recorded complication prior to completion of treatment was documented. The complications were divided into major and minor depending on the severity and long-term outcome and overall result. Results. With critical analysis there were 32 major complications: 12 required further surgery; 1 iatrogenic radial artery injury; 1 iatrogenic palmar branch of median nerve injury; 2 complex regional pain syndromes; 16 patients with less than 60 arc of movement. In addition 12 minor complications including hypertrophic scars, suture abscess and intermittent minor discomfort were also recorded. Conclusion. While volar distal radial fixation is well accepted and indeed commonly performed, the procedure is not without complications. We must pay meticulous attention to detail and technique to optimise results

Introduction and Objectives: Volar osteosynthesis with plates with angular stability in dorsal fractures has revolutionized the treatment of wrist fractures, since fixation is sufficiently stable to allow early physiotherapy and prevent fracture collapse, avoiding the great drawbacks of alternative treatments in unstable fractures. Materials and Methods: Retrospective study of 64 cases of wrist fracture with instability and dorsal deviation treated by means of a volar plate with angular stability. We carried out a clinical assessment that included: a quick-dash functional questionnaire, range of mobility, pain using a Virtual Analog Scale, fist grasping strength (Jamar dynamometer), associated lesions and postoperative complications. Radiological assessment included radiometry of the distal radius, time to radiological consolidation, and radiological post-traumatic complications. The statistical assessment of variables was carried out with an SPSS program version 15.0 for Windows. Results: We found that 86% of the patients were satisfied with the functional results, with a mean quick-dash score of 3.5. Radiological consolidation was achieved in all cases, without any need of a dorsal graft. Radiometry showed a morphology of the distal radius with no statistical differences when compared to the contralateral wrist. Discussion and Conclusions: This is an effective, reliable, reproducible method for the surgical treatment of unstable fractures of the distal radius, with minimum morbidity and early functional recovery

Introduction and aims: Minimal trauma fractures may be the first indication of osteoporosis [OP]. Available data suggests that the continuum of care [EDorthopaedic service-GP] is breaking down with respect to identification and treatment of osteoporosis. Our aim was to determine the extent of this breakdown in the Australasian context. Methods: Observational retrospective cohort study of patients aged 50 years or over who were treated and discharged with wrist fracture due to minimal trauma. Data collected included demographics, fracture details, cause of injury, bone density testing and osteoporosis-related medication change. Outcomes of interest were the proportion of patients who underwent bone density testing and treatment in the follow-up period. Results: 131 patients were studied; 83% were female with median age of 71 years. No patient was referred by ED or fracture clinic for bone density testing [0%, 95% CI 0–3.5%]. Telephone follow-up was obtained from 91 patients, of whom 28 [31%] reported having bone density testing after their fracture. 50% [14, 95% CI 32–67%] of these were found to have osteoporosis. Seven patients [8%] commenced treatment with a bisphosphonate and one [1%] commenced a selective oestrogen receptor modulator. Conclusion: Follow-up of ‘at risk’ patients suffering minimal trauma wrist fractures treated in the ED is poor. Systems to improve identification and treatment of osteoporosis in this group are needed if future osteoporotic fractures and their consequences are to be avoided. Possible models will be put forward

Introduction and Aims: Locking plates represent a major change in the way we stabilise fractures. The distal radius Locking Compression Plate (LCP, Synthes) theoretically enables palmar plating of dorsally comminuted and intra-articular wrist fractures. All current methods (Dorsal plates, K wires and external fixators) have considerable disadvantages. This is the first study to assess the clinical and biomechanical results of this new implant. Method: We created a synthetic bone fracture model to compare three plates (the LCP, Buttress and Pi). We tested 24 plates, eight in each group, using the Instrom biomechanical testing machine, axially loading the model to 200 Newtons for 500 cycles. The results show significantly less displacement for the LCP plate (p< 0.05). Results: Early clinical results are reported following a prospective study of the LCP plate to stabilise dorsally comminuted and intra-articular. The average age was 32 years. We report our results at an average follow-up of six months (range four to nine months). There were no complications. The Gartland & Werley scores were at least satisfactory in all patients and good in 75%. Conclusion: Both our biomechanical and early clinical results support the clinical use of the palmarly applied LCP for intra-articular and dorsally comminuted wrist fractures

Introduction and Aims: Osteoporotic fractures, especially hip fractures, represent a major health problem in terms of morbidity, mortality and cost. Since the availability of new treatments for osteoporosis, a better understanding of the disease is needed to define the indications for treatment. Method: A descriptive study of osteoporotic fractures and the evaluation of the relative risk of hip fracture following a minor fracture were done on a population aged 45 years old and older from 1980 to 1997 (2.5 million individuals, 1997). Results: During the follow-up period, 220,120 fractures (hip, wrist, proximal humerus and ankle) were recorded. The incidence rate of fractures was stable over time. The wrist fracture was the most frequent (42.2%), followed by the hip fracture (32.5%). Although the proportions of fracture sites were similar for both sexes, 75% of the fractures occurred in females. The mortality rate one year after a hip fracture is increased by 14–27% for men and 9–13% for women after 60 years of age. Men and women aged 45 years old and older have a risk for hip fracture after a humerus or a wrist fracture of 2.3–17.3 time the risk of people without previous fracture. Conclusion: Wrist and humerus fractures represent a major risk for future hip fracture, prevention of hip fracture should be revaluated regarding these new data and all these patients should be evaluated for osteoporosis and receive the appropriate treatment

Osteoporosis investigation following a low-trauma fracture is often missed. The aim of this study was to (i) measure the current rate of osteoporosis investigation and (ii) to test a simple intervention that seeks to increase patient awareness and physician alerting following these sentinel events. Our study showed that 92% of the intervention group was investigated compared to 18% of the control group. This study suggests that a simple inexpensive intervention can increase the rate of osteoporosis investigation in an at risk population. National guidelines (1–3) emphasize that low-trauma fractures should prompt to investigate for osteoporosis but more than 80% of “at risk” people are not investigated. To measure the rate of diagnosis of osteoporosis when patients with low-trauma wrist fractures obtain usual care compared to a patient education and physician alerting intervention. This is a prospective, controlled trial of patient education and physician alert following a distal radius fracture. Participants in the intervention group received four-parts: (i) an information sheet, (ii) a letter from the treating orthopedic surgeon to the patient’s family physician signaling the recent low-trauma fracture (iii) a follow-up reminder call to return to the family doctor for assessment and (iv) a fax to the family physician suggesting assessment and management of osteoporosis. The control group received usual care of the fracture and no specific information about osteoporosis. All participants were telephoned at 6 months to assess investigation status. Fifty-one participants > 50 yrs. with a fragility wrist fracture were enrolled: 92% of the Intervention participants were investigated for osteoporosis by the family physician compared to 18% of the Control group. This is a significant difference (p ≤ 0.01). This study suggests that a simple inexpensive intervention by the surgeon can increase the rate of osteoporosis investigation in an at risk population. Orthopedic surgeons can contribute to the care of osteoporosis by readily adopting simple clinical actions which will make patients more likely to be investigated for osteoporosis

My talk concentrates on the practical management of wrist fractures in adults. The management of complications of wrist fractures and the management of fractures in children are covered by other speakers. Epidemiology. Fractures of the distal end of the radius have been estimated to account for upwards of 1/6 of all fractures seen and treated in emergency rooms. Distal radius fractures are more common in women. Above the age of 50 years, 86% of wrist fractures are in women. Fractures increase in incidence in both sexes with advancing age, and usually result from a fall from level ground rather than from high energy trauma. 10% of adults older than 35 years will suffer a distal radius fracture in a 30 year period. Historical. Up until the early 18. th. century, it was thought that the injury that resulted from a fall on the outstretched hand was a dislocation and not a fracture. The first author to suggest that the injury was a fracture was probably JL Petit in 1783. Abraham Colles published his article in 1814 without having dissected a specimen showing a fractured wrist. Barton described the fracture associated with his name in 1838. RW Smith described extra-articular bending fractures of the distal end of the radius in 1847. Classification. There are very many different classifications used to describe fractures of the distal radius. The Frykman classification (1967) has been widely used in the past. It concentrates on the involvement of the radioulnar joint. The classification system of AO is useful for documenting fractures that does produce 144 possible combinations. The classification by Fernandez (In: Fractures of the Distal Radius Fernandez and Jupiter, Springer 1995) concentrates on the mechanism of the fracture and enables correlation with the management of the fracture. It is the most useful classification when deciding exactly what to do. Imaging. Plain radiographs are the mainstay of fracture management. Good quality AP and lateral views are essential. A lateral view with the forearm angled 20 degrees towards the tube gives a better view of the lunate fossa. Tomograms can be used to evaluate the joint surface in an intra-articular fracture but has been superseded by more sophisticated imaging. Uniplanar CT produced good images in 1 plain only. The reconstructed images in second plane were always of poor quality. Nowadays Spiral CT produces excellent images with rapid acquisition and low radiation dosage. MRI scanning has its use in evaluating soft tissue injuries and also injuries to the bone that have not caused a fracture, such as a “bone bruise”. Intraoperatively it is possible to arthroscope the wrist in order to guide fracture reduction. This should only be attempted by skilled wrist arthroscopists. Anaesthesia. In the UK, haematoma blocks have become the standard method of anaesthesia in the emergency room when manipulating fractures of the wrist. The degree of anaesthesia is somewhat unpredictable and the failure to achieve a complete anaesthesia leads to poor reductions. Intravenous regional anaesthetic (Biers block) used to being the main form of the anaesthesia in British emergency rooms. The technique requires two doctors and was going out of fashion even before the manufacturers of Prilocaine withdrew the preservative-free formulation generally used for Biers blocks. Axillary block anaesthesia is commonly used in the operating room but is less so in the emergency room. General Anaesthesia is my preference for patients undergoing more than just simple manipulation. Operative techniques. Surgeons should not limit themselves to only performing one method of stabilisation. They should be able to perform all forms. They should plan surgery in advance and should have the facility to adopt an alternative technique intraoperatively should this prove necessary. If a patient requires a manipulation in a proper operating theatre using anything other than a haematoma block anaesthetic, then K-wires should be inserted for most fractures. There are many ways of inserting K-wires but my preference is for Kapandji intrafocal pinning. External fixation can be used for many types of intra-articular fractures using the principle of ligamentotaxis. Most fixators are applied bridging the joint. If not put on with excessive distraction, stiffness is not usually a problem. McQueen has published on the application of nonbridging fixators which certainly has some clinical indications. In the older patient, the use of bone graft should always be considered to fill the defect left the following elevation of a fracture. The alternative is to use synthetic bone graft substitutes such as Biobon. ®. Sometimes it is necessary to combine external fixation with supplementary K-wires. Internal fixation. The volar approach through the terminal part of the Henry approach is relatively straightforward with low morbidity. This is used to apply volar buttress plates. The distal radius is approached dorsally through incisions between the extensor compartments. The routine application of dorsal plates is favoured by some. However there is considerable morbidity associated with even the modern low profile plates such as the Pi plate. Tendon rupture is a particular problem. The plate usually has to be removed once the fracture has united. An approach between the fourth and fifth extensor compartment is useful in elevating the lunate facet prior to K-wire or screw fixation. Limited internal fixation using cannulated screws is useful in stabilising major fracture fragments such as the radial styloid. As with any other fracture, the management of distal radius fractures is determined by the biology of the patient, the configuration of the fracture and the ability of the surgeon. The biggest errors come from considering all distal radius fractures as one, or applying one management protocol to all fractures

Aims: The aim of our study was to compare relative risk of hip fracture after wrist or spine fracture, in both men and women. Methods: We performed a systematic literature review of cohort studies reported since 1982 that included low-trauma wrist or spine fracture as a risk factor for subsequent hip fracture among (white) women and men aged 50 years or older. A fixed effects meta-analysis was used to calculate a common relative risk (RR) with 95% confidence interval (95% CI). Results: Ten cohort studies (six from the U.S.A. and four from Europe) contributed to this meta-analysis. Among postmenopausal women, RRs for future hip fracture after wrist and spine fracture were 1.53 (95% CI 1.34–1.74, p< 0.001) and 2.22 (95% CI 1.95–2.52, p< 0.001), respectively. The RR was significantly higher after spine fracture than after wrist fracture (p< 0.001). Among ageing men, these RRs for future hip fracture were 3.26 (95% CI 2.08–5.11, p< 0.001) and 3.54 (95% CI 2.01–6.23, p< 0.001), respectively. In contrast to the observation in women, this difference was not statistically significant (p=0.82). The RR was significantly higher in men than in women after wrist fracture (p=0.002), but not after spine fracture (p=0.12). Conclusions: Recent studies have shown consistent and strong prospective associations of hip fracture with previous wrist or spine fracture among postmenopausal women. The findings of our meta-analysis confirm these results and extend them to ageing men. In addition, our results indicate that wrist and spine fractures are equally important risk factors for future hip fracture in ageing men