Introduction: Distal radial fractures are common and sometimes surgery is necessary. The volar locking plate has become the standard solution in the last years in many hospitals but the method is unproven scientifically. In this series we have retrospectively followed our early cases of volar plates.

Patients and Material: We identified all 68 patients (44 women and 9 men) at Lund University Hospital undergoing surgery using the TriMed^® volar fixed-angle plate for distal radius fracture between January 2006 and December 2007. The mean age was 57 years (20–84). The patients were contacted by mail and sent a Quick-DASH, a validated outcome questionnaire. Eleven patients were excluded according to the protocol due to having another concomitant or bilateral fractures or other complicating conditions like stroke or hemiparesis or psychiatric disorder. 53 of the remaining 57 patients completed the Quick-DASH and plotted their subjective function, pain at rest and at activity as well as the cosmetic appearance on a 0–100 mm visual analogue scale (VAS). 50 patients came to the hospital for an additional radiogram and measurement of the range of motion (goniometer) and grip strength (JAMAR).

Results: Quick-DASH median was 4,5 (range 0–80), and mean 14. Seventeen (32%) of the patients had zero for VAS at rest. Ten (19%) had a DASH value of more than 30 implicating a less than satisfying result. Range of motion in de fractured wrists were 91% of the non-fractured and the grip strngth 82% of the contralateral.

Discussion: In the present study the patients regained near full function in their fractured wrists after the operation with the volar locking plate. The ROM of the fractured wrists was 91% of the ROM of the non-fractured wrists, whereas the grip strength of the fractured wrists was 82% compared to the contralateral side. These data are excellent and similar both to previous own results as well as other published studies.

The results of the Quick-DASH questionnaire, representing the subjective perception of the outcome, indicate that the patients are satisfied. Seventeen of the 53 patients scored zero on the DASH, suggesting a full recovery without any sequelae. In the population the median value is 2,5 (Abramo 2008). Ten of the patients had a DASH score over 30, indicating substantial subjective limitations in the daily life. Interestingly, there appears to be little or no correlation between high DASH scores and impaired ROM or grip strength. However, we noted that patients with high DASH scores also tended to score high in the VAS-question regarding subjective pain at activity. It was further noted that the patients with a DASH over 30 had a delay between injury and operation for a mean of 10,3 days (1–19 days) between injury and operation, compared to the patients with a DASH score below 30 who had a mean of 5,6 days (2–16 days) delay.

Purpose: The management of Dorsal Fracture Dislocations of the PIP joint is challenging, especially for the unstable ones. Complications are common and often lead to functional disability. Many treatment methods have been described in the past, illustrating that no optimal solution has been found. In the Hemi-Hamate autograft technique, introduced by Hastings in 1999, a reconstruction of the volar lip joint surface and stabilization of the joint is achieved. This autograft can be seen as a model of a non vascularised bone-cartilage composite graft. The purpose of the present retrospective study was to evaluate the long term results of the hemi-hamate autograft technique in unstable PIP fracture-dorsal dislocations with special reference to posttraumatic degenerative arthritis common in non vascularized joint transfers.

Materials and Methods: We report the results of 9 patients operated between November 2002 and March 2008 and with a minimum follow up of 26 months. The mean follow-up time was 56 months. There were 6 men and 3 women with a mean age at operation of 45 years (23–66). All fractures were unstable with comminution of the volar lip. In 3 patients the dominant hand was involved. The middle finger was injured in 4 patients, the ring finger in 4 and the little finger in 1 patient. All patients were treated with the operation technique described by Hastings and reanalyzed by Williams. The volar base of middle phalanx was debrided and reconstructed by a pre-sized autograft harvested from the dorsal side of the homolateral hamatum, and fixed with mini screws. A standard rehabilitation program was used postoperatively. Clinical (ROM, grip strength), radiographic and subjective outcomes (VAS) were examined in all patients.

Results: At the last follow up, the injured finger had an average active ROM at the MCP joints of 97o (90o–115o) at the PIP 69 o (45 o –95 o) and at the DIP 59 o (30 o –90 o). The extension lag in the PIP joints were mean 10 o (0 o –30 o). Grip strength of the injured hand was mean 89% of the uninjured contralateral side. On radiographs, severe arthritis in the treated PIP was found in 2 of 9 patients. Another 2 patients had degenerative arthritis in several PIP. The average subjective score of patient’s satisfaction was 85 (20–100) in a scale 0–100 (100 best).

Conclusions: The Hemi-Hamate autograft technique is a technically demanding operation but an alternative to arthrodesis or primary joint arthroplasty in the treatment of Fracture-Dorsal Dislocations of PIP joint. Our results are good and comparable to previously reported results (Williams 2001). Some deterioration will occur regarding joint osteoarthritis but a high degree of subjective patient satisfaction was found. Further studies and methods to decrease the osteoarthritis would be preferential.

Introduction: The choice of whether to use absorbable or non-absorbable suture in the closure of wounds following hand or upper limb surgery is usually surgeon dependent. In our unit both continuous absorbable subcutaneous suture and interrupted non-absorbable suture are utilised. The use of absorbable sutures offers a potential advantage to the patient and clinician in not requiring a clinic appointment for suture removal. The quality and aesthetic appearance of hand and upper limb surgical scars are of great importance to patients. Few studies have compared the aesthetic appearance of scars following the use of absorbable and non-absorbable suture in hand and upper limb surgical wound closure.

Method: 50 consecutive patients having undergone day case hand surgery between August 2007 and May 2008 with absorbable suture wound closure were identified along with 50 consecutive patients over the same time period who underwent non-absorbable wound closure. Each was sent a questionnaire comprising a visual analogue scale (VAS) for wound satisfaction, a validated 6 point patient scar assessment tool and the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH).

Results: 100 patients were contacted by post and 70 responses were received (37 absorbable, 33 non-absorbable). Both groups had undergone a similar spectrum of procedures including carpal tunnel decompression, Dupuytrens fasciectomy, excision of lesions and trigger finger release. Age, sex and QuickDASH scores were not significantly different between groups. Mean VAS was not significantly different between groups (Non-absorbable group 82.4 (95% CI 74.7–90.2) Absorbable group 80.4 (95% CI 71.9–89.0)). No significant difference was found between groups in terms of pain, itching, scar colour, stiffness, thickness or irregularity.

Conclusion: No significant difference in aesthetic appearance of scars exists following the closure of hand and upper limb wounds with either absorbable or non-absorbable suture. Either suture material can be used with confidence with respect to aesthetic outcome.

Background: Distal radius fractures are among the most common fractures, consisting of about 1/6 of all fractures shoving up at the ER. Many times surgical treatment is indicated. However which type of operation to chose is not known. The standard operative treatment has been external fixation but more modern techniques for internal fixation have become increasingly popular. Our aim was to evaluate if internal fixation is beneficial for the patients. To do this we did this randomized study.

Material and methods: Between May 2002 and March 2005 a randomized study between closed reduction and external fixation versus open reduction and internal fixation with the TriMed® system was performed in 42 consecutive patients. 29 were women and 13 were men in the ages between 20 and 63 with a mean age of 48 years. 20 were randomized to closed treatment and 22 to open treatment. Patients were followed with clinical examination, radiographs, examination of range of movement and grip strength and outcome measured by DASH for one year.

Results: DASH-scores showed no statistical significant differences between the groups neither early at seven weeks (32 in the open group an 29 in the closed) nor late at one year (9 vs. 13) postoperatively. Range of movement in flexion and extension was better in the internal fixation group at 5 weeks (45 degrees vs. 67) degrees postoperatively but this difference disappeared at one year (121d egrees in both groups). Grip strength was significantly better for the TriMed group at 5 weeks (32% of the opposite side vs. 8% in the external fixation group) and 7 weeks (47% vs. 34%) and at one year (78% vs. 90%) postop. Range of movement in forearm rotation was significantly better in the open group during the whole follow up (126deg. vs. 101deg. at seven weeks and 149 vs. 133 at one year). There were three cases of redislocation in the external fixation group. They were all later treated with osteotomy. However there were 15 cases of minor complications in the open group compared to 9 cases in the closed group. The minor complications were mainly consisting of transient tingling of the radial nerve in the open group and skin adherences in the closed group.

Conclusion: Open reduction and internal fixation for distal radial fractures give better result regarding motion and grip strength than External fixation but there is no difference in subjective outcome. Complications are common in both groups but these are often minor non lasting complications. However malunion is more common with external fixation.

Wrist fusion, ulna head resection and fusion of the MP or PIP joints are not anymore the only operations that can be offered to patients with RA. The modern medical treatment has changed the course of the disease and we are not anymore in front of patients with major joint destruction, very bad hand function and low demands. Young ladies with well controlled disease expect surgery to result in restitution of function which allows a life close to normal in terms of work and leisure time activities. If pain relief remains the main indication it has to be associated with reconstruction of function, preserving mobility and increasing grip strength. For these reasons it appears necessary to limit fusions and increase the use of joint implants. Accurate evaluation of the patients’ need and expectations will help in the choice of the appropriate surgical procedure to achieve the treatment goal.

Introduction: Systemic sclerosis of the hand is an uncommon form of arthritis that can cause significant functional loss in the hand. Because of decreased microcirculation, wound-healing problems are feared and surgical interventions avoided. We report the results after operations performed on the hand and forearm of patients with systemic sclerosis with special reference to wound healing problems.

Material and methods: This retrospective study evaluates the results of 41 consecutive operations performed in 19 patients between 1985 and 2000 at our unit. The mean age was 50 years (14 – 84 years). Sixteen patients were female and 3 male. Twelve patients were operated twice or more. Operations were elective in 27 cases, with excision of calcinosis in 8 patients, excision of calcinosis plus skin transplant in 2 patients, neurolysis of median, radial or ulnar nerve in 7 patients, wrist procedures (fusion or implant) in 3 patients and other procedures (e. g. finger joint fusion, removal of osteosynthetis material, finger osteotomy) in 7 patients.

In 14 cases the operations were indicated in reason of spontaneous skin necrosis or defects. These operations were: amputation with or without flap in 3 cases, wound revision in 6 cases, wound revision and flap in 5 cases (including skin transplantation in 3 of these patients).

Results: One wound healing problem occurred in the 27 elective operations. The patient operated with an arthrodesis of the small finger PIP-joint had to have both the cerclage wire and K-wire removed to obtain complete wound healing.

Seven of 14 patients in the group with spontaneous skin necrosis healed uneventfully after operation. Two patients had consecutive wound infections that caused a longer healing period of 5 months; another patient also had a longer healing period but his wounds healed shortly after he quit smoking. Four patients had necrosis/infections, which required additional surgery.

Conclusion: In systemic sclerosis, surgery performed in elective operations does not seem to have an increased rate of infections or other wound healing problems. Even larger operations like wrist arthrodesis or wrist prosthesis can be performed. In non-elective cases with spontaneous skin necrosis, in critically ischaemic fingers, the wound healing is not always easy and several operations can be necessary, however a good end result, without need for amputations, can be achieved.

Background: Distal radius fractures are the most common fractures at the ER and constitute about 1/6 of all fractures. We report the patient related outcome scores as measured prospectively and consecutively with the DASH- score (Disabilities of the Arm Shoulder and Hand) in an unselected cohort of distal radius fractures. It is often stated that fractures in a non-osteoporotic age group were more severe than in an elderly group.

Materials and Methods: 542 patients, at the age of 18 and above with a distal radius fracture were registered between September 2001 and June 2003,. Age, gender and treatment were registered and DASH-forms sent to the patients at 3 and 12 months post fracture. 50 patients were excluded because of physical or mental inability to fill out the form. 352 of the remaining 493 patients completed the 3 months form and 355 the 12 months form. 127 patients were operated with external fixation or internal fixation due to unstable fractures and the rest were treated conservatively in a cast for four weeks. The patients were subdivided in a non-osteoporotic group, defined as men under the age of 60 and women under the age of 50 and an osteoporotic group above that age. The DASH-form was sent to an age- and gender-matched control group for comparison

Results: The response rate was 72% at both 3 months and 12 months. For the whole group the DASH score decreased from 24 at 3 months to 17 at 12 months (p< 0,001; scale range 0–100). The DASH-score in the younger, non-osteoporotic group was 17 and 12 and for the osteoporotic group 27 and 18 at 3 and 12 months respectively. At one year there was no difference in DASH score between the operated patients and the patients treated conservatively. In the age and gender matched control-group DASH score was 8; in the older group 10 and in the younger 3.

Conclusion: A distal radius fracture has a great impact on the patients function the first year as measured with the validated DASH-score. Three months after fracture patients have markedly increased DASH-score, which decreases slowly for the next nine months but do not normalize as compared to a non-injured matched population. The worst scores are seen in the older population. In our experience operative treatment in the unstable fractures manages to restore function to a level equal to patients with stabile, conservatively treated fractures.

The MP joint is the key joint for function of the fingers. Rheumatoid arthritis involvement of this joint is frequent (1/3 of patients), and results in severe painful deformity and functional loss. The factors leading to the classic ulnar drift and volar luxation are multiple but the permanent pathophysiological element is synovitis of the joint. No deformation will occur in the MP joint without synovitis.

Etiopathogenesis: The causes of MP joint deformity in Rheumatoid arthritis are anatomical, pathological and indirect.

The asymmetry of the metacarpal heads with a slight ulnar tilt induce the deformation in this direction. The weakness and the length of the radial collateral ligaments compared to the ulnar collateral ligament makes the laxity to occur on the radial side of the joint. The obliquity of the extensor tendons pull the fingers ulnarly with a tendency of dislocation over the MP joints.

Synovitis is at the origin of elongation, rupture or destruction of the ligaments, attrition of the cartilage and bone resorption. The distention of the extensor hood predominate radially and accentuate the extensor tendon obliquity. The destruction of the A1 pulley of the flexor tendon participate to the volar luxation of the joints. The ulnar sliding and radial tilt of the carpus, the tension of Abductor Digiti Minimi and the contracture of the intrinsic muscle participate indirectly or aggravate the deformation. The thumb force in pinch grip and the ulnar deviation of the finger in heavy prehension participate also to the deformation.

Classification: Without prognostic factor the following classification gives information on the stage of the deformation and the treatment that can be proposed.

synovitis without deformation, normal radiographs

synovitis with ulnar deviation, normal radiographs

synovitis with ulnar deviation and volar subluxation, volar luxation on radiographs with almost normal cartilage

ulnar deviation and volar luxation with or without active synovitis, destroyed cartilage and more or less bone erosion on radiographs

Synovectomi with stabilization and realignment procedures can only be used in stage 1 and 2. In stage 3 and 4 arthroplasty is more appropriate.

Treatment: Indication are pain, loss of function and cosmesis.

Synovectomy. The prophylactic effect of synovectomy is still subject to debate. The almost impossible total synovectomy, the difficulties to control the effect of the procedure and the different stage in disease of each patient make the synovectomy unpredictable as a real prophylactic procedure.

Stabilization and realignment procedures has always to be part of a synovectomy. If the destruction of the cartilage and the bone erosion are irreversible process, the elongation of the ligaments or the destruction of their bony insertions can always be reconstructed. For this purpose different techniques can be used. Suture of the extensor hood on the radial side enables reorientation of the extensor tendons. The radial collateral ligaments can be strengthened or their attachments reinserted, the Abductor Digiti Minimi or the intrinsic tendons can be divided. Some tendon transfers (intrinsic, Extensor Indicis Proprius) can also be proposed.

Arthroplasty. The choice of the procedure depends most of the surgeon preferences. The silicon arthroplasties are the most often used. They associate a reduction of the ulnar and volar deformation and opened the hand with very good results on the aspect of the hand and on pain. The mobility of the MP joints is variable and depends of the mobility of the finger joints. The bone erosion and the rupture of these devices are in favor of autologous interposition arthroplasties which, on the other hand, gives lesser mobility and stability. For these reasons silicon and interposition arthroplasties are often indicated late in the MP joint destruction process. More recently, new non constrained implants have been proposed in order to offer an earlier treatment. When used with good ligament reconstruction and tendon rebalancing these devices have good results on pain, cosmesis and function. If the preliminary results are confirmed in the long term, these non constrained devices will have a good indication as early MP joint replacement in the active young rheumatoid patient.

Conclusion: MP joint deformity in rheumatoid arthritis is complex. The Etiopathogenesis will guide the treatment most appropriate in each patient. However some principles has to be respected in all cases. A good stabilization and recentralization is the key stone of the surgical procedure. The ulnar deviation can be reduced and corrected by ligaments and tendon procedures. The volar subluxation/luxation indicates an advanced deformity of the MP joint that requires arthroplasty.