The ITS volar radial plate (Implant Technology Systems, Graz/Austria) is a fixation device that allows for the distal locking screws to be fixed at variable angles (70°-110°). This occurs by the different material properties, with the screws (titanium alloy) cutting a thread through the plate holes (titanium). We present our experience with the ITS plate.

We retrospectively studied 26 patients who underwent ITS plate fixation for unstable multifragmentary distal radial fractures (AO types A3, B2, B3, C2, C3). The surgery was performed either by a consultant orthopaedic hand surgeon or senior registrar. A volar approach was used every time and 10 cases required synthetic bone grafting. Post-operatively they were immobilised for an average of 2.5 weeks.

The 26 patients had a mean age of 58 and the dominant side was affected in 46% of cases. 5 cases were open fractures and 10 cases followed failed manipulation under general anaesthesia. The average interval between injury and surgery was 7 days. Union was achieved in all cases. No implant infections, failure or tendon rupture/irritation occurred. There were two fractures which loss reduction, of which one required revision surgery. There was one case of CRPS. The six month average DASH score was 27.5.

We consider the ITS plate a technically easy plate to use and a reliable implant at early follow-up. We value the versatility of its variable angle screw fixation ability for complex intra-articular distal radial fractures.

Introduction and objective: Distal biceps tendon ruptures commonly occur in the dominant arm of male between 40 and 60 years of age. The degenerative tendon avulses from the radial tuberosity. Conservative treatment results in decreased flexion and supination strength. Surgical reattachment is the treatment of choice and several surgical approaches and fixation devices have been proposed. The purpose of this study was to compare the results of two different techniques.

Materials and Methods: Twenty-four consecutive patients with distal biceps tendon ruptures were randomly assigned to one of two treatment groups: 12 using 2 biodegradable anchors through a modified 2-incision technique (group A) and 12 patients underwent distal biceps repair using an Endobutton^® (Acufex Smith & Nephew, Andover MA) using a single transverse anterior incision (group B). All patients were male. Average age was 40 (33–57) in groupA and 42 (29–59) in group B. The rupture was located in the dominant arm in 6 patients in groupA and 7 in group B.

The interval between injury and surgery was similar in both groups (< 12 days). Postoperative protocol and rehabilitation was the same in both groups. Full range of motion as tolerated was allowed two week after surgery.

Active range of motion, Mayo Elbow Performance Score (MEPS), pain, strength (Dexter isokinetic testing), patient satisfaction, operative time and elbow radiographs were evaluated at 12 months postoperatively. The mean follow-up was 17 months (range, 12–34).

Results: Average operative time (minutes):50 (group A) and 42 (group B). There were no complications in group B. Two patients in group A had a transient posterior interosseous nerve neurapraxia with spontaneous full recovery after 3 months, and other one developed symptomatic heterotopic bone formation and synostosis was resected. There was no statistical significant difference in MEPS score, range of motion, time to return to work or strength between both groups. All patients in both groups were satisfied with their final result and eventually returned to their pre-injury activity level without sequelae after 12.2 (group A) and 10.3 (group B) weeks.

Conclusion: Functional results of the two techniques studied were similar. Anterior approach showed lesser complications and less time off work than 2-incision technique. Endobutton^® single approach assisted tecnique should be considered the gold standard procedure for distal biceps tendon repair due to its shorter operative time and lower morbidity. However, we need series with a longer follow-up to confirm these results.

Aim: To assess the functional and occupational outcome of open elbow arthrolysis for post-traumatic contractures.

Materials and Methods: Prospective evaluation of 60 consecutive cases (86% male,14%female) of post-traumatic extrinsic elbow stiffness. Average age was 37 years (24–48). Moderate to high physical demand at work in 96% of cases. 56% of cases involved the right side.

Open arthrolysis (column procedure) trough a lateral (72%) or posterior (28%) approach followed a minimum rehabilitation period of 6 months post original injury. In 8 cases, an anterior transposition of the ulnar nerve was required. Patients received postoperative analgesia with Bupivacaine 0,0125% trough an indwelling catheter. No chemical or radiotherapy ectopic calcification prophylaxis was used. Postoperative complications, range of motion, X-ray evaluation, time to return to work, activity level and workers’ compensation were evaluated at the end of follow-up (24 months, range 12–36).

Results: Complications occurred in 14% of cases. Two patients required revision surgery for ectopic calcifications restricting prono-supination. The flexo-extension (FE) arc of motion improved from 49 ° to 115 ° and that of prono-supination (PS) from 100 ° to 158 ° The results were found to be statistically significant for FE (p= 0.054) and PS (p> 0,00001).

In 20% of cases, patients returned to their previous job with some restrictions (33% disability) and 12% changed to a less physically demanding occupation.

Conclusions: Open arthrolysis is an effective surgical procedure to improve mobility in post-traumatic stiff elbows. It is indicated when the joint interline is preserved. Good functional and occupational outcome in a high percentage of case in the working population was observed.

Objective: The purpose of this study was to determine which factors may influence in the outcome of the surgical treatment of Carpal Tunnel Syndrome (CTS).

Material and Methods: During 2005, 175 patients were treated with the diagnosis of CTS by open carpal release (short palmar incision) without ligament reconstruction. 113 cases were selected: 39 males and 74 females, with an average age of 41 years (21 to 64 years) and a follow-up of 24 months (12–36 months). The dominant hand was treated in 58%. The subcutaneous cellular tissue (SCT) was sutured in 14% and 11% were immobilized with a cast for 2 weeks after surgery.

We considered factors such as: systemic conditions, functional work requirement, preoperative time, surgical technique, and their correlation with complications, clinical outcome and time to return to work and activity level.

Results: Complications: 41% pillar pain, 9% suture dehiscence, 3,5% ulnar neuritis, 1,7% trigger finger, 1,7% reflex sympathetic dystrophy, and 1,8% wound infection. 5 patients were re-operated. Complications rate due to surgery was 3,5% after 12 months of follow-up. The average time out of work was 9 weeks (2–43 weeks) and was higher (13 weeks) in patients with post-operative immobilization. All patients, except one, returned to their previous activity level. History of systemic conditions and dominance had not influence on the final outcome. The suture of the SCT and the postoperative immobilization showed lower wound dehiscence and pillar pain cases.

Conclusions: The surgical treatment of the CTS provides good clinical and labour results. Patients with suture of the SCT and cast immobilization show less post-operative surgical complications.

Objective: The purpose of this study was to compare the functional and workers compensation results of displaced intra-articular distal radius fractures treated with three diferent type of treatments.

Material and Methods: A randomized prospective study to evaluate 70 patients with displaced intraarticular distal radius fractures. The mean age were 40 years (range, 22–65 years) and all patients were medium or high level workers (40% dominant-hand). Three randomized groups were treated: 19 patients with close reduction and a cast (group 1); 24 patients with close reduction, percutaneous fixation with Kw and a cast (group 2); and 27 patiens with close reduction and external fixation and Kw (group 3).

Postoperative complications, pain (visual analogue scale), clinical and functional outcome based on DASH score, grip strength, X-ray evaluation, time to return to work and activity level were evaluated and compared at 3, 6 and 12 months of prospective follow-up.

Results: Consolidation was obtained in all cases at 7 weeks. Results at 12 months of follow-up: Pain evaluation score: 2.3 (group 1), 2.9 (group 2) and 1.5 (group 3); mean lost of ROM was 11° (group 1), 11° (group 2) and 23.9° (group 3); mean DASH score was 7 (group 1), 29 (group 2) and 12 (group 3). Average lost of pinch strength was 18.3% (group 1), 23% (group 2) and 35% (group 3). Non-aceptable X-ray parameters: 65% (group 1), 35% (group 2) and 50% (group 3).

Re-operations: 10% (group 1), 7.6% (group 2) and 14.8% (group 3). The average time to return to work (weeks) was 12 (group 1), 14 (group 2) and 19.3 (group 3). All patients return to the work and activity level they had before injury.

Conclusions: Similar results were obtained in the three groups at 12 months but better clinical results for the conservative group (group 1) at 3 and 6 months of FU. The orthopaedic treatment achieved better functional results with lesser lost of ROM, time out of work, more grip strength and better DASH score. Percutaneous fixation achieve better X-ray results at the end of FU with lesser re-operations. The functional and clinical outcomes after one year still are unknown. Hence, more and longer studies are required to confirm these results.

We present a retrospective study of comparision between two types of aritifical boen graft substitues. There is an overwhelming marketting drive on part of companies to sell alternative bone grafts/BMP. We in this study compae two such producsts and their cost effectiveness

This is an interventional, retrospective, non consecutive, non randamised case series study of 27 patients. Type I bone graft is Mini MIIG which is surgical grade calciun sulphate which is osteoconductive. Type II bone graft is Allomatrix which conatins bone marrow aspirate, bone morphogenic protein, concellous bone chips and surgical grade calciun sulphate which is osteogenic, osteoinductive and osteoconductive. In this study 14 cases were treated with Mini MIIG and 18 with Allomatrix. There were 24 primary fractures with bone defect, 2 non union and 1 delayed union. Complete bony union were seen in all 27 patients. Average time to heal since bone grafting is 3 months. Complications are extrubent callus formation, bone formatiom in soft tissue, but no patient required secondary procedure to trim the bone. Cost for Allomatrix is £ 356.00 and Mini MIIG is £348.00. Use of such artificial bone grafting avoids the complication of autografting which includes bone graft side morbidity like pain, bleeding and neurvascular damage. For fresh fractures useage of such artificial bone grafts doesnt shorten the healing time, doesnt prevent collapse at fracture site and it is not cost effective. For non union and delyaed unions it avoids the cost for artifical bone grafting. But autograft also incurs the cost of removing, theatre timing. human resources cost and hospital inpatient costs. There is no difference between one type of bone graft over the other and for fresh fracture both of them has no advantage over using no bone grafts.

Our study concludes artifical bone graft is of no advantage for fresh fractures and for non union and delayed unions it is too small a number to come to any conclusion.

We are presenting a prospective study of 25 patients with clavicle fracture treated with Rockwood Intramedullary pin fixation. Operative management is required for open fractures, neurovascular injury or compromise, displaced fractures with impending skin compromise and displaced middle third fractures with 20mm or more shortening. Plate osteosynthesis or intramedullary fixation devices are used for operative management.

Patients and Methods: 25 patients with clavicle fractures underwent fixation of clavicle fractures with threaded intramedullary Rockwood pin. The indications for internal fixation were persistent wide separation of fracture with interposition of soft tissue in 12, symptomatic non-union in 3, associated multiple injuries in 3,one of them had a floating shoulder, impending open fracture with tented skin in 4 and associated acromioclavicular joint injury in 3 and one of whom had bilateral fracture clavicle.. All patients underwent open reduction through an incision centred over the fracture site along the Langer line. Intramedullary pin was inserted in a retrograde manner. Autologous bone grafting from iliac crest was done in all patients with nonunion. Radiographic and functional assessment conducted using DASH scores.

Results: There were 21 male and 4 female patients with a mean age of 34 yrs (range 17 to 64 yrs). Mean follow up was 12 months (range 5 months to 30 months). Radiographic union occurred in all patients within 4 months. In our study the commonest indication for Rockwood pin fixation was displaced middle third clavicle fracture followed by impending open fractures. Commonest complication was skin irritation at the distal end of the pin with formation of a tender bursa occurring in 9 patients, 3 of whom had skin breakdown. Fracture union occurred in all these patients with no further intervention and wounds healed completely after removal of the pin. One patient developed non-union and was later treated with ORIF with DCP and bone-graft. There were no deep infections, pin breakage or migration or re-fractures after pin removal. At the time of last follow up the average DASH score was 25 with a range of 18 to 52.

Conclusion: Open reduction and intramedullary fixation of clavicle fractures with Rockwood pin is a safe and effective method of treatment when surgical fixation of displaced or non-union of middle third clavicle fracture is indicated. This technique has an advantage of minimal soft tissue dissection, compression at the fracture site, less risk of migration and ease of removal, along with early return to daily and sports activities.

Background: An important sign in the assessment of distal radioulnar joint instability is the ballottement test were passive movement of the affected joint is compared to the contralateral normal side. The subjective appreciation of increased laxity renders the test positive.

In cases in which the contralateral side can not be tested or is known to be abnormal the relevance of the ballottement test is compromised.

Based on the observation that distal radioulnar joint passive mobility decreases in normal subjects when the wrist is radially deviated we propose a modification of the ballottement test in which mobility of the DRUJ is tested both in radial and ulnar wrist deviation.

Objectives: We aim to verify the observed decreased range of motion of the DRUJ in normal individuals when assessed in radial deviation compared to ulnar deviation and report the intraoperative findings of a series of patients who demonstrated an abnormal modified ballottement test in the abscense of bony deformity in the DRUJ.

Method: A group of 38 healthy volunteers (76 wrists) with no history of significant wrist injuries were assessed and the amount of DRUJ mobility given a subjective score of between 1 and 3. All wrists were assessed in ulnar and radial deviation as well as in neutral. The average age of the participants was 32.4 years. There were 22 female and 16 male subjects.

Our clinical case series reports the review of clinic notes and operative records of 32 patients (age gender) (32 wrists) who demonstrated an abnormal modified ballottement test and whose degree of instability granted surgical intervention.

Results: Out of the 76 normal wrists, 72 demonstrated decreased range of movement of the DRUJ in wrist radial deviation compared to examination in neutral or ulnar deviation. In the remaining 4 no difference was perceived but examination in neutral was considered “stiff” (less than average on the examiners experience).

All patients in the case series were found to have an ulnar detachment of the dorsal aspect of the TFCC (Palmer 1B) for which they underwent open repair.

Conclusion: DRUJ mobility in normal wrists decreases in radial deviation compared to neutral.

The observed decreased mobility of the DRUJ is likely to be due to tightening of the ulno-carpal ligaments.

An abnormal modified ballottement test was an indicator of severity as those with a positive result required surgical intervention and also correlated with the anatomical lesion found at surgery (Palmer 1B TFCC tear)

We believe the proposed modification enhances the diagnostic value of the DRUJ ballottement test and also allows to detect abnormalities in those cases in which the contralateral side can not be examined.