Aims

There is no level I evidence dealing with the optimal period of immobilization for patients with a displaced distal radial fracture following closed reduction. A shorter period might lead to a better functional outcome due to less stiffness and pain. The aim of this study was to investigate whether this period could be safely reduced from six to four weeks.

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

The December 2022 Wrist & Hand Roundup³⁶⁰ looks at: Anti-tumour necrosis factor therapy for early-stage Dupuytren’s disease; Patient experiences of scaphoid waist fractures and their treatment; Postoperative complications following open a1 pulley release for a trigger finger or thumb; How certain are findings in distal radius fractures: a systematic review of randomized controlled trials; Partial wrist denervation in wrist osteoarthritis: patient-reported outcomes and objective function; Dorsal bridge plating versus bridging external fixation for management of complex distal radius fractures; How is reduction lost in distal radius fractures in females aged 50 years and older; The HAND-Q: psychometrics of a new patient-reported outcome measure for clinical and research applications.

Aims

To analyze the short-term outcome of two types of total wrist arthroplasty (TWA) in terms of wrist function, migration, and periprosthetic bone behaviour.

Aims

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

Aims

Plate and screw fixation has been the standard treatment for painful conditions of the wrist in non-rheumatoid patients in recent decades. We investigated the complications, re-operations, and final outcome in a consecutive series of patients who underwent wrist arthrodesis for non-inflammatory arthritis.

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

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

The aims of this study were to assess the efficacy of a newly designed radiological technique (the radial groove view) for the detection of protrusion of screws in the groove for the extensor pollicis longus tendon (EPL) during plating of distal radial fractures. We also aimed to determine the optimum position of the forearm to obtain this view. We initially analysed the anatomy of the EPL groove by performing three-dimensional CT on 51 normal forearms. The mean horizontal angle of the groove was 17.8° (14° to 23°). We found that the ideal position of the fluoroscopic beam to obtain this view was 20° in the horizontal plane and 5° in the sagittal plane.

We then intra-operatively assessed the use of the radial groove view for detecting protrusion of screws in the EPL groove in 93 fractures that were treated by volar plating. A total of 13 protruding screws were detected. They were changed to shorter screws and these patients underwent CT scans of the wrist immediately post-operatively. There remained one screw that was protruding. These findings suggest that the use of the radial groove view intra-operatively is a good method of assessing the possible protrusion of screws into the groove of EPL when plating a fracture of the distal radius.

Cite this article: Bone Joint J 2013;95-B:1372–6.

Disruption of the interosseous membrane is easily missed in patients with Essex-Lopresti syndrome. None of the imaging techniques available for diagnosing disruption of the interosseous membrane are completely dependable.

We undertook an investigation to identify whether a simple intra-operative test could be used to diagnose disruption of the interosseous membrane during surgery for fracture of the radial head and to see if the test was reproducible.

We studied 20 cadaveric forearms after excision of the radial head, ten with and ten without disruption of the interosseous membrane. On each forearm, we performed the radius joystick test: moderate lateral traction was applied to the radial neck with the forearm in maximal pronation, to look for lateral displacement of the proximal radius indicating that the interosseous membrane had been disrupted. Each of six surgeons (three junior and three senior) performed the test on two consecutive days.

Intra-observer agreement was 77% (95% confidence interval (CI) 67 to 85) and interobserver agreement was 97% (95% CI 92 to 100). Sensitivity was 100% (95% CI 97 to 100), specificity 88% (95% CI 81 to 93), positive predictive value 90% (95% CI 83 to 94), and negative predictive value 100%).

This cadaveric study suggests that the radius joystick test may be useful for detecting disruption of the interosseous membrane in patients undergoing open surgery for fracture of the radial head and is reproducible. A confirmatory study in vivo is now required.

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

This paper describes the presence of tenodesis effects in normal physiology and explores the uses of operative tenodesis in surgery of the upper limb.