The October 2024 Wrist & Hand Roundup360 looks at: Circumferential casting versus plaster splinting in preventing redisplacement of distal radial fractures; Comparable outcomes for operative versus nonoperative treatment of scapholunate ligament injuries in distal radius fractures; Perceived pain during the reduction of Colles fracture without anaesthesia; Diagnostic delays and physician training are key to reducing scaphoid fracture nonunion; Necrotizing fasciitis originating in the hand: a systematic review and meta-analysis; Study design influences outcomes in distal radial fracture research; Long-term results of index finger pollicization for congenital thumb anomalies: a systematic review; Enhancing nerve injury diagnosis: the evolving role of imaging and electrodiagnostic tools.

Background. Procedural sedation (PS) requires two suitably qualified clinicians and a dedicated monitored bed space. We present the results of intra-articular haematoma blocks (IAHB), using local anaesthetic, for the manipulation of closed ankle fracture dislocations and compared resource use with PS. Methods. Patients received intra-articular ankle haematoma blocks for displaced ankle fractures requiring manipulation between October 2020 to April 2021. The technique used 10ml of 1% lignocaine injected anteromedially into the tibiotalar joint. Pain scores (VAS), time from first x-ray to reduction, and acceptability of reduction were recorded. A comparison was made by retrospective analysis of patients who had undergone PS for manipulation of an ankle fracture over the six month period March – August 2020. Results. During the periods assessed, 25 patients received an IAHB and 28 received PS for ankle fractures requiring manipulation (mean age 57.8yr vs 55.1yr). Time from first x-ray to manipulation was 65.9 min (IAHB) vs 82.9 min (PS) (p = 0.087). In the IAHB group mean pain scores pre, during and post manipulation were 6.1, 4.7 and 2.0 respectively (‘pre’ to ‘during’ p < 0.05; ‘pre’ to ‘post’ p < 0.01). In the IAHB group, 23 (92%) had a satisfactory reduction without need of PS or general anaesthetic. In the PS group 23 (82%) had a satisfactory reduction. There was no significant difference in the number of unsatisfactory first attempt reductions between the groups. There were no cases of deep infection post operatively in either group. Conclusion. Intra-articular haematoma block of the ankle appears to be an efficacious, safe and inexpensive means of providing analgesia for manipulation of displaced ankle fractures. Advantages of this method include avoiding the risks of procedural sedation, removing the requirement of designated clinical space and need for qualified clinicians to give sedation, and the ability to re-manipulate under the same block

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.

Regional anaesthesia is integral to best practice analgesia for patients with neck of femur fractures (NOFFs). These patients are generally frail and are vulnerable to side effects of opioid analgesia. Femoral nerve block (FNB) or fascia-iliaca block (FIB) can reduce opioid requirement. Literature supports good efficacy for extra-capsular NOFFs however it is acknowledged to be suboptimal for intracapsular fractures.

We present a novel technique, using point of care ultrasound guidance to perform hip ultrasound guided haematoma (HUSH) aspiration, and injection of local anaesthetic (block) for intracapsular NOFFs.

This a case control series. A consecutive series of cognitively intact patients, with an isolated intra-capsular NOFF, received a HUSH block using 10mls of 0.75% Ropivicaine. Haematoma was aspirated and volume recorded. This was performed in addition to standard NOFF pathway analgesia that includes a FIB and multimodal analgesia including opioids. Visual Analogue Scale (VAS)pain scores at rest and on movement were recorded pre and post procedure as well as combined morphine equivalent units administered post HUSH block. The control arm was a retrospective group of similar patients who followed the routine care pathway including a FIB. VAS pain scores from observation charts and usage of morphine equivalent units were calculated.

Ten patients consented to receive HUSH blocks and we included thirty-eight patients in our control series. The HUSH block group showed mean VAS pain score of 4.2/10 at rest and 8.6 on movement prior to block. In the time after the block, VAS pain scores reduced to 1.5 at rest (p=0.007) and 3.1 on movement (p=0.0001) with a mean total morphine equivalent use of 8.75mg. This is significantly different from the control group's mean VAS pain at rest score 6.9 (p=0.0001) and 24.1mg total morphine equivalent (p=0.07).

HUSH Block in addition to fascia iliaca block appears to significantly better pain relief in intracapsular neck of femur fracture patients when compared to fascia iliaca block alone. We believe it is relatively easy to perform with readily available ultrasound scanners in emergency departments.

Aims. Displaced distal radius fractures were investigated at a level 1 major trauma centre during the COVID-19 2020 lockdown due to the implementation of temporary changes in practice. The primary aim was to establish if follow-up at one week in place of the 72-hour British Orthopaedic Association Standards for Trauma & Orthopaedics (BOAST) guidance was safe following manipulation under anaesthetic. A parallel adaptation during lockdown was the non-expectation of Bier’s block. The secondary aim was to compare clinical outcomes with respect to block type. Methods. Overall, 90 patients were assessed in a cross-sectional cohort study using a mixed, retrospective-prospective approach. Consecutive sampling of 30 patients pre-lockdown (P1), 30 during lockdown (P2), and 30 during post-lockdown (P3) was applied. Type of block, operative status, follow-up, and complications were extracted. Primary endpoints were early complications (≤ one week). Secondary endpoints were later complications including malunion, delayed union or osteotomy. Results. In P1, 86.6% of patients were seen between days one to three, 26.7% in P2, and 56.7% in P3. There were no documented complications from days one to three. Operative rate was 35.5%, which did not vary significantly (p= 0.712). Primary endpoints occurred between day four to seven, and included one patient each period treated for plaster cast pain. Secondary endpoints in P1 included delayed union (one patient). During P2, this included malunion (one patient), a pressure sore (one patient) and ulnar cutaneous nerve symptoms (two patients). In P3, malunion was identified in one patient. Mean follow-up was six months (4 to 9) with union rate 96%. Change in block practice varied significantly (p =＜0.05). The risk ratio of complications using regional block (Bier’s) over haematoma block was 0.65. Conclusion. Follow-up adaptations during lockdown did not adversely affect patient outcomes. Regional anaesthesia is gold standard for manipulation of displaced distal radial fractures. Cite this article: Bone Jt Open 2021;2(5):338–343

Aims

We hypothesized that the wide-awake local anaesthesia with no tourniquet (WALANT) technique is cost-effective, easy to use, safe, and reproducible, with a low learning curve towards mastery, having a high patient satisfaction rate. Furthermore, WALANT would be a suitable alternative for the austere and developing nation environments where lack of funds and resources are a common issue.

A retrospective study was performed in 100 children aged between two and 16 years, with a dorsally angulated stable fracture of the distal radius or forearm, who were treated with manipulation in the emergency department (ED) using intranasal diamorphine and 50% oxygen and nitrous oxide. Pre- and post-manipulation radiographs, the final radiographs and the clinical notes were reviewed. A successful reduction was achieved in 90 fractures (90%) and only three children (3%) required remanipulation and Kirschner wire fixation or internal fixation.

The use of Entonox and intranasal diamorphine is safe and effective for the closed reduction of a stable paediatric fracture of the distal radius and forearm in the ED.

By facilitating discharge on the same day, there is a substantial cost benefit to families and the NHS and we recommend this method.

Take home message: Simple easily reducible fractures of the distal radius and forearm in children can be successfully and safely treated in the ED using this approach, thus avoiding theatre admission and costly hospital stay.

Cite this article: Bone Joint J 2016;97-B:131–6.

To determine the effect of experience of the operator and the effect of type of anaesthesia used on re-manipulation rates of fracture distal radius manipulated in A& E, a retrospective review of distal radius fractures manipulated in A& E between January 2000 and January 2001. Operators were divided into two categories: junior (SHO grade) and senior (higher grade) doctor. 54 patients with fracture distal radius had manipulation in A& E. 15 male and 39 female patients with mean age of 61 years (52 for males and 63 for females) were included. 42 (78%) fractures were manipulated under haematoma block (18 by junior, 23 by senior doctor) and 12 (22%) fractures were manipulated under Bier block (1 by junior, 11 by senior doctor). Operator’s grade was not clearly mentioned in one case. 13 out of 54 patients (24%) needed fracture re-manipulation under general anaesthesia. 12 out of 42 fractures manipulated under haematoma block (30%) needed re-manipulation compared to only one out of 12 fractures (8%) manipulated under Bier block (p=0.25). 9 out of 19 fractures manipulated by junior doctors needed re-manipulation compared to only 4 out of 34 fractures manipulated by senior doctors (p=0.007). Haematoma block was used for 18 out of 19 cases by junior doctors and for 23 out of 34 cases by senior doctors (p=0.038). Average number of fracture clinic follow-ups was 4 (range 2 to 8). Junior doctors had significantly higher preference for haematoma block and significantly higher re-manipulation rate. Re-manipulation rates were higher with fractures manipulated under haematoma block compared to Bier block. Adequate training and supervision should be provided for SHOs while performing such procedures in A& E. Use of Bier block as a regional anaesthesia for manipulation of distal radius fractures in A& E should be encouraged

Aim: To assess the adequacy of reduction of Colles fracture by haematoma block and intravenous sedation and its outcome. Methodology: Retrospectively reviewed 70 Colles fracture reductions done in the A & E. 30 haematoma blocks and 40 intravenouss sedation. The prereduction radiographs were reviewed for the radial height & inclination and dorsal tilt. The outcome of the reduction was also reviewed. Results: The mean age was 59 years for haematoma block and 56 years for intravenous sedation. Fracture classifications were similar in both groups using the Frykman and Universal classification. The mean prereduction radial length, radial inclination and dorsal tilt were equal in both groups. There was significant difference in post reduction measurements between the two groups. 30% of the haematoma block group had further manipulation and K wiring done whereas only 15% of the intravenous sedation group had further procedures done. Conclusions: Our study showed that there was less remanipulation and better reduction in the intravenous group than the haematoma group. We recommend intravenous sedation as a preferred procedure for initial manipulation of Colles fratures for a better outcome

The 1995 Audit Commission report, “Setting the Record Straight- A study of hospital medical records,” criticised the poor standard of NHS record keeping. A retrospective audit of documentation of patients undergoing a closed manipulation of distal radius fractures (Colles type) in the Accident and Emergency department of the Queen Alexandra Hospital revealed that note keeping still needs to be improved. Only 15% of patients had adequate documentation.

We retrospectively reviewed 183 children with a simple fracture of the distal radius, with or without fracture of the ulna, treated by closed reduction and cast immobilisation. The fracture redisplaced after an initial, acceptable closed reduction in 46 (25%). Complete initial displacement was identified as the most important factor leading to redisplacement. Other contributing factors were the presence of an ipsilateral distal ulnar fracture, and the reduction of completely displaced fractures under deep sedation or local haematoma block. We recommend that completely displaced fractures of the distal radius in children should be reduced under general anaesthesia, and fixed by primary percutaneous Kirschner wires even when a satisfactory closed reduction has been achieved

Proximal Radius – Fractures of the proximal radius in children account for slightly more than 1% of all children’s fractures, represent 5 to 10% of all elbow fractures and accounts for 5% of all fractures involving the growth plate. The average age in the literature is 10 years (4 to 16 years) with no difference between boys and girls. The anatomical aspects should be emphasized for the comprehension of this fracture: 1) the radial head of the child only starts to ossify at age 5 so it is very rare to have a fracture before this age since all the head is cartilaginous and therefore more resistant to trauma. At the same time it makes more difficult the diagnosis because of the absence of ossification of the epiphysis. 2) There is a valgus angulation of 12.5° between the radial head and the shaft of the radius in the AP plan and an anterior angulation of 3° on the lateral plane that should not be misinterpreted as fractures. 3) The radial head is intrarticular in a similar way like the femoral head and trauma to this region may lead to AVN as a result of damage to the vascular supply of the epiphysis. 4) The proximal radioulnar joint has a very intimate continuity contributing to exact congruence of the articular surfaces. The axis of rotation lies directly in the center of the radial neck. Any deviation of the epiphysis over the neck has a major reflect over the axis of rotation causing a “cam” effect when the radial head rotates with loss of pronosupination. The mechanism of injury responsible for this injury result from a fall on the outstretched upper extremity in which the elbow is extended and a valgus force is applied to the elbow joint. In more rare cases it result from direct pressure to the radial head during dislocation of the elbow. There are different classifications mostly based on the anatomical lesion or degree of deformity. Wilkins divides this fracture in two major groups: Group I (valgus fracture) subdivided in three types: type A – the Salter-Harris type I and II, type B – Salter-Harris type IV and type C – fractures involving only the proximal radial metaphysis and Group II (fractures associated with elbow dislocation) subdivided in two types: type D – reduction injuries and type E – dislocation injuries. O’Brien divides the common valgus injury in three types according to the degree of angulation between the radial head and the axis of the radius: Type I (0 to 30° angulation) Type II (between 30° and 60°) and Type III (more than 60°). The clinical symptoms may vary according to the magnitude of the injury. The child will mostly complaint of pain and tenderness on the lateral side of the joint. In young children pain may first be referred to the wrist. The pain usually increases with pronosupination and extension of the elbow. The diagnosis relies mostly on the x-ray view (AP and lateral) and the fracture will be easily visualized in either film. In the cases where the fracture line is superimposed over the ulna an oblique view will be necessary. In the young child, whereas the epiphysis is still not ossified, an ultrasound may be helpful differentiating the position of the radial head. An arthrogram may also be of benefit especially during the process of reduction to check the accuracy of the treatment. The prognosis of this lesion depends on several factors. A poor result can be expected if the fracture is associated with other injuries such as elbow dislocation and ulna or medial epicondylar fractures. A residual tilt of the radial head, provided is not superior to 30°, is more tolerable than a translocation of the radial head superior to 4mm. Age is also an important factor since the older the child the less remodeling it will have. The treatment has also an important role in the prognosis of this injury since it is unanimous acceptable that an open reduction is associated with poor results. Therefore the treatment of a young child with an isolated minimal displaced fracture-separation of the proximal radius (less than 30°) should be a simple long arm cast. In a more displaced fracture (more than 30° of tilt) a closed reduction should be performed under general anesthesia as suggested by Patterson. If the maneuver is not successful other attempts should be made with lateral pin compression applied directly to the radial head as suggested by Pesudo or an indirect reduction by an intramedullary kirschner wire as suggested by Metaizeau. Open reduction should be only reserved for dislocated Grade IV Salter-Harris type fractures, incarcerated radial head or in the presence of failure of closed treatment. The incidence of complications especially if associated with a dislocation of the elbow or other fractures can be high. The most common are loss of motion, radial head overgrowth usually with no clinical significance, notching of the radial neck and premature physeal closure. Avascular necrosis of the radial head is most commonly associated with open reduction. Distal Radius – It is the most common fracture separation in children and represent 46% of all fractures involving the growth plate. A fracture of the ulna is associated in 6 to 11% of the injuries. The average age is 12 years with a minimum of 7 and a maximum of 16 years. Although this high incidence it is very uncommon subsequent growth disturbance. The usual mechanism of injury is similar to the proximal radius injury and result from a fall on the outstretched upper extremity with the wrist hyperextended. This type of injury is classified by the Salter-Harris classification for physeal fractures and the most commons are the types I and II. The clinical symptoms vary from mild tenderness over the fracture site to a noticeable deformity most often with the apex volar. Attention should be given to the possibility of vascular and neural injury associated, mostly from the time of the acute deformation, and the diagnosis is made by x-ray view (AP and lateral) with the fracture well visualized. The prognosis is in general good since even in the presence of a markedly displaced fracture it can be expected a remarkably remodeling even in an older child. Treatment in a nondisplaced fracture only requires a below elbow cast for 4 weeks. In a displaced fracture a closed reduction should be performed under hematoma block or general anesthesia (in a young child). The reduction is stable most of the times in a plaster with the wrist in slight flexion. The incidence of complications is very rare

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