The management of comminuted metaphyseal fractures is a technical challenge and satisfactory outcomes of such fixations often remain elusive. The small articular fragments and bone loss often make it difficult for standard fixation implants for proper fixation. We developed a novel technique to achieve anatomical reduction in multiple cases of comminuted metaphyseal fractures at different sites by employing the cantilever mechanism with the help of multiple thin Kirschner wires augmented by standard fixation implants.

We performed a retrospective study of 10 patients with different metaphyseal fractures complicated by comminution and loss of bone stock. All patients were treated with the help of cantilever mechanism using multiple Kirschner wires augmented by compression plates. All the patients were operated by the same surgeon between November 2020 to March 2021 and followed up till March 2023. Surgical outcomes were evaluated according to the clinical and radiological criteria.

A total of 10 patients were included in the study. Since we only included patients with highly unstable and comminuted fractures which were difficult to fix with traditional methods, the number of patients in the study were less. All 10 patients showed satisfactory clinical and radiological union at the end of the study with good range of motion. One of the patient in the study had post-operative wound complication which was managed conservatively with regular dressings and oral antibiotics.

Comminuted metaphyseal fractures might differ in pattern and presentation with every patient and there can be no standard treatment for all. The cantilever technique of fracture fixation is based on the principle of cantilever mechanism used in bridges and helps achieve good anatomical reduction and fixation. It provides a decent alternative when standard modes of fixation don't give desired result owing to comminuted nature of fractures and deficiency of bone stock.

Distal interphalangeal joint (DIPJ) fusion using a k-wire has been the gold standard treatment for DIPJ arthritis. Recent studies have shown similar patient outcomes with the headless compression screws (HCS), however there has been no cost analysis to compare the two. Therefore, this study aims to 1) review the cost of DIPJ fusion between k-wire and HCS 2) compare functional outcome and patient satisfaction between the two groups. A retrospective review was performed over a nine-year period from 2012-2021 in Counties Manukau. Cost analysis was performed between patients who underwent DIPJ fusion with either HCS or k-wire. Costs included were surgical cost, repeat operations and follow-up clinic costs. The difference in pre-operative and post-operative functional and pain scores were also compared using the patient rate wrist/hand evaluation (PRWHE). Of the 85 eligible patients, 49 underwent fusion with k-wires and 36 had HCS. The overall cost was significantly lower in the HCS group which was 6554 New Zealand Dollars (NZD), whereas this was 10408 NZD in the k-wire group (p<0.0001). The adjusted relative risk of 1.3 indicate that the cost of k-wires is 1.3 times more than HCS (P=0.0053). The patients’ post-operative PRWHE pain (−22 vs −18, p<0.0001) and functional scores (−38 vs −36, p<0.0001) improved significantly in HCS group compared to the k-wire group. Literatures have shown similar DIPJ fusion outcomes between k-wire and HCS. K-wires often need to be removed post-operatively due to the metalware irritation. This leads to more surgical procedures and clinic follow-ups, which overall increases the cost of DIPJ fusion with k-wires. DIPJ fusion with HCS is a more cost-effective with a lower surgical and follow-up costs compared to the k-wiring technique. Patients with HCS also tend to have a significant improvement in post-operative pain and functional scores

Aims

The aim of this study was to examine trends in the management of fractures of the distal radius in Ireland over a ten-year period, and to determine if there were any changes in response to the English Distal Radius Acute Fracture Fixation Trial (DRAFFT).

Aims

Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union.

The results of the DRAFFT (distal radius acute fracture fixation trial) study, which compared volar plating with Kirschner (K-) wire fixation for dorsally displaced fractures of the distal radius, were published in August 2014. The use of K-wires to treat these fractures is now increasing, with a concomitant decline in the use of volar locking plates.

We provide a critical appraisal of the DRAFFT study and question whether surgeons have been unduly influenced by its headline conclusions.

Cite this article: Bone Joint J 2016;98-B:298–300.

This article is a systematic review of the published literature about the biomechanics, functional outcome and complications of intramedullary nailing of fractures of the distal radius.

We searched the Medline and EMBASE databases and included all studies which reported the outcome of intramedullary (IM) nailing of fractures of the distal radius. Data about functional outcome, range of movement (ROM), strength and complications, were extracted. The studies included were appraised independently by both authors using a validated quality assessment scale for non-controlled studies and the CONSORT statement for randomised controlled trials (RCTs).

The search strategy revealed 785 studies, of which 16 were included for full paper review. These included three biomechanical studies, eight case series and five randomised controlled trials (RCTs).

The biomechanical studies concluded that IM nails were at least as strong as locking plates. The clinical studies reported that IM nailing gave a comparable ROM, functional outcome and grip strength to other fixation techniques.

However, the mean complication rate of intramedullary nailing was 17.6% (0% to 50%). This is higher than the rates reported in contemporary studies for volar plating. It raises concerns about the role of intramedullary nailing, particularly when comparative studies have failed to show that it has any major advantage over other techniques. Further adequately powered RCTs comparing the technique to both volar plating and percutaneous wire fixation are needed.

Cite this article: Bone Joint J 2015;97-B:1370–6.

A small proportion of children with Gartland type III supracondylar humeral fracture (SCHF) experience troubling limited or delayed recovery after operative treatment. We hypothesised that the fracture level relative to the isthmus of the humerus would affect the outcome.

We retrospectively reviewed 230 children who underwent closed reduction and percutaneous pinning (CRPP) for their Gartland type III SCHFs between March 2003 and December 2012. There were 144 boys and 86 girls, with the mean age of six years (1.1 to 15.2). The clinico-radiological characteristics and surgical outcomes (recovery of the elbow range of movement, post-operative angulation, and the final Flynn grade) were recorded. Multivariate analysis was employed to identify prognostic factors that influenced outcome, including fracture level. Multivariate analysis revealed that a fracture below the humeral isthmus was significantly associated with poor prognosis in terms of the range of elbow movement (p < 0.001), angulation (p = 0.001) and Flynn grade (p = 0.003). Age over ten years was also a poor prognostic factor for recovery of the range of elbow movement (p = 0.027).

This is the first study demonstrating a subclassification system of Gartland III fractures with prognostic significance. This will guide surgeons in peri-operative planning and counselling as well as directing future research aimed at improving outcomes.

Cite this article: Bone Joint J 2015;97-B:134–40.

Introduction. A recent retrospective study of distal femoral physeal fractures (DFPFs) suggested closed manipulation alone has a high incidence of re-displacement, malunion or physeal bar formation. The paper concluded that all displaced DFPFs require internal fixation, and breaching the physis with k-wires is safe. We agree that hyper-extension/flexion injuries need stabilisation using k-wires but, in our experience, purely valgus/varus deformities can be successfully managed by manipulation under anaesthesia (MUA) and a moulded cylinder cast. Method. We prospectively observed DFPFs presenting over 12 months. Departmental policy is to treat varus/valgus deformities by MUA, with cylinder casting providing 3 point fixation. Hyper-extension/flexion injuries are reduced on a traction table. 2mm cross k-wiring is performed, leaving the wires under the skin, and a cylinder plaster applied. A post-operative CT scanogram accurately assesses limb alignment. Patients are mobilised immediately using crutches and weight-bearing as pain allows. Plaster and k-wires are removed after 4–5 weeks. Scanogram is then repeated, and again at 6 months and 1 year. Results. 17 cases presented over 1 year. 16 were male, with a median age of 15. 13 were injured playing soccer, 1 in a motor vehicle accident and 3 by other mechanisms. Internal fixation supplemented reduction in 13 cases. 1 patient required repeat MUA and k-wiring when post-operative scanogram identified significant varus mal-alignment. In all cases, cylinder casting was unproblematic and range of movement quickly recovered after plaster/wire removal. To date none have developed significant malunion or growth arrest requiring intervention. Conclusion. DFPFs are uncommon, almost always occurring in teenage males. Accurate reduction and stabilisation is vital to restore and maintain a correct mechanical axis. MUA and cylinder casting is adequate in appropriate cases. Early imaging with CT scanogram can detect mal-alignment. Growth arrest is unusual and unlikely to be significant in most patients, who are approaching skeletal maturity. NO DISCLOSURES

Aim. Differing reports about the surgical management of the supracondylar humeral fracture make evidence-based practice very difficult, so knowledge of the contemporary practices and opinions of an expert body can provide a useful benchmark for appraisal; the aim of this study was to obtain this information. Methods. An electronic 18 item, single response multiple-choice questionnaire was designed to investigate various aspects of the surgical management of supracondylar fractures, with particular focus on areas that remain controversial in the literature. Members of BSCOS were invited by email, on three occasions, to complete the questionnaire, which was posted on the web-based SurveyMonkey™ platform (. www.surveymonkey.com. , California, USA). The survey was available for completion for a period of 10 weeks. Results. 102 responses were received (response rate 56.7%); all respondents completed the entire questionnaire. There was almost complete agreement (>90%) in only three areas: -The preferred management of Gartland 3 fractures; The management of the fracture with an absent radial pulse and impaired digital perfusion; An ulnar nerve palsy detected four weeks post-operatively. Majority agreement (>60%) was found regarding: - Possible consequences of delay in performing closed reduction; Management of the pink, perfused hand with an absent radial pulse; Necessity of anatomical reduction. There was no consensus regarding: - K-wiring of Gartland 2 fractures; Management of ulnar nerve palsy detected one week post-operatively; Open insertion of the medial K-wire. Conclusion. Reflecting current trends and attitudes, this survey provides information against which an individual surgeon can appraise their own practice. Strong consensus existed in areas in which clear evidence is available to inform practice. This highlights the importance of good-quality research, and identifies areas requiring further investigation

Aim. To investigate the effectiveness of a decision-based protocol designed to minimise the use of medial incisions when performing crossed-wire fixation of supracondylar fractures of the distal humerus whilst minimising ulnar nerve injury. Method. We have employed a protocol for placing the medial wire during crossed k-wire fixation of supracondylar fractures dependent upon the medial epicondyle. When this is palpable, the wire is introduced percutaneously; when it is not, a mini-incision is made. All cases of closed reduction and crossed K-wiring of supracondylar fracture over a three year period (2008–2011) were identified from our department database. Cases with a neurological injury identified pre-operatively, and those in which the protocol had not been followed were excluded. Casenotes were reviewed to determine the incidence and outcomes of post-operative ulnar nerve deficit. Results. A total of 106 cases were identified, from which 36 cases were excluded, leaving 70 cases in the study. The mean age was 5 (range 1–11). 68 were extension-type injuries, of which 29 (41%) were type 2 and 39 (56%) type 3 according to the classification of Gartland. 2 were flexion-type. A mini-incision for placement of the medial K-wire was required in only 3 cases (4.3%), with percutaneous placement in all other cases. There was clinical evidence of partial ulnar nerve injury in 1 case (1.4%) which recovered spontaneously within 11 months. Conclusion. The results of this study demonstrate our protocol to be effective. Careful percutaneous placement of the medial wire can be performed in the majority of cases with little risk of significant or permanent injury to the ulnar nerve. Open placement of the medial wire is indicated in only a small proportion of cases. We suggest that the routine use of a medial mini-incision should be re-considered

Background. Proximal phalangeal fractures are caused by an injury to the dorsum of the hand. This usually causes volar angulation which is unstable when reduced. K-wiring or external fixation can damage the soft tissue envelope, can introduce infection and can loosen or displace. Traction splinting is not well described for these fractures. Objectives. Functional and radiographic assessment of all patients with proximal phalangeal fractures treated with traction splinting. Methods. Theatre records were examined for relevant injuries over a 2 year period. These patients were then assessed using a QuickDASH score, a questionnaire specific to traction splinting and with pre-op, intra-op, post-op and follow-up radiographs. Results. A total of 7 patients were treated with traction splinting, all by the senior author (FJS). Clinical follow was 16 months (range12-20). QuickDASH scores were 0, 0, 0, 0, 0, 2.5, 25/100. With regard to work (n=6), all patients but one scored 0/100 for disability with one patient describing mild work related difficulties. Those participating in sports/performing arts (n=6) scored 0/100. There were no finger-tip pain or numbness issues. Finger length perception was satisfactory in all patients. The splint slipped in 3 patients, secondary to horse riding, showering and through scratching. Two patients reported having a measurable loss of motion in the affected digit (follow-up 18 and 20 months), both with mild functional deficit. Radiographic outcomes showed that traction achieved acceptable length restoration, with no angular deformities. Finger length was maintained in all but one patient who had a shortening of 3.2mm. Conclusions. Traction splinting is a non-invasive, safe and inexpensive method of treating proximal phalangeal fractures. Results of our follow-up study show excellent functional and radiographic outcomes with minimal long term morbidity for this treatment option

Purpose. To elucidate whether there is an advantage in external fixation supplementation of K-wires in comparison to K-wires and plaster, in the treatment of distal radius fractures without metaphyseal comminution. Indications. Distal intraarticular radius fractures, Frykman VIII or VIII without metaphyseal comminution. Contraindications. Metaphyseal comminution, general medical contraindications for surgical intervention. Study design. Fifty-one patients were prospectively randomised in two groups: 24 patients were treated with K-wire and spanning external fixation supplementation, and 27 were treated with K-wires and plaster. Results. Patients were monitored following the operation with a minimum follow up of 1 year, and checked independently of surgeon for pain, satisfaction and range of motion. There was a statistically significant difference in favour of the external fixation patient group for pain (Visual Analogue Score, Ex-Fix group: mean 14.9, plaster group: mean 28.1, p<0.001) and satisfaction (Ex-Fix group: mean 89.7, plaster group: mean 76.3, p<0.001,). Although one would expect that range of motion would be reduced in the external fixation group, there were no statistically significant differences found in favour of plaster; on the contrary supination results were surprisingly in favour of the external fixation group (Ex-Fix group: mean 54.4, plaster group: mean 45.2, p<0.05). Conclusion. In this study, external fixation supplementation of K-wiring had statistically significant superior results in patient satisfaction score, pain score, and wrist supination in comparison to plaster augmentation of K-wiring

Introduction: Distal radius metaphyseal fractures in children are not uncommon, but when they occur proximal to the insertion of the pronator quadratus muscle, reduction and maintenance of reduction can be challenging. The deforming forces at the fracture site result in pronation and shortening of the distal fragment. Manual manipulation of this fracture often results in tearing of the dorsal periosteum and hence renders this fracture highly unstable. Aim: We present a novel easily reproducible mini-open surgical technique and functionally and radiologically evaluate a series of eleven patients who have undergone this technique. Materials and Methods: The surgical technique consists of a mini-open intrafocal image intensifier guided reduction technique with percutaneous k-wiring fixation. Five males and six females with an average age of 8.8 years (range 5 to 13 years), who sustained a pronator quadratus distal radius fracture and subsequently underwent this surgical technique from 2005 to 2007, were evaluated both radiologically in terms of radial length, radial tilt and volar tilt compared with the contralateral limb and functionally using the Mayo Modified wrist score and the patient related wrist evaluation questionnaire. Results: Patients were followed up for an average of 18 months (range 2–31 months). All patients achieved clinical and radiological union. No patient required remanipulation for loss of reduction. Radiological outcome measures similar to contralateral limb with good functional scores. No complications were noted. All patients returned to preoperative level of function. Conclusion: This minimally invasive technique has been shown to be technically easy, reliable and reproducible with excellent results and low risk of displacement compared to other techniques used to treat this potentially challenging fracture

We retrospectively analysed the clinical results of 30 patients with injuries of the sternoclavicular joint at a minimum of 12 months’ follow-up. A closed reduction was attempted in 14 cases. It was successful in only five of ten dislocations, and failed in all four epiphyseal disruptions. A total of 25 patients underwent surgical reduction, in 18 cases in conjunction with a stabilisation procedure.

At a mean follow-up of 60 months, four patients were lost to follow-up. The functional results in the remainder were satisfactory, and 18 patients were able to resume their usual sports activity at the same level. There was no statistically significant difference between epiphyseal disruption and sternoclavicular dislocation (p > 0.05), but the functional scores (Simple Shoulder Test, Disability of Arm, Shoulder, Hand, and Constant scores) were better when an associated stabilisation procedure had been performed rather than reduction alone (p = 0.05, p = 0.04 and p = 0.07, respectively).

We recommend meticulous pre-operative clinical assessment with CT scans. In sternoclavicular dislocation managed within the first 48 hours and with no sign of mediastinal complication, a closed reduction can be attempted, although this was unsuccessful in half of our cases. A control CT scan is mandatory. In all other cases, and particularly if epiphyseal disruption is suspected, we recommend open reduction with a stabilisation procedure by costaclavicular cerclage or tenodesis. The use of a Kirschner wire should be avoided.

We compared two management strategies for the perfused but pulseless hand after stabilisation of a Gartland type III supracondylar fracture. We identified 19 patients, of whom 11 were treated conservatively after closed reduction (group 1). Four required secondary exploration, of whom three had median and/or anterior interosseus nerve palsy at presentation. All four were found to have tethering or entrapment of both nerve and vessel at the fracture site. Only two regained patency of the brachial artery, and one patient has a persistent neurological deficit.

In six of the eight patients who were explored early (group 2) the vessel was tethered at the fracture site. In group 2 four patients also had a nerve palsy at presentation and were similarly found to have tethering or entrapment of both the nerve and the vessel. The patency of the brachial artery was restored in all six cases and their neurological deficits recovered completely.

We would recommend early exploration of a Gartland type III supracondylar fracture in patients who present with a coexisting anterior interosseous or median nerve palsy, as these appear to be strongly predictive of nerve and vessel entrapment.