The median nerve compression in the carpal tunnel is the most common compression syndrome of the upper limb. In most cases it is idiopathic but may also occur from anatomical, traumatic, endocrine, rheumatic or tumoral causes. Chow's endoscopic technique was initially used to treat this disease and then modified to a mini-open approach through a single palmar incision. This incision is similar to the one used in endoscopic release by Agee. After exposing the proximal part of the transverse carpal ligament a meniscus knife is advanced until there is a complete section of the ligament, without endoscopic equipment. Between 2004 and 2006, 200 hands in 179 patients with a diagnosis based on clinical and electromyographic criteria were operated by this mini-open technique. The mean follow-up was 49 months (minimum of 34 months and a maximum of 70 months). 50 randomly selected patients were submitted to the self-administered Boston questionnaire. 50 patients treated by the minimal-incision decompression during the same period were also given the questionnaire. The aesthetic satisfaction was registered as well as if they would have surgery on the other hand or would recommend the procedure. This mini-open technique is another technique available to the surgeon that allows very similar functional results to endoscopic surgery, without use of specific material and with a shorter surgical time

Introduction. Carpal tunnel syndrome is the commonest peripheral nerve compression neuropathy. Carpal tunnel release (CTR) is a very successful operation. Failed CTR mainly presents as persistence of symptoms, recurrence and new symptoms. The commonest presentation is persistence of symptoms suggested to be due to inadequate release of transverse carpal ligament (TCL) [3], and ante brachial fascia (ABF) [2]. Aim. We were looking at the rate of recurrence after CTR and the levels of skills of the primary surgeon. Materials and method. In a retrospective study we reviewed 49 cases of failed CTR in Kent and Sussex area in the South East of England covering the period between 1978 and 2008. The data was generated from the revision open CTR operation notes following referral to the specialist hand surgeon in the region. Results. There is 34 female and 13 male with age range of 41 to 90. The time between primary CTR to revision CTR is 3 months to 30 years. In our series, more than 55% was due to persistence. Incomplete division of TCL was noted in over 55% of cases and intact ABF in 34% of cases. In 49% of cases of recurrent carpal tunnel syndrome post CTR the primary surgery was done by GPs. Conclusion. This questions the role of GPs with special interest (GPSI) and surgical care practitioners as surgeons. Is this “a tip of the iceberg” This initiative is target driven not patient centred

Carpal tunnel syndrome (CTS) is the most common peripheral mononeuropathy seen in clinical practice. Approximately 34% of CTS patients undergo carpal tunnel decompression (CTD) surgery, in the UK. We investigated the change in epidemiology of CTD based on sex, age, socio-economic deprivation and geographical location, in Scotland, over the last 20 years. 76,076 CTD were performed between 1996–2015 (71% female, M:F ratio 1:2.4). The overall incidence rate of CTD was 73/100,000 person years. The mean age was 50–59 years old for both sexes. Socio-economic deprivation was associated with higher incidence rates of CTD (most deprived 89/100,000 person years and least deprived 64/100,000 person years) (p<0.01). NHS health boards with low populations and a more rural location had higher incidence rates; mean 98/100,000 person years (range 4–238/100,000 person years) compared to high population heath boards in urban locations; mean 74/100,000 person years (range 4–149/100,000 person years) (p<0.01). There has been a significant increase in number and overall incidence of CTD, in Scotland, during the study period: in 1996, 1,156 CTD performed (incidence 23/100,000 person years) vs. 2015, 5,292 CTD performed (incidence 87/100,000 person years) (p<0.01). We conclude that middle aged females are still the most common demographic undergoing CTD but the incidence rate is increasing over time. There appears to be an association between CTD and socio-economic deprivation. The incidence of CTD, and change over time, differs between health boards

Pain produced by the tourniquet is a common source of complaint for patients undergoing carpal tunnel decompression. Practice varies as to tourniquet position. There is little evidence to suggest benefit of one position over another. Our aim was to compare the experience of both the patient and the surgeon with the tourniquet placed either on the arm or the forearm. Ethical approval was granted. Following power calculation and a significance level set at 0.05, 100 patients undergoing open carpal tunnel decompression under local anaesthetic were randomised to arm or forearm group. Visual Analogue Scores (VAS) (0–100) for pain, blood pressure and heart rate were taken at 2 minute intervals. The operating surgeon provided a VAS for bloodless field achieved and obstruction caused by the tourniquet. The demographics of the groups was similar. There were no statistically significant differences in any measure between the groups. Average tourniquet times were 8.8 minutes (forearm) and 8.2 minutes (arm). The average VAS score for forearm and arm was 13 and 11 respectively for bloodless field, 9 and 2 for obstruction. Average overall VAS for pain was 27 in each group, however interval VAS scores for pain were higher in the arm group. The average change Mean Arterial Pressure was −5 mmHg (forearm) −2 mmHg (arm) pulse rate was −1 bpm (forearm) and −2 bpm (arm). Tourniquet placement on the arm does not result in significant difference in patient pain, physiological response or length of operation. Surgeons reported less obstruction and better bloodless fields with an arm tourniquet, however there was a trend for forearm tourniquet to result in less pain for the patient

Introduction. Carpal tunnel syndrome is a common neuropathy of the median nerve. Occupation has been widely examined as a risk factor for the development of carpal tunnel syndrome. The aim of this study was to examine the validity of the United Kingdom (UK) NS-SEC (National Statistics Socioeconomic Classification) in the assessment of correlation between occupation and CTS. Methods. A prospective audit database was collected of patients diagnosed with CTS over a 6 year period. Occupation was assessed using the NS-SEC self coded method, where occupation is classified depending on the type of job and the size of the employer. UK Census data from 2001 was used to compare the occupation profile of the cohort with the regional population. Results. There were 1564 patients diagnosed with CTS over a 6 year period. There were fewer patients with CTS in managerial and professional occupations (OR 0.77 95% CI 0.66 to 0.9), lower supervisory and technical occupations (OR 0.33, 0.23 to 0.45), and semi-routine and routine occupations (OR 0.68, 95% CI 0.58 to 0.79). There was a higher proportion of patients who were self-employed (OR 4.60, 3.93 to 5.30). Discussion. The NS-SeC is superficially attractive to assess occupational differences between a general population and a study group due to the availability of census data. This study has shown a higher proportion of patients having CTS in the self-employed category than in the general population. Such occupational classifications that are based on economic inidicators may not be useful in assessing exposure to risk factors for musculoskeletal disorders. Caution should be exercised in their use and more accurate scores developed that address physical intensity of an occupation

Introduction. Nerve conduction studies are considered to be the investigation of choice for the diagnosis of Carpal Tunnel Syndrome. However they are expensive and can be painful. We scored patients based on a ten point scoring system; four symptoms (Katz Hand Diagram – Classic and Probable pattern for tingling and numbness, nocturnal paresthesia, bilateral symptoms), four signs (weak thumb abduction test, Tinel sign, Phalen sign, Hypoalgesia in median nerve territory) and two risk factors (age more than 40 years and female sex). This was done in an effort to predict the severity of carpal tunnel syndrome and to correlate it with nerve conduction studies. Method. A prospective study of 59 patients was performed between May 2009 and March 2010. For every patient in the study we completed a scoring system based on ten points and correlated it with the severity (normal, mild, moderate and severe) result from the nerve conduction studies. Results. There were 61 completed data sets (59 patients, two patients had bilateral carpal tunnel release). The mean age of patients was 60 years (range: 37–91 years). The mean duration of symptoms was 17 months. The female to male ratio was 2.3:1. All scores greater than seven matched with nerve conduction study of moderate to severe intensity apart from three scores which were greater than seven that matched with a normal result. Conclusion. Based on this study, we believe that patients who score less than eight may require nerve conduction studies to confirm the diagnosis of carpal tunnel syndrome. However patients who score more than seven have a 93% chance of having moderate to severe carpal tunnel syndrome on nerve conduction studies

Aims. The objective of our study is to identify the causes for recurrence and to evaluate the results of our technique. Material and Methods. We retrospectively analysed 18 patients (12 females; 6 males) who had both clinical and electrophysiological confirmation (7 focal entrapments; 11 severe entrapments) of recurrent carpal tunnel syndrome. In all the patients, after releasing the nerve a vascularised fat pad flap was mobilised from hypothenar region and sutured to the lateral cut end of flexor retinaculum. All the patients were assessed post-operatively for relief of pain, recovery of sensory and motor dysfunction. Results. The average age was 61 years and dominant hand was involved in 13/18. The average time between the first and second surgery was fifty-nine months. Intra-operatively ten had completely reformed retinaculum, two partially reformed (proximally) and five had scar tissue between the cut ends and one had scar tissue and fibrosis around the nerve. All patients had improvement of symptoms post-operatively. Ten had complete recovery immediately after surgery, the remaining patients had severe focal entrapment and had scar tissue intraoperatively. The patients with delayed recovery had high incidence of a) Early recuurence (average of nine months), b) Diabetes mellitus c) Obese/over-weight and d) cervical spine problems. Conclusions. The hypothenar fat pad transposition flap provides a reliable source of vascularised local tissue that prevents scar formation and helps nerve gliding. 80% of the patients in whom recurrence occurred within a year are associated with poor outcome/delayed recovery

We investigated the response of chronic neck and shoulder pain to decompression of the carpal tunnel in 38 patients with whiplash injury. We also determined the plasma levels of substance P (SP) and calcitonin gene-related peptide (CGRP), which are inflammatory peptides that sensitise nociceptors. Compared with normal control subjects, the mean concentrations of SP (220 v 28 ng/l; p < 0.0001) and CGRP (400 v 85 ng/l; p < 0.0005) were high in patients with chronic shoulder and neck pain before surgery. After operation their levels fell to normal. There was resolution of neurological symptoms with improvement of pain in 90% of patients. Only two of the 30 with chronic neck and shoulder pain who had been treated conservatively showed improvement when followed up at two years. In spite of having neuropathic pain arising from the median nerve, all these patients had normal electromyographic and nerve-conduction studies. Chronic pain in whiplash injury may be caused by ‘atypical’ carpal tunnel syndrome and responds favourably to surgery which is indicated in patients with neck, shoulder and arm pain but not in those with mild symptoms in the hand. Previously, the presence of persistent neurological symptoms has been accepted as a sign of a poor outcome after a whiplash injury, but our study suggests that it may be possible to treat chronic pain by carpal tunnel decompression

The primary aim was to determine the rate of complications and re-intervention rate in a consecutive series of operatively managed distal radius fractures. Data was retrospectively collected on 304 adult distal radius fractures treated at our institution in a year. Acute unstable displaced distal radius fractures surgically managed within 28 days of injury were included. Demographic and injury data, as well as details of complications and their subsequent management were recorded. There were 304 fractures in 297 patients. The mean age was 57yrs and 74% were female. Most patients were managed with open reduction and internal fixation (ORIF) (n=278, 91%), with 6% (n=17) managed with manipulation and Kirschner wires and 3% (n=9) with bridging external fixation. Twenty-seven percent (n=81) encountered a post-operative complication. Complex regional pain syndrome was most common (5%, n=14), followed by loss of reduction (4%). Ten patients (3%) had a superficial wound infection managed with oral antibiotics. Deep infection occurred in one patient. Fourteen percent (n=42) required re-operation. The most common indication was removal of metalwork (n=27), followed by carpal tunnel decompression (n=4) and revision ORIF (n=4). Increasing age (p=0.02), male gender (p=0.02) and high energy mechanism of injury (p<0.001) were associated with developing a complication. High energy mechanism was the only factor associated with re-operation (p<0.001). This study has documented the complication and re-intervention rates following distal radius fracture fixation. Given the increased risk of complications and the positive outcomes reported in the literature, non-operative management of displaced fractures should be considered in older patients

Introduction. The flexor carpi radialis (FCR) approach is widely used for volar plate fixation of distal radius fractures. However, patients sometimes complain of postoperative numbness at the thenar eminence. We propose this is derived from injury to the palmar cutaneous branch of the median nerve (PCBm). Materials and methods. From March 2010 to March 2012, we performed 10 operations of volar plate fixation for distal radius fractures using the FCR approach. We detected the PCBm intraoperatively and investigated the anatomy. Results. On average, the PCBm arises from the median nerve 44 mm proximal to the distal wrist crease. It arose from the radial side of the median nerve in nine cases and the ulnar side in one case. In all cases, it ran between the FCR and the palmaris longus tendon under the antebrachial fascia. Nerve supply to the FCR sheath was not observed in the field of operation. Discussion. Numerous studies report the necessity to preserve the PCBm during carpal tunnel release surgery, but the relationship between the FCR approach and the PCBm has not been emphasized. Our results generally agree with past reports on PCBm anatomy. In our experience, the FCR tendon should be retracted to the ulnar side to prevent PCBm injury. If the FCR tendon is retracted radially, the PCBm should be detected and retracted gently. Some studies report that the PCBm joins the FCR sheath at the level of the distal wrist crease. Thus, the distal sheath incision should not be extended blindly

Aims

We introduced a self-care pathway for minimally displaced distal radius fractures, which involved the patient being discharged from a Virtual Fracture Clinic (VFC) without a physical review and being provided with written instructions on how to remove their own cast or splint at home, plus advice on exercises and return to function.

Aims

The purpose was to compare operative treatment with a volar plate and nonoperative treatment of displaced distal radius fractures in patients aged 65 years and over in a cost-effectiveness analysis.

Aims

To compare operative and nonoperative treatment for displaced distal radius fractures in patients aged over 65 years.

Objectives

Patient-reported outcome measures (PROMs) are often used to evaluate the outcome of treatment in patients with distal radial fractures. Which PROM to select is often based on assessment of measurement properties, such as validity and reliability. Measurement properties are assessed in clinimetric studies, and results are often reviewed without considering the methodological quality of these studies. Our aim was to systematically review the methodological quality of clinimetric studies that evaluated measurement properties of PROMs used in patients with distal radial fractures, and to make recommendations for the selection of PROMs based on the level of evidence of each individual measurement property.

Aims

Outcome measures quantifying aspects of health in a precise, efficient, and user-friendly manner are in demand. Computer adaptive tests (CATs) may overcome the limitations of established fixed scales and be more adept at measuring outcomes in trauma. The primary objective of this review was to gain a comprehensive understanding of the psychometric properties of CATs compared with fixed-length scales in the assessment of outcome in patients who have suffered trauma of the upper limb. Study designs, outcome measures and methodological quality are defined, along with trends in investigation.

Aims

To synthesise the literature and perform a meta-analysis detailing the longitudinal recovery in the first two years following a distal radius fracture (DRF) managed with volar plate fixation.

We studied prospectively the regional inflammatory response to a unilateral distal radial fracture in 114 patients at eight to nine weeks after injury and again at one year. Our aim was to identify patients at risk for a delayed recovery and particularly those likely to develop complex regional pain syndrome. In order to quantify clinically the inflammatory response, a regional inflammatory score was developed. In addition, blood samples were collected from the antecubital veins of both arms for comparative biochemical and blood-gas analysis.

The severity of the inflammatory response was related to the type of treatment (Kruskal-Wallis test, p = 0.002). A highly significantly-positive correlation was found between the regional inflammatory score and the length of time to full recovery (r² = 0.92, p = 0.01, linear regession). A regional inflammatory score of 5 points with a sensitivity of 100% but a specificity of only 16% also identified patients at risk of complex regional pain syndrome. None of the biochemical parameters studied correlated with regional inflammatory score or predicted the development of complex regional pain syndrome.

Our study suggests that patients with a distal radial fracture and a regional inflammatory score of 5 points or more at eight to nine weeks after injury should be considered for specific anti-inflammatory treatment.

This study compares the cost-effectiveness of treating dorsally displaced distal radial fractures with a volar locking plate and percutaneous fixation. It was performed from the perspective of the National Health Service (NHS) using data from a single-centre randomised controlled trial. In total 130 patients (18 to 73 years of age) with a dorsally displaced distal radial fracture were randomised to treatment with either a volar locking plate (n = 66) or percutaneous fixation (n = 64). The methodology was according to National Institute for Health and Care Excellence guidance for technology appraisals. .

There were no significant differences in quality of life scores between groups at any time point in the study. Both groups returned to baseline one year post-operatively.

NHS costs for the plate group were significantly higher (p < 0.001, 95% confidence interval 497 to 930). For an additional £713, fixation with a volar locking plate offered 0.0178 additional quality-adjusted life years in the year after surgery. The incremental cost-effectiveness ratio (ICER) for plate fixation relative to percutaneous fixation at list price was £40 068. When adjusting the prices of the implants for a 20% hospital discount, the ICER was £31 898. Patients who underwent plate fixation did not return to work earlier.

We found no evidence to support the cost-effectiveness, from the perspective of the NHS, of fixation using a volar locking plate over percutaneous fixation for the operative treatment of a dorsally displaced radial fracture.

Cite this article: Bone Joint J 2015;97-B:1264–70.

We identified 11 women with a mean age of 74 years (65 to 81) who sustained comminuted distal radial and ulnar fractures and were treated by volar plating and slight shortening of the radius combined with a primary Sauvé-Kapandji procedure.

At a mean of 46 months (16 to 58), union of distal radial fractures and arthrodesis of the distal radioulnar joint was seen in all patients. The mean shortening of the radius was 12 mm (5 to 18) compared to the contralateral side. Flexion and extension of the wrist was a mean of 54° and 50°, respectively, and the mean pronation and supination of the forearm was 82° and 86°, respectively. The final mean disabilities of the arm, shoulder and hand score was 26 points. According to the Green and O’Brien rating system, eight patients had an excellent, two a good and one a fair result.

The good clinical and radiological results, and the minor complications without the need for further operations related to late ulnar-sided wrist pain, justify this procedure in the elderly patient.

A total of 179 adult patients with displaced intra-articular fractures of the distal radius was randomised to receive indirect percutaneous reduction and external fixation (n = 88) or open reduction and internal fixation (n = 91). Patients were followed up for two years. During the first year the upper limb musculoskeletal function assessment score, the SF-36 bodily pain sub-scale score, the overall Jebsen score, pinch strength and grip strength improved significantly in all patients. There was no statistically significant difference in the radiological restoration of anatomical features or the range of movement between the groups.

During the period of two years, patients who underwent indirect reduction and percutaneous fixation had a more rapid return of function and a better functional outcome than those who underwent open reduction and internal fixation, provided that the intra-articular step and gap deformity were minimised.