Developments in plate technology have increased interest in the operative fixation of Colles' fracture. The vast majority of patients are treated non-operatively, yet there are few medium or long-term outcome studies. The aim of this study was to evaluate medium-term outcome of a cohort of patients who previously received treatment in a plaster cast. 236 patients entered two previous prospective, randomised control studies comparing closed reduction techniques or plaster cast type. Both studies showed no difference in clinical or radiological outcome between groups. 43% of this cohort had a final dorsal tilt of > 10° and 44% had final radial shortening of >2mm. All patients now have a minimum follow-up of five years and 60 have died. The remaining 176 patients were contacted by post and asked to complete two validated patient-based questionnaires: a modified Patient Evaluation Measure and a quickDASH. 112 replies were received. The mean age of patients is 67 years (range 23 – 91 years). 31 patients are employed and 57 retired. 77% of patients had a quickDASH score of less than 20. 59% of patients never experience wrist pain whilst 8% of patients have daily pain. All Patient Evaluation Measures have shown a median score of 12 or less (0=excellent, 100= terrible). The best score was for pain (median 4; IQR 2-12) and the worst for grip strength (median 12; IQR 4 – 41). No radiological outcome 5 weeks after injury correlated with any outcome score, except for dorsal tilt, which correlated with difficulty with fiddly tasks (p=0.04) and carpal malalignment which correlated with interference with work (p=0.04). In conclusion, our results show a good functional outcome five years after non-operative management of Colles' fracture. A degree of malunion is acceptable and in the light of our results the economic impact of surgery must be evaluated

Introduction. The classical Colles fracture (extraarticular, dorsally angulated distal radius fracture) in patients with osteoporotic bone is becoming increasingly more frequent. There still appears to be no clear consensus on the most appropriate surgical management of these injuries. The purpose of this study is to appraise the use of percutaneous extra-focal pinning, in the management of the classical colles fracture. Methods. We retrospectively analysed 72 consecutive cases of Colles fractures treated with interfragmentary K-wire fixation, in female patients over sixty years of age, in two orthopaedic centres, under the care of twelve different orthopaedic surgeons. We correlated the radiographic distal radius measurements (ulnar variance, volar tilt, and radial inclination) at the pre-operative and intra-operative stages with the final radiographic outcome. Result. Mean dorsal angulation was 21° at time of presentation. Closed reduction significantly improved fracture position to a mean of 2.7° volar angulation (p<0.05). Mean angulation at time of k-wire removal was 1.6° dorsal, this was not significant in comparison to post reduction measurements (p< 0.05). Mean ulnar variance at time of presentation was 2.5mm (range 7.4 to -4.2). Reduction improved fracture displacement to a mean of 0mm, which was statistically significant (p<0.05). Mean ulnar variance at time of k-wire removal was 2.4mm (p<0.05). 56.8% of cases demonstrated radial shortening of 2mm or more. Conclusion. In female patients over 60 years of age, the best predictor of radial length, when K-wire fixation is to be used, is the radial length prior to fracture reduction. Thus if there is radial shortening visible in the initial radiographs as measured in terms of ulnar variance, one should consider a method of fixation other than inter-fragmentary K-wires

Background. One of the prime concerns when managing patients in plaster casts is loss of reduction. There have been studies showing that proper moulding of the plaster cast is critical in maintaining reduction. Recent studies have negated concerns that fibreglass (FG) casts do not allow swelling, when compared to plaster of Paris (POP) casts. However, their potential in maintenance of reduction has not been investigated. Materials and methods. We compared the three-point bending properties of FG casts with POP casts over the first 48 hours. The effect of splitting the casts, at one hour and 24 hours, was studied. Three identical jigs with hinged metal rods were designed to simulate a Colles fracture. The bending force was provided by 0.5 kg weight applied at one end of the jig. The resultant displacement was measured to nearest 0.01 mm over the next 48 hours. Each test was repeated 6 times (total 6 groups and 36 tests). Results. Most deformation occurred within 1 hour for FG casts and 24 hours for POP casts. The total deformation in FG cast (mean 2.4 mm) was significantly less than in POP casts (mean 4.7 mm) (p < 0.01). Splitting at 1 hour increased the final deformation of the POP cast and not of the FG cast (p < 0.05). No significant difference was noticed if the casts were split at 24 hours. Conclusion. Three-point moulding with FG casts can provide better constant loading at the fracture site than the POP casts. Early setting of FG cast allows earlier splitting. We recommend clinical trials to ascertain the safety and efficacy of split FG casts

Practice variation may occur when there is no standardised approach to specific clinical problems and there is a lack of scientific evidence for alternative treatments. Practice variation suggests that a segment of the patient population may be managed sub-optimally, and indicates a need for further research in order to establish stronger evidence-based practice guidelines. We surveyed Australian orthopaedic surgeons to examine practice variation in common orthopaedic presentations. In February 2009, members of the Australian Orthopaedic Association were emailed an online survey, which collected information regarding experience level (number of years as a consultant), sub-specialty interests, state where the surgeon works, on- call participation, as well as five common (anecdotally controversial) orthopaedic trauma cases with a number of management options. Surgeons were asked to choose their one most likely management choice from the list provided, which was either surgical or non-surgical in nature. A reminder was sent two weeks later. Exploratory regression was modeled to examine the predictors of choosing surgical management for each case and overall. Of 760 surgeons, 358 (47%) provided responses. For undisplaced scaphoid fractures, respondents selected short-arm cast (53%), ORIF (22%), percutaneous screw (22%) and long-arm cast (3%). Less experienced (0 to 5 years) (p=0.006) and hand surgeons (p=0.008) were more likely to operate. For a displaced mid-shaft clavicle fracture, respondents selected non-operative (62%), plating (31%) and intramedullary fixation (7%). Shoulder surgeons were more likely to operate (p<0.001). For an undisplaced Weber B lateral malleolus fracture, respondents selected plaster cast or boot (59%), lateral plating (31%), posterior plating (9%) and no splinting (2%). For a displaced Colles fracture in an older patient, respondents selected plating (47%), Kirschner wires (28%), cast/splint (23%) and external fixation (1%). Less experienced (p<0.001) and hand surgeons (p=0.024) were more likely to operate. For a two-part neck of humerus fracture in an older patient, respondents selected non-operative (74%), locking plate (14%), and hemiarthroplasty (7%). Shoulder surgeons were more likely to operate (p<0.001). Accounting for all answers in multiple regression modeling, it was found that more experienced surgeons (>15 years) were 25% less likely to operate (p=0.001). Overall, there was no difference among sub-specialties, or whether a surgeon participated in an on-call roster. Considerable practice variation exists among orthopaedic surgeons in the approach to common orthopaedic problems. Surgeons who identify with a sub-specialty are more likely to manage conditions in their area of interest operatively, and more experienced surgeons are less likely to recommend surgical management