Distal femoral physeal fractures in children have a high incidence of physeal arrest, occurring in a mean of 40% of cases. The underlying nature of the distal femoral physis may be the primary cause, but other factors have been postulated to contribute to the formation of a physeal bar. The purpose of this study was to assess the significance of contributing factors to physeal bar formation, in particular the use of percutaneous pins across the physis. We reviewed 55 patients with a median age of ten years (3 to 13), who had sustained displaced distal femoral physeal fractures. Most (40 of 55) were treated with percutaneous pinning after reduction, four were treated with screws and 11 with plaster. A total of 40 patients were assessed clinically and radiologically after skeletal maturity or at the time of formation of a bar. The remaining 15 were followed up for a minimum of two years. Formation of a physeal bar occurred in 12 (21.8%) patients, with the rate rising to 30.6% in patients with high-energy injuries compared with 5.3% in those with low-energy injuries. There was a significant trend for physeal arrest according to increasing severity using the Salter-Harris classification. Percutaneous smooth pins across the physis were not statistically associated with growth arrest

Aims: The purpose of the study was to analyse the early experience of the technique of transitory percutaneous pinning to manage three and four part proximal humeral fractures. Methods: An independent review of 66 consecutive patients with proximal humeral fractures treated in our unit over a three-year period was carried out. The patients underwent closed reduction under image intensiþer guidance with percutaneous pinning using an average of 3.5 wires (range 3–4). A standard three dose prophylactic antibiotic regime was used. A protective collar and cuff was the used for 4 weeks, and a physiotherapy program of pendular movements going on to assisted active exercises started after this. The wires were typically removed in an outpatient setting at 4 to 6 weeks. Results: The postoperative radiographs were deemed satisfactory with good overall alignment by two external observers in all cases. Our þndings were however remarkable for a very high early complication rate. This included pin migration (50%), stiffness (41%), pain (33%), infection (25%), nonunion (8%) and radial nerve palsy (8%). The complication rate increased dramatically in those over the age of 50 or those with osteopenia. Conclusions: The technique of transitory percutaneous humeral pinning is technically demanding. Our early experience would suggest high rates of early complications and readmissions. This technique should be applied with caution in older patients with osteopenia

Pin placement into the medial calcaneus places a number of structures at risk of damage. Research evidence suggests that the greatest risk of posterior pin placement is to the medial calcaneal branch of the tibial nerve. By using palpable anatomical landmarks, we attempted to redefine the safe zone taking into account possible variations. The medial heel region of twenty-four cadavers was dissected to find the major structures at risk. The inferior tip of the medial malleolus (point A), insertion point of tendo calcaneus (point B), navicular tuberosity (point C) and the medial process of the calcaneal tuberosity (point D) were all selected as anatomic landmarks from which to measure the identified structures using digital electronic calipers. The commonest variation in origins of medial calcaneal nerves was found to be one arising before the bifurcation of the tibial nerve along with one arising from the medial plantar nerve (10/24). The safest zone for percutaneous pin placement has been calculated as beyond two-thirds of the distances AB, CD, AD and CB. More posterior pin placement reduces the risk of damage to the medial calcaneal nerve and its branches, although the risk remains and blunt dissection before pin placement is recommended

Distal radial fractures are common in children. Recent outcome studies have cast doubt on the success of treatment by closed reduction and application of plaster. The most important risk factor for poor outcome is translation of the fracture. If a distal radial fracture is displaced by more than half the diameter of the bone at the fracture site it should be classified as high risk. We performed percutaneous Kirschner-wire pinning on 157 such high-risk distal radial fractures in children under 16 years of age. The predicted early and late failure rate was reduced from 60% to 14% and only 1.5% of patients had significant limitation of forearm movement of more than 15 degrees in the final assessment at a mean of 31 months after operation. There were no cases of early physeal closure or deep infection

Objectives

There are various pin-in-plaster methods for treating fractures of the distal radius. The purpose of this study is to introduce a modified technique of ‘pin in plaster’.

Technology within medicine has great potential to bring about more accessible, efficient, and a higher quality delivery of care. Paediatric supracondylar fractures are the most common elbow fracture in children and at our institution often have high rates of unnecessary long term clinical follow-up, leading to an inefficient use of healthcare and patient resources. This study aims to evaluate patient and clinical factors that significantly predict necessity for further clinical visits following closed reduction and percutaneous pinning. A total of 246 children who underwent closed reduction and percutaneous pinning following supracondylar humerus fractures were prospectively enrolled over a two year period. Patient demographics, perioperative course, goniometric measurements, functional outcome measures, clinical assessment and decision making for further follow up were assessed. Categorical and continuous variables were analyzed and screened for significance via bivariate regression. Significant covariates were used to develop a predictive model through multivariate logistical regression. A probability cut-off was determined on the Receiver Operator Characteristic (ROC) curve using the Youden index to maximize sensitivity and specificity. The regression model performance was then prospectively tested against 22 patients in a blind comparison to evaluate accuracy. 246 paediatrics patients were collected, with 29 cases requiring further follow up past the three month visit. Significant predictive factors for follow up were residual nerve palsy (p < 0 .001) and maximum active flexion angle of injured elbow (p < 0 .001). Insignificant factors included other goniometric measures, subjective evaluations, and functional outcomes scores. The probability of requiring further clinical follow up at the 3 month post-op point can be estimated with the equation: logit(follow-up) = 11.319 + 5.518(nerve palsy) − 0.108(maximum active flexion). Goodness of fit of the model was verified with Nagelkerke R2 = 0.574 and Hosmer & Lemeshow chi-square (p = 0.739). Area Under Curve of the ROC curve was C = 0.919 (SE = 0.035, 95% CI 0.850 – 0.988). Using Youden's Index, a cut-off for probability of follow up was set at 0.094 with the overall sensitivity and specificity maximized to 86.2% and 88% respectively. Using this model and cohort, 194 three month clinic visits would have been deemed medically unnecessary. Preliminary blind prospective testing against the 22 patient cohort demonstrates a model sensitivity and specificity at 100% and 75% respectively, correctly deeming 15 visits unnecessary. Virtual clinics and automated clinical decision making can improve healthcare inefficiencies, unclog clinic wait times, and ultimately enhance quality of care delivery. Our regression model is highly accurate in determining medical necessity for physician examination at the three month visit following supracondylar fracture closed reduction and percutaneous pinning. When applied correctly, there is potential for significant reductions in health care expenditures and in the economic burden on patient families by removing unnecessary visits. In light of positive patient and family receptiveness toward technology, our promising findings and predictive model may pave the way for remote health care delivery, virtual clinics, and automated clinical decision making

We performed a prospective, randomised study on 57 patients older than 60 years of age with unstable, extra-articular fractures of the distal radius to compare the outcome of immobilisation in a cast alone with that using supplementary, percutaneous pinning. Patients treated by percutaneous wires had a statistically significant improvement in dorsal angulation (mean 7°), radial length (mean 3 mm) and radial inclination (mean 3 mm) at one year. However, there was no significant difference in functional outcome in terms of pain, range of movement, grip strength, activities of daily living and the SF-36 score except for an improved range of movement in ulnar deviation in the percutaneous wire group. One patient developed a pin-track infection which required removal of the wires at two weeks. We conclude that percutaneous pinning of unstable, extra-articular fractures of the distal radius provides only a marginal improvement in the radiological parameters compared with immobilisation in a cast alone. This does not correlate with an improved functional outcome in a low-demand, elderly population

Introduction: To compare olecranon screw traction with percutaneous pinning for the treatment of Gartland III supracondylar fractures in children. Methods: This was a retrospective study of 151 patients between 1986 and 1996 treated with olecranon screw traction and 92 patients between 1996 and 2002 treated with percutaneous pinning. Both sets of patients were followed up clinically and radiologically following their injuries until there was evidence of fracture union and the child could demonstrate a satisfactory range of movement. Data recorded included demographics, fracture information, neurovascular injury, operation details, length of stay, length of follow up and clinical outcome. Radiographs were used to measure initial and final Baumann angles to give an indication of outcomes of distal humerus alignment. Results: Results are shown for the percutaneous pinning group with the olecranon screw traction results in brackets for comparison. The percutaneous pinning study included 54 (88) males and 38 (63) females with 63% (63%) left and 37% (37%) right elbow fractures. 46% (29%) of fractures occurred at home, 46% (56%) sustained the injury whilst playing and 7% (7%) occurred at school/nursery. The mean age was 6.0 (6.8) years with a range of 21–165 (12–168) months. The radial pulse was absent in 12% (13%). None of the fractures were open (compared with 5%). There were neurological deficits in 20% (17%). The median time to surgery was 5 hours. The fracture needed to be opened in 12% of cases as satisfactory reduction could not be achieved closed. The median stay length was 1 day (compared to a median stay on traction of 14 days). Mean follow up was 15.2 weeks. (Compared to 38.0 weeks). 2 % (3%) had cubitus varus detectable clinically. Median time to recovery for neurological deficit was 24 weeks (18 weeks). Mean initial Baumann’s angle was 74.6 degrees (73.7degrees). Mean final Baumann’s angle was 75.3 degrees (76.0 degrees). Discussion: Outcomes achieved from percutaneous pinning of displaced supracondylar fractures are similar to those from olecranon screw traction. The advantage of percutaneous pinning to both patient and provider is the reduced hospital stay and duration of follow up. Olecranon screw traction remains a possible treatment option for the management of this injury

There is no agreement as to the superiority or specific indications for cast treatment, percutaneous pinning or open fracture fixation for Bennett's fractures of the thumb metacarpal. We undertook this study to compare the outcomes of treatment for patients treated for Bennett's fracture in the medium term. We reviewed 33 patients treated in our unit for a bennett's fracture to the thumb metacarpal with closed reduction and casting. Each patient was matched with a patient treated surgically. Patients were matched for sex, age, Gedda grade of injury and hand dominance. Patients were reviewed at a minimum of 5-years and 66-patients were reviewed in total. Patients were examined clinically and also asked to complete a DASH questionnaire score and the brief Michigan hand questionnaire. Follow up plain radiographs were taken of the thumb and these were reviewed and graded for degenerative change using the Eaton-Littler score. Sixty-six patients were included in the study, with 33 in the surgical and non-surgical cohorts respectively. The average age was 39 years old. In each cohort, 12/33 were female, 19/33 were right-handed with 25% of individuals injuring their dominant hand. In each coort there were 16 Grade 1 fractures, 4 Grade 2 and 13 Grade 3 fractures. There was no difference between the surgically treated and cast-treatment cohorts of patients when radiographic arthritis, pinch grip, the brief Michigan Hand Questionnaire and pain were assessed at final review. The surgical cohort had significantly lower DASH scores at final follow-up. There was no significant difference in the normalised bMHQ scores. Our study was unable to demonstrate superiority of either operative or non-operative fracture stabilization. Patients in the surgical cohort reported superior satisfaction and DASH scores but did not demonstrate any superiority in any other objectively measured domain

This study was conducted to investigate the characteristics, complications, radiologic features and clinical course of patients undergoing reduction of forearm fractures in order to better inform patient prognosis and postoperative management. We conducted a retrospective cohort study of 1079 pediatric patients treated for forearm fractures between January 2014 and September 2021 in a 327 bed regional medical center. A preoperative radiological assessment and chart review was performed. Percent fracture displacement, location, orientation, comonution, fracture line visibility and angle of angulation were determined by AP and lateral radiographs. Percent fracture displacement was derived by: (Displacement of Bone Shafts / Diameter) x 100% = %Fracture Displacement. Angle of angulation and percent fracture displacement were calculated by averaging AP and lateral radiograph measurements. 80 cases, averaging 13.5±8.3 years, were identified as having a complete fracture of the radius and/or ulna with 69 receiving closed reduction and 11 receiving fixation via an intramedullary device or percutaneous pinning. Eight patients (10%) experienced complications with four resulting in a refracture and four resulting in significant loss of reduction (LOR) without refracture. Fractures in the proximal ⅔s of the radius were associated with a significant increase in complications compared to fractures in the distal ⅓ of the radius (31.6% vs 3.4%) (P=.000428). Likewise, a higher percent fracture displacement was associated with a decreased risk of complications (28.7% vs 5.9% displacement)(P=0.0403). No elevated risk of complications was found based on fracture orientation, angulation, fracture line visibility, forearm bone(s) fractured, sex, age or arm affected. Our result highlights radius fracture location and percent fracture displacement as markers with prognostic value following forearm fracture. These measurements are simply calculated via pre-reduction radiographs, providing an efficient method of informing risk of complications following forearm fracture

In-office surgeries have the potential to offer high quality medical care in a more efficient, cost-effective setting than outpatient surgical centers for certain procedures. The primary concerns with operating on patients in the office setting are insufficient sterility and lack of appropriate resources in case of excessive bleeding or other surgical complications. This study serves to investigate these concerns and determine whether in-office hand surgeries are safe and clinically effective. A retrospective review of patients who underwent minor hand operations in the office setting between December 2020 and December 2021 was performed. The surgical procedures included in this analysis are needle aponeurotomy, trigger finger release, mass/foreign body removal and reduction of hand/wrist fracture with or without percutaneous pinning. No major complications requiring extended observation or hospital admission occurred. 122 of the 132 patients (92.4%) were successfully treated with no complications and only mild symptoms within one month of surgery. Five patients (3.8%) returned to the office for pain, inflammation and/or stiffness of the affected finger, with two of the five returning due to osteoarthritis and/or pseudogout flare-ups. Five additional patients returned due to incomplete treatment with continued presence of Dupuytren's contracture (3), trigger finger (1) or infected foreign body (1). One patient (0.8%) developed infection, due to incomplete removal of an infected foreign body, which was subsequently treated with antibiotics and complete foreign body removal. The absence of major complications and high success rate for minor hand procedures shows the high degree of safety and efficacy which can be achieved via the in-office setting for select procedures. While proper patient selection is key, our result shows the in-office procedure room setting can offer the necessary elements of sterility and hemostatic support for several common hand surgeries

Paediatric supracondylar fractures are the most common elbow fracture in children, and is associated with an 11% incidence of neurologic injury. The goal of this study is to investigate the natural history and outcome of motor nerve recovery following closed reduction and percutaneous pinning of this injury. A total of 246 children who underwent closed reduction and percutaneous pinning following supracondylar humerus fractures were prospectively enrolled over a two year period. Patient demographics (age, weight), Gartland fracture classification, and associated traumatic neurologic injury were collected and analyzed with descriptive statistics. Patients with neurologic palsies were separated based on nerve injury distribution, and followed long term to monitor for neurologic recovery at set time points for follow up. Of the 246 patient cohort, 46 patients (18.6%) sustained a motor nerve palsy (Group 1) and 200 patients (82.4%) did not (Group 2) following elbow injury. Forty three cases involved one nerve palsy, and three cases involved two nerve palsies. No differences were found between patient age (Group 1 – 6.6 years old, Group 2 – 6.2 years old, p = 0.11) or weight (Group 1 – 24.3kg, Group 2 – 24.5kg, p = 0.44). A significantly higher proportion of Gartland type III and IV injuries were found in those with nerve palsies (Group 1 – 93.5%, Group 2 – 59%, p < 0 .001). Thirty four Anterior Interosseous Nerve (AIN) palsies were observed, of which 22 (64.7%) made a full recovery by three month. Refractory AIN injuries requiring longer than three month recovered on average 6.8 months post injury. Ten Posterior Interosseous Nerve (PIN) palsies occurred, of which four (40%) made full recovery at three month. Refractory PIN injuries requiring longer than three month recovered on average 8.4 months post injury. Six ulnar nerve motor palsies occurred, of which zero (0%) made full recovery at three month. Ulnar nerve injuries recovered on average 5.8 months post injury. Neurologic injury occurs significantly higher in Gartland type III and IV paediatric supracondylar fractures. AIN palsies remain the most common, with an expected 65% chance of full recovery by three month. 40% of all PIN palsies are expected to fully recover by three month. Ulnar motor nerve palsies were slowest to recover at 0% by the three month mark, and had an average recovery time of approximately 5.8 months. Our study findings provide further evidence for setting clinical and parental expectations following neurologic injury in paediatric supracondylar elbow fractures

Aims. We aimed to evaluate the health-related quality of life (HRQoL) in children with supracondylar humeral fractures (SCHFs), who were treated following the recommendations of the Paediatric Comprehensive AO Classification, and to assess if HRQoL was associated with AO fracture classification, or fixation with a lateral external fixator compared with closed reduction and percutaneous pinning (CRPP). Methods. We were able to follow-up on 775 patients (395 girls, 380 boys) who sustained a SCHF from 2004 to 2017. Patients completed questionnaires including the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH; primary outcome), and the Pediatric Quality of Life Inventory (PedsQL). Results. An AO type I SCHF was most frequent (327 children; type II: 143; type III: 150; type IV: 155 children). All children with type I fractures were treated nonoperatively. Two children with a type II fracture, 136 with a type III fracture, and 141 children with a type IV fracture underwent CRPP. In the remaining 27 children with type III or IV fractures, a lateral external fixator was necessary for closed reduction. There were no open reductions. After a mean follow-up of 6.3 years (SD 3.7), patients with a type I fracture had a mean QuickDASH of 2.0 (SD 5.2), at a scale of 0 to 100, with lower values representing better HRQoL (type II: 2.8 (SD 10.7); type III: 3.3 (SD 8.0); type IV: 1.8 (SD 4.6)). The mean function score of the PedsQL ranged from 97.4 (SD 8.0) for type I to 96.1 (SD 9.1) for type III fractures, at a scale of 0 to 100, with higher values representing better HRQoL. Conclusion. In this cohort of 775 patients in whom nonoperative treatment was chosen for AO type I and II fractures and CRPP or a lateral external fixator was used in AO type III and IV fractures, there was equally excellent mid- and long-term HRQoL when assessed by the QuickDASH and PedsQL. These results indicate that the treatment protocol followed in this study is unambiguous, avoids open reductions, and is associated with excellent treatment outcomes. Cite this article: Bone Joint J 2020;102-B(6):755–765

The majority of pediatric proximal humerus fractures are successfully treated non-operatively. Significantly displaced fractures have traditionally been treated surgically with percutaneous pinning. This review of twenty-three surgically treated patients demonstrates a high rate of infection associated with percutaneous pinning. The technique of cannulated screw fixation offers a safe surgical alternative for the treatment of these fractures in the adolescent population. To compare the results of percutaneous pinning to cannulated screw fixation for the treatment of pediatric proximal humerus fractures. A high complication rate, including pin tract infection and loss of reduction, was observed in the percutaneous pinning group. Given the rigid fixation afforded by cannulated screws and the minimal morbidity associated with proximal humeral physeal arrest in the older adolescent, this technique offers a safe alternative for the treatment of proximal humerus fractures. Average age was 13.0 years for the pinning group and 14.7 years for the cannulated screw group. Regardless of fixation technique, all fractures healed completely with no difference in rates of physeal closure. Significant pin tract drainage was encountered in six of twenty patients treated with pinning: Two with Staphylococcus Aureus infection and one deep infection requiring surgical debridement. Loss of reduction and pin migration was noted in a seventh patient. The only complication observed in the cannulated screw group was a transient axial nerve paresthesia. There were no significant differences in operative time, rate of open reduction, or length of hospitalization (p> 0.05). Twenty-three pediatric proximal humerus fractures treated operatively over a seven-year period were followed clinically and radiographically. Thirty percent of the patients treated with pinning developed pin tract infections. Similar to femoral external fixation pins, proximal humeral pins also cross a large muscle group that may result in pin micro-motion. This may create persistent drainage that ultimately leads to infection

We compared the radiographs, clinical outcomes, and complications of two techniques used for treatment of unstable distal radius fractures in young adults. Fifty patients were randomized to percutaneous pinning or augmented external fixation. At one year follow-up, the external fixator did not improve the parameters of radial length, radial angulation or volar tilt. Reduction of intra-articular steps was slightly improved. No differences in DASH scores or functional outcomes were observed, but more complications were noted with the fixator. While articular restoration can be slightly improved with use of the external fixator, a higher incidence of complications and patient dissatisfaction was noted. Two common techniques for treatment of unstable distal radius fractures in young adults include percutaneous pinning combined with plaster cast, and application of an external fixator, frequently with adjunctive pinning. The objective of this study was to:. 1. To compare the short and mid-term radiographic and clinical outcomes of these two common fixation techniques. 2. To compare the complications of the two techniques. Fifty patients (< 65 yrs) with unstable fractures of the distal radius were recruited. Patients were randomized pre-operatively to percutaneous pinning or external fixation. All surgery was performed by one of three surgeons. Patients were followed for one year with radiographs and an independent clinical exam including DASH questionnaires. 86% of fractures were AO classification C2 or C3, with an equal distribution of all types in both treatment groups. Use of an external fixator did not improve the parameters of radial length, radial angulation or volar tilt. However, reduction of intra-articular steps was slightly improved with its’ use. No differences in mean DASH scores, total ROM or grip strength were observed. More pin complications were noted with the fixator, and all three patients diagnosed with RSD received external fixation. While external fixation represents a popular first line treatment for unstable distal radius fractures, this study suggests that similar gross radiographic and clinical results can be obtained with percutaneous pinning. While articular restoration can be slightly improved with use of the external fixator in highly comminuted fractures, this must be balanced by a higher incidence of complications and patient dissatisfaction. Funding: Stryker-Howmedica-Osteonics

In a randomised prospective study, 20 patients with intra-articular fractures of the distal radius underwent arthroscopically- and fluoroscopically-assisted reduction and external fixation plus percutaneous pinning. Another group of 20 patients with the same fracture characteristics underwent fluoroscopically-assisted reduction alone and external fixation plus percutaneous pinning. The patients were evaluated clinically and radiologically at follow-up of 24 months. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and modified Mayo wrist score were used at 3, 9, 12 and 24 months postoperatively. In the arthroscopically- and fluoroscopically-assisted group, triangular fibrocartilage complex tears were found in 12 patients (60%), complete or incomplete scapholunate ligament tears in nine (45%), and lunotriquetral ligament tears in four (20%). They were treated either arthroscopically or by open operation. Patients who underwent arthroscopically- and fluoroscopically-assisted treatment had significantly better supination, extension and flexion at all time points than those who had fluoroscopically-assisted surgery. The mean DASH scores were similar for both groups at 24 months, whereas the difference in the mean modified Mayo wrist scores remained statistically significant. Although the groups are small, it is clear that the addition of arthroscopy to the fluoroscopically-assisted treatment of intra-articular distal radius fractures improves the outcome. Better treatment of associated intra-articular injuries might also have been a reason for the improved outcome

Introduction. External fixators are attached to bones with percutaneous pins and wires inserted through soft tissues and bone increasing the risk of infections. Such infections compromise patient outcomes e.g., through pin loosening or loss, failure of fixator to stabilise the fracture, additional surgery, increased pain, and delayed mobilisation. These infections also impact the healthcare system for example, increased OPD visits, hospitalisations, treatments, surgeries and costs. Nurses have a responsibility in the care and management of patients with external fixators and ultimately in the prevention of pin-site infection. Yet, evidence on best practices in the prevention of pin-site infection is limited and variation in pin-site management practices is evident. Various strategies are used for the prevention of pin-site infection including the use of different types of non-medicated and medicated wound dressings. The aim of this retrospective study was to investigate the use of dry gauze or iodine tulle dressings for the prevention of pin-site infections in patients with lower limb external fixators. Methodology. A retrospective study of patients with lower limb external fixators who attended the research site between 2015–2022. Setting & Sample: The setting was the outpatient's (OPD) orthopaedic clinic in a University Teaching Hospital in Dublin, Ireland. Eligibility Criteria:. Over the age of 16, treated with an Ilizarov, Taylor Spatial frame (TSF) or Limb Reconstruction System (LRS) external fixators on lower limbs,. Pin-sites dressed with dry gauze or iodine tulle,. Those with pre-existing infected wounds close to the pin site and/or were on long term antibiotics were excluded. Follow Up Period: From time of external fixator application to first pin-site infection or removal of external fixator. Outcome Assessment: The primary outcome was pin-site infection, secondary outcomes included but were not limited to frequency of pin-site infection according to types of bone fixation, frequency of pin/wire removal and hospitalisation due to infection. Data analysis: IBM SPSS Version 25 was used for statistical analysis. Descriptive and inferential statistics were conducted as appropriate. Categorical data were analysed by counting the frequencies (number and percentages) of participants with an event as opposed to counting the number of episodes for each event. Differences between groups were analysed using Chi-square test or Fisher's exact test, where appropriate. Continuous variables were reported using mean and standard deviations and difference analysed using a two-sample independent t-test or non-parametric test (Mann-Whitney), where appropriate. Using Kaplan-Meier, survival analysis explored time to development of infection. Ethical approval: granted by local institute Research Ethics Committee on 12th March 2018. Results. During the study period, 97 lower limb external fixators were applied with 43 patients meeting the study eligibility criteria. The mean age was 38 (SD 14.1; median 37) and the majority male (n=32, 74%). At least 50% (n=25) of participants had an IIizarov fixator, with 56% (n=24) of all fixators applied to the tibia and fibula. Pin/wire sites were dressed using iodine (n=26, 61%) or dry gauze dressings (n=15, 35%). The mean age of participants in the iodine group was significantly higher than the dry gauze group (p=.012). The only significant difference between the iodine and dry gauze dressing groups at baseline was age. A total of 30 (70%) participants developed a pin-site infection with 26% (n=11) classified as grade 2 infection. Clinical presentation included redness (n=18, 42%), discharge (n=16, 37%) and pain (n=15, 35%). Over half of participants were prescribed oral antibiotics (n=28, 65%); one required intravenous antibiotics and hospitalization due to pin-site infection. Ten (23%) participants required removal of pin/wires; two due to pin-site infection. There was no association between baseline data and pin-site infection. The median time to developing an infection was 7 weeks (95%, CI 2.7 to 11.29). Overall, there were 21 (81%, n=26) pin-site infections in the iodine group and nine (60%, n=15) in the dry gauze group, difference in proportion and relative risk between the dressing groups were not statistically significant (RR 1.35, 95% CI 0.86–2.12; p= .272). There was no association between baseline data, pin-site infection, and type of dressing. Conclusions. At the research site, patients are referred to the OPD orthopaedic clinic from internal and external clinical sites e.g., from Hospital Consultants, General Practitioners and occasionally from multidisciplinary teams, throughout Ireland. Our retrospective observation study found that 97 lower limb external fixators were applied over a seven-year period which is lower than that reported in the literature. However, the study period included the COVID pandemic years (2020 and 2021) which saw a lower number of external fixators applied due to lack of theatre availability, cancelled admissions and social/travel restrictions that resulted in fewer accidents and lower limb trauma cases requiring external fixator application. The study highlighted a high infection rate with 70% of participants developing pin-site infection which is in keeping with findings reporting in other studies. Our study showed that neither an iodine nor dry gauze dressing was successful in preventing pin-site infection. In the iodine group 81% of participants developed infection compared to 60% in the dry gauze group. Given the lack of difference between the two groups consideration needs to be given to the continued use of iodine dressings in the prevention of pin-site infection. Pin-site infections result in a high portion of participants being prescribed antibiotics and, in an era, that stresses the importance of antimicrobial stewardship there is a need to implement effective infection prevention and control strategies that minimise infection. Further research is therefore needed to investigate more innovative medicated dressings such as those that contain anti-microbial or anti-bacterial agents

We reviewed 16 metaphyseal-diaphyseal junction (MDJ) fractures treated over the four-year period 1997 to 2000. MDJ fractures occur in the area proximal to the supracondylar fossae and distal to the intersection of the metaphyseal flange and diaphysis of the humerus. MDJ fractures are far less common than displaced classic supracondylar (SC) fractures: on average we see four MDJ and 80 SC fractures a year. The mean age of patients with MDJ fractures is 4.8 years, while the mean age of patients with SC fractures is 6.3 years. MDJ fractures are more often the result of a violent force: 56% occurred in falls and 38% in pedestrian traffic accidents, while 100% of SC fractures were due to falls. Only 1% of SC fractures were compound, while 13.5% of MDJ fractures were. MDJ fractures were of the extension type in 63% and of the flexion type in 37%. Only 3.7% of SC fractures were of the flexion type. We treated four of the 16 MDJ fractures conservatively in a U-slab and 12 with percutaneous pinning (three with cross pinning, nine with one or both pins up the intramedullary shaft). At a mean follow-up of two years (1 to 4) there were 11 satisfactory and five poor results. Three of the four patients managed conservatively had a poor result with varus malunion. The other two poor results were in percutaneously pinned fractures. One was pinned in varus and one refractured after the pins were removed at three weeks. We conclude that MDJ fractures are distinct from SC fractures, and that percutaneous pinning is the best form of treatment. Because the fractures are more diaphyseal, immobilisation for four weeks rather than three is advised to prevent refracture

To compare 24-month patient-reported outcomes after surgical treatment or casting in patients age 60 years of age or older with unstable distal radius fractures (DRF's). The Wrist and Radius Injury Surgical Trial (WRIST), is the largest randomized, multicenter trial in Hand Surgery, which enrolled 304 adults with isolated, unstable DRF's at 24 institutions. WRIST participants were followed for 24 months- longest follow-up among prospective studies comparing four treatment methods. Patients who agreed to surgical treatment (n=187) were randomized to internal fixation with volar plate (VLPS), external fixation, or percutaneous pinning; patients who preferred conservative management (n=117) received casting. The primary outcome was 24-month Michigan Hand Outcomes Questionnaire (MHQ) Summary score. Secondary outcomes were MHQ Domain scores. At 24-month assessment, participants' mean MHQ Summary score was 86 (95% CI: 83,88), representing good hand function. Participants reported good return of their Activities of Daily Living (ADLs) with a mean MHQ ADL score of 88 (95% CI: 85,91). Finally, participants were satisfied, with a mean MHQ Satisfaction score of 84 (95% CI: 80,88). There were no significant differences in score by treatment group in any MHQ domain at 24 months. Six weeks after surgery, VLPS participants scored significantly higher than the other three groups on (ADLs) and Satisfaction (both p<0.0001), whereas participants who received external fixation scored significantly lower than the casting and VLPS groups on the same domains. By the 3-month assessment, the gap between VLPS and casting had disappeared but external fixation participants continued to report significantly worse scores. External fixation participants did not report comparable ADL scores to the other three groups until 12 months after surgery. Participants reported good outcomes 24 months after DRF regardless of treatment. Casting and VLPS are both acceptable treatments for older adults. The decision between the two treatments should be made considering patient goals regarding recovery speed and desire to avoid surgical risks. External fixation should be avoided because of worse outcomes in the year after surgery and the risk of pin site infections

This study aimed to evaluate the use of pin leverage in the reduction of Gartland type III supracondylar fractures of the humerus in children. The study comprised 95 children, who were split into three groups according to the type of method of reduction used. Group 1, had an open reduction, group 2, had closed reduction and percutaneous pin fixation and group 3, the pin leverage technique. Each group was analysed according to the time to surgery, the duration of the procedure, the incidence of complications, and the clinical and radiological outcome. The mean duration of the operative procedure in groups 1, 2 and 3 was 119 minutes (80 to 235), 57 minutes (20 to 110) and 68 minutes (30 to 90), respectively. At a mean follow-up of 30 months (12 to 63) the clinical results were declared excellent or good in all children and the radiological results intermediate in five patients in group 2. The results of the closed reduction using the pin leverage technique was classified as failure in two children. Our findings lead us to believe that the pin leverage method of reduction gives good results in the treatment of Gartland type III fractures