The aim of this study was to determine the floor and ceiling effects for both the QuickDASH and PRWE following a fracture of the distal radius. Secondary aims were to determine the degree to which patients with a floor or ceiling effect felt that their wrist was ‘normal’, and if there were patient factors associated with achieving a floor or ceiling effect. A retrospective cohort study of patients sustaining a distal radius fracture and managed at the study centre during a single year was undertaken. Outcome measures included the QuickDASH, the PRWE, EuroQol-5 Dimension-3 Levels (EQ-5D-3L), and the normal wrist score. There were 526 patients with a mean age of 65yrs (20–95) and 421 (77%) were female. Most patients were managed non-operatively (73%, n=385). The mean follow-up was 4.8yrs (4.3–5.5). A ceiling effect was observed for both the QuickDASH (22.3%) and PRWE (28.5%). When defined to be within the minimum clinical important difference of the best available score, the ceiling effect increased to 62.8% for the QuickDASH and 60% for the PRWE. Patients that achieved a ceiling score for the QuickDASH and PRWE subjectively felt their wrist was only 91% and 92% normal, respectively. On logistic regression analysis, a dominant hand injury and better health-related quality of life were the common factors associated with achieving a ceiling score for both the QuickDASH and PRWE (all p<0.05). The QuickDASH and PRWE demonstrate ceiling effects when used to assess the outcome of fractures of the distal radius. Patients achieving ceiling scores did not consider their wrist to be ‘normal’. Future patient-reported outcome assessment tools for fractures of the distal radius should aim to limit the ceiling effect, especially for individuals or groups that are more likely to achieve a ceiling score

Abstract. Introduction. In our quality improvement project we implemented a novel pathway, performing acute fixation in mid-third clavicle fractures with >15% shortening. Patients with <15% shortening reviewed at 6 weeks, non-union risk identified as per Edinburgh protocol and decision to operate made accordingly. Methods. Retrospective pre-pathway analysis of patients presenting 04/2017–04/2019. Prospective post-pathway analysis of patients presenting 10/2020–10/2021. Fracture shortening measured using Matsumura technique. QuickDASH and recovery questionnaires posted to >15% shortening patients and done post-pathway at 3 months. Results. Pre-pathway retrospective cohort included 141 patients; 69 <15%, 72 >15% shortening. Acute ORIF performed in 15(22%) <15% and 34(47%) >15%. In those conservatively managed, non-union occurred in 2 patients with <15% shortening, and 5 with >15% shortening. Union time was significantly longer in >15% treated non-operatively compared to those requiring ORIF and <15% (18.4 vs 13.4 vs 12.0 weeks; p<0.05). QuickDASH significantly worse in >15% managed conservatively than operatively (17.6 vs 2.8; p<0.05). >15% ORIF had significantly fewer number of weeks until undisturbed sleep than those treated non-operatively (2.3 vs 10.1; p<0.05). Post-pathway prospective cohort included 37 patients; 17 <15% (of which 1 underwent delayed ORIF), 20 >15% shortening (of which 15 underwent acute ORIF). No significant increase in proportion ORIF performed (43% vs 38%). No non-unions occurred. Conclusion. Acute fixation in >15% shortening was associated with better QuickDash scores and reduced union times than those treated non-operatively. Implementation of our pathway resulted in no nonunions compared to 5% pre-implementation and thus identifies patients benefitting from acute fixation

Osteoarthritis (OA) is a disease of the synovial joint with synovial inflammation, capsular contracture, articular cartilage degradation, subchondral sclerosis and osteophyte formation contributing to pain and disability. Transcriptomic datasets have identified genetic loci in hip and knee OA demonstrating joint specificity. A limited number of studies have directly investigated transcriptional changes in shoulder OA. Further, gene expression patterns of periarticular tissues in OA have not been thoroughly investigated. This prospective case control series details transcriptomic expression of shoulder OA by analysing periarticular tissues in patients undergoing shoulder replacement for OA as correlated with a validated patient reported outcome measure of shoulder function, an increasing (clinically worsening) QuickDASH score. We then compared transcriptomic expression profiles in capsular tissue biopsies from the OA group (N=6) as compared to patients undergoing shoulder stabilisation for recurrent instability (the control group, N=26). Results indicated that top ranked genes associated with increasing QuickDASH score across all tissues involved inflammation and response to stress, namely interleukins, chemokines, complement components, nuclear response factors and immediate early response genes. Some of these genes were upregulated, and some downregulated, suggestive of a state of flux between inflammatory and anti-inflammatory signalling pathways. We have also described gene expression pathways in shoulder OA not previously identified in hip and knee OA, as well as novel genes involved in shoulder OA

Over 500 supracondylar humerus fractures (SCHF) are treated at our institution each year. Our standard post-operative pathway includes a 3-week visit for splint removal, wire removal, and radiographs. Subsequent follow-up occurs at 12 weeks for a clinical examination. In an effort to minimize unnecessary follow-up visits, we investigated whether photographs and/or patient-reported outcome measure (PROM) scores could identify patients who do not need routine 3-month in-person follow-up. At the 3-month visit, 248 SCHF patients (mean 6.2 yrs; 0.75-11yrs) had bilateral elbow motion (ROM) and carrying angles measured; and photographs documenting frontal and sagittal alignment of both injured and uninjured upper extremities, in both maximum elbow flexion and extension. Two independent assessors made the same measurements off the clinical photographs to compare these with the clinical measurements. Two PROMs: Self-Assessment Questionnaire (SAQ: 0 best to 14 worst) and QuickDASH (0 best to 100 worst) were completed at the 3-month visit. Inter-rater reliability of the photograph measurements was excellent (Kappa: 0.88-0.93), but weakly concordant with clinical measurements (carrying angle Kappa=0.51;max flexion Kappa=0.68;max extension Kappa=0.64). SAQ moderately correlated with QuickDASH (Kappa=0.59) and performed better at identifying patients with abnormalities. SAQ score ≥ 4 identified patients meeting 3-month follow-up criteria, with sensitivity: 36.1%; specificity: 96.8% and negative-predictive-value (NPV): 87%. We did not find that photographs were reliable. Although SAQ-score has high NPV, a more sensitive fracture-specific PROM is needed to identify patients who do not need a 3-month follow-up visit

Aim. Studies have shown that retention of antibiotic cement spacer in selected elderly patients with low functional demand represents a viable option for periprosthetic joint infections (PJI) treatment. 1,2. . The aim of this study is to compare the efficacy in infection treating among modular taylored preformed and hand-made antibiotic spacers. Our hypothesis is that modular tailored preformed spacer provides a better rate of infection resolution, better radiological and functional outcomes compared to hand-made spacers. Materials and methods. We identified 48 patients treated with antibiotic cement spacer for shoulder chronic infection between 2015 and 2021 in our institution; (13 hand-made spacers and 35 modular tailored preformed spacers). We collected data about comorbidities, associated microorganism, infection resolution, clinical and radiographic evaluation. Results. The mean age at surgery was 63.2 years, (45.8% female − 54.2% male), mean BMI 28.3. The mean time of infection diagnosis after first surgery was 30 months; (31.2% infection after ORIF in proximal humeral fractures, 68.8% PJI after shoulder arthroplasty). The main pathogens were Propionibacterium Acnes (37.5%), Staphylococcus Epidermidis (29.2%), Staphylococcus Aureus (16.7%), negative intraoperative coltures (14.6%), Enterococcus (4.17%), Pseudomonas Aeruginosa (4.17%). The mean time of antibiotic spacer retention was 18 months: 23 patients (47.9%) underwent second stage surgery for prosthesis implantation; 2 removed the spacer because of spacer dislocation, 2 died during follow up; while 21 patients still hold the antibiotic spacer (17 patients in treatment with prefabricated spacers and 4 with self-constructed spacer). The mean value for clinical assessment for patients with modular tailored preformed spacer were: Constant Score 34 – QuickDASH 40 – SST 33 – ASES Score 66 – VAS 2. Patients treated with hand-made spacer registered the following scores: Constant Score 20 – QuickDASH 51 – SST 25 – ASES Score 38 – VAS 6. Two patients presented fracture of the spacer (one hand-made spacer and one tailored preformed). Conclusions. According to our data patients treated with modular tailored preformed antibiotic spacer show better functional outcomes. Patients are more likely to retain the spacer as a permanent implant, avoiding the risks of a second stage surgery in those low-demanding patients, achieving a reasonable satisfying quality of shoulder motion without pain

Ulnocarpal impaction (UCI) is a common cause of ulnar-sided wrist pain. UCI typically occurs in wrists with positive ulnar variance, which causes altered loading mechanics between the ulnar head, lunate and triquetrum. However, many individuals with positive ulnar variance never develop UCI, and some with neutral or negative ulnar variance do experience UCI. This suggests that other variables contribute to the development of UCI. Suspected culprits include lunate morphology, and dynamic changes with loaded (grip) pronation. If these anatomic variations are contributing to UCI, we expect them to influence functional impairment scores. Therefore, the objective of this study was to evaluate the relationship between radiographic parameters and pre-surgical upper extremity patient-rated outcomes scores (PROS) in patients with a diagnosis of UCI. Retrospective cohort study of patients undergoing ulnar shortening osteotomy or arthroscopic wafer procedure for UCI. Data derived from prospectively collected departmental database that captured demographic, clinical, functional and radiographic information. Radiographic parameters evaluated were: lunate morphology [presence vs. absence of hamate facet; Antuna-Zapico (A-Z) classification], and dynamic changes on grip view [difference in lunate-ulnar head distance (LUD); difference in lunate uncovering index (LUI)]. PROS assessed were QuickDASH and Patient-Rated Wrist Evaluation (PRWE) scores, collected at patient enrolment. ANOVA was used to assess for differences in PROS between A-Z classification groups. Student's t-test was used to assess for differences in PROS based on presence/absence of a hamate facet. Regression analysis evaluated a relationship between change in LUD with grip and PROS, and change in LUI with grip and PROS. Preliminary analysis included 23 wrists, with a mean patient age of 48.9 years [standard deviation (SD) 14.5 years]. Forty-eight percent were male, and the dominant limb was involved in 52.2% of cases. Average QuickDASH and PRWE scores at enrolment were 50.9 (SD 22.2) and 62.2 (SD 22.0), respectively. Assessment of radiographs revealed 17 patients (73.9%) without a hamate facet. Five patients (21.7%) had A-Z Type I lunate morphology, and nine (39.1%) had Type II and Type III morphology, respectively. ANOVA revealed no differences in enrolment QuickDASH (p = 0.185) or PRWE (p = 0.256) scores between A-Z classification groups. Similarly, Student's t-test found no difference based on presence/absence of a hamate facet (QuickDASH p = 0.594; PRWE p = 0.573). Regression analysis revealed no relationship between change in LUD with grip and PROS (QuickDash R2 = 0.020, p = 0.619; PRWE R2 = 0.009, p = 0.733), and no relationship between change in LUI with grip and PROS (QuickDash R2 = 0.000, p = 0.913; PRWE R2 = 0.010, p = 0.722). Preliminary results suggest no relationship between A-Z classification lunate morphology, presence/absence of a hamate facet, change in LUD, or change in LUI and pre-surgical PROS. It is unclear if our findings represent the true relationship between these radiographic parameters and PROS, or reflect our preliminary sample size. Data analysis is ongoing to add clarity to this question

Abstract. Background. We know that tears of the Triangular fibrocartilage complex (TFCC) can cause DRUJ instability and ulnar sided wrist pain. This study shows the clinical result of patients who had arthroscopic transosseous repair of the TFCC tear with DRUJ instability. Arthroscopic repair of TFCC tear is a promising, minimally invasive surgical technique especially in patients with DRUJ instability. Materials and methods. Fifteen patients who underwent TFCC one tunnel repair form 2018–2021 were reviewed retrospectively in hospital. The proximal component of TFCC was repaired through arthroscopic one- tunnel transosseous suture technique. VAS score for pain, wrist range of motion, grip strength and post operative complications were evaluated and each patient was rated according to the DASH score. Results. The patients had a TFCC tear confirmed on MRI and was confirmed on arthroscopy by doing a hook test. The patients were followed up for 6 months. Twelve patients had normal stability of DRUJ and three patients showed mild laxity compared with the contralateral side. The mean VAS score reduced from 4.7 to 0.8 (P=0.001) and grip strength increased significantly. The quick DASH score (P=0.001)also showed significant functional improvement. No surgical related complications occurred. Conclusions. Arthroscopic one tunnel transosseous TFCC foveal repair can be an excellent and safe method for repair of TFCC tear with DRUJ instability. Its a good treatment option in terms of reliable pain relief, functional improvement and reestablishment of DRUJ stability

In Australia nearly two-thirds of arthroplasty procedures are performed in the private setting, which is disproportionate to the dimensioning 43.5% of the population with private health cover. The rapid growth of shoulder arthroplasty surgery will be absorbed by both private and public sectors. This study aimed to assess the influence of healthcare setting on elective shoulder arthroplasty outcomes, defined by revision rate, and functional measures. Data was collected on all primary procedures performed from 2004 – 2019 within a regional area of Victoria, Australia. Patients were categorised into private or public settings. Trauma cases for acute proximal humerus fractures were excluded. The primary outcome of revision surgery was recorded as a cumulative percentage, and survival analysis conducted to calculate a hazard ratio (HR). Functional outcomes were measured through range-of-motion (ROM) and multiple validated patient-reported-outcome-measures (PROMs). 458 patients were identified in the study: 290 private and 168 public. There was no difference in the revision rate (3.8% private, 4.8% public), with an adjusted HR of 1.25 (p=0.66) for public compared to private. Baseline and post-operative functional measures were significantly greater in the private setting for ROMs and PROMs analysis, in particular post-operative QuickDASH (15.9±14.7 to 32.7±23.5; p<0.001) and Oxford Shoulder Score (42.6±6.3 to 35.7±11.2; p<0.001). However, there was no significant difference for any of the functional measures in the amount of change from baseline to 12-months between settings. Although healthcare setting does not appear to influence revision rate for shoulder arthroplasty, clear differences were demonstrated for functional measures both pre and post operatively. This may be attributed to factors such as access to perioperative rehabilitation and should be an area to target future investigations

Introduction. Despite the rising popularity of 1st carpometacarpal joint (CMCJ) arthrodesis as one of the surgical options for basilar thumb arthritis, the available literature on this is poor. This study aims to investigate post-operative pinch and grip strength following 1st CMCJ arthrodesis, at a minimum of 1 year follow-up. Complication rates, range of motion and patient reported scores were also evaluated. Methods. A retrospective cohort (2012–2020) was used, which included patients who had arthrodesis performed by the Hands surgeons at Counties Manukau DHB. In a 15 minute visit, we took the measurements using our standard dynamometer and pinch gauge, and collected three questionnaires [QuickDASH, PRWHE, PEM]. For analysis, we compared our results to the preoperative measures, contralateral hand, and to a previous study on a similar cohort looking at thumb strength following trapeziectomy. Results. 42 arthrodesis were performed, and 24 were available for follow-up. The average follow-up time was 77 months and the average age was 51 years old. Overall, we found a statistically significant improvement in thumb strength following surgery. Mean preoperative grip strength was 21.4kg and 32.5kg postoperatively (= +11kg). Preoperative pinch strength was 5.5kg and 7kg postoperatively (= +1.5kg). These results were significantly higher compared to the trapeziectomy cohort. We also found an improvement in 1st CMCJ ROM post-operatively. 7 complications were reported (29.1%). 4 were metalware-related and 3 were non-union. QuickDASH score significantly improved from a median of 42.95 to 12.5 while PRWHE from 67.5 to 14.5. Overall patient satisfaction was 87.4%. Conclusion. 1st CMCJ arthrodesis leads to an improvement in thumb function, pain and range of movement and results in high patient satisfaction, and therefore should be recommended for younger patients who need a pain-free and strong thumb

Background. Traditional teaching recommends against arthroplasty in the index finger, due to concerns over failure with pinch stress, and prefers arthrodesis is for its stability. We aim to allay these fears and present the results of our series of index finger silastic PIPJ arthroplasties. Methods: Between 2007 & 2018 48 silastic index finger PIPJ arthroplasties were undertaken in 37 patients at our Hand Unit. All were performed under local anaesthetic ring block. Eleven patients underwent PIPJ arthroplasty in both Index fingers. Thirty-five women and two men made up the cohort with a mean age of 69 years. A retrospective analysis of all patients has been undertaken to determine the clinical results including patient satisfaction, grip and pinch strength and reoperation rates. Mean follow up was 5.1 years. Results. Six index fingers developed ulnar deviation greater than 10 degrees and there were five reoperations (10.2%). There was an excellent arc of movement of mean 44 degrees with high patient satisfaction and functional scores (mean VAS pain score 1.1, Quickdash 34, PEM 44). 90% of patients would undergo the procedure again and no patient would prefer a fusion. Conclusions: Silastic Interposition arthroplasty of the PIPJ of the Index finger is a durable procedure with excellent clinical outcomes. Our large study refutes the established technique of arthrodesis for Index finger OA, with low incidence of ulnar deviation and excellent patient satisfaction

Total elbow arthroplasty (TEA) usage is increasing owing to expanded surgical indications, better implant designs, and improved long-term survival. Correct humeral implant positioning has been shown to diminish stem loading in vitro, and radiographic loosening in in the long-term. Replication of the native elbow centre of rotation is thought to restore normal muscle moment arms and has been suggested to improve elbow strength and function. While much of the focus has been on humeral component positioning, little is known about the effect of positioning of the ulnar stem on post-operative range of motion and clinical outcomes. The purpose of this study is to determine the effect of the sagittal alignment and positioning of the humeral and ulnar components on the functional outcomes after TEA. Between 2003 and 2016, 173 semi-constrained TEAs (Wright-Tornier Latitude/Latitude EV, Memphis, TN, USA) were performed at our institution, and our preliminary analysis includes 46 elbows in 41 patients (39 female, 7 male). Patients were excluded if they had severe elbow deformity precluding reliable measurement, experienced a major complication related to an ipsilateral upper limb procedure, or underwent revision TEA. For each elbow, saggital alignment was compared pre- and post-operatively. A best fit circle of the trochlea and capitellum was drawn, with its centre representing the rotation axis. Ninety degree tangent lines from the intramedullary axes of the ulna and humerus, and from the olecranon tip to the centre of rotation were drawn and measured relative to the rotation axis, representing the ulna posterior offset, humerus offset, and ulna proximal offset, respectively. In addition, we measured the ulna stem angle (angle subtended by the implant and the intramedullary axis of the ulna), as well as radial neck offset (the length of a 90o tangent line from the intramedullary axis of the radial neck and the centre of rotation) in patients with retained or replaced radial heads. Our primary outcome measure was the quickDASH score recorded at the latest follow-up for each patient. Our secondary outcome measures were postoperative flexion, extension, pronation and supination measured at the same timepoints. Each variable was tested for linear correlation with the primary and secondary outcome measures using the Pearson two-tailed test. At an average follow-up of 6.8 years (range 2–14 years), there was a strong positive correlation between anterior radial neck offset and the quickDASH (r=0.60, p=0.001). There was also a weak negative correlation between the posterior offset of the ulnar component and the qDASH (r=0.39, p=0.031), and a moderate positive correlation between the change in humeral offset and elbow supination (r=0.41, p=0.044). The ulna proximal offset and ulna stem angle were not correlated with either the primary, or secondary outcome measures. When performing primary TEA with radial head retention, or replacement, care should be taken to ensure that the ulnar component is correctly positioned such that intramedullary axis of the radial neck lines up with the centre of elbow rotation, as this strongly correlates with better function and less pain after surgery

Abstract. Background. Scaphoid non-union can result in pain, altered wrist kinematics leading to a Scaphoid Non-union Advance Collapse, ultimately to symptomatic radio-carpal arthritis. Open techniques have their limitations. We describe the rationale, surgical technique and outcomes of our series of arthroscopic bone-grafting (ABG) and fixation of scaphoid non-union. Methods. We performed a prospective single-surgeon series of 22 consecutive patients with clinico-radiologically established scaphoid non-union between March 2015 and April 2019. Data was collected from Electronic Patient Records, Patient Archived Computer system (PACS) and hand therapy assessments. We collected demographic data including age, hand-dominance, occupation and mechanism of injury. The Disabilities of the Arm, Shoulder and Hand Score (Quick DASH), Mayo wrist score, Patient Rated Wrist Evaluation (PRWE) and grip-strength measurements were collected preoperatively and at follow-up appointments. Results. There was an improvement in all outcome measures when comparing preoperative and postoperative results. The Quick DASH score improved by a mean of 24 points, Mayo wrist and PRWE scores improved by 15.1 and 29.7 points, respectively. Grip-strength analysis also improved by 6.1 kgf (Right) and 3.3kgf (Left). Follow-up computerised tomography scans revealed union in 18/22 patients with 2 patients lost to follow-up. One patient required revision ABG procedure to achieve union. Conclusion. Arthroscopic bone grafting and fixation of scaphoid non-union allows a minimally invasive method of managing these injuries. It has advantages of minimal morbidity and accurate articular reduction resulting in less postoperative stiffness and increased functional outcomes. It is an effective alternative to conventional open treatment of established scaphoid non-union

Aim. To construct and validate a simple patient related outcome measure scheme to quantify the disability caused by Dupuytren's Disease thus enabling prioritisation of treatment, allow reliable audit of surgical outcome and support future research. Methods. The Southampton Dupuytren's Scoring System (SDSS) was developed in a staged fashion according to the recommendations of Derby Outcomes Conference. item generation from questionnaire filled in by 20 patients;. item reduction to create a 20-question proforma;. Internal consistency (Cronbach's alpha). Test-retest (3 week interval testing on 61 patients). Field management was used to assess the user friendliness of the scoring system. Sensitivity to change Standardised response mean. Construct validity: ability of the SDSS to measure what it is supposed to measure. comparing SDSS with QuickDASH (Disability of Arm, Shoulder and Hand). Results. Internal consistency. Cronbach's alpha was 0.87. (Cronbach's alpha of 0.8–0.9 indicates acceptable reliability). Test-retest reliability. The test re-test correlation coefficient was 0.79 between SDSS scores at a three-week interval (high reliability). Field-testing. The SDSS ratings were found to be higher than the QDASH ratings evaluated by the patients who answered both questionnaires. Sensitivity to change. Standardised response mean was more sensitive for SDSS compared to QuickDASH (−1.76 vs −1.19 p>0.05). Construct Validity. To assess if the SDSS is measuring what is supposed to measure, we compared the SDSS with QuickDASH. A high significant correlation (Pearson correlation-0.598) was found between the two scoring-systems. Conclusions. SDSS is a suitable disease-specific patient related outcome measure for DD. It has good internal consistency and is performs better than QuickDASH in terms of test-retest reliability and sensitivity to change. SDSS shows better field-testing attributes suggesting that it is a relatively more patient and practitioner friendly scoring-system. We propose the SDSS is a useful patient related outcome measure for DD

Supercharged end-to-side nerve transfer for severe cubital tunnel syndrome is a recently developed technique which involves augmenting the ulnar motor branch with anterior interosseous nerve (AIN). Previous studies suggested that this technique augments or “babysits” the motor end plates until reinnervation occurs, however, some authors suggested possible reinnervation by the donor nerve. We present two cases where this transfer was done for rapid progressive (6–9 months) cubital tunnel syndrome. The first case was a 57 year-old right hand dominant female who presented to us with severe right cubital tunnel syndrome clinically, including intrinsic wasting and claw deformity. The patient had significant loss of function and visible atrophy to her hand intrinsics over the last few months. Electrodiagnostic studies confirmed the diagnosis of severe cubital tunnel syndrome demonstrating axonal loss, positive sharp waves and fibrillations in the ulnar nerve distribution distally. The patient underwent cubital tunnel ulnar nerve release, subcutaneous anterior transposition, Guyon's canal release along with an AIN to ulnar motor nerve end-to-side transfer. Patient-based functional outcome instruments were prospectively collected with improved overall pain and function as demonstrated from a quickDASH score of 9.1 1 year post-op in comparison to a score of 34.1 pre-op. Recovery was monitored clinically and electrodiagnostic studies at 6 months and 1 year post-operatively. She demonstrated improved intrinsic muscle bulk and strength. The nerve studies at one year showed reinnervation with large amplitude motor unit potentials in the 1st dorsal interosseous and abductor digiti minimi but the 5th finger sensory response remained absent. The second case was a 58 year-old right hand dominant male diagnosed with severe and progressive right cubital tunnel syndrome. Clinically, he had significant muscle wasting and weakness and confirmed denervation on electrodiagnostic studies. He underwent the same surgical procedure as described for the first case and follow-up regimen. The patient demonstrated improved pain score and significant overall function recovery with a quickDASH score of 11.4 one year post-op in comparison to 72.7 pre-op. Nerve studies at one year confirmed our clinical impression, showing ulnar nerve reinnervation with large amplitude motor unit potentials in the 1st dorsal interosseous, while sensory response remained absent. It is yet unclear if end-to-side nerve transfers allow reinnervation of the target muscles. Previous studies have demonstrated clinical improvement with this transfer, however we are unaware of any electrodiagnostic studies demonstrating this effect. These two cases support the notion of reinnervation after an end-to-side procedure. Further studies are needed to assess outcomes of such nerve transfers

Introduction. Clavicle fractures accounting for 3–5% of all adult fractures are usually treated non-operatively. There is an increasing trend towards their surgical fixation. Objective. The aim of our study was to investigate the outcome following titanium elastic stable intramedullary nailing (ESIN) for midshaft non-comminuted clavicle fractures with >20mm shortening/displacement. Methods. 38 patients, which met inclusion criteria, were reviewed retrospectively. There were 32 males and 6 females. The mean age was 27.6 years. The patients were assessed for clinical/radiological union and by Oxford Shoulder and QuickDASH scores. 71% patients required open reduction. Results. 100% union was achieved at average of 11.3 weeks. The average follow-up was 12 months. The average Oxford Shoulder and QuickDASH scores were 45.6 and 6.7 respectively. 47% patients had nail removal. One patient had lateral nail protrusion while other required its medial trimming. Conclusion. In our hands, ESIN is safe and minimally invasive with good patient satisfaction, cosmetic appearance and overall outcome

Purpose. Assess and report the functional and post-operative outcomes of complex acute radial head fractures with elbow instability treated by arthroplasty using an uncemented modular anatomic prosthesis. Methods. Over a 3-year period (2007–2010), 21 patients (mean age 51.9 years) were treated primarily with modular radial head arthroplasty (mean follow up of 27.1 months). Data was collected retrospectively using clinical notes, operation documentation and prospectively using validated scoring systems namely the Oxford Elbow Index, Quick DASH and the Mayo Elbow Performance Score. Associated elbow fractures, ligamentous injury and short to mid term post-operative outcomes including radiographic assessment were recorded. Results. The mean Oxford Elbow Score was 34.80 (range 20–48). The mean Quick Dash score was 26.01 (range 0–68.2). The Mayo Performance score showed 6 scored excellent, 5 scored good, 3 scored fair and 2 scored poor. Regarding post-operative outcomes, 1 patient had a radial head dislocation, 1 patient had prosthesis removal for ongoing pain and 1 patient had a total elbow replacement due to associated proximal ulna fracture non-union. 11 patients had an associated ligamentous injury of which 6 had an associated coronoid fracture. Of note, 7 patient's radiographs showed early signs of implant loosening; this was mainly asymptomatic. Conclusions. With regard to complex radial head fractures with elbow instability, patient outcome measures showed good functionality and overall patient satisfaction despite radiographic evidence of loosening. Post-operative complication rates were low. These findings support the use of this radial head prosthesis in arthoplasty surgery for the treatment of complex acute radial head fractures with elbow instability

Introduction. The distal radius is the most frequently fractured bone in the forearm with an annual fracture incidence in the UK of about 9–37 in 10,000. Restoration of normal anatomy is an important factor that dictates the final functional outcome. A number of operative options are available, including Kirschner wiring, bridging or non-bridging external fixation and open reduction and internal fixation by means of dorsal, radial or volar plates. We designed this study to analyse the clinical and radiological outcome of distal radial fracture fixation using volar plating. Materials/Methods. Thirty-seven patients with distal radius fractures undergoing open reduction and internal fixation using volar plates were included. Tilt of the fractured distal radial fragment was recorded from the initial radiograph and classification of fractures was done using the Orthopaedic Trauma Association system. The QuickDASH questionnaire was used for evaluation of symptomatic and functional outcome six months to one year after surgery. The radiological outcome was assessed using measurements of radial inclination, ulnar variance and volar tilt. Of the thirty-seven patients, 13 were male and 24 were female. The mean age was 55.6 years (range 18–87 years). According to the AO classification, there were 8 cases each of C2 and C3 fractures, 6 cases of C1 fractures and 3 cases each of class A2, A3, B1 and B3 fractures. There were 2 patients with class B2 fracture. Results. Post-operatively, the average restoration of volar tilt was 6.47 degrees (range −12.4 to 20.3 degrees). Mean restoration of radial inclination was 23 degrees (range 12.5 to 30.0 degrees). Ulnar variance on average was 0.09 mm (range −5.0–6.7mm). The mean QuickDASH score was 9.8. Conclusion. The results of this study indicate that fixation of displaced intra- and extra-articular distal radial fractures is achieved satisfactorily with restoration of both normal anatomy and function using volar plates

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. The evolution of locked anatomical clavicular plating in combination with evidence to suggest that fixation of clavicle fractures yields better outcome to conservative treatments has led to an increasing trend towards operative management. There is no evidence however to compare early fixation with delayed reconstruction for symptomatic non- or mal-union. We hypothesize that early intervention yields better functional results to delayed fixation. Methods. Between August 2006 and May 2010, 97 patients were managed with operative fixation for their clavicular fracture. Sixty eight with initial fixation and 29 delayed fixation for clavicular non- or mal-union. Patients were prospectively followed up to radiographic union, and outcomes were measured with the Oxford Shoulder Score, QuickDASH, EQ5D and a patient interview. Mean follow-up was to 30 months. All patients were managed with Acumed anatomical clavicular plates. Results. The radiographic and clinical outcomes were available for all patients. Scores were available for 62 (62/97). There were no statistically significant differences in age (p>0.05), sex (p>0.05), energy of injury (p>0.05), number of open fractures (p>0.05) between the two groups. The mean quickDASH was 8.9 early, 9.1 delayed (p< 0.05), Oxford Shoulder score was 15.7 early, 16.1 delayed (p< 0.05). In the early fixation group 5 patients had wound healing complications, and 8 went on subsequently to have removal of prominent metalwork. In the delayed fixation group 2 had wound healing complications and 4 had removal of prominent metalwork. There were no statistically significant differences in the EQ5D quality of life questionnaire. Conclusion. There are no statistically significant differences in shoulder performance, wound or operative complications between early and delayed fixation of clavicular fractures. Our series does not support early fixation of clavicular fractures, as results for delayed intervention in those who become symptomatic appear comparable

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