Introduction and aim: In the rheumatoid hand, a radial inclination of the wrist is commonly observed in the presence of an ulnar drift of the fingers. The question that remains is: Which came first? To find an answer to this question, we have studied the radiographs of 122 hand affected by rheumatoid arthritis. Material and methods: In group I (44 hands), the disease was restricted to the wrist joint, which presented an average ulnar inclination of 15°, ranging from neutral to 43° of ulnar inclination. In group II (13 hands), the disease was limited to the MP joints, with an average of 30° of ulnar inclination of the fingers, ranging from 10° to 70°. A compensatory radial inclination of 12° was observed at the wrist, ranging from 2° to 26°. In group III (28 hands), both the wrist and MP joints were affected by the disease. The fingers presented an average ulnar inclination of 17°, ranging from 7° to 40°. The wrist presented an average radial inclination of 4°. In group IV (34 hands) and V (3 hands), measurements were done before and after the finger deformity was corrected from an average of 45° to 7°, while the wrist corrected itself, without wrist balancing procedures, on an average from 30° to 2° of radial inclination. Results: When only the wrist is involved, the metacarpals are always inclined towards the ulnar side. We have observed a radial inclination of the wrist only in the hands presenting an ulnar inclination of the fingers. When the ulnar drift of the fingers is surgically corrected, the radial inclination of the wrist will tend to correct itself. Conclusion: It has been generally accepted that radial inclination of the metacarpals is one of the causes of the ulnar drift of the fingers, but from our studies the radial inclination of the metacarpals should not be considered the cause but rather a consequence of the ulnar drift of the fingers

Aims. A conventional arthroscopic capsuloligamentous repair is a reliable surgical solution in most patients with scapholunate instability. However, this repair does not seem to be sufficient for more advanced injuries. The aim of this study was to evaluate the functional results of a wide arthroscopic dorsal capsuloligamentous repair (WADCLR) in the management of severe scapholunate instability. Methods. This was a prospective single-centre study undertaken between March 2019 and May 2021. The primary outcome was the evaluation of the reduction of the radiological deformity and the functional outcomes after WADCLR. A secondary outcome was the evaluation of the effectiveness of this technique in patients with the most severe instability (European Wrist Arthroscopy Society (EWAS) stage 5). The patients were reviewed postoperatively at three, six, and 12 months. Results. The study included 112 patients (70 male and 42 female). Their mean age was 31.6 years (16 to 55). A total of three patients had EWAS stage 3A injuries, 12 had stage 3B injuries, 29 had stage 3C injuries, 56 had stage 4 injuries, and 12 had stage 5 injuries. There was a significant improvement of the radiological signs in all patients with a return to normal values. There was also a significant improvement in all aspects of function except for flexion, in which the mean increase was negligible (0.18° on average). There was also a significant improvement in all criteria for patients with a stage 5 injury, except for some limitation of extension, flexion, and radial and ulnar deviation, although these showed a trend towards improvement (except for flexion). Conclusion. WADCLR is a minimally invasive, easy, and reproducible technique with few complications, offering a clear improvement in function and a reduction in the radiological deformity at one year postoperatively. Cite this article: Bone Joint J 2023;105-B(3):307–314

One hundred normal fingers were dissected and arthrographs obtained by injection of a chromopaquegelatin mixture, allowing comparison between the radiographic and macroscopic configuration of the synovial capsule. Synovial recesses protruding from each side of every metacarpo-phalangeal joint were found in relation to the collateral ligaments and corresponding exactly with the site of radiological erosions. A group of bursae lying on the superficial aspect of collateral ligaments were also demonstrated. A rudimentary infra-articular meniscus was found. The results of examination of the insertions of the interossei showed differences from traditional descriptions.

The cause of rheumatoid deformity was suggested to be the rheumatoid process arising in the lateral recesses and lateral bursae, weakening the collateral ligaments, which give way in the directions of the deforming forces. These are derived from the long flexor tendons, which were shown to exert an ulnar and volar strain on the metacarpo-phalangeal joint of every finger during grip.

The August 2023 Trauma Roundup. 360. looks at: A comparison of functional cast and volar-flexion ulnar deviation for dorsally displaced distal radius fractures; Give your stable ankle fractures some AIR!; Early stabilization of rib fractures – an effective thing to do?; Locked plating versus nailing for proximal tibia fractures: A multicentre randomized controlled trial; Time to flap coverage in open tibia fractures; Does tranexamic acid affect the incidence of heterotropic ossification around the elbow?; High BMI – good or bad in surgical fixation of hip fractures?

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

A prospective study was performed to develop a clinical prediction rule that incorporated demographic and clinical factors predictive of a fracture of the scaphoid. Of 260 consecutive patients with a clinically suspected or radiologically confirmed scaphoid fracture, 223 returned for evaluation two weeks after injury and formed the basis of our analysis. Patients were evaluated within 72 hours of injury and at approximately two and six weeks after injury using clinical assessment and standard radiographs. Demographic data and the results of seven specific tests in the clinical examination were recorded. There were 116 (52%) men and their mean age was 33 years (13 to 95; . sd. 17.9). In 62 patients (28%) a scaphoid fracture was confirmed. A logistic regression model identified male gender (p = 0.002), sports injury (p = 0.004), anatomical snuff box pain on ulnar deviation of the wrist within 72 hours of injury (p < 0.001), and scaphoid tubercle tenderness at two weeks (p < 0.001) as independent predictors of fracture. All patients with no pain at the anatomical snuff box on ulnar deviation of the wrist within 72 hours of injury did not have a fracture (n = 72, 32%). With four independently significant factors positive, the risk of fracture was 91%. Our study has demonstrated that clinical prediction rules have a considerable influence on the probability of a suspected scaphoid fracture. This will help improve the use of supplementary investigations where the diagnosis remains in doubt

Four-Corner Fusions (4CF) and Proximal Row Carpectomies (PRC) are common procedures utilized to treat carpal pathologies and radial sided wrist pain. Usually, the range of motion (ROM) and grip strength (GS) is affected by such conditions. Literature quotes significant reduction in ROM (50–60%) and grip strength (GS) (80% of normal) with PRC and 4CF. This study aims to determine the correlation between pre-operative ROM and GS and post-operative ROM and GS for patients with wrist pain undergoing PRC or 4CF. We hypothesize that ROM between pre-operative and post-operative patients does not change, but GS improves. Data from a prospective database of patients with wrist pain was searched to identify patients who have undergone PRC or 4CF with one year follow-up completed in the past two years. 17 such participants were identified. The diagnosis, pre-operative ROM in flexion, extension, radial deviation, ulnar deviation, pronation and supination, as well as GS at time of surgery and at six months and one year follow up were identified and assessed. The data was analysed to determine correlation between pre-and postoperative ROM and GS. The analysis was subdivided to compare patients treated with PRC versus patients with 4CF. No significant difference between pre- and post-operative ROM was detected, except in flexion at 6 months post-operatively. The average flexion was significantly lower at 6 months (p=0.0251) compared to pre-operative levels. Average flexion pre-operatively and at 6 and 12 months was found to be 46.6 (SD=15), 34.3 (SD=13.3), 51.2 (SD=21.5) respectively. Extension was at 41.4 (SD=15.3) pre-operatively and at 33.4 (SD=12.8) and 42.1 (SD=15.5) at 6 and 12 months post-operatively. Similarly, radial and ulnar deviation averages pre-operatively and at 6 and 12 months post-operatively were found to be 11.33 (SD=5.9), 11.9 (SD=4.5), 16 (SD=8.2) [radial deviation] and 24.1 (SD=8.3), 21.4 (SD=7.3), 26 (SD=12.8) [ulnar deviation]. No significant difference was found in GS at 6 months post-operative. However, significant difference at 12 months post-operatively was observed with an average GS of 28.4 kg (SD=12.8) [p=0.0385]. Average GS pre-operatively and at 6 months was 15.8 kg (SD=9.7) and 17.3 kg (SD=8.9) respectively. This study provides an insight on ROM and GS after PRC and 4CF. It shows that patients do not gain or lose ROM after surgery. As expected, GS improves with treatment as the pain diminishes. It is interesting to note that flexion gets worse at 6 months post-operatively before it bounces back to pre-operative levels

Ulnar drift is a common deformity in the hands of patients with rheumatoid arthritis. There is little in the literature regarding the value of crossed intrinsic transfer with MCPJ arthroplasty (Hellum 1968, Stothard et al 1991). In addition the significance of recurrent ulnar drift on hand function is unknown. The aim of this study is to assess if the addition of crossed intrinsic transfer to metacarpophalangeal arthroplasty has an effect on the recurrence of ulnar drift and to overall hand function. This is a retrospective comparative study. 73 hands in patients with rheumatoid arthritis undergoing primary 2nd to 5th metacarpophalangeal joint (MCPJ) replacements were studied. In 28 hands a crossed intrinsic transfer was performed and in 45 hands it was not . A similar splintage and rehabilitation programme was followed in each group. Mean follow up was 50 months. Ulnar drift and active range range of motion, Sequential Occupational Dexterity Assessment (SODA) functional score, patient satisfaction , grip strength. The two groups had similar preoperative ulnar drift (crossed intrinsic transfer group mean 27 degrees, comparative group 29 degrees, p=0.44). At follow up the crossed intrinsic transfer group had statistically less ulnar drift (crossed intrinsic transfer group mean 6 degrees, comparative group 14 degrees, p=0.01). There was no difference at follow up in active flexion, extensor lag, SODA score, grip strength and patient satisfaction (both groups had 70% improved function)

The MP joint is the key joint for function of the fingers. Rheumatoid arthritis involvement of this joint is frequent (1/3 of patients), and results in severe painful deformity and functional loss. The factors leading to the classic ulnar drift and volar luxation are multiple but the permanent pathophysiological element is synovitis of the joint. No deformation will occur in the MP joint without synovitis. Etiopathogenesis: The causes of MP joint deformity in Rheumatoid arthritis are anatomical, pathological and indirect. The asymmetry of the metacarpal heads with a slight ulnar tilt induce the deformation in this direction. The weakness and the length of the radial collateral ligaments compared to the ulnar collateral ligament makes the laxity to occur on the radial side of the joint. The obliquity of the extensor tendons pull the fingers ulnarly with a tendency of dislocation over the MP joints. Synovitis is at the origin of elongation, rupture or destruction of the ligaments, attrition of the cartilage and bone resorption. The distention of the extensor hood predominate radially and accentuate the extensor tendon obliquity. The destruction of the A1 pulley of the flexor tendon participate to the volar luxation of the joints. The ulnar sliding and radial tilt of the carpus, the tension of Abductor Digiti Minimi and the contracture of the intrinsic muscle participate indirectly or aggravate the deformation. The thumb force in pinch grip and the ulnar deviation of the finger in heavy prehension participate also to the deformation. Classification: Without prognostic factor the following classification gives information on the stage of the deformation and the treatment that can be proposed. synovitis without deformation, normal radiographs. synovitis with ulnar deviation, normal radiographs. synovitis with ulnar deviation and volar subluxation, volar luxation on radiographs with almost normal cartilage. ulnar deviation and volar luxation with or without active synovitis, destroyed cartilage and more or less bone erosion on radiographs. Synovectomi with stabilization and realignment procedures can only be used in stage 1 and 2. In stage 3 and 4 arthroplasty is more appropriate. Treatment: Indication are pain, loss of function and cosmesis. Synovectomy. The prophylactic effect of synovectomy is still subject to debate. The almost impossible total synovectomy, the difficulties to control the effect of the procedure and the different stage in disease of each patient make the synovectomy unpredictable as a real prophylactic procedure. Stabilization and realignment procedures has always to be part of a synovectomy. If the destruction of the cartilage and the bone erosion are irreversible process, the elongation of the ligaments or the destruction of their bony insertions can always be reconstructed. For this purpose different techniques can be used. Suture of the extensor hood on the radial side enables reorientation of the extensor tendons. The radial collateral ligaments can be strengthened or their attachments reinserted, the Abductor Digiti Minimi or the intrinsic tendons can be divided. Some tendon transfers (intrinsic, Extensor Indicis Proprius) can also be proposed. Arthroplasty. The choice of the procedure depends most of the surgeon preferences. The silicon arthroplasties are the most often used. They associate a reduction of the ulnar and volar deformation and opened the hand with very good results on the aspect of the hand and on pain. The mobility of the MP joints is variable and depends of the mobility of the finger joints. The bone erosion and the rupture of these devices are in favor of autologous interposition arthroplasties which, on the other hand, gives lesser mobility and stability. For these reasons silicon and interposition arthroplasties are often indicated late in the MP joint destruction process. More recently, new non constrained implants have been proposed in order to offer an earlier treatment. When used with good ligament reconstruction and tendon rebalancing these devices have good results on pain, cosmesis and function. If the preliminary results are confirmed in the long term, these non constrained devices will have a good indication as early MP joint replacement in the active young rheumatoid patient. Conclusion: MP joint deformity in rheumatoid arthritis is complex. The Etiopathogenesis will guide the treatment most appropriate in each patient. However some principles has to be respected in all cases. A good stabilization and recentralization is the key stone of the surgical procedure. The ulnar deviation can be reduced and corrected by ligaments and tendon procedures. The volar subluxation/luxation indicates an advanced deformity of the MP joint that requires arthroplasty

A study has been made of fifty-six patients suffering from rheumatoid arthritis in whom sixty-nine wrists were fused. The purpose of the investigation was to evaluate to what extent the position of the fused wrist influenced the position of the fingers in the frontal plane. All sixty-nine wrists were followed up by radiographic examination controls, and thirty-seven of the wrists were also examined clinically. The mean period of observation after operation was seven years and ten months. The findings support the so-called "zigzag" theory based on the concept of carpus-metacarpus acting as Landsmeer's intercalated bone in a bi-articular system. When the wrists were fused in more than 5 degrees of radial deviation seventeen of twenty hands showed ulnar drift of the fingers on radiographic examination. Of the nine patients in this group examined clinically, all showed ulnar drift. A strong tendency to correction of the finger position is seen when the hands are pressed against the cassette. For this reason the clinical examination, during which the finger deviation was examined with the metacarpo-phalangeal joints in 30 degrees of flexion regularly revealed an ulnar deviation of 5 degrees more than that shown by radiographic examination. In eighteen wrists the fusion had been done in more than 5 degrees of ulnar deviation. Fourteen of these hands showed a resulting radial deviation of the fingers on radiographic examination. In a group of thirty-one wrists fused in neutral position (0 degrees±5 degrees) only six hands showed more than 5 degrees of finger deviation to either side. The condition of the metacarpo-phalangeal joints asjudged from radiographs did not seem to influence the deviation of the fingers either in direction or in degree. The direction of the deviation of the fingers was almost regularly the opposite to that of the fused wrist. Five hands showing no visible pathological changes in the metacarpo-phalangeal joints displayed finger drift

Summary. Increased lateral ulnotrochlear joint space due to improper sizing in radial head arthroplasty may result in medial collateral ligament laxity, leading to increased osteophytes and arthritis. Introduction. Radial head (RH) arthroplasty is a common response to comminuted RH fractures. Typical complications include improper sizing, leading to changes in joint kinematics. Evidence of these changes should be visible through fluoroscopic images of affected joints. The two examined changes in this study are the ulnar deviation from distal radial translation (DRT), and the widening of the lateral ulnotrochlear joint space (LUT). Methods. Eight fresh-frozen cadaver arms were used. Initial images were taken with the native RH intact. The Kocher approach exposed the radiocapitellar (RC) joint capsule, preserving all ligaments. The RH was excised and Integra Katalyst CoCr (Plainsboro, NJ) telescoping, bipolar, RH inserted. Images were taken with implant sizings: −2mm, 0mm, +2mm, and +4mm, (from native) using 1mm washers preventing implant bipolarity. AP fluoroscopic images of the elbow were taken at full extension. Joint spaces were measured using image analysis, normalised using known radio-opaque lengths. Four LUT measurements were made, two medially and two laterally, and normalised by measuring the RH implant diameter. Each set (medial and lateral) were averaged together and the resulting value used for all comparisons. Images of distal ulnar deviation at the wrist were taken with the wrist in supination, the hand rotated medially. Measurements were from the distal medial radial tip to the distal lateral ulnar tip. Images were normalised by placing a scalpel in the same plane as measurement. Results. DRT values were difference paired for each arm using the 0mm values as baselines. One-way ANOVA of the paired values resulted in significant DT with sizing increases (p<0.01). The quotient of DRT and sizing determined comparative impact with the LUT increase. LUT joint gap measurements were percentage paired, with natives as the baseline, and One-way ANOVA used. A significant increase in LUT spacing occurred with increased sizings (p<0.01). Discussion. Increased ulnar deviation can increase loading on the TFCC, leading to possible TFCC tear, increased articular cartilage wear from carpal misalignment, and eventual wrist instability and arthritis. The percentage of the radial lengthening is represented in DRT. Over-sizing results in small percentages of increased radial length at the wrist, therefore deviation at the elbow must take place, either through rotation of the ulna, or translation. Either of these can be seen through LUT measurements. Previous measurements of the LUT space were made by Frank (2009), with similar results. This was being used as a method of improper sizing detection using radiographs. The percentage difference of LUT space for corresponding sizing: there is an increase in LUT space for every sizing; maybe due to loosening of the soft tissue from arthroplasty. Increased LUT space indicates the medial translation of proximal ulna. This can result in Medial Collateral Ligament laxity, leading to increased osteophytes, and arthritis. Use and non-treatment, can create a chronic, painful, disorder

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

Purpose of study: Aim was to evaluate the functional outcome of External fixation supplemented by K-wire fixation in communited fractures of lower end radius and compare the outcome in closed and open fractures treated by this method. Methods: External fixation along with K-wire fixation was done in 25 consecutive patients (mean age-41.9 years; range-20 to 72 years). According to Frykman’s classification, there were 3 Type VII fractures and 22 Type VIII fractures. 15 fractures were closed type, 4 were Open grade I, 4 were Open grade II and 2 were Open grade III according to Gustilo and Anderson classification. The mean follow-up period was 14.1 months (range- 6 to 25 months). Results: The mean union time was 7 weeks (range-5 to 8 weeks). Mean dorsiflexion was 37.6 degrees, mean palmar flexion was 44.4 degrees, mean ulnar deviation was 16.2 degrees, mean radial deviation was 14.2 degrees, mean supination was 73 degrees and mean pronation was 79 degrees. Comparison of union time, dorsiflexion, palmarflexion, ulnar deviation, radial deviation, supination and pronation between closed, Open grade I, Open grade II and Open grade III fractures revealed no significant difference. Significant radial shortening was observed in patients with open fractures (P=0.004). 1 patient developed schanz pin tract infection and late distal radioulnar joint subluxation was seen in 4 patients. Conclusion: Supplementation of External fixator with K-wires is an effective method for treating both closed and open fractures of distal end radius however; radial shortening is seen in some cases with open fractures

Forearm lengthening in children is controversial. Paley (1990) and Peterson (1994) advocate aggressive treatment of the deformity for cosmetic and functional reasons. Scoenecker (1997) has shown that mature patients are comfortable with their appearance and functional deficit. We reviewed 8 forearm lengthenings performed in 8 children in the 14 year period from 1991 to 2004. Five patients had ulnar shortening (osteochondromata = 4, growth arrest due to trauma = 1). Of the three patients with radial shortening, one was due to a congenital short radius and two following growth arrest (post trauma and meningococcal septicemia). The shortening resulted in a cosmetically unacceptable ulnar or radial tilt with absent radial or ulnar deviation of the wrist and decreased supination and/or pronation. One patient with a proximal ulnar osteochondroma had a dislocation of the radial head with cubitus varus. Excision of the osteochondroma was done 6 months prior to lengthening. Lengthening was accomplished with two Ilizarov rings and a distal corticotomy for radial and proximal for ulnar shortening. Reduction of the dislocated radial head was achieved with an olive wire. Associated procedures were: hemiepiphyseal stapling of the distal radius for an increased radial articular angle in 3 patients with osteochondroma, and corrective osteotomy of the distal radius in 1 patient with growth arrest. The average lengthening obtained was 23 mm (range 13–40 mm) with an average lengthening index of 1.45 months per cm. At an average follow-up of six years (range 2–15 years; 7 to maturity) all patients were satisfied with the cosmetic improvement and had full radial and ulnar deviation. Except for two patients the supination/pronation was improved. We concluded the forearm lengthening is warranted for cosmetic and functional reasons

Aims: The aim of the present study was to compare the functional outcome between silastic Swanson and Sutter implants in metacarpophalangeal joints in a prospective and randomised of study of patients with rheumatoid arthritis. Methods: The study was prospective and randomised. Thematerial comprised 53 patients (6 men, 47 women) and 58 hands; a total of 89 Swanson and 126 Sutter implants were installed. The mean follow-up time was 57 (40–80) and 55 (36–79) months, respectively. Results: Active extension was corrected similarly in both groups. In the Swanson group from median [inter-quartile rate (IQR)] 22° (8, 44) to 12° (0,20), and in the Sutter group from 19° (7, 37) to 16 (5, 25). The median active flexion decreased less in the Sutter group from 75° (69, 84) to 64° (53, 72) vs. Swanson from 83° (77, 90) to 58° (48, 64) during the follow-up, and with that respect the difference between the groups was statistically significant (p=0.01). Statistically significant difference (p=0.03) was detected in correction of ulnar deviation only in ring finger: in the Swanson group from median 25°(6°, 34°) ulnar deviation to 1°(2°radial, 9°) radial deviation and in the Sutter group from 14°(7°, 28°) to 5°(0°, 13∞) respectively. Conclusion: It appears that the Sutter implant yields at least as good functional results in the MCP replacement as the Swanson prosthesis

There is ongoing debate regarding the optimal management of displaced distal radius fractures in the elderly. The aim of this review was to compare outcomes of operatively versus non-operatively managed displaced extra-articular or undisplaced intra-articular distal radius fractures in patients 65 years and older. All patients over the age of 65 years with displaced extra-articular or undisplaced intra-articular fractures seen in Tauranga Hospital between 1. st. January 2009 and 31st December 2009 were included in the study. Patients from out of town, with incomplete radiographs or who had since passed away were excluded as were patients with comminuted intra-articular or undisplaced/minimally displaced extra-articular fractures. Patients attended follow-up where clinical assessment was carried out by a single Hand Therapist who was blinded to the side of injury and previous management, completed the Patient Rated Wrist Evaluation (PRWE) and DASH questionnaires and a visual analogue satisfaction score. There were 91 distal radius fractures in patients 65 years and older seen in Tauranga Hospital over this 1 year period. 44 were excluded leaving 47 patients. 6 declined follow-up and 5 failed to attend. 36 patients (3 males, 33 females, average age 74.7 years) were included in the study – 23 had been treated non-operatively with casting +/− manipulation while the remaining 13 patients had undergone open reduction and internal fixation. Comparing the injured with the uninjured wrist in the operatively managed group there was an average loss of 5.8 degrees flexion, 1.2 degrees extension, 1.7 degrees ulnar deviation and 3.8 degrees supination with a gain of 0.7 degrees radial deviation, no change in pronation and a loss of 1.2kg in grip strength. These operatively managed patients had an average PRWE score of 6.5, DASH score of 31.5 and satisfaction score of 8.8. Conversely, in the non-operatively managed group there was an average loss of 17.5 degrees flexion, 9.4 degrees extension, 11.3 degrees ulnar deviation and 10.9 degrees supination with a gain of 0.1 degrees radial deviation, no change in pronation and a loss of 4.7kg in grip strength. These non-operatively managed patients had higher PRWE (42.5) and DASH (56) scores and were in general less pleased with their outcomes (mean satisfaction score – 5.6). Patients in the operatively managed group at 12–24 months post-injury had less significant loss of function as well as lower PRWE and DASH scores and higher satisfaction outcome scores

Aim: The use of volar plates in the management of distal radius fractures has increased dramatically over the last decade. Our aim was to ascertain if long term outcome could be predicted at clinical review four months following operation. Patients and Methods: Between January 2003 and January 2005, all patients presenting with unilateral distal radius fractures and treated with volar locking plate fixation (Synthes) were invited to participate in long-term follow up. The decision to use a volar plate and the operative procedure itself was undertaken by the on-call consultant and his team. Patients who agreed to enter the study were evaluated at 4, 6 and 12 months following operation. Patient demographics, hand dominance and fracture type were recorded. Assessment of grip strength and wrist movements were undertaken and expressed as a percentage of the contralateral, uninjured side. Results: A total of 76 out of 100 eligible patients agreed to participate in the study. Of those patients, 23 (30%) failed to attend all their follow-up appointments, leaving a dataset of 53 patients (70%) available for analysis. There were 28 females (53%) and the mean patient age was 55 years (range 28–83). Grip strength, pinch grip, wrist flexion, wrist extension, radial deviation, ulnar deviation, pronation and supination all showed graded improvement in the year following fracture, achieving a mean range of 73% to 95% of function compared to the contralateral side at 12 months. Wrist flexion and ulnar deviation showed near maximum improvement by 6 months, whereas the other variables continued to show significant improvement between 6 and 12 months. Logistic regression analysis suggested that improvement in wrist extension at four months was the best predictor of a good outcome at one year. Discussion: Use of volar plate fixation is an increasingly common method of managing distal radius fractures. Our study suggests that good functional results can be achieved by this method of treatment. Failure to regain reasonable wrist extension by four months appears to predict higher risk of poor outcome and therefore patients in this group should be followed up more closely

This prospective controlled clinical trial compares the outcomes of metacarpophalangeal (MCP) arthroplasty in rheumatoid arthritis patients using the Swanson (S) and NeuFlex (N) MCP implants. Forty hands (thirty-seven patients) were randomised and evaluated preoperatively and at one year following MCP arthroplasty in digits two to five for range of motion (ROM; active and passive extension and flexion), ulnar drift and grip strength. Both implants restored extension and corrected flexion deformities. There was no significant difference in extension of all digits (summed) between the NeuFlex and Swanson implants (N: −20.8°; S: −13.8°; p=0.29). The NeuFlex implant, which is pre-flexed at 30°, preserved more flexion at the MCP joint than the Swanson implant in all digits (summed) (N:74.5°; S:55.8°; p=0.005), with the greatest difference observed in the fifth digit (N:69.6°; S:48.7°; p=0.009). The total arc of motion improved in all digits, with no significant differences between the Neu-Flex and Swanson groups in the second through fourth digits (N:53.8°; S:43.8°; p=0.154); a significantly greater improvement was observed in the NeuFlex group for the fifth digit (N:53.3°; S:42.5°; p=0.028). Both implants corrected ulnar drift deformity, while neither led to loss of grip strength. Hand function as measured by Sollerman score and Michigan Hand Questionnaire (MHQ) improved significantly in both groups (p=0.0119, p< 0.0001, respectively) with no significant difference between the Swanson and NeuFlex implants, except for MHQ function, aesthetics, and overall scores, which demonstrated superiority of the Swanson. Overall, there was a significant improvement in the range of motion, deformity and grip strength following MCP arthroplasty for the full patient group. While both implants restored similar amounts of extension, the NeuFlex implant maintained greater flexion and total range of motion, with the greatest difference in the fifth digit. The Swanson implant had better MHQ function and aesthetics subscores

The aim was to compare the medium term results of metacarpophalangeal joint (MCPJ) arthroplasty using three different types of silicone hinged implants. All rheumatoid arthritis patients undergoing four finger MCPJ arthroplasty at Burwood Hospital have had standardised pre and post operative assessments for up to four years consisting of: measurement of MCPJ active arc of motion (AOM); finger ulnar drift (UD) and the Baltimore upper extremity function test (UEFT). All surgery was undertaken or directly supervised by one surgeon using a standardised technique followed by a dynamic and static splintage programme supervised by the same hand therapists. Implants – Swanson; 25 hands, 100 joints, 1989 to 1995 – Avanta; 27 hands, 108 joints, 1995 to 2000 – Neuflex; 11 hands, 44 joints, 1999 to 2003. Swanson – at two years the AOM changed from 46 – 80° to 15 – 51°; UD reduced from 33 to 4°and 66% had improved from partial and poor to functional UE categories. Avanta – the AOM changed from 51 – 79 to 15– 60; UD from 31 to 7° and 67% had improved to functional. Neuflex – the AOM changed from 42 – 68 to 17 – 63°; UD from 32 to 11 and 45% had improved to functional classification. From two to four years the UEFT for the Swanson and Avanta had significantly deteriorated. The medium term outcomes for the three implants were very similar. Neuflex use was discontinued in 2003 because of early recurrence of ulnar drift. The significant deterioration of hand function from two to four years is likely to be the effect of progressive rheumatoid disease as the AOM and UD remained unchanged

Background: An important sign in the assessment of distal radioulnar joint instability is the ballottement test were passive movement of the affected joint is compared to the contralateral normal side. The subjective appreciation of increased laxity renders the test positive. In cases in which the contralateral side can not be tested or is known to be abnormal the relevance of the ballottement test is compromised. Based on the observation that distal radioulnar joint passive mobility decreases in normal subjects when the wrist is radially deviated we propose a modification of the ballottement test in which mobility of the DRUJ is tested both in radial and ulnar wrist deviation. Objectives: We aim to verify the observed decreased range of motion of the DRUJ in normal individuals when assessed in radial deviation compared to ulnar deviation and report the intraoperative findings of a series of patients who demonstrated an abnormal modified ballottement test in the abscense of bony deformity in the DRUJ. Method: A group of 38 healthy volunteers (76 wrists) with no history of significant wrist injuries were assessed and the amount of DRUJ mobility given a subjective score of between 1 and 3. All wrists were assessed in ulnar and radial deviation as well as in neutral. The average age of the participants was 32.4 years. There were 22 female and 16 male subjects. Our clinical case series reports the review of clinic notes and operative records of 32 patients (age gender) (32 wrists) who demonstrated an abnormal modified ballottement test and whose degree of instability granted surgical intervention. Results: Out of the 76 normal wrists, 72 demonstrated decreased range of movement of the DRUJ in wrist radial deviation compared to examination in neutral or ulnar deviation. In the remaining 4 no difference was perceived but examination in neutral was considered “stiff” (less than average on the examiners experience). All patients in the case series were found to have an ulnar detachment of the dorsal aspect of the TFCC (Palmer 1B) for which they underwent open repair. Conclusion: DRUJ mobility in normal wrists decreases in radial deviation compared to neutral. The observed decreased mobility of the DRUJ is likely to be due to tightening of the ulno-carpal ligaments. An abnormal modified ballottement test was an indicator of severity as those with a positive result required surgical intervention and also correlated with the anatomical lesion found at surgery (Palmer 1B TFCC tear). We believe the proposed modification enhances the diagnostic value of the DRUJ ballottement test and also allows to detect abnormalities in those cases in which the contralateral side can not be examined