Distal radius fractures are common, particularly in post-menopausal women. Several factors have been identified such as osteopenia and an increased risk of falling. We hypothesised that increased soft tissue padding from muscle and fat in the volar hand may confer an element of protection against fractures more in men than women and more in younger than older patients.

The aim of the study was to assess for thenar and hypothenar thickness and assess whether it varies between sexes and changes with age.

We retrospectively evaluated hand MRI scans performed for non-acute conditions in adults without previous injury or surgery. Using the Patient Archiving and Communication System (PACS) we measured the distance (mm) from the volar surface of the trapezium to the skin, the hook of the hamate to skin and the pisiform to skin as measures of thenar and hypothenar thickness. We also recorded the sex and age of the subjects.

Soft tissue thickness was corrected for hand size by dividing by capitate length which we measured; we have already established this as a surrogate measure of hand size.

The scans of 51 men (mean age 35, range 19–66) years and 27 women (mean age 49, range 19–79) years were reviewed. Men had significantly thicker soft tissues compared to women over both the thenar and hypothenar eminences (p=0.0001). Soft tissue thickness did not change significantly with age (p> 0.05).

The study confirms a significant difference in volar hand soft tissue thickness between men and women accounting for differences in hand size. Our previous research has shown how we fall onto our outstretched hands in the upper limb falling reflex and we have shown that padding the thenar and hypothenar eminences reduces force transmission to the forearm bones. In theory thicker thenar and hypothenar musculature would help protect against distal radius fractures following a fall on an outstretched hand. The thinner musculature on women may further predispose them to an increased risk of distal radius fractures. Further research is needed to assess for any loss of volar hand soft tissue thickness beyond age 75 years.

Metacarpal fractures represent up to 33% of all hand fractures; of which the majority can be treated non-operatively. Previous research has shown excellent putcomes with non-operative treatment yet surgical stabilisation is recommended to avoid malrotation and symptomatic shortening. It is unknown whether operative is superior to non-operative treatment in oblique or spiral metacarpal shaft fractures.

The aim of the study was to compare non-operative treatment of mobilisation with open surgical stabilisation.

42 adults (≥ 18 years) with a single displaced oblique or spiral metacarpal shaft fractures were randomly assigned in a 1:1 pattern to either non-operative treatment with free mobilisation or operative treatment with open reduction and fixation with lag screws in a prospective study. The primary outcome measure was grip-strength in the injured hand in comparison to the uninjured hand at 1-year follow-up. The Disabilities of the Arm, Shoulder and Hand Score, ranges of motion, metacarpal shortening, complications, time off work, patient satisfaction and costs were secondary outcomes.

All 42 patients attended final follow-up after 1 year. The mean grip strength in the non-operative group was 104% (range 73–250%) of the contralateral hand and 96% (range 58–121%) in the operatively treated patients. Mean metacarpal shortening was 5.0 (range 0–9) mm in the non-operative group and 0.6 (range 0–7) mm in the operative group. There were five minor complications and three revision operations, all in the operative group.

The costs for non-operative treatment were estimated at 1,347 USD compared to 3,834USD for operative treatment; sick leave was significantly longer in the operative group (35 days, range 0–147) than in the non-operative group (12 days, range 0–62) (p=0.008).

When treated with immediate free mobilization single, patients with displaced spiral or oblique metacarpal shaft fractures have outcomes that are comparable to those after operative treatment, despite some metacarpal shortening. Complication rates, costs and sick leave are higher with operative treatment. Early mobilisation of spiral or long oblique single metacarpal fractures is the preferred treatment.

Trial registration number: ClinicalTrials.gov NCT03067454

Abstract

Abstract

Objective

We explanted NeuFlex metacarpophalangeal (MP) joint prostheses to identify common features, such as position of fracture, and thus better understand the reasons for implant failure.

Most patients with a nightstick fracture of the ulna are treated conservatively. Various techniques of immobilisation or early mobilisation have been studied. We performed a systematic review of all published randomised controlled trials and observational studies that have assessed the outcome of these fractures following above- or below-elbow immobilisation, bracing and early mobilisation. We searched multiple electronic databases, related bibliographies and other studies. We included 27 studies comprising 1629 fractures in the final analysis. The data relating to the time to radiological union and the rates of delayed union and nonunion could be pooled and analysed statistically.

We found that early mobilisation produced the shortest radiological time to union (mean 8.0 weeks) and the lowest mean rate of nonunion (0.6%). Fractures treated with above- or below-elbow immobilisation and braces had longer mean radiological times to union (9.2 weeks, 9.2 weeks and 8.7 weeks, respectively) and higher mean rates of nonunion (3.8%, 2.1% and 0.8%, respectively). There was no statistically significant difference in the rate of non- or delayed union between those treated by early mobilisation and the three forms of immobilisation (p = 0.142 to p = 1.000, respectively). All the studies had significant biases, but until a robust randomised controlled trial is undertaken the best advice for the treatment of undisplaced or partially displaced nightstick fractures appears to be early mobilisation, with a removable forearm support for comfort as required.

Cite this article: Bone Joint J 2013;95-B:952–9.

Introduction

Ten explanted pyrolytic carbon components of a number of finger prostheses were obtained at revision surgery for wear analysis. Implants were removed for either dislocation or failure of fixation. Hypothesis Failure of the components was due to wear from the articulating surfaces, as occurs in many hip and knee prostheses.

Aim

The purpose of this study was to develop and test the utility of a hybrid barbed-suture in the core repair of digital flexor tendon injuries. Despite offering advantages over traditional suture methods, concerns over the cost, strength to failure and biocompatibility of barbed sutures have hindered their development. Moreover the recent designs have been very complex. We have attempted to develop and test a simple barbed suture, to assess it's viability in flexor tendon repair and in particular to establish a baseline for the efficacy and modes of failure barbed sutures, in order to help provide a basis for future research.

Distal radio-ulnar joint (DRUJ) instability is increasingly recognised and can lead to disabling symptoms. Clinical assessment can detect gross instability but is much less reliable for subtle instability. The normal range of DRUJ dorso-palmar translation is not known. Previous biomechanical research has studied DRUJ kinematics using cadaveric models.

We aim to develop a simple, reliable and reproducible tool to measure DRUJ stability and thereby assess the normal range of DRUJ dorso-palmar translation in-vivo.

A test rig was designed and 20 volunteers recruited. The rig held the subject’s elbows at 90° flexion with the distal ulnar secured and the forearm in neutral rotation. Dorso-palmar shear force was applied to the distal radius and displacement measured 3 times on each wrist alternately by the same operator. Volunteers with previous wrist injuries were excluded.

Ten male and 10 female volunteers were recruited. Mean male age 39.1 years (range 22–74). Mean female age 35.8 years (range 25–57). Mean male translation 5.4mm (range 3–9, SD 1.1). Mean female translation 5.5mm (range 4–7, SD 0.9). Mean right sided translation 5.3mm (range 3–8, SD 1.0). Mean left sided translation 5.6mm (range 3–9, SD 1.0). Total mean translation 5.5mm (SD 1.0). Same-sided mean measurements for two subjects taken days apart varied by only 1mm. Intraclass correlation coefficient was 0.93.

The rig is reliable, reproducible and appears to be a valid test of DRUJ translation. The mean DRUJ translation in neutral is 5.5mm. Contralateral sides and between sexes were comparable. We anticipate that the rig will be a research tool to guide clinical practice in DRUJ instability.

Introduction: There are risks attached to performing hand surgery and not just due to the fact that there are many important structures in a compact area, but because of increasing litigation. To date the cost of litigation is unknown. We have reviewed NHSLA data for closed litigation claims from 1995–2001.

Method: NHSLA provided data detailing litigation claims and settlements for orthopaedic hand problems. Data sets include: incident date, creation date, incident details, damages paid, defence costs, claimant costs, total claim, cause, injury location, speciality. We analysed the data with respect to: A& E, inpatients, out-patients department and surgery to understand where most claims were made and subsequent costs.

Results: There is a clear trend of increasing numbers of litigation cases, successful claims and settlement amounts. The clinical areas making the most claims and resulting in the greatest costs are: 1-Surgery, 2-Outpa-tients, 3-A& E, 4-Inpatients and lastly 5-Administration. The top 5 pathologies claimed for are: 1-wrist fracture, 2-carpal tunnel release, 3-ganglion excision, 4-metacarpal fracture, and 5-missed scaphoid fractures.

Conclusion: This data is very interesting as litigation is a very emotive and sensitive issue. We confirm that litigation is on the rise and needs to be addressed. It’s evident that the majority of claims involve routine procedures or routine management decisions. Of note there are no cases relating to more complex hand surgery or difficult management issues.

Malunion of digital fractures can be difficult to correct especially for rotational phalangeal malunion. We describe the simple closed corrective technique.

Materials/Methods: Patients whose phalangeal fractures were treated closed (mobilised or POP +/− K wires) and malunited, typically with mal-rotation.

The technique is performed under LA. The bone is cut by percutaneous passage of a 1.1 mm K wire multiple times until the bone is fractured. The malunion is corrected and held with one longitudinal 1.1 mm K wire. The osteotomies are supported for 6 weeks in POP/splint and the wire(s) removed.

Results: 11 patients with 12 post fracture malunion–All metaphyseal osteotomies healed within 6 weeks with correction of malrotation and no significant angular deformity. The one diaphyseal osteotomy united late healing only partially (inadequately) corrected and requires revision. Apart from the malunion there were no major complications albeit short-term PIP joint stiffness.

Conclusion: This is a safe and reliable technique that avoids most of the complications of more challenging open techniques in the phalanges or the compromises of distant techniques e.g. metacarpal correction of phalangeal malrotation. It does however require immobilisation precluding any major simultaneous soft tissue releases. It appears unsuited to diaphyseal correction.

Osteoporosis is an increasing problem due to increasing age and inactivity. Distal radial fractures are often the first symptom of this disease. Medical treatment can reduce the risk of further fractures (including hip fractures with the associated mortality and morbidity).

To develop a method for accurate assessment of bone density from routine wrist radiographs:

Various bone substitutes were tested until one was found that gave reasonable density matches with fresh bone over a limited X-ray kV range;

Wrist and radius thickness were measured from the radiograph. This was combined with the optical density of the distal radius (relative to the bone substitute) to calculate a value for the bone density. The patients subsequently underwent a DEXA scan of the contralateral (uninjured) wrist. [The X-ray calculated bone density and the DEXA density compare well. (R> 0.5]

Conclusion: This technique gives reasonably accurate results. It is not yet ready for clinical practice. A larger study is required to improve the accuracy of this technique, perhaps comparing results with lumbar spine DEXA.

Background and Purpose: There is a high incidence of arthritis in the hand, but joint replacement technology in the wrist and other small joints is still in its infancy compared with the larger joints. The wrist is the most complex small joint and so there is a need for fundamental research into the way in which it works. At present there is no generally agreed upon satisfactory explanation for the complex movement patterns of the carpal bones. The purpose of the work was to test a new hypothesis on wrist kinematics. The basis of the hypothesis was that the bones of the wrist move in such a manner as to maximise total contact area in the joint, thereby minimising contact stress. Such a strategy would minimise the bone mass requirements, thereby minimising the biological “cost” of creating and maintaining the joint. This agrees with the minimum energy principle, which governs many natural processes.

Methods: A computer model was created to test the hypothesis. A cadaveric wrist was dissected and 3D faceted models of the carpal bones were created using laser digitisation. The model contained a program to evaluate the closeness of packing of the carpal bones and an optimisation algorithm [1] to maximise this quantity by adjusting the positions of the bones. The evaluation program computed the contact area and level of intersection between nine pairs of interacting bones. Rotation in the radial-ulnar deviation plane was applied in 1.0° increments to four rigidly connected bones defining the overall posture of the wrist, and an optimisation algorithm was used to maximise the contact area by adjusting the positions and orientations of the remaining bones.

Results: The results of the work are encouraging because certain known characteristics of carpal behaviour were clearly predicted by the model. The results for the scaphoid in particular were similar to the characteristic movements of this bone in both radial and ulnar deviation. During 20° of unlar deviation, the bone demonstrated 14.3° of extension, which is near to the 20.4° reported by an experimental study [2]. In 10° of radial deviation, the bone underwent 6.4° of flexion, which again is close to the 8.1° experimental result.

Conclusion: Although the computer model predicted certain aspects of carpal behaviour, the initial hypothesis was not conclusively proved. This is due in part to the computational complexity of the task. Despite some simplifying assumptions, there were still a large number of degrees of freedom, and it is almost certain that the optimisation process was afflicted with local minima problems. If the technical hurdles can be overcome and the hypothesis is proved correct, then we will gain a new explanation of the laws governing the kinematics of the wrist joint, which are not fully understood at present. This will provide invaluable information for surgical applications, where a thorough understanding of normal kinematics is essential for the treatment of joint injury and instability.

Introduction: Impingement syndrome has been reported to occur in a proportion of patients (9%) following whiplash injuries to the neck. In this study we aim to examine this finding to establish the association and incidence of subacromial impingement following whiplash injuries to the cervical spine.

Method and results: We examined 219 patients who had presented to a single surgeon for a medico-legal report, at an average of 13.8 months (range 1–52) following a whiplash injury to the neck. All patients were assessed for clinical evidence of subacromial impingement. The patients were asked if the symptoms had developed following their neck injury and those with past history of shoulder pain were identified and excluded. 56 patients (26%) had shoulder pain following the injury; of these, 11 (5%) had clinical evidence of impingement syndrome, however in the majority other clinicians had overlooked this. The seatbelt shoulder (driver’s right and front passenger’s left) was involved in 9 (82%) of the cases (p< 0.001). The average age was 38.2 years compared with 57.8 years in those with subacromial impingement (p< 0.05). Impingement is therefore likely to be due to direct trauma from the seatbelt in the older age group with an already compromised subacromial space.

Conclusion: It is now established that subacromial impingement occurs following whiplash injuries to the neck. This is however, frequently overlooked and shoulder pain is attributed to pain radiating from the neck. It is important that this is appreciated and patients are specifically examined for signs of impingement so that appropriate treatment can be instigated. Direct trauma from the seatbelt is one likely explanation for this association.

Introduction: Osteoporosis is an increasing problem due to increasing age and inactivity. Distal radial fractures are often the first symptom of this disease. Medical treatment can reduce the risk of further fractures (including hip fractures with the associated mortality and morbidity). Aims: To develop a method for accurate assessment of bone density from routine wrist radiographs. Material and Methods: 1. Various bone substitutes were tested until one was found that gave reasonable density matches with fresh bone over a limited X-ray kV range. 2. Patients with distal radius fractures had the bone substitute placed beside the wrist being X-rayed. Wrist and radius thickness were measured from the radiograph. This was combined with the optical density of the distal radius (relative to the bone substitute) to calculate a value for the bone density. The patients subsequently underwent a DEXA scan of the contralateral (uninjured) wrist. Results: 20 patients. The X-ray calculated bone density and the DEXA density compare well. (R> 0.5)Discussion and Conclusion: This technique gives reasonably accurate results. It is not yet ready for clinical practice. A larger study is required to improve the accuracy of this technique, perhaps comparing results with lumbar spine DEXA.

Aim: To assess the efficacy of percutaneous needle bursting and limited percutaneous pulley division in the treatment of seed ganglia.

Methods: A prospective cohort study was run. All patients in the study had ganglia bursting by lignocaine injection. If this failed a limited percutaneous release was performed as at open release for trigger finger.

Results: There were 52 patients treated over a four-year period. 31 were female and 21 male with an average age of 37 years. The fingers involved were: index (6), middle (21), ring (19), little (5) and thumb (1)

Complications were 3 patients with mild stiffness at review (6 months, 1year and 2years), and one digital nerve injury.

Conclusions: Burst alone works in 50% of patients. Percutaneous release is effective in 69% of patients. It appears to be a safe and reliable alternative to open surgery, especially if restricted to midline lesions.

The wrist is arguably the most complex joint in the body and is essential for optimal hand function. The joint may be represented as two roughly orthogonal hinge axes, providing flexion-extension and radial-ulnar deviation. The location and orientation of these axes with respect to the underlying anatomy is essential for the design of successful joint prostheses. A population study was performed in order to obtain the parameters of this two-hinge joint.

Data for 108 normal right wrists was gathered using a Fastrak electrogoniometer with sensors fixed to the distal medial radial styloid and the distal third metacarpal head. Data was recorded as a series of three-dimensional coordinates covering the entire locus of movement.

The two-hinge geometry of the joint was represented mathematically with nine parameters describing the configuration of the axes and two angles controlling rotation about these axes. The configuration giving the closest kinematic match to the experimental data was determined using two nested optimisation processes. During the inner optimisation process, the third metacarpal head was brought as close as possible to each of the experimental points in turn by adjusting the two positioning angles. The sum of distances from each experimental point to the point of closest approach gave the “cost” of the current configuration. The outer optimisation process repeated the inner process iteratively, minimising the cost by adjusting the nine configuration parameters.

The double optimisation method was found to offer an innovative solution to the problem of analysing kinematic data from a population study. The mean joint configuration showed the axis of radial-ulnar deviation to be 1.9 mm (sd = 12.5 mm), distal to the flexion-extension axis, with axes almost orthogonal to one another. This data together with the radii of the rotations is invaluable in determining the optimal articulation geometries for wrist joint replacement prostheses.