This study reports the results of open reduction and internal fixation of 26 unstable, intra-articular, dorsally displaced fractures of the distal radius using a bio absorbable dorsal distal radius (Reunite) plate and calcium phosphate (Biobon) bone substitute. The bio absorbable plate has the advantages of being low profile, easily contourable due to temporary malleability and is angularly stable. It retains its strength for 6 to 8 weeks and undergoes complete mass loss within one year, thereby allowing gradual load transfer to the healing bone. In the majority of cases, this plate produces functional results comparable with metal plates.

The Gartland and Werley score was excellent or good in 21 patients. The most important advantage over metal plates is in eliminating the need to remove the plate and hence the need for a second operation if implant related extensor tenosynovitis occurs. Inflammatory tissue reaction to the degradation products of the plate is a potential concern, although the co-polymer ratio used in this plate appears to have reduced the severity of this reaction, which was seen in two patients in this series. The reduction was lost in five patients with severe dorsal comminution. For such fractures, the plate did not retain its strength for long enough to allow adequate healing for satisfactory load transfer.

Following this experience, we do not recommend this plating system for fractures with a metaphyseal gap of greater than 7 mm following reduction. For fractures that cannot be treated by closed means but where the metaphyseal gap following reduction is less than 7 mm, this plate provides all the theoretical advantages. Further developments allowing the plate to retain its strength for longer while maintaining the low incidence of inflammatory reactions will make it more universally applicable for the treatment of a greater spectrum of unstable distal radius fractures.

To assess whether by improving patient’s knowledge about the wrist arthroscopy procedure would positively affect the amount of postoperative pain. We tested the effect of a fact sheet that contained detailed information about the procedure on the outcome of such a surgery.

Fifty-five patients undergoing diagnostic wrist arthroscopy were randomly allocated into 2 groups. Group 1 included 28 patients to whom an explanatory form named fact sheet was provided prior to the procedure. 27 patients in the second group did not have the fact sheet. However both groups had the usual preoperative verbal instructions during consenting and all patients had Visual analogue scale pain assessment before surgery. Pain scores were recorded over a 10 day period postoperatively, the end point being the day on which the patient returned to the preoperative pain status.

There were 34 females and 21 males with 47 right and eight left wrists but all were the dominant side. The mean age of the patients was 35 years (range of 16 to 54 years).

In the first 48 hours all patients had flare up of pain in their wrists but by day five, 75% of patients who had the fact sheet, recovered to their preoperative pain status whereas only 22% of patients in the control group had done so. Furthermore, Patients in group 1 resumed their routine daily activities on average three days earlier (day seven) when compared to the control group in whom this return was not complete up to day 10.

Supplying a fact sheet prior to wrist arthroscopy has a positive influence in terms of decreasing the preoperative pain score and reducing the time patients required off work. Given the clear benefits demonstrated by this simple manoeuvre, it is now our practice to provide such a fact sheet to all patients.

A retrospective analysis of the treatment of distal radius fractures with an angularly stable locking plate (Matrix Plate, Stryker, UK) via a dorsal approach performed at Southend University Hospital in the United Kingdom.

91 fractures were treated over a three year period between 2004 and 2007. Dorsally angulated and displaced (including intraarticular) fractures were included. All patients commenced early mobilization without splintage on the first post-operative day.

The study group consisted of 42 men and 49 women with a mean age of 63 years. The average time to follow up was 19 months (range 6–29). The average tourniquet time was 44 minutes (20–81).

Assessment consisted of range of motion and grip strength measurement, Mayo wrist score, quick DASH questionnaire and Gartland and Werley scoring.

Complications consisted of 1 EPL rupture and 3 patients suffered extensor irritation. To date only 5 plates (5.4%) have been removed.

We demonstrate that dorsal plating using a low profile, angularly stable plate produces comparable results to volar plating. The combination of a low profile, angular stable plate, together with a modification of the standard dorsal approach, a sub-periosteal approach via the fourth and deep to the third extensor compartment reduces the incidence extensor tendon irritation. The modified approach has the benefit of direct visualization of the articular surface and direct reduction with the plate being used in both and angularly stable and buttress mode.

Aims: To demonstrate that the double incision technique produces a signiþcant reduction in pillar pain and an earlier return to work. Methods: A randomised controlled trial of twenty-four patients (32 wrists), 18 wrists being allocated to the single incision group (S) and 14 to the double incision group (D), was carried out between 1996 and 1999, after clinical evaluation and complimentary EMG studies. Mean ages were 49.6 (32 to 69) and 45.8 (30 to 54) in the S and D groups respectively. Results: There was a difference in pillar pain in the two groups, being signiþcantly less in the D group (Chi-squared = 8.22) (P = 0.004). There were also differences in the return to work, being much less in Group D Ð Mean = 2.6 weeks (1 to 12) cf. 5.6 weeks (2 to 16). (Willcoxon Rank Sum Test P = 0.0004). There were no differences in the post-operative clinical symptoms (P > 0.05), scar sensitivity (Chi-squared = 1.025) (P = 0.506) or grip strength (P =0.506). The tourniquet time was longer for the double incision technique D = 15.3 minutes (12 to18) cf. S = 12.2 minutes (10 to 18). Conclusions: The Double incision technique is a simple and safe procedure for uncomplicated carpal tunnel syndrome, producing a signiþcant reduction in pillar pain and and earlier post-operative rehabilitation and an earlier return to work.

Aim: To demonstrate that external þxation cannot be used alone to treat unstable distal radial fractures associated with a combination of dorsal and volar comminution. Methods: 17 patients with a mean age of 47.5 years, sustaining Frykman grades VII and VIII fractures of the distal radius associated with high energy trauma between 1996 and 1998, treated solely with external þxation were assessed. The mean time to operation was 3.4 days. The mean time to review was 15.8 months. There was dorsal comminution in 7 patients with additional volar comminution in 10 cases. Results: Excellent functional outcome results were obtained with a mean mass grip strength of 79.6%. However, when comparing patients with a combination of dorsal and volar comminution with those sustaining dorsal comminution alone, loss of radiographic parameters resulted in the former at review. Post-operative and review mean volar tilt values were + 1.5¡ and Ð 3.6¡ respectively cf. + 2.3¡ and 6.6¡, whilst the mean post-operative and review radial length values were 13.9 mm and 10.7 mm respectively cf. 11.6 mm and 11.4 mm. Comparison of the two groups for volar tilt and radial length gave P values of 0.004 and 0.02. Conclusion: External þxation is not an effective sole modality of treatment in cases associated with both dorsal and volar comminution. It is also highly recommended that when considering the use of external þxation, the degree and type of comminution is appreciated on the pre-operative radiographs.

Aim: To demonstrate that early open reduction and dorsal wedge corticocancellous bone grafting is an effective modality of treatment in the younger population with inherently unstable distal radial fractures sustained by high energy trauma. Methods: 17 patients with an average age of 53.7 years sustaining Frykman grades VII and VIII underwent open reduction and dorsal wedge cortico-cancellous bone grafting between 1994 and 1998. The study included eight men and nine women; the right wrist being affected in eight cases and the left in nine. There was dorsal comminution in 10 wrists with additional volar comminution in the remaining 7 cases. The mean time to operation was 6.5 days and the time to review averaged 16.5 months. Results: Good functional outcome results with a mean mass grip strength of 68.8% (Range = 40 to 100%) and patient satisfaction (94%) were obtained. A signiþcant improvement of radiographic parameters were observed postoperatively (Mean radial length = 11.7mm; Mean volar tilt = + 1.4¡) and remained so at the time of assessment (Mean radial length = 11.0mm; Mean volar tilt = -0.1¡) indicating structural support of the cortico-cancellous graft. Conclusion: Open reduction and dorsal wedge cortico-cancellous bone grafting is an effective modality of treatment of unstable fractures of the distal radius in the younger population. Donor site morbidity was not a disadvantage.

Aim: To demonstrate that a novel tricalcium phosphate bone cement (Biobon) could be effectively used to þll the dorsal metaphyseal defect after unstable distal radial fractures in the osteopenic wrist, and to conþrm with biomechanical studies that its mechanical properties were incompatible with its sole use. Methods: Compression and Biaxial ßexure testing was performed under both dry and wet conditions of physiological Saline and Ringers Lactate solutions at 37ûC. 9 female patients with a mean age of 65 years sustaining Frykman grade VIII fractures of the distal radius between 1999 and 2000 underwent open reduction and internal þxation with supplementation of the dorsal metaphyseal defect with Biobon. Results: Youngs Modulus (E) and the Ultimate compressive strength (UCS) for the two solutions were identical at 10 hours (406 MPa and 3.24 MPa respectively), reaching a maximum for Ringers Lactate solution. The Biaxial ßexure stress also reached a maximum value at 10 hours for Saline at 37û C (3.96 MPa). A signiþcant improvement of radiographic parameters were observed post-operatively (Mean volar tilt = + 1.1û; Mean radial length = 10.4mm: Mean radial inclination = 20.5û) and remained so at the time of assessment (Mean volar tilt = +2.5û; Mean radial length = 10.4 mm; Mean radial inclination = 21.8û).Conclusion: The use of a tri-calcium phosphate bone cement is an effective means of addressing the dorsal comminution sustained after unstable distal radial fractures. Its biomechanical properties precludes its sole use for the treatment of distal radial fractures.

A randomised controlled trial involving 24 patients ( 32 wrists ), 18 wrists being allocated to the single incision group ( S ) and 14 to the double incision group ( D ), was carried out between 1996 and 1999, after clinical evaluation and complimentary EMG studies. Randomisation was performed by one of the orthopaedic secretaries using an envelope technique on the morning of admission. Mean ages were 49.6 ( 32 to 69 ) and 45.8 ( 30 to 54 ) in the S and D groups respectively. The male to female ratios were 2/12 and 5/7 respectively. The pre- and post-operative mass grip strength was measured by a Jamar dynanometer and assessment of post-operative parameters included pillar pain, scar sensitivity, nerve compression symptoms and return to work.

Pillar pain was significantly less in Group D ( Chi-squared = 8.22; P = 0.004 ).

Return to work was less in Group D ( average = 2.6 weeks ( 1 to 12 weeks )) cf. to Group S ( average = 5.6 weeks ( 2 to 16 weeks ) ). ( Wilcoxon Rank Sum Test P = 0.0004 ). No differences occurred in post-operative clinical symptoms ( P > 0.05 ), scar sensitivity ( Chi-squared = 1.025 ; P = 0.506 ) or mass grip strength ( P= 0.506 ).

The tourniquet time was longer for the double incision technique ( average = 15.3 minutes ( 12 to 18 minutes )) cf. to the single incision technique ( average = 12.2 minutes ( average = 10 to 18 minutes )).

The double incision technique is a safe and easy technique for uncomplicated carpal tunnel syndrome resulting in a significant reduction in pillar pain and a more rapid return to work.