Comparison of distal radius fracture intra-articular step reduction with volar locking plates and K wires: a retrospective review of quality and maintenance of fracture reduction.

This study investigated the accuracy and maintenance of reduction of intra-articular steps achieved with closed reduction and percutaneous K wires and open reduction and a volar locking plate for the treatment of intra-articular distal radius fractures. We performed a retrospective review of 359 patients with an intra-articular fracture of their distal radius. Multivariate linear regression was undertaken to investigate the influence of multiple variables such as age, gender, initial displacement and treatment method on reduction despite differences between groups. A total of 36% of patients treated with K wires and 29% with volar locking plate had a step greater than or equal to 1 mm present on the first post-operative radiograph. A total of 23% treated with K wires and 28% with volar locking plate had a residual step of 1 mm or more on the last available radiograph. There was no difference identified between the two techniques for quality of initial reduction or persisting step on the last available radiographs. Step behaviour and further reduction of step post-operatively was similar for both treatment methods. Initial displacement and increased age influenced initial reduction. Initial fracture displacement shown radiologically was the only variable identified that influenced the persistence of a step on post-operative radiographs. LEVEL OF EVIDENCE: IV.

Complications after volar locking plate fixation of distal radius fractures.

Volar locking plates are an increasingly popular treatment for distal radius fractures. We reviewed complications observed after volar locking plate fixation in a busy teaching hospital. The purpose of the study was to assess whether complication rates after volar locking plate use in general, routine trauma practice were higher than published literature from expert users. A retrospective review was carried out of patients treated with a volar locking plate between January 2009 and December 2010. The series included 206 procedures in 204 patients (77 males and 127 females) with mean age of 55 years (range 16-94). Surgery was performed by 18 different consultant surgeons and 11 registrars. A total of 22 complications were observed in 20 patients with an overall complication rate of 9.7%. Seven (3.4%) patients developed tendon problems including four (1.9%) tendon ruptures. Four (1.9%) patients required re-operation for metalwork problems; four patients developed complex regional pain syndrome (CRPS). Three fracture reduction problems were noted. A total of 16 further operations were carried out for complications. The overall complication rate was low even when surgery was done by many surgeons, suggesting that this is a safe and reproducible technique. This study provides information which can be used to counsel patients about risks, including those of tendon and metalwork problems. This allows patients to make an informed decision. Surgeons must have specific strategies to avoid these complications and remain vigilant so that these can be identified and managed early.

Clinical and radiological outcome of cast immobilisation versus surgical treatment of acute scaphoid fractures at a mean follow-up of 93 months.

We report the outcome at a mean of 93 months (73 to 110) of 71 patients with an acute fracture of the scaphoid who were randomised to Herbert screw fixation (35) or below-elbow plaster cast immobilisation (36). These 71 patients represent the majority of a randomised series of 88 patients whose short-term outcome has previously been reported. Those patients available for later review were similar in age, gender and hand dominance. There was no statistical difference in symptoms and disability as assessed by the mean Patient Evaluation Measure (p = 0.4), or mean Patient-Rated Wrist Evaluation (p = 0.9), the mean range of movement of the wrist (p = 0.4), mean grip strength (p = 0.8), or mean pinch strength (p = 0.4). Radiographs were available from the final review for 59 patients. Osteoarthritic changes were seen in the scaphotrapezial and radioscaphoid joints in eight (13.5%) and six patients (10.2%), respectively. Three patients had asymptomatic lucency surrounding the screw. One non-operatively treated patient developed nonunion with avascular necrosis. In five patients who were treated non-operatively (16%) there was an abnormal scapholunate angle ( > 60 degrees ), but in four of these patients this finding was asymptomatic. No medium-term difference in function or radiological outcome was identified between the two treatment groups.

Should acute scaphoid fractures be fixed? A randomized controlled trial.

BACKGROUND: With the proliferation of different fixation screws, there is an increasing trend to recommend early internal fixation of the broken scaphoid even if the fracture is not displaced. The benefits and risks of early fixation of scaphoid fractures have not been established. These were investigated in eighty-eight patients who were of working age with clearly defined minimally displaced or undisplaced bicortical fractures of the waist of the scaphoid. METHODS: Patients who provided informed consent were randomized to treatment with early internal fixation with use of a Herbert screw without a cast (forty-four patients) or to nonoperative treatment for eight weeks with immobilization in a below-the-elbow plaster cast with the thumb left free (forty-four patients). The patients were evaluated at two, eight, twelve, twenty-six, and fifty-two weeks with respect to the severity of pain; tenderness; swelling; wrist movement; grip strength; and symptoms and disability, which were assessed with the Patient Evaluation Measure. In addition, radiographs were made and assessed at each visit. RESULTS: No difference was detected between the groups with respect to age, sex, hand dominance, side of injury, mechanism of injury, or the occupation of the patients. The range of motion, score on the Patient Evaluation Measure, and grip strength were significantly better in the group managed operatively than in the group managed nonoperatively at the eight-week follow-up evaluation, which corresponded with the visit when the cast was removed in that group. Patients returned to work at five to six weeks after the injury in both groups. At twelve weeks, grip strength was better in patients who had had surgery. No significant difference was detected between the two groups with respect to any other outcome measure at any other time. Ten of the forty-four fractures treated nonoperatively had not healed radiographically at twelve weeks, and, as a consequence, the treatment was altered. Complications occurred in thirteen patients who had been managed operatively. All complications were minor, and ten were related to the scar. CONCLUSIONS: This study did not demonstrate a clear overall benefit of early fixation of acute scaphoid fractures beyond the decrease in the rate of a change in treatment because of a delayed union at twelve weeks. Early internal fixation of minimally displaced or nondisplaced fractures of the scaphoid waist, which would heal in a cast, could lead to overtreatment of a large proportion of such fractures, exposing such patients to avoidable surgical risk. Thus, we have adopted a program of so-called aggressive conservative treatment, whereby we carefully assess fracture-healing with plain radiographs, and computed tomography scans if necessary, after six to eight weeks of cast immobilization and recommend surgical fixation with or without bone-grafting at that time if a gap is identified at the fracture site. Such an approach should result in fracture union in over 95% of such patients. LEVEL OF EVIDENCE: Therapeutic Level I.

Carpal tunnel syndrome and work.

The incidence, age at presentation, disability and outcome after surgery were investigated in 327 consecutive women of working age presenting to a hand unit with carpal tunnel syndrome. Two hundred and seventeen were working, 55 of these in repetitive occupations. One hundred and ten were not in employment. All three groups had similar mean ages (around 46 years). On a population basis more women in non-repetitive occupations presented with carpal tunnel syndrome (220/100,000/year) than those in repetitive work (122/100,000/year) or those not working (129/100,000/year), and more were offered surgery (82% versus 67% for those in repetitive work and 58% for those not working). However, symptoms and disability; as assessed with the Michigan Hand Questionnaire and the SF-12, were less severe in working women. This study suggests that working in repetitive or non-repetitive occupations does not cause, aggravate or accelerate carpal tunnel syndrome. Working women may struggle to accommodate their symptoms compared to women who are not in employment causing more to seek help.

Carpal tunnel decompression. Is lengthening of the flexor retinaculum better than simple division?

This prospective randomized double-blind control trial compared lengthening and simple division of the flexor retinaculum in carpal tunnel decompression. Twenty-six patients with bilateral carpal tunnel syndrome were randomly allocated to have the flexor retinaculum divided on one side and lengthened on the other. All 52 hands were reviewed at regular intervals up to 25 weeks. The patients, therapists and the final reviewer were unaware of treatment allocation. The Levine symptom and function scores were used to assess the severity of the carpal tunnel syndrome and showed that the two treatments were comparable for relief of carpal tunnel symptoms. The two treatments were also similar for function measured with the Jebsen-Taylor test. There is no identifiable benefit in lengthening the flexor retinaculum when decompressing the carpal tunnel. Moderate or severe pillar and scar pain is common, occurring in 13 of 52 hands after surgery, but only in four by the 12th week and two by the 25th week.

Assessing the outcome of disorders of the hand. Is the patient evaluation measure reliable, valid, responsive and without bias?

The different attributes of the Patient Evaluation Measure (PEM) questionnaire were investigated in 80 patients with a fracture of the scaphoid. Assessments were made at 2, 8, 12, 26 and 52 weeks. Reliability was assessed by measurement of the internal consistency of the different questions in 275 completed PEM forms. Cronbach's alpha, which needs to lie between 0.7 and 0.9, was 0.9 for the PEM. Pain, tenderness, swelling, wrist movement and grip strength correlated with the PEM score confirming the validity of the assessment. Changes in the different variables between visits correlated significantly with changes in the PEM score; its effect size and standardised response mean were comparable to those of grip strength and movement, confirming the responsiveness of this questionnaire. Gender, dominance and the side injured did not influence the scores. Older patients had a poorer outcome as assessed by the score which appeared to be a true effect and not age bias. Our study confirmed that the PEM is a reliable, valid and responsive instrument in assessing outcomes of disorders of the hand.

The incidence of simultaneous fractures of the scaphoid and radial head.

In a 2-year period 181 scaphoid fractures were seen at our institution, of which 11 (6%) had a simultaneous fracture of the radial head. In four of these cases the scaphoid fracture was diagnosed late.

In vivo pressure profiles of thigh-length graduated compression stockings.

BACKGROUND: The aim of the study was to assess whether the appropriate pressure profile is generated by thigh-length graduated compression stockings in human subjects. The effect of leg posture on the pressure profile was assessed in three commonly used brands of graduated compression stockings. METHODS: The study involved 17 human volunteers from the Department of Orthopaedic Surgery. Three different brands of stockings commonly recommended for the prevention of deep vein thrombosis were applied to each individual and the interface pressure profile under the stocking was measured. The effect of posture was assessed by comparing the interface pressure profile with the subject supine and in standing and sitting positions. RESULTS: Appropriate median pressure profiles were achieved only with the subject standing or supine. In the sitting position with the knee flexed, a high median interface pressure in excess of 28 mmHg was generated at the popliteal fossa. Overall, inconsistent performance was found in all three brands of stockings; fewer than 30 per cent of the pressure readings fell within 20 per cent of the 'ideal'. Reversed pressure profile was observed in over 70 per cent of subjects. CONCLUSION: Thigh-length graduated compression stockings may be most effective in bedridden patients. Knee-length stockings may be more suitable for the prevention of deep vein thrombosis in ambulant patients.