Reduction in ionizing radiation exposure during minimally invasive anterior plate osteosynthesis of distal radius fracture: Naive versus deliberate practice.

This study aimed to decrease surgeon exposure to ionizing radiation through a new learning technique, "deliberate practice", which consists in improving performance by setting goals with feedback. The hypothesis was that exposure to ionizing radiation during distal radius fracture surgery using the minimally invasive plate osteosynthesis (MIPO) technique decreased faster with "deliberate" practice than with "naïve" practice. Radiographic dosimetry was measured in the first 30 fractures operated on by MIPO by 6 surgeons. The first 3 surgeons operated "naively" (Group 1) and the next 3 according to the "deliberate" procedure (Group 2). Group 2 received weekly feedback (number of exposed hands, number of fluoroscopic views, exposure duration, and X-ray dose). An expert, using fluoroscopic images and surgical videos, provided suggestions for improvement. Mean number of exposed hands was 23.66 in Group 1 and 1.9 in Group 2. Mean number of fluoroscopic views was 78.31 and 35.0, respectively. Mean X-ray exposure time was 74.34 and 32.89 s, respectively. Mean dosimetry was 1.40 mGy (and 0.59 mGy, respectively. The hypothesis was thus confirmed: dosimetry decreased faster in Group 2 than in Group 1. Teaching this deliberate practice should be generalized, to decrease the growth phase and increase the plateau phase of the learning curve.

Immobilization protocols following trapeziectomy for osteoarthritis of the thumb: 2 weeks versus 4 weeks.

We compared the clinical outcomes of post-trapeziectomy protocols according to their duration. The main hypothesis was that there would be no significant difference in postoperative function whether immobilization duration was 2 or 4 weeks. The secondary hypotheses were that there would be no significant difference in postoperative pain, motion, or strength. 40 trapeziectomies were reviewed. Two weeks' postoperative commissural immobilization was systematic. Patients were then divided in two groups. For the first 20 patients (group I), immobilization stopped at 2 weeks. For the next 20 patients (group II) it was replaced by a splint for further 2 weeks. We compared mean pre- and post-operative (10-20 weeks) function (QuickDASH score), pain (visual analog scale - VAS), thumb opposition (Kapandji score) and strength (palmar pinch test) between the two groups. There was no significant difference between groups in postoperative values or in pre- to post-operative progression. The main hypothesis was confirmed: there was no significant difference in the postoperative function whether the immobilization was for 2 or 4 weeks. The secondary hypotheses regarding postoperative pain, motion and strength were also confirmed.

Comparison of a standard locking screw versus a double-threaded cortical compression screw for fixation of die-punch fragments in distal radius fractures with volar plating.

The aim of this study was to use a compression screw in the epiphyseal medial orifice of a volar plate to reduce and stabilize the die-punch fragment in distal radius fractures (DRF) undergoing open reduction and internal fixation (ORIF). The main hypothesis was that the range of motion (ROM) in supination would be poorer when a standard screw was used. Our case series included 19 patients with an average age of 59 years (24-91) (SD -35.32) (10 male patients and 9 females) who underwent ORIF of DRFs with a volar plate. Group I included 10 patients in which the die-punch fragment was fixed with a standard locking screw and group II included the 9 patients in which the die-punch fragment was fixed with an angle stable compression screw through both cortices. At the 6-month follow-up visit, the average ROM in flexion was 83% in group I and 81% in group II (-2.327 [-13.657; 8.960]), the ROM in extension was 91% and 89% (-2.754 [-13.410; 7.602]), the ROM in pronation was 100% and 102% (+3.178 [-5.242; 11.457]), the ROM in supination 100% and 97% (-3.171 [-10.825; 4.537]), the pain level was 0.6/10 and 1/10 (+0.106 [-0.809; 0.977]), the QuickDASH score was 8.1/100 and 17.17/100 (+5.790 [-2.934; 15.012]), the PRWE was 6.2/100 and 22/100 (+13.109 [4.416; 22.779]) and the grip strength was 95% and 74% of the contralateral side (-12.478 [-24.832; 0.538]). No complications, nonunions or revision surgery were reported in the two groups. One case of secondary displacement of the die-punch fragment occurred in each group. The main hypothesis was not proven. In conclusion, despite what several biomechanical studies have suggested, the use of double-threaded compression screws for die-punch fragment fixation in DRFs does not improve the clinical outcomes compared to standard locking screws.

Treatment of finger phalangeal fractures using the Ichi-Fixator system: A prospective study of 12 cases.

External fixators are an effective treatment option for comminuted or unstable phalangeal fractures. We developed a new linked-wire type of external fixator (the Ichi-Fixator) for finger phalangeal fractures, which enables fine adjustment of the fixation under fluoroscopy guidance either in a static way or with distraction through small screws inside the fixator. This technique was designed to improve on the stability and rigidity of conventional percutaneous Kirchner wire fixation. We assessed the effectiveness of the fixator through 12 cases of open or percutaneous fixation in comminuted or unstable phalangeal fractures. All patients were examined for postoperative complications, functional recovery, pain on visual analog scale (VAS), and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score at the final follow-up visit. Patients could perform all routine activities with normal grip strength and a full range of hand motion without pain after treatment. This treatment, which reduces the postoperative discomfort and may allow an immediate return to work, will clearly boost patient satisfaction. Linked-wire type external fixation enhances the security of fixation, facilitates postoperative mobilization, and may allow an immediate return to work.

Antimyotoxic Activity of Synthetic Peptides Derived from Bothrops atrox Snake Gamma Phospholipase A2 Inhibitor Selected by Virtual Screening.

BACKGROUND: Several studies have aimed to identify molecules that inhibit the toxic actions of snake venom phospholipases A2 (PLA2s). Studies carried out with PLA2 inhibitors (PLIs) have been shown to be efficient in this assignment. OBJECTIVE: This work aimed to analyze the interaction of peptides derived from Bothrops atrox PLIγ (atPLIγ) with a PLA2 and to evaluate the ability of these peptides to reduce phospholipase and myotoxic activities. METHODS: Peptides were subjected to molecular docking with a homologous Lys49 PLA2 from B. atrox venom modeled by homology. Phospholipase activity neutralization assay was performed with BthTX-II and different ratios of the peptides. A catalytically active and an inactive PLA2 were purified from the B. atrox venom and used together in the in vitro myotoxic activity neutralization experiments with the peptides. RESULTS: The peptides interacted with amino acids near the PLA2 hydrophobic channel and the loop that would be bound to calcium in Asp49 PLA2. They were able to reduce phospholipase activity and peptides DFCHNV and ATHEE reached the highest reduction levels, being these two peptides the best that also interacted in the in silico experiments. The peptides reduced the myotubes cell damage with a highlight for the DFCHNV peptide, which reduced by about 65%. It has been suggested that myotoxic activity reduction is related to the sites occupied in the PLA2 structure, which could corroborate the results observed in molecular docking. CONCLUSION: This study should contribute to the investigation of the potential of PLIs to inhibit the toxic effects of PLA2s.

Comparison of tactile sensitivity measured with a new digital esthesiometer (Beam Test) relative to Semmes-Weinstein monofilament analog esthesiometer.

The assessment of tactile sensitivity uses many tests, of which monofilaments are considered the best. The aim of this study was to develop a tactile sensitivity test, similar to the monofilament test, which eliminates the error risk related to manipulations by the observer, and to establish a correspondence scale. We studied 29 healthy subjects (18 women and 11 men) with a mean age of 27.8 years. The Semmes-Weinstein monofilament (SWM) analog esthesiometer and a digital beam esthesiometer (DBE) were used. We evaluated the tactile sensitivity threshold on the fingertip of each subject's dominant index using the SWM and the DBE. The DBE test consisted of applying the index against the tip of the beam. During a cycle of four elevations/depressions, the subject would press a button each time he/she felt pressure. The test was repeated three times. The screen displayed an average force value between 0 and 200 allowing the result to be expressed in grams (g). The minimum perceived force was 0.06656g (0.023, 0.166) on average with the SWM test and 0.51773g (0.4824, 0.8062) with the DBE test. Our results confirm the DBE test suppresses the observer's manipulations and that a SWM correspondence scale can be established. With the DBE test, the normal sensation ranged from 0.4824g to 0.757g and light touch decreased from 0.758g to 0.8062g. The threshold value of pathological tactile sensitivity was 0.8063g. The DBE test could therefore be used for preventive diagnosis of carpal tunnel syndrome in occupational medicine.

Arthrodesis of the thumb metacarpophalangeal joint: Conventional open technique with a locking plate or compression pins versus minimally invasive technique with compression pins or screws.

Arthrodesis of the thumb metacarpophalangeal (MCP) joint usually leads to satisfying results when performed with an open technique. The main complication is adhesion of the extensor tendons that sometimes requires hardware removal associated with tenolysis. The goal of this study was to assess whether a minimally invasive technique could reduce the risk of this complication. Arthrodesis of the thumb MCP was performed using an open technique with a locking plate or compression pins in 12 cases (group I) and using a minimally invasive technique with compression pins or screws in 12 cases, for a total of 24 patients aged 48.9 years on average, among which 15 were women. At the last follow-up, the average pain level was rated at 2/10 in group I and 2.3/10 in group II. The QuickDASH was 40.70/100 in group I and 36.24 in group II, grip strength was 79% of the contralateral side in group I and 51% in group II. Pinch strength was 81% of the contralateral side in group I and 45% in group II. Fusion was achieved in all cases in group I and in 7 of 12 cases in group II. Surgical revision for non-union was needed in 5 cases in group II, with hardware removal and tenolysis performed in 2 cases. The non-unions were observed in non-rheumatoid cases. While the two groups were not identical, arthrodesis of the thumb MCP using a minimally invasive technique with compression pins or screws seems to give satisfying results for rheumatoid cases in which no cartilage remains.

Revision surgery in carpal tunnel syndrome: a retrospective study comparing the Canaletto® device alone versus a combination of Canaletto® and Dynavisc® gel.

The aim of our study was to demonstrate the benefits of combining the Canaletto® implant with carboxymethylcellulose/polyethylene oxide gel in the surgical treatment of carpal tunnel syndrome (CTS) recurrences. Our case series included 39 patients (40 hands, one bilateral case) who underwent revision surgery for recurrent CTS (28 cases) or resistant CTS (12 cases). The mean age of the patients was 56 years. The Canaletto® only was implanted in the first 21 cases (group I). In the following 19 cases (group II), Dynavisc® gel was added to the protocol and applied around the median nerve when the Canaletto® was implanted. At 12 months' follow-up (group I) and 11 months' follow-up (group II), the pre-versus post-operative difference between the average values of the DN4 neuropathic Pain Score was 0.55/10 in group I and 2.25/10 in group II; the Pain Score was 2.23/10 (in group I) and 2.52/10 (in group II); the Quick DASH Score was 18.98/100 (group I) and 19.06/100 (in group II); the hand grip strength was 19.55% (group I) and 28.53% (group II); the sensory nerve conduction velocity was 8.67 m/s (group I) and 10.27 m/s (group II); the distal motor latency was 1.05 m/s (group I) and 1.75 m/s (group II). Nine patients recovered from hypoesthesia in both groups, 5 patients regained satisfactory trophism of the thenar muscles in group I and 3 patients in group II. No improvement whatsoever was noted in 2 patients in group II, despite the electromyogram being normal. One patient from group II suffered an infection that required revision surgery to remove the Canaletto®; this led to a moderate improvement. Our results show that when resistant or recurrent CTS is diagnosed, the combined treatment of an anti-adhesion gel such as Dynavics® around the median nerve with the Canaletto® implant after performing secondary neurolysis leads to satisfactory post-operative outcomes. Compared to other techniques described in the current literature, our technique is less invasive, quicker and associated with minimal morbidity of the surgical site.

Relevance of intraoperative ultrasound imaging for detecting foreign bodies in the hand: A series of 19 cases.

Radiolucent foreign bodies of the hand are frequent and may lead to pain, infection, hematoma and/or migration. Their diagnosis and removal can be difficult. The goal of this study was to assess the usefulness of intraoperative ultrasound imaging for detecting translucent foreign bodies in the hand to facilitate their removal. Our single-center retrospective study included 19 patients with preoperatively radiolucent but echogenic foreign bodies. An intraoperative ultrasound was performed to assist with and confirm the removal of the foreign body. The foreign bodies were vegetal in 15 cases, made of glass in 2 cases, rock in 1 case and undetermined in 1 case. The average length was 4.65 mm (min 1, max 16) and the average width 1.02 mm. All foreign bodies were visible during the intraoperative ultrasound and were no longer visible after their removal. Because intraoperative ultrasound imaging was able to guide the removal of all radiolucent foreign bodies in our study, it can be a useful tool for the removal of radiolucent foreign bodies.

Arthroscopic scapholunate dorsal capsulodesis: A 30-patient case series comparing postoperative splint immobilization versus immobilization and connected K-wiring.

The aim of this retrospective study was to compare the results of arthroscopic dorsal capsulodesis performed with or without temporary K-wiring to treat patients who had sustained scapholunate ligament injuries. Our case series included 30 patients with an average age of 37 years (range: 19-55) of whom 12 were female. Dorsal scapholunate capsulodesis was carried out in all patients. In 15 patients, splint immobilization only was used (group I). For the remaining 15 patients, supplementary scapholunate and scaphocapitate K-wiring was performed (group II). The outcomes, whether K-wiring was used or not, were not as good as the outcomes of other published studies. In our study, the reported QuickDASH score was on average higher than 20/100, pain score was higher than 2/10, grip strength was less than 70% of the contralateral side. There was one postoperative complication in the first group and three complications in the second group; five cases of DISI were reported in the first group and three in the second group. There were no significant differences between the two groups. Based on our findings, supplementary K-wiring is not necessary when a dorsal scapholunate capsulodesis is performed. The outcomes of our study were not as good as those of other published series, potentially due to a shorter follow-up and the more severe ligament injuries in our case series.

Ultrasound for the diagnosis of pyogenic flexor tenosynovitis.

The usefulness of ultrasound for making the diagnosis of pyogenic flexor tenosynovitis (PFTS) has been demonstrated. The primary goal of this study was to show that the diameter of the flexor sheath near the A2 pulley was larger when PFTS was present compared to the healthy contralateral finger. The secondary goal was to determine the reproducibility of these ultrasound measurements. Our series included 20 patients (12 men and 8 women) operated due to PFTS. The average age was 41.7 years old. The average diameter of the digital sheath measured near the A2 pulley on transverse and longitudinal ultrasound sections was 5.01mm (transverse 5mm, longitudinal 5.03mm) on infected fingers, and 4.17mm on healthy contralateral fingers. Reproducibility, as measured by the intraclass coefficient between transverse and longitudinal values, was 0.910 for infected fingers and 0.928 for contralateral fingers, thus was excellent. Our hypothesis was confirmed. A unilateral increase of more than 20% in diameter of the flexor sheath measured in transverse or longitudinal ultrasound sections near the pulley A2 contributes to the surgical indication when a patient presents with PFTS.

Fixation of the nail plate by tension band suture versus 2-octyl-cyanoacrylate gluing for traumatic nail bed injuries reduced without suture: A retrospective study of 27 cases.

Repair of the nail bed and plate after distal phalanx trauma remains controversial. The aim of this study was to determine whether simple approximation of the nail bed flaps maintained by tension band suture of the nail plate is sufficient to prevent nail dystrophies. Our series gathered 27 fingers in 25 patients with a mean age of 36 years. In 15 cases (Group I), the nail plate was fixed in a single layer by a point in a frame, and in 12 cases (Group II), the bed and the plate were fixed layer-by-layer using the wound adhesive, 2-octylcyanoacrylate. At the last follow-up, the Zook score was excellent and very good in 100% of Group I patients, and in 83.3% of Group II patients. Within 8 days, the average pain was 1/10 in Group I, and 2.5/10 in Group II. There was one infection in Group I and four hematomas in Group II. The Quick DASH score was 1.13/100 in Group I and 0 in Group II. Our results show that in the case of a traumatic nail bed injury, suturing the nail bed and applying 2-octylcyanoacrylate adhesive is less effective than simple approximation of the nail bed flaps by tension band suture of the nail plate.

Comparison of proximal interphalangeal arthroplasty outcomes with Swanson implant performed by volar versus dorsal approach.

No study has compared the QuickDASH score after Swanson implant arthroplasty performed by dorsal versus volar approaches. This study compared the outcomes of PIP arthroplasties through a volar approach as described by Schneider versus a dorsal approach as described by Chamay by determining the QuickDASH score, pain and range of motion. Our series included 21 Swanson implant arthroplasty cases in 17 patients aged 62 years on average, among which 12 were females. A volar approach was performed in 9 cases (group I) and a dorsal approach was performed in 12 cases (group II). The difference between the average QuickDASH score preoperatively and at the last follow-up was strong (group I: -16.584; group II: -1.444), the difference between the average pain level preoperatively and at the last follow up was very strong (group I: -2.098; group II: -4.506), the difference in average PIP extension was not different from 0 (group: I -5.805; group II: -11.332), the difference in average PIP flexion was very strong (group I: -2.716; group II: -2.007). There were four recurrences of swan neck deformity (3 in group, 1 in group II) and one implant fracture in each group. For Swanson implant arthroplasty, the volar approach leads to better QuickDASH scores and PIP flexion compared to the dorsal approach. The volar approach did not improve PIP extension, or pain, and did not lead to dysesthesia.

Parathyroid hormone, calcidiol, calcitriol and adverse events in the acute coronary syndrome. / Hormona paratiroidea, calcidiol, calcitriol y riesgo de eventos adversos en pacientes con síndrome coronario agudo.

OBJECTIVE: To know the clinical profile as well as the prognostic significance of elevated levels of parathyroid hormone (PTH) in patients admitted for acute coronary syndrome (ACS). DESIGN AND SETTING: Observational and prospective study of patients admitted for ACS in a single Spanish center during a period of six months. INTERVENTION AND VARIABLES OF INTEREST: The circulating concentrations of PTH, calcidiol, calcitriol, NT-proBNP, C-reactive protein, cystatinC and fibrinogen were determined within the first 48h at admission. We performed adjusted models to predict death or re-entry for ACS after hospital discharge. RESULTS: A total of 161 patients were recruited (age 67±14 years, 75.2% were men). Forty-one (25.5%) patients had elevated PTH values. During follow-up for a period of 275 person-years, 50 adverse events were recorded. Patients with elevated PTH levels were proportionally more women (21.2 vs. 39.0%) and older (63.3 vs. 77.8 years, both P<.05). Likewise, they presented significantly more cardiovascular risk and a worse prognosis during follow-up (incidence rate ratio 2.64 CI 95%: 1.5-4.6). However, in an adjusted model by the GRACE score, PTH levels were not shown to be an independent risk factor (hazard ratio=1.1; 95% CI: 0.6-2.2), neither other components of the panel. CONCLUSIONS: The proportion of patients with elevated levels of PTH admitted for ACS was high. The presence of high PTH levels was associated with an unfavorable clinical profile and a worse outcome during the follow-up, although it was not an independent predictor of poor prognosis.

Learning of supermicrosurgical vascular anastomosis: MicroChirSim® procedural simulator versus Anastomosis Training Kit® procedural simulator.

Many biological and non-biological simulators have been developed to reduce the length of the learning curve for supermicrosurgery. All of them have disadvantages. The goal of this study was to evaluate the feasibility of the new MicrochirSim® (0.5mm) non-biological procedural simulator by comparing it to the Anastomosis Training Kit® (2mm). After viewing a video of end-to-end anastomosis of a rat-tail artery, 10 residents in surgery reproduced the same technique on a procedural simulator: 5 on the MicroChirSim® (group 1) and 5 on the Anastomosis Training Kit® (group 2). The 10 residents then each performed five end-to-end anastomoses of the rat-tail artery on which they were evaluated. The average length of the procedure was 33minutes in group 1 and 45minutes in group 2. The average number of suture points was 3.7 in group 1 and 5.4 in group 2, which suggests training with a 0.5mm simulator improves suturing. The anastomosis was patent in 25 cases in group 1 and in 22 cases in group 2. The anastomosis was free of leaks in 25 cases in group 1 and in 19 cases in group 2. In conclusion, the MicroChirSim® procedural simulator accelerates the learning curve for vascular supermicrosurgery.

The new digit tourniquet ForgetMeNot®.

BACKGROUND: Digit tourniquets are widely used in the operating room and even more often in the emergency department to allow the exploration of injuries. A rolled surgical glove finger or silicone catheter placed at the base of the digit is a common method. However, rolled glove tourniquets are easily forgotten under the dressing and may then cause ischemia, which may require amputation. Silicone catheters are expensive single-use devices that may fail to provide effective exsanguination and must be removed by cutting, which may result in skin lesions. The ForgetMeNot® digit tourniquet (Arex, Palaiseau, France) was designed to overcome these drawbacks. The objective of this study was to assess the use of ForgetMeNot® in our clinical practice. HYPOTHESIS: The ForgetMeNot® digit tourniquet is easy to position and remove, effective, and difficult to accidentally leave in place. MATERIAL AND METHODS: ForgetMeNot® is composed of two solid cylindrical silicone strands emerging from a central crosspiece bearing two holes through which the ends of the strands can be threaded until stopped by beads on each strand. The device can be sterilised and re-used. It is easy to put in place and to remove. Threading the ends through the holes in the crosspiece forms two loops, which are passed around the tip of the finger. The device is then rolled down to the base of the digit, wrapping around itself and thus tightening gradually. At the end of the surgical procedure, pulling on the flat central crosspiece releases the device. ForgetMeNot® was tested by junior and senior surgeons in 86 patients. The following were assessed: pain, tourniquet time, effectiveness of exsanguination, complications, and the learning curve. RESULTS: Positioning the device caused no pain. No patient reported paraesthesia. Remembering to remove the device was made easy by its bright blue or yellow colour. The pressure applied ensured effective exsanguination of the digit. In no case was cutting the device required for removal. Each device was sterilised and re-used several times. DISCUSSION: The new digit tourniquet ForgetMeNot® is unlikely to be forgotten, effective, easy to use, re-usable, and associated with a low risk of skin lesions upon removal. LEVEL OF EVIDENCE: III, retrospective uncontrolled study.

Which surgery should be offered for carpal tunnel syndrome in a patient who was previously treated for recurrence on the contralateral side? Preliminary study of 13 patients with the Canaletto® implant.

There are no published studies on the management of carpal tunnel syndrome (CTS) patients who have already been operated for recurrent CTS on the contralateral side. The aim of this study was to evaluate 13 patients with CTS who underwent primary release using a Canaletto® implant. The 13 patients had all been operated for recurrent CTS previously. On the contralateral side, they all had subjective signs, and two of them already had complications. All were operated with the Canaletto® implant according to Duché's technique, in a mean of 20minutes. After a mean 19.3-month follow-up, paresthesia, pain, and QuickDASH scores were significantly improved, even in one patient who underwent revision at another facility. This preliminary study suggests that use of a Canaletto® implant as first-line treatment for CTS in patients who already underwent revision surgery on the other side is a simple and safe technique, without worsening of symptoms. These findings should be assessed with a prospective randomized controlled trial.

Erratum to: The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections.

[This corrects the article DOI: 10.1186/s13017-017-0141-6.].

Posterior interosseous nerve to the superficial branch of the ulnar nerve transfer at the distal third of the forearm through a single anterior approach: Anatomical feasibility study.

The purpose of this study was to determine in a cadaver model, whether transfer of the posterior interosseous nerve (PIN) to the superficial branch of the ulnar nerve (SBUN) by a single approach was feasible. The experiment was carried out on five fresh cadavers. The ulnar nerve was split into its motor branches and the SBUN. The PIN was collected behind the interosseous membrane and sutured to the SBUN on its anterior surface. All sutures were tensionless and technically possible with the PIN's diameter being at least 50% of the SBUN's diameter in all cases. Our results demonstrate that PIN to SBUN transfer through a single anterior approach is feasible in a cadaver model.

Design and evaluation of a new synthetic wrist procedural simulator (Wristsim®) for training of distal radius fracture fixation by volar plating.

Legislation concerning workload of surgical trainees and pressure to reduce learning curves have forced us reconsider surgical training. Our goal was to evaluate a synthetic procedural simulator for teaching open reduction and internal fixation (ORIF) of distal radius fractures (DRF). Twenty surgeons used a synthetic procedural simulator (Wristsim®) made by 3D printing for ORIF of DRF with a volar plate (Newclip Technics®). The evaluation consisted of grading the simulator's realism compared to the surgeons' own experience with surgery on cadavers. The Wristsim® was graded 5.10/10, compared to 8.18/10 for the cadaver specimen for introduction of the plate under pronator quadratus. For fracture reproduction, Wristsim® scored 6.40/10, with the cadaver specimen scoring 7.15/10. For fracture reduction, Wristsim® scored 5.62/10, with the cadaver specimen scoring 7.38/10. Plate application was scored 7.05/10 for Wristsim® and 8.23/10 for the cadaver. Drilling was scored 6.60/10 for the Wristsim® and 8.23/10 for the cadaver. Screw fixation was scored 7.40/10 for the Wristsim® and 8.12/10 for the cadaver. Our results demonstrated that Wristsim® is still inferior to a cadaver specimen for teaching ORIF by volar plating of DRF. A new model of Wristsim® is being developed that will address shortcomings in pronator quadratus thickness, passive ROM in flexion/extension and bone size.