A randomized prospective study on the treatment of intra-articular distal radius fractures: open reduction and internal fixation with dorsal plating versus mini open reduction, percutaneous fixation, and external fixation.

PURPOSE: To compare 2 methods of surgical treatment for displaced intra-articular fractures of the distal radius: open reduction and internal fixation with dorsal plating (Pi Plate; Synthes, Paoli, PA) versus mini open reduction with percutaneous K-wire and external fixation. METHODS: Patients with AO type C intra-articular distal radius fractures were randomized into 2 groups: open reduction and internal fixation and dorsal plating or external fixation and K-wires and mini-open reduction. Patients over the age of 70 years with any associated soft-tissue or skeletal injury to the same limb and pre-existing wrist arthrosis or disability were excluded from the study. Objective, subjective, and radiographic outcomes were assessed at 2 weeks, 4 to 6 weeks, 10 to 12 weeks, 6 months, and 1- and 2-year intervals. The minimum follow-up period was 6 months; the average follow-up period was 18 months. The principal outcome analyzed was the Disabilities of the Arm, Shoulder, and Hand score. Secondary outcomes included grip strength, range of motion, surgical procedure time, complications, and radiographic parameters. The groups were equal with respect to age, gender, fracture subtype, and number of workers' compensation cases. RESULTS: No significant difference was found in the Disabilities of the Arm, Shoulder, and Hand scores, our primary outcome. The dorsal plate group, however, showed a higher complication rate when compared with the external fixator group. The plate group had significantly longer tourniquet times when compared with the external fixator group. The plate group also had higher levels of pain at 1 year when compared with the external fixator group; however, this equalized after hardware removal. The external fixator group showed an average grip strength of 97% compared with the normal side and 86% in the dorsal plate group. CONCLUSIONS: At midterm analysis the dorsal plate group showed a significantly higher complication rate compared with the external fixator group; therefore enrollment in the study was terminated. The dorsal plate group also showed statistically significant higher levels of pain, weaker grip strength, and longer surgical and tourniquet times. Based on these results we cannot recommend the use of dorsal plates in treating complex intra-articular fractures of the distal radius.

Review of the effect of early amniocentesis on foot deformity in the neonate.

A recent publication by the Canadian Early and Mid-Trimester Amniocentesis Trial Group reported an increase in orthopaedic foot deformities in infants whose mothers underwent an amniocentesis from 11 to 12 + 6 gestational weeks versus a group sampled between 15 to 16 + 6 gestational weeks. Because the sampling of the former group was at the time of maximum foot growth and maximum acquisition of amniotic fluid, the authors hypothesize that the foot deformities are secondary to decreased fetal movement during a key phase in foot and ankle development.

Pediatric tourniquets: analysis of cuff and limb interface, current practice, and guidelines for use.

There are few clear guidelines on the proper use of tourniquets in pediatric surgery, in particular on how to set the tourniquet pressure, how to select the most appropriate cuff, and whether to use some type of soft padding beneath the cuff for limb protection. The authors could find only one published study specifically addressing pediatric cuff pressures, and no studies showing what types of cuff and/or padding create the smoothest skin surface under the cuff. Of 46 pediatric orthopaedic surgeons surveyed, 44 use a tourniquet 4.6 times per week on average and 2 have discontinued their use as a result of complications. To set cuff pressure, 13 of 44 use a standard value, 14 of 44 base pressure on age, extremity, and size, and 17 of 44 base cuff pressure on blood pressure. Thirty-four of 44 use skin protection under the cuff, but damage to the skin is common, accounting for 21 of the 67 reported complications. Nerve (15/67) and muscle (8/67) complications, related to both pressure and tourniquet time, were also reported. Using a molding and digital measurement technique, the authors compared the maximum wrinkle heights and the sums of all wrinkle heights in the skin surface under four different cuff/padding configurations. In a total of 44 trials on the upper arms and thighs of two healthy child volunteers, one type of pediatric cuff with a matching limb-protection sleeve designed and recommended by the manufacturer (Delfi) produced significantly fewer, less severe pinches and wrinkles in the skin surface than a second type of tourniquet cuff (Zimmer) with or without two layers of commonly available cast padding, and a third type (Kidde) with padding. With the second type of cuff, using cast padding reduced skin wrinkling compared to applying the same cuff on unprotected skin. In view of the survey, clinical literature, and results of this study, a guideline for use of pediatric tourniquets is proposed.