Classification and treatment of distal radius fractures: a survey among orthopaedic trauma surgeons and residents

Purpose: Classification, the definition of an acceptable reduction and indications for surgery in distal radius fracturemanagement are still subject of debate. The purpose of this study was to characterise current distal radius fracture management in Europe. Methods: During the European Congress of Trauma and Emergency Surgery (ECTES) 2015 a 20-question multiple-choice survey was conducted among the attending surgeons and residents of the hand and wrist session. Consensus was defined as more than 50 % identical answers (moderate consensus 50–75 % and high consensus more than 75 %). Results: A total of 46 surgeons and residents participated in the survey. High consensus was found among both surgeons and residents for defining the AO/OTA classification as the preferred classification system. For the definition of an acceptable reduction, a moderate to high consensus could be determined. Overall, high consensus was found for non-operative treatment instead of operative treatment in dislocated extra- and intra-articular distal radius fractures with an acceptable closed reduction, regardless of age. We found high (surgeons) and moderate (residents) consensus on the statement that an intra-articular gap or step-off ≥2 mm, in patients younger than 65 years, is an absolute indication for ORIF. The same applied for ORIF in dislocated fractures without an acceptable closed reduction in patients younger than 75 years of age. Conclusion: Current distal radius fracture management in Europe is characterised by a moderate to high consensus on the majority of aspects of fracture management

Repair of the pronator quadratus after volar plate fixation in distal radius fractures: a systematic review

To position the volar plate on the distal radius fracture site, the pronator quadratus muscle needs to be detached from its distal and radial side and lifted for optimal exposure to the fracture site. Although the conventional approach involves repair of the pronator quadratus, controversy surrounds the merits of this repair. The purpose of this study was to compare the functional outcomes of patients with distal radius fractures treated with pronator quadratus repair after volar plate fixation versus no pronator quadratus repair. A systematic search was conducted in Medline, EMBASE and the Cochrane Central Register of Controlled Trials, on 23 July 2015. All studies comparing pronator quadratus repair with no pronator quadratus repair in adult patients undergoing volar plate fixation for distal radius fractures were included. The primary outcome was the Disability of the Arm, Shoulder and Hand (DASH) score at 12 months. Secondary outcomes included range of motion, grip strength, post-operative pain and complications. A total of 169 patients were included, of which 95 underwent pronator quadratus repair, while 74 patients underwent no pronator quadratus repair. At 12 months follow-up no statistically significant differences in DASH-scores and range of motion were observed between pronator quadratus repair and no repair. Moreover, post-operative pain and complication rates were similar between both groups. At 12 months of follow-up, we do not see any advantages of pronator quadratus repair after volar plate fixation in the distal radius. However, a definitive conclusion cannot be drawn from this systematic review due to a lack of available evidence

Stability of the Elbow Joint: Relevant Anatomy and Clinical Implications of In Vitro Biomechanical Studies

The aim of this literature review is to describe the clinical anatomy of the elbow joint based on information from in vitro biomechanical studies. The clinical consequences of this literature review are described and recommendations are given for the treatment of elbow joint dislocation

Posterior interosseous nerve palsy after closed proximal forearm fractures

Although rare, posterior interosseous nerve (PIN) palsy can occur in patients with a closed proximal forearm fracture and may present in a delayed fashion after initial trauma. In this case series, three cases of posterior interosseous nerve (PIN) injury following proximal forearm fractures are presented and discussed. Our literature search yielded six studies concerning PIN injury in radial head/neck fractures and proximal forearm fractures. Out of a total of 8 patients, 7 patients were treated non-operatively and in one patient a PIN release was performed. One patient was lost to follow-up, all other 7 patients showed successful recovery. A treatment algorithm for PIN palsy after proximal forearm fractures is provided. Based on our experience and what we found in literature, it seems safe to treat PIN palsies conservatively

Eenvoudige elleboogluxaties in Nederland: Wat doen Nederlandse chirurgen?

Abstract: Er is weinig evidence voor de optimale behandeling van eenvoudige elleboogluxaties. Hoewel er aanwijzingen zijn dat eenvoudige elleboogluxaties niet te lang moeten worden geïmmobiliseerd en functioneel kunnen worden nabehandeld. Om een overzicht te krijgen over hoe eenvoudige elleboogluxaties in Nederland worden behandeld, verrichtten wij een enquête onder leden van de Nederlandse Vereniging van Traumatologie. Alle leden ontvingen een e-mail met het verzoek om een digitale vragenlijst over de behandeling van elleboogluxaties in te vullen. Het response percentage was 17% (n=90). Vijfendertig (39%) chirurgen verbinden geen consequenties aan stabiliteitsonderzoek van de elleboog na repositie. Drieënzestig procent van deze chirurgen behandelt de patiënten met een gipsverband gedurende gemiddeld 3.4 weken. Bij 55 (61%) van de 90 respondenten beïnvloed het stabiliteitsonderzoek wel de vorm van behandeling. Bij een stabiel gewricht wordt in ongeveer 64% van de gevallen een functionele behandeling voorgeschreven en bij een instabiel gewricht behandelen 24% van de respondenten functioneel met een functionele fixateur. De resultaten van de enquête onder Nederlandse chirurgen laat zien, dat de meeste ondervraagden immobilisatie verkiezen boven functionele behandelingAbstract Background: Randomised controlled trials and observational comparative studies show little proof for the optimal form of treatment for simple elbow dislocations. However, there is some evidence that functional treatment in simple elbow dislocations may lead to better functional outcome. To get an overview of how simple elbow dislocations are treated in the Netherlands we performed a survey among Dutch surgeons. Methods: All members of the Dutch Society of Traumatology received an e-mail with the request to fill out an electronic questionnaire. Results: The response rate was 17% (n=90) . Thirty vive (39%) of them stated that stability testing after reposition of the joint did not influence subsequent form of treatment. Sixty three percent of them treated patients with a above the elbow cast for a mean of 3.4 weeks. Fifty five (61%) responders used stability testing as a guide for treatment. joint is stable after reposition. In the case of a stabile joint 64% of these surgeons treat patients with functional treatment. When there is joint instability 24% prefer functional treatment with a hinged external fixator. Conclusion: The results of this inquiry among Dutch surgeons showed that the majority of simple elbow dislocations are treated with immobilisation and that functional treatment is not widespread

Management of biliary complications following damage control surgery for liver trauma

Background: The liver is the most frequently injured solid intra-abdominal organ. The major cause of early death following severe liver trauma is exsanguination. Although perihepatic packing improves survival in severe liver trauma, this leaves parenchymal damage untreated, often resulting in post-traumatic biliary leakage and a subsequent rise in morbidity. The aim of this study was to analyze the incidence and treatment of biliary leakage following the operative management of liver trauma. Methods: Patients presenting between 2000 and 2009 to Erasmus University Medical Centre with traumatic liver injury were identified. Data from 125 patients were collected and analyzed. Sixty-eight (54 %) patients required operation. All consecutive patients with post-operative biliary complications were analyzed. Post-operative biliary complications were defined as biloma, biliary fistula, and bilhemia. Results: Ten (15 %) patients were diagnosed with post-operative biliary leakage following liver injury. Three patients with a biloma were treated with percutaneous drainage, without further intervention. Seven patients with significant biliary leakage were managed by endoscopic stenting of the common bile duct to decompress the internal biliary pressure. One patient had a relaparotomy and right hemihepatectomy to control biliary leakage and injury of the right hepatic duct. Conclusion: Biliary complications continue to occur frequently following damage control surgery for liver trauma. The majority of biliary complications can be managed without an operation. Endoscopic retrograde cholangiopancreatography (ERCP) and internal stenting represent a safe strategy to manage post-operative biliary leakage and bilhemia in patients following liver trauma. Minor biliary leakage should be managed by percutaneous drainage alone

Three-dimensional virtual planning of corrective osteotomies of distal radius malunions: a systematic review and meta-analysis

The purpose of this study was to summarize and evaluate results of three-dimensional (3D-) planned corrective osteotomies of malunited distal radius fractures. 3D-planning techniques provide the possibility to address 3D-deformity that conventional planning methods might not address. We systematically searched PubMed, EMBASE and the Cochrane library for studies that performed a 3D-planned corrective osteotomy on patients with a malunited distal radius fracture. Fifteen studies with a total of 68 patients were included in the analysis. In 96% of cases, the preoperatively present palmar tilt, radial inclination and ulnar variance showed statistically significant improvement postoperatively with restoration to within 5° or 2 mm of their normal values. Mean flexion–extension, pro-supination and grip strength showed statistically significant improvement (p < 0.05). Complications were reported in 11 out of 68 patients (16%). With the current advances in 3D printing technology, 3D-planned corrective osteotomies seem a promising technique in the treatment of complex distal radius malunions. Level of evidence IV Systematic review of case series, Level IV

Dislocation of the Elbow: A Retrospective Multicentre Study of 86 Patients

The objective of this retrospective multicentre cohort study was to prospectively assess the long-term functional outcomes of simple and complex elbow dislocations.We analysed the hospital and outpatient records of 86 patients between 01.03.1999 and 25.02.2009 with an elbow dislocation. After a mean follow-up of 3.3 years, all patients were re-examined at the outpatient clinic for measurement of different outcomes.The mean range of motion was ROM 135.5 degrees . The Mayo elbow performance index (MEPI) scored an average of 91.9 (87.5% of the patients were rated excellent or good). The average Quick disabilities of the arm, shoulder and hand (Quick- DASH) score was 9.7, the sports/music score 11.5 and work score 6.1. The Oxford function score was 75.7, Oxford pain score 75.2 and Oxford social-psychological score 73.9.Elbow dislocation is a mild disease and generally, the outcome is excellent. Functional results might improve with early active movements

Treatment of extra-articular proximal and middle phalangeal fractures of the hand: a systematic review

The aim of the study was to systematically review the patient reported and functional outcomes of treatment for extra-articular proximal or middle phalangeal fractures of the hand in order to determine the best treatment options. The review methodology was registered with PROSPERO. A systematic literature search was conducted in electronic bibliographic databases. Two independent reviewers performed screening and data extraction. The evaluation of quality of the included studies was performed using the Structured Effectiveness Quality Evaluation scale. The initial search yielded 2354 studies. The full text manuscripts of 79 studies were evaluated of which 16 studies met the inclusion criteria. In total, 513 extra-articular proximal and middle phalangeal fractures of the hand were included of which 118 (23%) were treated non-operatively, 188 (37%) were treated by closed reduction internal fixation (CRIF) and 207 (40%) by open reduction internal fixation. It can be recommended that closed displaced extra-articular phalangeal fractures can be treated non-operatively, even fractures with an oblique or complex pattern, provided that closed reduction is possible and maintained. Conservative treatment is preferably performed with a cast/brace allowing free mobilization of the wrist. No definite conclusion could be drawn upon whether closed reduction with extra-articular K-wire pinning or transarticular pinning is superior; however, it might be suggested that extra-articular K-wire pinning is favoured. When open reduction is necessary for oblique or spiral extra-articular fractures, lag screw fixation is preferable to plate and screw fixation. But, similar recovery and functional results are achieved with transversally inserted K-wires compared to lag screw fixation. Type of study/level of evidence: therapeutic III

Rasch analysis of the Dutch version of the Oxford elbow score

Background: The Oxford elbow score (OES) is a patient-rated, 12-item questionnaire that measures quality of life in relation to elbow disorders. This English questionnaire has been proven to be a reliable and valid instrument. Recently, the OES has been translated into Dutch and examined for its reliability, validity, and responsiveness in a group of Dutch patients with elbow pathology. The aim of this study was to analyze the Dutch version of the OES (OES-DV) in combination with Rasch analysis or the one-parameter item response theory to examine the structure of the questionnaire. Methods: The OES-DV was administered to 103 patients (68 female, 35 male). The mean age of the patients was 44.3 ± 14.7 (range 15–75) years. Rasch analysis was performed using the Winsteps® Rasch Measurement Version 3.70.1.1 and a rating scale parameterization. Results: The person separation index, which is a measure of person reliability, was excellent (2.30). All the items of the OES had a reasonable mean square infit or outfit value between 0.6 and 1.7. The threshold of items were ordered, so the categories can function as intended. Principal component analysis of the residuals partly confirmed the multidimensionality of the English version of the OES. The OES distinguished 3.4 strata, which indicates that about three ranges can be differentiated. Conclusion: Rasch analysis of the OES-DV showed that the data fit to the stringent Rasch model. The multidimensionality of the English version of the OES was partly confirmed, and the four items of the function and three items of the pain domain were recognized as separate domains. The category rating scale of the OES-DV works well. The OES can distinguish 3.4 strata. This conclusion can only be applied to elbow dislocations, which were the largest group of patients studied