Background: Traditionally, non-displaced scaphoid fractures are considered by most as stable with predictable rates of healing with conservative treatment. There is a current trend in orthopedic practice, however, to treat non- or minimal displaced fractures with early open reduction and internal fixation. This trend is not evidence based. In this systematic review and meta-analysis, we pool data from trials comparing surgical and conservative treatment for acute scaphoid fractures, thus aiming to summarize the best available evidence.

Methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL and reference list of articles, and contacted researchers in the field. We selected eight randomized controlled trials comparing surgical versus conservative interventions for acute scaphoid fractures in adults. Data were pooled using fixed-effects and randomeffects models with standard mean differences (SMD) and risk ratios for continuous and dichotomous variables respectively. Heterogeneity across studies was assessed with Forest plots and calculation of the I2 statistic.

Results: Four-hundred seventeen patients were included in eight trials (205 fractures were treated surgically and 212 conservatively). Most trials lacked scientific rigor. Four studies assessed functional outcome with validated physician- and patient-based outcome instruments. With the numbers available (200 patients), we found a significant difference according to our primary outcome measure, standardized patient-based outcome in favor of surgical treatment (p< 0.0001). With regard to our secondary parameters, we found heterogeneous results that favored surgical treatment for grip strength, time to union and time off work. In contrast we found no significant differences between surgical and conservative treatment for pain, range of motion, rate of nonunion, malunion, and infection, rate of complications, and total treatment costs.

Conclusions: Patient-rated functional outcome and satisfaction as well as time to return to function favored surgical treatment for acute scaphoid fractures. However, there is no evidence from prospective randomized controlled trials on physician-rated functional outcome, radiographic outcome, complication rates and treatment costs to favor surgical or conservative treatment for acute scaphoid fractures.

Background: Extra-articular fractures of the distal radius in children are most often treated with closed reduction and cast immobilization. The purpose of this retrospective study was to evaluate long term (> 12 years follow-up) objective and subjective outcomes in a consecutive series of pediatric patients treated with closed reduction with standardized outcome instruments. We hypothesized that children treated with closed reduction and cast immobilization have little or no objective functional impairment in later life and therefore subjective factors are the strongest determinants of outcome.

Methods: Twenty-seven patients with an average age at time of injury of 9 years (range, five to sixteen years) were evaluated at an average of twenty-one years (range, twelve to twenty seven years) after injury (patients aged 21 to 39) after closed reduction of an extra-articular distal radius fracture. Patients were evaluated using 2 physician-based evaluation instruments (modified Mayo wrist score; MMWS, and the Sarmiento modification of the Gartland and Werley score; MGWS) and an upper extremity-specific health status questionnaire (Disabilities of the Arm, Shoulder and Hand; DASH) questionnaire. Radiographic measurements were also made. Multivariable analysis of variance and multiple linear regression modelling were used to identify the degree to which various factors affect variability in the scores derived with these measures.

Results: All fractures had healed without significant loss of alignment. Final functional results according to the MGWS were rated as excellent or good in all patients. The average MMWS score was 90 points, and the median DASH score was 0 points. Twenty patients (74%) considered themselves pain free. Bivariate analysis revealed pain -as rated according to scales used in the MMWS- and age at time of injury to be correlated with DASH scores, with pain as the only independent predictor of patient-based outcome in multivariable analysis. This explains almost three quarters of the variability in DASH scores. Pain, range of motion, and radiographic measurement of radial length correlated with the physician based scoring system MMWS;

Conclusions: Twenty-one years after injury 96% of patients have a satisfactory outcome according to physician-based MMWS categorical ratings and patient-based DASH scores. It is remarkable that pain explained 74% of the variation in DASH scores. Perhaps when there is very little impairment, subjective factors are more important determinants of disability.

Background: This study tested the null hypothesis that computed tomography (CT) and magnetic resonance imaging (MRI) have the same diagnostic performance characteristics for triage of suspected scaphoid fractures.

Methods: Thirty-four consecutive patients with a suspected scaphoid fracture (post-injury tenderness of the scaphoid and normal radiographs) underwent CT and MRI within ten days after trauma. CT-reconstructions were made in planes defined by the long axis of the scaphoid. The reference standard for a true fracture of the scaphoid was 6-week follow-up radiographs in four views, based on current literature. A panel including surgeons and radiologists came to a consensus diagnosis for each type of imaging considered in a randomized and blinded fashion, independent of the other types of imaging. We calculated sensitivity, specificity and accuracy as well as positive (PPV) and negative predictive values (NPV) for both imaging modalities.

Results: According to the reference standard there were six true fractures of the scaphoid (prevalence 18%). CT diagnosed fracture of the scaphoid in five patients (15%), with one false positive, two false negative and four true positive results. MRI diagnosed a fracture in seven patients (21%), with three false positive, two false negative and four true positive results. Sensitivity, specificity and accuracy for CT were 67%, 96% and 91%; and for MRI 67%, 89% and 85% respectively. According to the McNemar test for paired binary data for each imaging modality these differences were not significant. The positive predictive values using Bayes’ formula were 76% for CT and 54% for MRI. Negative predictive values were 94% for CT and 93% for MRI.

Conclusions: CT and MRI had comparable diagnostic characteristics. Both were subject to both false positive and false negative interpretations. They were better to rule out a fracture than to rule one in. The best reference standard for a true fracture is debatable

Background: It is well established that unstable fractures of the distal part of the radius may require operative treatment to restore alignment and that failure to restore alignment often leads to wrist and forearm dysfunction. There is ongoing debate in the literature whether or not there is a strict relationship between the quality of anatomical reconstruction and functional outcome. We hypothesize that there is no difference in objective- and subjective functional outcome between patients with AO type B versus more complex AO type C fractures.

Methods: Ninety-four patients with an average age of 42 years (range, 20 to 78 years) at the time of injury were evaluated an average of 20 years (range, 8 to 32 years) after treatment of an intra-articular distal radius fracture. At long-term follow-up patients were evaluated using a physician-based evaluation instruments (modified Mayo wrist score; MMWS and an upper extremity-specific health status questionnaire (Disabilities of the Arm, Shoulder and Hand; DASH) questionnaire. Objective and subjective functional outcome of patients with AO Type B and AO Type C fractures were compared.

Results: An average of 20 years after injury (average age 62 years, range 35 to 90), all fractures healed without significant loss of alignment. There was no difference in physician based outcome measure according to the Mayo score between 17 patients with 18 AO type B fractures (average, 80,3 points; range 45 to 100) and 27 patients with 31 AO type C fractures (average, 75.9 points; range 10 to 95, p=0.42). Differences in subjective DASH scores were not statistically significant either (p = 0.47); average 13 points for Type B patients (range, 0 to 58 points) and an average of 16 points for Type C patients (range, 0 to 71 points).

Groups were statistically comparable. No statistical differences were found in flexion extension arc (average 103 degrees, range 10 to 145 degrees), pronation supination arc (average 150 degrees, range 0 to 180 degrees) or radial ulnar deviation (average 52 degrees, range 0 to 85 degrees), as well as grip strength and osteoarthritis (all p> 0.05)

Conclusions: Twenty years after injury 67% of patients have a satisfactory outcome according to physician-based MMWS categorical ratings. There is no difference in functional long term outcome between patient with more extensive intra-articular comminution (type C fractures) and AO type B fractures. This is consistent with previous long term outcome studies with similar methodology; when more complex injuries are not correlated with decreased long term functional outcome, other (subjective) factors are more important determinants of disability.

In the past, the treatment of acute elbow fracture-dislocations has emphasized repair to the medial collateral ligament (MCL), with favorable results. We report improved results using a strategy based on lateral-sided repair (lateral collateral ligament, radial head, coronoid) without MCL repair. In forty-seven patients, this strategy resulted in a high degree of success with no residual instability (valgus or otherwise). The dynamic stabilizers of the elbow activated through early postoperative motion, are important adjunct to stability. We have devised a reproducible radiographic method to demonstrate this.

To review the surgical treatment of elbow dislocations without surgical MCL repair, and to determine if early active motion aids in restoring stability and concentric joint reduction.

In the setting of acute fracture-dislocation of the elbow, concentric elbow stability with excellent functional results can be achieved using laterally-based surgical strategy without MCL repair. The dynamic stabilizers of the elbow, activated through the early motion, assist in providing joint congruity and stability.

Forty-seven patients with acute elbow fracture-dislocations requiring operative treatment were treated at two university-affiliated teaching hospitals and evaluated an average of twenty-one months after injury. The protocol consisted of repair of the ulna and coronoid, repair or replacement of the radial head, and repair of the LCL, and early motion. The MCL was not routinely repaired. The LCL origin had been avulsed and reattached in all patients. One patient had a second procedure related to malpositioned radial head prosthesis. A stable mobile (average one hundred and one degree arc) articulation was restored in all patients. There was no evidence of valgus instability in any patient. Early motion was initiated at a mean of two weeks postoperatively. Postoperative ulnohumeral joint space opening improved from 4.9 ± 1.2 mm in the early postoperative period to 2.0 ± 0.5 mm (p < 0.00003) at final follow-up. We believe this is due to the effect of the dynamic stabilizers, which were allowed to function through early motion.

Introduction: The aim of this retrospective study is to identify factors that might influence the final result in the treatment of volarly displaced distal radius fractures

Material : 31 patients with an average age of 39 years and a volarly displaced distal radius fracture were treated by ORIF. According to the Comprehensive classification of fractures thee were 3 B3.1, 7 B3.2, and 21 B3.3. All the fractures approached volarly and fixed with a T plate. 3 patients required bone graft. All patients were evaluated with postop radiographs and results were assessed according to the system described by Gartland and Werley.

Results: The average follow up was 50 months. There were twenty excellent, six good and five poor results. Although all fractures healed, six patients had evidence of osteoarthrosis, and there were four early and six late complications, which adversely influenced the final result. Reversal of the volar tilt and evidence of osteoarthrosis found to have a significant association with a fair or poor outcome.

Conclusion: Treatment of such injuries require careful preoperative evaluation and identification of fracture morphology, otherwise the postoperative rate of complications can be quite high, a factor that may negatively influence the final result.

Purpose: Post-traumatic instability of the elbow is defined as a subluxation of the humeroulnar joint at least three weeks after trauma. Treatment is based on restitution of the three elements essential for stability: the coronoid process, the height of the head of the radius, repair of the lateral ligaments. The purpose of this study was to analyse treatment modalities for these unstable elbows and assess mid-term results.

Material and methods: This consecutive series included all patients who underwent surgery between 1992 and 2000. There were 22 patients (twelve men and ten women, mean age, 46 years, age range 26–74 years). The left elbow was involved in 16 cases (two dominant) and the right elbow in six cases (six dominant). The initial trauma was isolated dislocation in six patients, dislocation with fracture of the coronoid process and the head of the radius in nine, trans-olecranon fracture-dislocation in seven. Mean time from trauma to revision for instability was four months. A dynamic external fixator was used for stabilisation in all cases, with or without restoration of the height of the radius with a radial head prosthesis (n=12), and reconstruction of the coronoid process (n=7). Reinsertion of the lateral ligaments was necessary in 17 patients.

Results: Mean follow-up was 33 months. Six patients required a second procedure for transposition of the ulnar nerve in three and arthrolysis of the elbow joint in three. There was one failure requiring total elbow arthroplasty less than one year after revision. At last follow-up, outcome according to the Mayo Clinic classification was excellent in ten patients, good in five, fair in one, and poor in five (four trans-olecranon fracture-dislocations). Twenty patients had a stable elbow. Mean flexion-extension was 113° with a 19° mean extension deficit. At last follow-up, six patients had radiographic signs of osteoarthritis.

Discussion and conclusion: The results were directly correlated with the nature of the initial trauma and the quality of the restoration of he stabilising elements. The poorest results were observed after trans-olecranon fracture-dislocation, which led to osteoarthritic degradation in three out of four cases. In our experience, treatment of sequelae of elbow dislocation, or the terrible triade, can give satisfactory results with an appropriate treatment strategy.

Introduction: The aim of the study was to assess the efficacy of the distal radius π-plate in the surgical treatment of acute, dorsally displaced, unstable distal radius fractures.

Material: 37 patients with an average age of 41 yrs included in the study. Upon dorsal exposure of the fracture and provisional reduction with the aid of a distractor and K-wires, a bending template was used to verify plate length and contour. The plate was then applied and the type, number and location of screws and buttress pins to be used were determined. Eight patients had supplementary fixation. Autologus bone graft was used to fill defects in 28 patients.

Results: The average follow up was 21 months. Radiographic evidence of union was documented at an average of 6 weeks postop. No loss of reduction occurred in any of the patients and no patient complained of residual deformity. The average ROM was 79% of the contralateral side, the average grip strength was 64% of the contralateral wrist and the average pinch strength was 76% of the contralateral hand. No infections, nonunions, wound problems or plate failures occurred. 5 patients developed irritation and 4 had their plates removed.

Concussion: The results of this study verify the safety and the efficacy of the π-plate for the treatment of complex fractures of the distal radius. Furthermore considering the technical advantages of the π,-plate it seems that complex distal radius fractures can effectively be addressed through a dorsal approach and stable internal fixation.

Objective: Deformity post distal radius fracture can be associated with alterations in carpal kinematics. This study presents a review to detect the prevalence and clinical implications of such deformities and the variables that influence the outcome following osteotomy.

Material & Methods: 29 patients with distal radius mal-union, and an average age of 43 yrs, were treated by a single surgeon with a corrective osteotomy. Along with pain scales, wrist motion, and grip strength, pre and post osteotomy radiographs were evaluated. Preoperatively, 18 patients had dorsal deformity, 9 volar and 2 shortening and malrotation alone. 20 patients had carpal malalignment and 9 normal carpal alignment.

Results: The average follow up was 21 months. 24 out of 29 radial deformities were corrected to normal. Overall 17 patients had post-op normal carpal alignment. Three groups resulted; Group I: 11 patients with pre and post-op “fixed” deformities. Group II: 8 patients with normal pre and post-op carpal alignment; and Group III: 9 patients with “lax” pre-op malalignment converted to normal post-op. 1 patient was normal pre-op and converted to DISI at post-op. There was no statistically difference in outcome with regard to pain, forearm rotation, wrist extension, patient age or time to surgery between the three groups. There was statistically significant greater wrist flexion in Group II and III compared to Group I.

Conclusions: Carpal malalignement post radius osteotomy will have a negative effect on the functional outcome compared to those patients with preoperative carpal deformity, which corrects with radius osteotomy. Knowledge of this association will help advice patients of expected outcomes.

We treated 15 patients with atrophic nonunion of a diaphyseal fracture of the humerus with an associated bony defect using an autogenous cancellous bone graft and a plate to bridge the defect. There were nine men and six women with a mean age of 48 years. The mean length of the bony defect was 3 cm.

At a mean follow-up of 30 months only one fracture failed to unite. This suggests that, in the presence of a well-vascularised envelope of muscle, the application of an autogenous cancellous bone graft in conjunction with a bridging plate represents a good alternative to more demanding surgical techniques.

We have treated 42 consecutive complex ununited fractures of the femoral shaft by wave-plate osteosynthesis at five different medical centres. There were 13 with previous infection, 12 with segmental cortical defects, and 3 were pathological fractures. In 39 cases there had been previous internal fixation and 21 patients had had more than one earlier operation.

Union was achieved in 41 patients at an average of six months, although three had required a second bone graft. Two patients had recurrence of infection and in one this resulted in the persistence of nonunion. There were no failures of the implant. All 41 patients with union are now fully weight-bearing, but four have a leg-length discrepancy, one has axial malalignment, and nine have residual stiffness of the knee. These results are surprisingly good, despite the complexity of the initial problem, and appear to confirm the biological and mechanical advantages of the wave plate over the conventional plate for such cases.

We reviewed 36 consecutive patients with Monteggia fracture-dislocations of the forearm; 28 had been treated within 24 hours and 8 had been referred a week or more after the initial injury with persisting or recurrent dislocation of the proximal radio-ulnar joint after treatment elsewhere. We treated 15 of the 16 complete fractures and 3 of the 11 incomplete fractures of the ulna by operative fixation.

All the early fractures and six of the eight late referrals had good or excellent results. The two poor results were in patients with malalignment and dislocation of the radial head persisting for at least two weeks before definitive treatment.

A good outcome after a Monteggia injury in a child requires early diagnosis and prompt, stable, anatomical reduction of the ulnar fracture. In our experience, selective operative fixation of unstable fractures provides reliable reduction and causes few complications.