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The elbow is prone to stiffness due to its unique anatomy and profound capsular reaction to inflammation. The resulting movement impairment may significantly interfere with a patient’s activities of daily living. Trauma (including surgery for trauma), posttraumatic arthritis, and heterotopic ossification (HO) are the most common causes of elbow stiffness. In stiffness caused by soft tissue contractures, initial conservative treatment with physiotherapy (PT) and splinting is advised. In cases in which osseous deformities limit range of motion (e.g. malunion, osseous impingement, or HO), early surgical intervention is recommended. Open and arthroscopic arthrolysis are the primary surgical options. Arthroscopic arthrolysis has a lower complication and revision rate but has narrower indications. Early active mobilization using PT after surgery is recommended in postoperative rehabilitation and may be complemented by splinting or continuous passive motion therapy. Most results are gained within the first few months but can continue to improve until 12 months. This paper reviews the current literature and provides state-of-the-art guidance on the management regarding prevention, evaluation, and treatment of elbow stiffness.

Purpose Most patients with a clinically suspected scaphoid fracture and normal initial radiograph are unnecessarily treated. Previously developed prediction rules using demographic and clinical risk are unable to accurately predict occult fractures. Adding other risk factors could enhance this. Therefore, we aim to explore if there are morphological risk factors of the wrist for sustaining a scaphoid fracture. Methods We retrospectively included adult patients with a clinically suspected scaphoid fracture between 2013 and 2019 in our case–control study. There were 82 patients with a scaphoid fracture and 158 patients with a wrist contusion. Morphological risk factors were identified using statistical shape modelling (SSM) and linear measurements. Independent wrist shape variations on posteroanterior and lateral radiographs were captured in modes using SSM. Associations between outcomes and a scaphoid fracture were explored using logistic regression and the reliability was assessed. Results Of the 15 posteroanterior modes and 8 lateral modes identified and linear measurements performed, 1 PA mode was associated with a scaphoid fracture (PA mode 4; OR 1.40, CI 1.04–1.93, p = 0.031). We described this mode as an ulna plus and narrower distal radius with more volar tilt and radial inclination. The reliability of the posteroanterior modes and linear measurements was mostly good/excellent and moderate/poor for the lateral modes. Conclusion There was one complex wrist shape significantly associated with a scaphoid fracture. Since the association was weak and the shape is difficult to identify radiographs, we believe this morphological risk factor would not enhance identifying occult scaphoid fractures in the future.

Introduction The use of MRI scans for pre-operative surgical planning of forearm osteotomies provides additional information of joint cartilage and soft tissue structures and reduces radiation exposure in comparison with the use of CT scans. In this study, we investigated whether using 3D information obtained from MRI with and without cartilage information leads to a different outcome of pre-operative planning. Methods Bilateral CT and MRI scans of the forearms of 10 adolescent and young adult patients with a unilateral bone deformation were acquired in a prospective study. The bones were segmented from CT and MRI, and cartilage only from MRI. The deformed bones were virtually reconstructed, by registering the joint ends to the healthy contralateral side. An optimal osteotomy plane was determined that minimized the distance between the resulting fragments. This process was performed in threefold: using the CT and MRI bone segmentations, and the MRI cartilage segmentations. Results Comparison of bone segmentation from MRI and CT scan resulted in a 0.95 ± 0.02 Dice Similarity Coefficient and 0.42 ± 0.07 mm Mean Absolute Surface Distance. All realignment parameters showed excellent reliability across the different segmentations. However, the mean differences in translational realignment between CT and MRI bone segmentations (4.5 ± 2.1 mm) and between MRI bone and MRI bone and cartilage segmentations (2.8 ± 2.1 mm) were shown to be clinically and statistically significant. A significant positive correlation was found between the translational realignment and the relative amount of cartilage. Conclusion This study indicates that although bone realignment remained largely similar when using MRI with and without cartilage information compared to using CT, the small differences in segmentation could induce statistically and clinically significant differences in the osteotomy planning. We also showed that endochondral cartilage might be a non-negligible factor when planning osteotomies for young patients.

Closed treatment of paediatric diaphyseal forearm fractures carries the risk of re-displacement, which can lead to symptomatic malunions. This is because growth will not correct angulation deformity as it does in metaphyseal fractures. The purpose of this prospective cohort study was to evaluate the outcomes after 3-D-planned corrective osteotomy with patient-specific surgical guides for paediatric malunited forearm fractures causing impaired pro-supination. Our primary outcome measure was the gain in pro-supination at 12 months follow-up. Fifteen patients with a mean age at trauma of 9.6 years and time until osteotomy of 5.9 years were included. Preoperatively, patients displayed a mean pro-supination of 67° corresponding to 44% of the contralateral forearm. At final follow-up, this improved to 128°, achieving 85% of the contralateral side. Multivariate linear regression analysis revealed that predictors of greater functional gain after 3-D corrective osteotomy are severe preoperative impairment in pro-supination, shorter interval until 3-D corrective osteotomy and greater angulation of the radius.Level of evidence: III. ispartof: JOURNAL OF HAND SURGERY-EUROPEAN VOLUME vol:47 issue:2 pages:164-171 ispartof: location:England status: published

Purpose: If early active motion after 3-ligament tenodesis is safe, it may yield more patient comfort and an early return to activities. Therefore, the aim of this study was to investigate whether early active motion is noninferior to late active motion after 3-ligament tenodesis for scapholunate interosseous ligament injuries. Methods: This prospective, multicenter cohort study, using a noninferiority design with propensity score matching, compared a late active motion protocol (immobilization for 10–16 days, wrist therapy in weeks 5–6) with an early active motion protocol (immobilization for 3–5 days, wrist therapy during week 2). Patients who were older than 18 years, had complete baseline information on demographics, and underwent 3-ligament tenodesis were included. The outcome measures were postoperative Patient-Reported Wrist/Hand Evaluation scores, pain, complications, return to work, range of motion, grip strength, and satisfaction with treatment results at 3 months of follow-up. Results: After propensity matching, a total of 108 patients were included. Patient-Reported Wrist/Hand Evaluation and pain scores during physical load following an early active motion protocol were noninferior compared with scores following a late active motion protocol. Furthermore, early active motion did not lead to an increase of complications, differences in range of motion or grip strength, or less satisfaction with the treatment result. An earlier return to work was not observed. Conclusions: Early active motion leads to noninferior results without more complications as compared with late active motion. Based on these findings, early active motion can be considered safe, and might be recommended due to its potential benefits compared with late active motion after 3-ligament tenodesis. Type of study/level of evidence: Therapeutic III.

Background: Since all patients with a scaphoid nonunion are generally treated surgically to prevent progressive osteoarthritis, it is important to set postoperative expectations regarding physical functioning and pain. Previous study mainly focus on postoperative scaphoid union and physician-based outcomes. Therefore we aim to report the change from preoperative to postoperative patient-reported outcomes to inform patients with a scaphoid nonunion about their postoperative expectations. Material and Methods: Data were prospectively collected as part of usual care at the Xpert Clinic in the Netherlands. Adult patients who underwent scaphoid nonunion surgery minimally 3 months after a scaphoid fracture, were eligible for inclusion. Only patients with complete preoperative and postoperative questionnaires regarding our primary outcome (Patient Rated Hand/Wrist Evaluation (PRWHE) were included. As secondary outcomes, we assessed the Visual Analog Scale (VAS) pain and hand function, range of motion of the injured wrist measured by a hand therapist, and patient satisfaction with questionnaires. Results: We included 118 patients with complete preoperative and postoperative (11 – 92 months) PRWHE questionnaires. The median PRWHE score improved significantly from 47 [IQR 27 - 62]) preoperative to 11 [IQR 5 - 23] postoperative (p

Background: Trapeziometacarpal osteoarthritis is commonly treated with a trapeziectomy combined with a form of tendon plasty. The type of tendon plasty used is based on the surgeon's preference. The purpose of this observational study was to compare the outcomes of four different tendon plasties combined with trapeziectomy used to treat osteoarthritis of the trapeziometacarpal joint: the Weilby, Burton-Pellegrini, Zancolli, and anchovy plasty procedures. Methods: Patients treated with a trapeziectomy followed by a tendon plasty completed patient-reported outcome measures at baseline and 12 months postoperatively. The primary outcome was the Michigan Hand Outcomes Questionnaire pain subscale. Secondary outcomes were the minimal clinically important difference of Michigan Hand Outcomes Questionnaire pain scale score, Michigan Hand Outcomes Questionnaire hand function, satisfaction, and complication rate. Results: Seven hundred ninety-three patients underwent a trapeziectomy with a tendon plasty between November of 2013 and December of 2018. There was no difference in pain score after 12 months between the four tendon plasty techniques. Patients undergoing an anchovy plasty had a higher chance of reaching the minimal clinically important difference for Michigan Hand Outcomes Questionnaire pain score compared to the other techniques (OR, 2.3; 95 percent CI, 1.2 to 4.6). Overall, more than 80 percent of the patients were satisfied with the treatment outcome, independent of which technique was used. Complication rates of the different techniques were similar. Conclusions: Surgical treatment of osteoarthritis of the trapeziometacarpal joint reduced pain after 12 months, independent of which tendon plasty was used. Patients undergoing an anchovy plasty were more likely to experience a clinically relevant improvement in pain while having similar hand function, satisfaction, and complication rates. This suggests that anchovy plasty is the preferred tendon plasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Background and purpose — We have previously shown that children with minimally displaced metaphyseal both-bone forearm fractures, who were treated with a below-elbow cast (BEC) instead of an above-elbow cast (AEC), experienced more comfort, less interference in daily activities, and similar functional outcomes at 7 months’ follow-up (FU). This study evaluates outcomes at 7 years’ follow-up.Patients and methods — A secondary analysis was performed of the 7 years’ follow-up data from our RCT. Primary outcome was loss of forearm rotation compared with the contralateral forearm. Secondary outcomes were patient-reported outcome measures (PROMs) consisting of the ABILHAND-kids and the DASH questionnaire, grip strength, radiological assessment, and cosmetic appearance.Results — The mean length of FU was 7.3 years (5.9–8.7). Of the initial 66 children who were included in the RCT, 51 children were evaluated at long-term FU. Loss of forearm rotation and secondary outcomes were similar in the 2 treatment groups.Interpretation — We suggest that children with minimally displaced metaphyseal both-bone forearm fractures should be treated with a below-elbow cast.

The use of computed tomography (CT) in fractures is time consuming, challenging and suffers from poor inter-surgeon reliability. Convolutional neural networks (CNNs), a subset of artificial intelligence (AI), may overcome shortcomings and reduce clinical burdens to detect and classify fractures. The aim of this review was to summarize literature on CNNs for the detection and classification of fractures on CT scans, focusing on its accuracy and to evaluate the beneficial role in daily practice.Literature search was performed according to the PRISMA statement, and Embase, Medline ALL, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar databases were searched. Studies were eligible when the use of AI for the detection of fractures on CT scans was described. Quality assessment was done with a modified version of the methodologic index for nonrandomized studies (MINORS), with a seven-item checklist. Performance of AI was defined as accuracy, F1-score and area under the curve (AUC).Of the 1140 identified studies, 17 were included. Accuracy ranged from 69 to 99%, the F1-score ranged from 0.35 to 0.94 and the AUC, ranging from 0.77 to 0.95. Based on ten studies, CNN showed a similar or improved diagnostic accuracy in addition to clinical evaluation only.CNNs are applicable for the detection and classification fractures on CT scans. This can improve automated and clinician-aided diagnostics. Further research should focus on the additional value of CNN used for CT scans in daily clinics.

Item does not contain fulltext BACKGROUND: Midcarpal osteoarthritis is a debilitating wrist pain, and a mainstay treatment is midcarpal fusion. The accepted standard for midcarpal fusion is four-corner fusion, but lately, two-corner fusion (i.e., capitolunate fusion) has gained popularity. This is the first prospective, multicenter, cohort study comparing capitolunate fusion with four-corner fusion for midcarpal osteoarthritis. METHODS: Patients with scaphoid nonunion advanced collapse or scapholunate advanced collapse wrist of grade 2 to 3 undergoing capitolunate fusion or four-corner fusion between 2013 and 2019 were included. Sixty-three patients (34 with capitolunate fusion, 29 with four-corner fusion) were included. Patient demographics were similar between groups. Patient-Rated Wrist Hand Evaluation questionnaire score, visual analog scale pain score, grip strength, range of motion, and complications were measured at baseline and 3 months and 12 months postoperatively. Complications (i.e., nonunion, hardware migration, conversion to wrist arthrodesis, or arthroplasty) were determined. RESULTS: A significant difference in Patient-Rated Wrist Hand Evaluation or visual analog scale pain score at 3 and 12 months postoperatively between the capitolunate fusion and four-corner fusion groups was not found. There were no differences in grip strength between patient groups preoperatively or 12 months postoperatively. At 12 months postoperatively, capitolunate fusion patients had better flexion compared with that in the four-corner fusion group (p = 0.002); there were no differences in complications and reoperation rates between groups. CONCLUSIONS: Capitolunate fusion and four-corner fusion were comparable in terms of functional scores (i.e., Patient-Rated Wrist Hand Evaluation and visual analog scale pain scores) and complication scores. Capitolunate fusion showed favorable wrist mobility compared with four-corner fusion in treatment of midcarpal osteoarthritis. Capitolunate fusion advantages include use of less material, less need for bone-graft harvesting, and easier reduction of the lunate during fixation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Most patients with a clinically suspected scaphoid fracture and normal initial radiograph are unnecessarily treated. Previously developed prediction rules using demographic and clinical risk are unable to accurately predict occult fractures. Adding other risk factors could enhance this. Therefore, we aim to explore if there are morphological risk factors of the wrist for sustaining a scaphoid fracture.We retrospectively included adult patients with a clinically suspected scaphoid fracture between 2013 and 2019 in our case-control study. There were 82 patients with a scaphoid fracture and 158 patients with a wrist contusion. Morphological risk factors were identified using statistical shape modelling (SSM) and linear measurements. Independent wrist shape variations on posteroanterior and lateral radiographs were captured in modes using SSM. Associations between outcomes and a scaphoid fracture were explored using logistic regression and the reliability was assessed.Of the 15 posteroanterior modes and 8 lateral modes identified and linear measurements performed, 1 PA mode was associated with a scaphoid fracture (PA mode 4; OR 1.40, CI 1.04-1.93, p = 0.031). We described this mode as an ulna plus and narrower distal radius with more volar tilt and radial inclination. The reliability of the posteroanterior modes and linear measurements was mostly good/excellent and moderate/poor for the lateral modes.There was one complex wrist shape significantly associated with a scaphoid fracture. Since the association was weak and the shape is difficult to identify radiographs, we believe this morphological risk factor would not enhance identifying occult scaphoid fractures in the future.

Last decades there is an increased tendency of performing surgery on displaced distal radius fractures. However, it is unclear whether this affects the development of osteoarthritis. This study aims to determine the relation between anatomical position, radiological osteoarthritis and functional outcome of the elderly wrist, 10–15 years after a distal radius fracture. 173 patients between the age of 50 and 70 at time of trauma were included in this retrospective cohort study with a 10–15-year follow-up. Based on the reassessed initial X-rays, the patients were placed into 4 groups (1: anatomical, 2a: acceptable, 2b: current operative indication but treated conservative, 2c: operative indication and operated). Functional outcome was measured, questionnaires were answered, and new bilateral X-rays of the wrist were obtained. Factors influencing osteoarthritis, the difference in osteoarthritis between the groups and the difference between the fractured and non-fractured wrists were studied. Group 2b showed a significantly higher degree of osteoarthritis in comparison with the contralateral wrist. In the other groups, this difference was not observed. We found no significant difference in OA and functional outcomes between the groups. The degree of osteoarthritis of the non-fractured wrist appeared to be highly associated with osteoarthritis of the fractured wrist. The results of this study showed that the degree of radiocarpal osteoarthritis is higher in conservatively treated patients that should have been operated on according to current guidelines in comparison with patients without an indication for surgery. This might suggest that our current guidelines can be effective in prevention of posttraumatic osteoarthritis. However, the effect on the functional outcome is very limited. Since the degree of radiocarpal osteoarthritis of the non-fractured wrist appeared to be highly associated with the degree of osteoarthritis of the fractured wrist, future studies should always assess osteoarthritis of both wrists in order to study the real posttraumatic effect of a fracture.

The aim of this study was to determine the difference in functional outcomes after open reduction and internal fixation (ORIF) with and without arthroscopic debridement in adults with displaced intra-articular distal radius fractures. In this multicentre trial, 50 patients were randomized between ORIF with or without arthroscopic debridement. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE) score. Secondary outcome measures were Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, pain scores, range of wrist motion, grip strength, and complications. Median PRWE was worse for the intervention group at 3 months and was equal for both groups at 12 months. The secondary outcome measures did not show consistent patterns of differences at different time-points of follow-up. We conclude that patients treated with additional arthroscopy to remove intra-articular hematoma and debris did not have better outcomes than those treated with ORIF alone. We therefore do not recommend arthroscopy for removal of hematoma and debris when surgically fixing distal radius fractures. Level of evidence: I

Background Injury of the scapholunate interosseous ligament is the most frequently diagnosed cause of carpal instability and can be treated with a Mayo capsulodesis procedure. During this procedure, a radially based flap of the dorsal radiocarpal complex is attached to the lunate. The procedure attempts to reduce flexion of the scaphoid and restore the scapholunate relationship by crossing the scapholunate interval. To obtain a better understanding of the biomechanical properties and possibly improve the postoperative rehabilitation process, a better understanding of the reconstructions biomechanics is needed. Methods Ten dorsal intercarpal ligament capsulodesis were performed on embalmed wrists to assess the flexion elongation relation at the dorsal intercarpal reconstruction, the dorsal intercarpal complex, and the type of failure during flexion of the wrist. Results The mean elongation of the dorsal intercarpal reconstruction at 70-degree flexion was 0.8 mm. During flexion, the dorsal intercarpal reconstruction showed no ligament tears or failure of the bone anchor. The mean elongation of the dorsal intercarpal complex was 3.9 mm at 70 degrees. During subsequent repeated flexion, four sutures to connect the dorsal intercarpal complex to the surrounding tissue loosened between 55 and 60 degrees. Conclusions These findings suggest that capsulodesis can safely withstand flexion of the wrist until 50 degrees. Clinical Relevance Clinicians should consider the opportunity to start early with controlled active motion. Level of Evidence Not applicable.

Background The diagnosis and treatment of scapholunate interosseous ligament (SLIL) pathology is debated and notably variable. This study assessed the influence of diagnostic arthroscopy on treatment recommendations and the interobserver reliability of the arthroscopic classification of SLIL pathology. Methods The influence of diagnostic arthroscopy on treatment recommendations and the reliability of the arthroscopic classification of SLIL pathology were tested in a survey-based experiment. Seventy-seven surgeons evaluated 16 scenarios of people with wrist pain with variation in symptoms, scaphoid shift, time of symptom onset, and MRI appearance of the SLIL. Participants were randomized to view or not to view diagnostic wrist arthroscopy. Factors associated with recommendation for repair, capsulodesis, or tenodesis were analyzed. Results Viewing arthroscopic videos was associated with both offering surgery and a more reconstructive option. Other factors independently associated with recommendation for surgery included greater pain intensity and activity intolerance, women surgeons, an asymmetric scaphoid shift, and a recent onset of symptoms. The interobserver reliability of SLIL classification was slight. Conclusions Diagnostic arthroscopy leads to more surgery, and more invasive surgery, in spite of unreliable assessment of pathology. Clinical Relevance This points to the need to measure the potential benefits and harms of diagnostic wrist arthroscopy among people with wrist pain and no clear diagnosis on interview, examination, and radiographs. Level of Evidence Not applicable.

IntroductionHand osteoarthritis (OA) is a common joint disorder in the adult population. No cure for hand OA is known yet, but treatment aims to reduce symptoms. Non-surgical and non-pharmacological therapy interventions can include splinting, patient education, and strengthening and range of movement exercises. However, it is still unclear which treatment is most beneficial for which patient. This study aims to identify subgroups of patients with hand OA that benefit most from the different non-surgical and non-pharmacological treatments.Methods and analysisWe will conduct an individual patient data (IPD) meta-analysis by extracting IPD of eligible published randomised controlled trials (RCTs). A systematic literature search through Embase, Medline and Cochrane was performed on 8 February 2021. The primary outcome will be hand pain, and our secondary outcomes are objective and subjective hand physical functions. Subgroups include age, sex, body mass index, hypermobility and other comorbidities, pain medication, occupation, baseline pain, erosive OA, type and the number of hand joints involved, radiological severity of OA, and duration of symptoms. IPD of RCTs with homogeneous treatment interventions will be pooled and analysed using a two-stage approach to evaluate treatment effect on different subgroups.Ethics and disseminationNo new data will be collected, so research ethical or governance approval is exempt. Findings will be disseminated via national and international conferences, publications in peer-reviewed journals, and summaries posted on websites accessed by the public and clinicians.

BACKGROUND: Short-term follow-up studies have shown that reduced metaphyseal both-bone forearm fractures in children should be treated with K-wires to prevent redisplacement and inferior functional results. Minimum 5-year follow-up studies are limited. Range of motion, patient-reported outcome measures, and radiographic parameters at minimum 5-year follow-up should be evaluated because they could change insights into how to treat pediatric metaphyseal forearm fractures. QUESTIONS/PURPOSES: (1) Does K-wire stabilization of reduced metaphyseal both-bone forearm fractures in children provide better forearm rotation at minimum 5-year follow-up? (2) Do malunions (untreated redisplaced fractures) of reduced metaphyseal both-bone forearm fractures in children induce worse functional results? (3) Which factors lead to limited forearm rotation at minimum 5-year follow-up? METHODS: We analyzed the extended minimum 5-year follow-up of a randomized controlled trial in which children with a reduced metaphyseal both-bone forearm fracture were randomized to either an above-elbow cast (casting group) or fixation with K-wires and an above-elbow cast (K-wire group). Between January 2006 and December 2010, 128 patients were included in the original randomized controlled trial: 67 in the casting group and 61 in the K-wire group. For the current study, based on an a priori calculation, it was determined that, with an anticipated mean limitation in prosupination (forearm rotation) of 7° ± 7° in the casting group and 3° ± 5° in the K-wire group, a power of 80% and a significance of 0.05, the two groups should consist of 50 patients each. Between January 2014 and May 2016, 82% (105 of 128) of patients were included, with a mean follow-up of 6.8 ± 1.4 years: 54 in the casting group and 51 in the K-wire group. At trauma, patients had a mean age of 9 ± 3 years and had mean angulations of the radius and ulna of 25° ± 14° and 23° ± 18°, respectively. The primary result was limitation in forearm rotation. Secondary outcome measures were radiologic assessment, patient-reported outcome measures (QuickDASH and ABILHAND-kids), handgrip strength, and VAS score for cosmetic appearance. Assessments were performed by the first author (unblinded). Multivariable logistic regression analysis was performed to analyze which factors led to a clinically relevant limitation in forearm rotation. RESULTS: There was a mean limitation in forearm rotation of 5° ± 11° in the casting group and 5° ± 8° in the K-wire group, with a mean difference of 0.3° (95% CI -3° to 4°; p = 0.86). Malunions occurred more often in the casting group than in the K-wire group: 19% (13 of 67) versus 7% (4 of 61) with an odds ratio of 0.22 for K-wiring (95% CI 0.06 to 0.80; p = 0.02). In patients in whom a malunion occurred (malunion group), there was a mean limitation in forearm rotation of 6° ± 16° versus 5° ± 9° in patients who did not have a malunion (acceptable alignment group), with a mean difference 0.8° (95% CI -5° to 7°; p = 0.87). Factors associated with a limited forearm rotation ≥ 20° were a malunion after above-elbow casting (OR 5.2 [95% CI 1.0 to 27]; p = 0.045) and a refracture (OR 7.1 [95% CI 1.4 to 37]; p = 0.02). CONCLUSION: At a minimum of 5 years after injury, in children with a reduced metaphyseal both-bone forearm fracture, there were no differences in forearm rotation, patient-reported outcome measures, or radiographic parameters between patients treated with only an above-elbow cast compared with those treated with additional K-wire fixation. Redisplacements occurred more often if treated by an above-elbow cast alone. If fracture redisplacement is not treated promptly, this leads to a malunion, which is a risk factor for a clinically relevant (≥ 20°) limitation in forearm rotation at minimum 5-year follow-up. Children with metaphyseal both-bone forearm fractures can be treated with closed reduction and casting without additional K-wire fixation. Nevertheless, a clinician should inform parents and patient about the high risk of fracture redisplacement (and therefore malunion), with risk for limited forearm rotation if left untreated. Weekly radiographic monitoring is essential. If redisplacement occurs, remanipulation and fixation with K-wires should be considered based on gender, age, and direction of angulation. Future research is required to establish the influence of (skeletal) age, gender, and the direction of malunion angulation on clinical outcome. LEVEL OF EVIDENCE: Level I, therapeutic study.

Purpose: This study compared the interobserver agreement of arthroscopic classification of suspected scapholunate interosseous ligament (SLIL) pathology with and without midcarpal arthroscopy to help inform diagnostic strategies. It also measured the association of midcarpal arthroscopy with recommendations for reconstructive surgery. The association of midcarpal arthroscopy with the type of surgery recommended was also studied. Methods: Fourteen consecutive videos of diagnostic radiocarpal and midcarpal wrist arthroscopy for suspected SLIL pathology were selected. An international survey-based experiment was conducted among upper extremity surgeons of the Science of Variation Group. Participants were randomized to view either radiocarpal arthroscopic videos or radiocarpal and midcarpal videos. Surgeons rated SLIL pathology according to the Geissler classification and recommended surgical or nonsurgical treatment. If surgical treatment was recommended, they indicated the type of procedure. Results: The interobserver agreement for the Geissler classification was slight/fair for observers who reviewed midcarpal and radiocarpal videos and for those who viewed radiocarpal videos only. Viewing midcarpal videos was associated with higher pathology grades, the recommendation for reconstructive surgery, and a preference for tenodesis over scapholunate ligament repair. Conclusions: Diagnostic wrist arthroscopy for a wrist with normal radiological alignment has poor interobserver agreement. Clinical relevance: The pursuit of a pathology that accounts for wrist symptoms in a nonspecific interview and examination and normal radiographs is understandable; however, the low reliability of the scapholunate pathology of diagnostic arthroscopy might be associated with more potential harm than benefit.

Purpose: To identify predictors of a true scaphoid fracture among patients with radial wrist pain following acute trauma, train 5 machine learning (ML) algorithms in predicting scaphoid fracture probability, and design a decision rule to initiate advanced imaging in high-risk patients. Methods: Two prospective cohorts including 422 patients with radial wrist pain following wrist trauma were combined. There were 117 scaphoid fractures (28%) confirmed on computed tomography, magnetic resonance imaging, or radiographs. Eighteen fractures (15%) were occult. Predictors of a scaphoid fracture were identified among demographics, mechanism of injury and examination maneuvers. Five ML-algorithms were trained in calculating scaphoid fracture probability. ML-algorithms were assessed on ability to discriminate between patients with and without a fracture (area under the receiver operating characteristic curve), agreement between observed and predicted probabilities (calibration), and overall performance (Brier score). The best performing ML-algorithm was incorporated into a probability calculator. A decision rule was proposed to initiate advanced imaging among patients with negative radiographs. Results: Pain over the scaphoid on ulnar deviation, sex, age, and mechanism of injury were most strongly associated with a true scaphoid fracture. The best performing ML-algorithm yielded an area under the receiver operating characteristic curve, calibration slope, intercept, and Brier score of 0.77, 0.84, −0.01 and 0.159, respectively. The ML-derived decision rule proposes to initiate advanced imaging in patients with radial-sided wrist pain, negative radiographs, and a fracture probability of ≥10%. When applied to our cohort, this would yield 100% sensitivity, 38% specificity, and would have reduced the number of patients undergoing advanced imaging by 36% without missing a fracture. Conclusions: The ML-algorithm accurately calculated scaphoid fracture probability based on scaphoid pain on ulnar deviation, sex, age, and mechanism of injury. The ML-decision rule may reduce the number of patients undergoing advanced imaging by a third with a small risk of missing a fracture. External validation is required before implementation. Type of study/level of evidence: Diagnostic II.

Forearm fractures are the most common fractures among children. When treating pediatric forearm fractures, the basic principle is to accurately align, angularly and rotationally, both the radius and the ulna. Both bone diaphyseal forearm fractures which are minimally displaced can be treated nonoperatively. Displaced fractures need reduction and unstable fractures after reduction need additional fixation.

Distal forearm fractures are one of the most common fractures accounting for about 40% of all long bone fractures in children. A peak incidence is seen in girls between 10 and 12 years and in boys between 12 and 14 years. The key difference between the child's bone and that of an adult is the physis that needs to be taken into account for the treatment of these fractures. Physeal injuries are very common in children, making up 15% of all distal forearm fractures. The distal physis of the radius accounts for 75% of the growth of the radius and 40% of the growth of the entire upper extremity, thereby remodeling potential in the distal forearm is highest in the sagittal plane because of the highest range of motion in this plane (flexion-extension). Multiple attempts at reduction, and late re-manipulation more than 7 days post injury are known risk factors for physeal growth arrest. Remodeling potential of pediatric distal radius fractures (DRFs) makes the choice between nonoperative treatment and operative treatment more complex than in the adult population.

IntroductionTreatment of distal radius fractures (DRFs) aims to restore anatomic position of the fracture fragments and congruity of the articular surface to optimise functional outcomes and prevent osteoarthritis in the long term. While ligament injury of the wrist is often associated with DRFs and sole ligament injuries of the wrist lead to osteoarthritis, it is plausible that concomitant ligament injury in DRFs may aggravate degenerative changes of the wrist. The relationship between concomitant ligament injury and post-traumatic osteoarthritis in patients with DRFs is unclear. This study aims to identify the types of associated ligament injury in patients with a DRF and to elucidate the association of ligament injury on the development of post-traumatic osteoarthritis.Methods and analysisThis protocol is written in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P) guidelines. An electronic search in MEDLINE, Embase, Web of Science, Cochrane Central Register of Trials and Google Scholar has been created and performed by a Health Sciences librarian with expertise in systematic review searching. Original research articles in English literature, which report on concomitant ligament injury of the wrist in relation to post-traumatic osteoarthritis, patient-reported outcome measures or clinician-reported outcome measures in patients (aged ≥18 years) with DRFs will be included. Two reviewers will independently screen and appraise articles and perform data extraction. In case of any disagreements, a third reviewer will be consulted. A systematic qualitative synthesis will be performed using text and tables.Ethics and disseminationNo ethical approval is required, since this is a protocol for a systematic review. The systematic review will be submitted for publication in a peer-reviewed scientific journal and for presentation at relevant conferences.PROSPERO registration numberCRD42020165007.

IntroductionSome scaphoid fractures become visible on radiographs weeks after a trauma which makes normal radiographs directly after trauma unreliable. Untreated scaphoid fractures can lead to scaphoid non-union progressing to osteoarthritis. Therefore, the general treatment for patients with a clinically suspected scaphoid fracture and normal initial radiographs is immobilisation with below-elbow cast for 2 weeks. However, most of these patients are treated unnecessarily because eventually less than 10% of them are diagnosed with an occult scaphoid fracture. To reduce overtreatment and costs as a result of unnecessary cast treatment in patients with a clinically suspected scaphoid fracture and normal initial radiographs, we designed a study to compare below-elbow cast treatment with supportive bandage treatment. We hypothesise that the functional outcome after 3 months is not inferior in patients treated with supportive bandage compared to patients treated with below-elbow cast, but with lower costs in the supportive bandage group.Methods and analysisThe SUSPECT study is an open-labelled multicentre randomised controlled trial with non-inferiority design. A total of 180 adult patients with a clinically suspected scaphoid fracture and normal initial radiographs are randomised between two groups: 3 days of supportive bandage or 2 weeks of below-elbow cast. We aim to evaluate the functional outcome and cost-effectiveness of both treatments. The primary outcome is the functional outcome after 3 months, assessed with the Quick Disability of the Arm, Shoulder and Hand score. Secondary outcomes include functional outcome, recovery of function, pain, patient satisfaction, quality of life and cost-effectiveness measured by medical consumption, absence from work or decreased productivity.Ethics and disseminationThe Medical Ethics Committee of the Erasmus MC Medical Centre, Rotterdam, approved the study protocol (MEC-2017-504). We plan to present the results after completion of the study at (inter)national conferences and publish in general peer-reviewed journals.Trial registration numberNL6976.

A 65-year-old woman, who had been suffering from erosive rheumatoid arthritis, presented with swollen shoulders. Also, she experienced a weary feeling in her left arm. An MRI scan of the left shoulder showed multiple nodules ('rice bodies') in the subacromial-subdeltoid bursa. We extracted the nodules via a deltopectoral approach, after which the symptoms disappeared.

Background In the past several years, an increase in open reduction and internal fixation (ORIF) for intra-articular distal radius fractures has been observed. This technique leads to a quicker recovery of function compared to non-operative treatment. However, some patients continue to have a painful and stiff wrist postoperatively. Arthroscopically assisted removal of intra-articular fracture haematoma and debris may improve the functional outcomes following operative treatment of intra-articular distal radius fractures. The purpose of this randomised controlled trial is to determine the difference in functional outcome, assessed with the Patient-Rated Wrist Evaluation (PRWE) score, after ORIF with and without an additional wrist arthroscopy in adult patients with displaced complete articular distal radius fractures. Methods In this multicentre trial, adult patients with a displaced complete articular distal radius fracture are randomised between ORIF with an additional wrist arthroscopy to remove fracture haematoma and debris (intervention group) and conventional fluoroscopic-assisted ORIF (control group). The primary outcome is functional outcome assessed with the PRWE score after three months. Secondary outcomes are wrist function assessed with the Disability of the Arm, Shoulder and Hand (DASH) score, postoperative pain, range of motion, grip strength, complications and cost-effectiveness. Additionally, in the intervention group, the quality of reduction, associated ligamentous injuries and cartilage damage will be assessed. A total of 50 patients will be included in this study. Discussion Although ORIF of intra-articular distal radius fractures leads to a quicker resume of function compared to non-operative treatment, some patients continue to have a painful and stiff wrist postoperatively. We hypothesise that, due to the removal of fracture haematoma and debris by an additional arthroscopy, functional outcomes will be better compared to the non-arthroscopically treated group. Trial registration ClinicalTrials.gov, NCT02660515. Registered on 13 January 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2409-2) contains supplementary material, which is available to authorized users.

The aim of this study was to identify predictors of a superior functional outcome after corrective osteotomy for paediatric malunited radius and both-bone forearm fractures. We performed a systematic review and meta-analysis of individual participant data, searching databases up to 1 October 2016. Our primary outcome was the gain in pronosupination seen after corrective osteotomy. Individual participant data of 11 cohort studies were included, concerning 71 participants with a median age of 11 years at trauma. Corrective osteotomy was performed after a median of 12 months after trauma, leading to a mean gain of 77° in pronosupination after a median follow-up of 29 months. Analysis of variance and multiple regression analysis revealed that predictors of superior functional outcome after corrective osteotomy are: an interval between trauma and corrective osteotomy of less than 1 year, an angular deformity of greater than 20° and the use of three-dimensional computer-assisted techniques. Level of evidence: II

Introduction: Traumatic bowing is a commonly missed diagnosis on which only little information is available, inadequate treatment can cause permanent function loss. Method: A systematic review would determine what the effect is of treatment of traumatic bowing of the lower arm in children on the functional outcome. A search on Embase, Medline, Web of Science, Scopus, Cochrane, Pubmed publisher, CINAHL and Google scholar, last accessed at the 15th of May 2016. Intervention of interest was treatment; with reduction, reduction and cast or cast only. The primary outcome measure was (I) function; pro and supination, (II) posttraumatic function, (III) posttreatment function and (IV) residual bowing. Results: Five articles were included. Treatment by reduction only showed a normal function, 4 weeks to 8 weeks of cast and reduction followed by cast, both resulted in 0 degrees to 20 degrees residual of pronation loss. Discussion: The treatment was overall well tolerated, had a direct effect and lead to faster restore of function. It is unclear to what amount of bowing can be accepted without any loss of function. But in view of the few complications and good results for reduction, the overall opinion is to reduce all significant bowing fractures of the lower arm in children with limited function.

Introduction: Although limitation of pronation/supination following both-bone forearm fractures in children is often attributed to an angular malunion, no clinical study has compared pronation/supination and angular malalignment of the same child by analysis of prospectively collected clinical data. Aim: The purpose of this trial is to explore whether limitation of pronation/supination can be predicted by the degree of angular malalignment in children who sustained a both-bone forearm fracture. Methods: In four Dutch hospitals, children aged = 16 degrees had a 60% chance. Children with diaphyseal both-bone forearm fractures with

Introduction: Both-bone forearm fractures in children frequently result in a limitation of pronation/supination, which hinders daily activities. The purpose of this prospective multicentre study was to investigate which clinical factors are related to the limitation of pronation/supination in children with a both-bone forearm fracture. Methods: In four Dutch hospitals, consecutive children (= 208) and several clinical factors. Results: A group of 410 children with both-bone forearm fractures were included, of which 10 children missed the final examination (follow-up rate of 97.6%). We found that a re-fracture (odds ratio (OR) 11.7, 95% confidence interval (CI) 1.2; 118.5), a fracture in the diaphysis (OR 3.3, 95% CI 1.4; 7.9) and less physiotherapy during follow-up (OR 0.90, 95% CI 0.82; 0.98) were independently associated with a limitation of pronation/supination of 208 or more. Conclusions: These findings imply that a re-fracture and a diaphyseal located fracture were associated independently of each other with a limitation of pronation/supination in children with a both-bone forearm fracture. Furthermore, in children with severe limitation extensive physiotherapy is associated with better functional outcome. (C) 2013 Elsevier Ltd. All rights reserved.

Although both-bone forearm fractures in children may result in severe limitation of forearm rotation, finding the cause remains a diagnostic challenge. This study tries to evaluate the role of rotational malunion, bony impingement and contractures of the interosseous membrane. Children (5–16 years) who suffered from a both-bone forearm fracture in diaphysis or distal metaphysis with a limitation of pronation/supination ≥40° at ≥6 months after trauma were included for analysis with conventional radiographs, computed tomography (CT) and magnetic resonance imaging (MRI). A total of 410 children with a both-bone forearm fracture were prospectively followed in four Dutch hospitals. At a median of 205 days, 7.3 % suffered from a limitation of pronation/supination ≥40°. 14 children were included (median limitation of 40°) and the radiographs revealed a median maximum angular malunion of 16°. CT analysis showed rotational malunion of both radius (median 19°) and ulna (median 9°). MRI analysis revealed neither bony impingement nor contractures of the interosseous membrane. Three-dimensional imaging of children with a severe limitation of pronation/supination after a both-bone forearm fracture revealed rotational malunions of both radius and ulna without bony impingement or soft tissue contractures. Prospective multicenter study, Level 2.

Introduction: Displaced metaphyseal both-bone fractures of the distal forearm are generally reduced and stabilised by an above-elbow cast (AEC) with or without additional pinning. The purpose of this study was to find out if re-displacement of a reduced stable metaphyseal both-bone fracture of the distal forearm in a child could be prevented by stabilisation with Kirschner wires. Methods: Consecutive children aged

This multicentre randomised controlled trial was designed to explore whether 6 weeks above-elbow cast (AEC) or 3 weeks AEC followed by 3 weeks below-elbow cast (BEC) cause similar limitation of pronation and supination in non-reduced diaphyseal both-bone forearm fractures in children. Children were randomly allocated to 6 weeks AEC or to 3 weeks AEC followed by 3 weeks BEC. The primary outcome was limitation of pronation and supination after 6 months. The secondary outcomes were re-displacement of the fracture, complication rate, limitation of flexion and extension of wrist and elbow, cast comfort, cosmetics, complaints in daily life and assessment of radiographs. A group of 23 children was treated with 6 weeks AEC and 24 children with 3 weeks AEC and 3 weeks BEC. The follow-up rate was 98 % with a mean follow-up of 7.0 months. The mean limitation of pronation and supination was 23.3 +/- A 22.0 for children treated with AEC and 18.0 +/- A 16.9 for children treated with AEC and BEC. The other study outcomes were similar in both groups. Early conversion to BEC is safe in the treatment of non-reduced diaphyseal both-bone forearm fractures in children. Multicentre randomised controlled trial, Level II.

Minimally displaced metaphyseal both-bone fractures of the distal forearm in children are often treated with an above-elbow cast (AEC). Treatment with a below-elbow cast (BEC) could give more comfort, but might lead to fracture displacement reducing pronation and supination. Because this has not been systematically investigated, we set up a randomised multicentre study. The purpose of this study was to find out whether BEC causes equal limitation of pronation and supination but with higher comfort level, compared with AEC.In four hospitals, consecutive children aged16 (mean 7.1) years with a minimally displaced metaphyseal both-bone fracture of the distal forearm were randomised to 4 weeks BEC (n=35) or 4 weeks AEC (n=31). Primary outcome was limitation of pronation and supination 6 months after initial trauma. The secondary outcomes were cast comfort, limitation of flexion/extension of wrist/elbow, complications, cosmetics, complaints, and radiological assessment.A group of 35 children received BEC and 31 children received AEC. All children attended for the final examination at a mean follow-up of 7.0 months (range 5.0-11.6 months). Limitation of pronation and supination 6 months after initial trauma showed no significant difference between the two groups [4.4° (± 5.8) for BEC and 5.8° (± 9.8) for AEC]. Children treated with BEC had significantly higher cast comfort on a visual analogue scale [5.6 (± 2.7) vs. 8.4 (± 1.4)] and needed significantly less help with dressing (8.2 days vs. 15.1 days). Six complications occurred in the BEC group and 14 in the AEC group. Other secondary outcomes were similar between the two groups.Children with minimally displaced metaphyseal both-bone fractures of the distal forearm should be treated with a below-elbow cast.

Background and purpose Activated platelets release a cocktail of growth factors, some of which are thought to stimulate repair. We investigated whether the use of autologous platelet gel (PG) in total knee arthroplasty (TKA) would improve wound healing and knee function, and reduce blood loss and the use of analgesics. Patients and methods 102 patients undergoing TKA were randomly assigned to a PG group (n = 50) or to a control (C) group (n = 52). The primary analysis was based on 73 participants (PG: 32; C: 41) with comparison of postoperative wound scores, VAS, WOMAC, knee function, use of analgesics, and the pre- and postoperative hemoglobin values after a follow-up of 3 months. 29 participants were excluded due to insufficient data. Results The characteristics of the protocol-compliant patients were similar to those of the patients who were excluded. Analysis was per protocol and focused on the remaining 73 patients. At baseline and after 3 months of follow-up, there were no statistically significant differences between both groups regarding age, height, weight, sex, side of operation, platelet count, hemoglobin values, severity of complaints (WOMAC), and level of pain. Interpretation In our patients undergoing TKA, application of PG to the wound site did not promote wound healing. Also, we found that PG had no effect on pain, knee function, or hemoglobin values.

We present a case of symptomatic, incomplete bony carpal coalition between capitate and trapezoid. We describe previous case reports and possible therapeutic options.

Treatment of displaced paediatric distal forearm fractures is not always successful. Re-occurrence of angular deformity is a frequent complication. No consensus exists when to perform secondary manipulations. The purpose of this study was to analyse the long-term outcome of re-angulated paediatric forearm fractures to determine if re-manipulations can be avoided. Children who underwent closed reduction for distal forearm fractures and presented with re-angulation at follow-up were included in this retrospective cohort study. We compared those that were re-manipulated to those managed conservatively. Re-angulation was defined as ≥15° of angulation on either the AP or lateral view. Children were reviewed after 1–8 years post injury. Outcome measures were residual angulation on radiographs, active range of motion, grip strength, Visual Analogue Scales (satisfaction, cosmetics and pain) and the ABILHANDS-kids questionnaire. Sixty-six children (mean age of 9.6 years) were included. Twenty-four fractures were re-manipulated and 42 fractures had been left to heal in angulated position. At time of re-angulation, children

A 24-year-old woman with Ehlers-Danlos syndrome visited the emergency department because of a post-traumatic painful and swollen left elbow with impaired function. A plain radiograph showed chronic luxation of the radial head with impression in the humeral capitellum. The clinical presentation of chronic luxation of the radial head is easily confused with that of an acute dislocation of the radial head, which may wrongly result in subsequent reduction.