Single-bone intramedullary fixation of unstable both-bone diaphyseal forearm fractures in children leads to increased re-displacement: a multicentre randomised controlled trial

INTRODUCTION

Both-bone diaphyseal forearm fractures in children can be stabilised without cast by a flexible intramedullary nail in both the radius and the ulna. Adequate results with single-bone fixation combined with a complementary cast are also reported. However, because those results are based on a selection of children, this trial investigates whether single-bone intramedullary fixation, compared with both-bone intramedullary fixation, results in similar pronation and supination in children with an unstable diaphyseal both-bone forearm fracture.

MATERIALS AND METHODS

In four Dutch hospitals, 24 consecutive children aged <16 years with a displaced unstable both-bone diaphyseal forearm fracture were randomly allocated to single-bone or both-bone intramedullary fixation. Primary outcome was limitation of pronation and supination 9 months after initial trauma. Secondary outcomes were limitation of flexion/extension of wrist/elbow, complication rate, operation time, cosmetics of the fractured arm, complaints in daily life, and assessment of radiographs.

RESULTS

Between January 2006 and August 2010, 11 children were randomised to single-bone fixation and 13 to both-bone fixation. In the both-bone fixation group, two fractures were stabilized by only one nail. In both groups, median limitation of pronation/supination at 9-month follow-up was 5°-10°. In both groups operation time was similar but in the single-bone fixation group cast immobilisation was longer (median of 37 vs. 28 days). In four children, re-displacement of the fracture occurred in those fractures without an intramedullary nail.

CONCLUSIONS

These results caution against the use of single-bone fixation in all both-bone forearm fractures. This method may lead to increased re-displacement and reduced clinical results.

Diagnostic accuracy of history taking, physical examination and imaging for phalangeal, metacarpal and carpal fractures: a systematic review update

BACKGROUND

The standard diagnostic work-up for hand and wrist fractures consists of history taking, physical examination and imaging if needed, but the supporting evidence for this work-up is limited. The purpose of this study was to systematically examine the diagnostic accuracy of tests for hand and wrist fractures.

METHODS

A systematic search for relevant studies was performed. Methodological quality was assessed and sensitivity (Se), specificity (Sp), accuracy, positive predictive value (PPV) and negative predictive value (NPV) were extracted from the eligible studies.

RESULTS

Of the 35 eligible studies, two described the diagnostic accuracy of history taking for hand and wrist fractures. Physical examination with or without radiological examination for diagnosing scaphoid fractures (five studies) showed Se, Sp, accuracy, PPV and NPV ranging from 15 to 100%, 13-98%, 55-73%, 14-73% and 75-100%, respectively. Physical examination with radiological examination for diagnosing other carpal bone fractures (one study) showed a Se of 100%, with the exception of the triquetrum (75%). Physical examination for diagnosing phalangeal and metacarpal fractures (one study) showed Se, Sp, accuracy, PPV and NPV ranging from 26 to 55%, 13-89%, 45-76%, 41-77% and 63-75%, respectively. Imaging modalities of scaphoid fractures showed predominantly low values for PPV and the highest values for Sp and NPV (24 studies). Magnetic Resonance Imaging (MRI), Computed Tomography (CT), Ultrasonography (US) and Bone Scintigraphy (BS) were comparable in diagnostic accuracy for diagnosing a scaphoid fracture, with an accuracy ranging from 85 to 100%, 79-100%, 49-100% and 86-97%, respectively. Imaging for metacarpal and finger fractures showed Se, Sp, accuracy, PPV and NPV ranging from 73 to 100%, 78-100%, 70-100%, 79-100% and 70-100%, respectively.

CONCLUSIONS

Only two studies were found on the diagnostic accuracy of history taking for hand and wrist fractures in the current review. Physical examination was of moderate use for diagnosing a scaphoid fracture and of limited use for diagnosing phalangeal, metacarpal and remaining carpal fractures. MRI, CT and BS were found to be moderately accurate for the definitive diagnosis of clinically suspected carpal fractures.

Anatomical study of the dorsal cutaneous branch of the ulnar nerve (DCBUN) and its clinical relevance in TFCC repair

The aim of this study was to define a detailed description of the dorsal cutaneous branch of the ulnar nerve (DCBUN) in particular in relevance to triangular fibrocartilage complex (TFCC) repairs. In 20 formalin-embalmed arms, the DCBUN was dissected, and the course in each arm was mapped and categorized. Furthermore, the point of origin of the DCBUN, that is, from the ulnar nerve in association with the ulnar styloid process, was defined. Finally, the distance between the ulnar styloid process and the branching of the radial-ulnar communicating branch (RUCB) and the first branch of DCBUN was measured. The distance between the origin of the DCBUN in relation to the ulnar styloid process ranges from 55 to 111 mm (mean 87 mm; STD 14 mm). The distance between the ulnar styloid process and the RUCB ranges from 1 to 54 mm (mean 19 mm; STD 12 mm). Finally, the distance between the ulnar styloid process and the lateral distal branch shows a range of -6 to 28 mm (mean 10 mm; STD 9 mm). In general, three dorsal digital nerves (medial, intermediate, and lateral branch), run at the dorsal ulnar aspect of the hand. The RUCB is often less abundant and shows a large amount of variation. No complete safe zone could be identified; the course of the DCBUN suggests a longitudinal incision for the 6R portal. In fact, a more dorsal incision also prevents damage to the main branches of the DCBUN.

The open-modified Bankart procedure: long-term follow-up 'a 16-26-year follow-up study'

INTRODUCTION

A Bankart procedure is a surgical technique for the repair of recurrent shoulder joint dislocations. This study reports the long-term results of the 'open'-modified Bankart procedure.

METHODS

We performed a retrospective cohort study in which patients are studied who had open-modified Bankart surgery for instability problems in the absence of a substantial osseous glenoid defect after a traumatic shoulder dislocation, 16-26 years ago, in a large regional hospital. Instability was measured with the Rowe and Oxford shoulder instability score. Furthermore, we measured physical functioning with the Constant-Murley score and the Dutch simple shoulder test. Pain was measured with the NRS for pain. Osteoarthritis was scored according the Samilson-Prieto score. Quality of life was measured with the SF-12 score. The operated shoulder was compared to the non-operated contralateral shoulder regarding instability and osteoarthritis.

RESULTS

39 patients were included with an average follow-up of 21 years (range 16-26 years). The number of patients with redislocations of their shoulder after surgery was 4 (10%). 23% of the study group described moments of subluxation or positive apprehension. Radiological signs of osteoarthritis were present in 20 shoulders (51%), of which 75% had grade 1 arthropathy according to the Samilson Prieto score. The incidence of osteoarthritis of the operated shoulder was significantly greater compared to the non-operated shoulder. The mean Rowe score was 85 points (25-100) and the Constant score 92 points (70-100).

CONCLUSION

We conclude that the open-modified Bankart procedure is a reliable surgical procedure with good long-term results, 16-26 years after surgery. However, it does not prevent the development of shoulder osteoarthritis, since a high number of patients had (mainly mild) radiological osteoarthritis.

Psychometric qualities of the patient rated Wrist/Hand evaluation (PRWHE) in dutch primary care patients with wrist complaints

Background

Knowledge on the course, disability and functionality of wrist complaints is still compendious in primary care guidelines, despite the high prevalence in primary care. Valid questionnaires can facilitate the monitoring of patients in primary care and research initiatives. In this study, we aimed to study the psychometric qualities of the Dutch version of the Patient Rated Wrist/Hand Evaluation (PRWHE-DLV) among adults with (sub)acute wrist complaints in primary care.

Methods

An observational cohort of 35 adults with (sub)acute wrist complaints in Dutch primary care was established. The content validity of the PRWHE-DLV was validated by assessing the floor and ceiling effects at baseline (T0). Reproducibility was assessed by the test-retest reliability between T0 and T1 (2–5 days after T0), using the Intra-class Correlation Coefficient. The construct validity was assessed based on the correlation between the PRWHE-DLV and the Quick-DASH, Physical Component Score (SF-12), VAS-function, Physical Functioning (SF-12), VAS-pain and Bodily Pain (SF-12) at T0. Responsiveness was defined as the ability of the PRWHE-DLV to measure change 3 weeks after T0 (internal) and the relation of these changes to clinically important outcomes (external).

Results

Psychometric qualities of the PRWHE-DLV demonstrated high content validity with no floor or ceiling effects, excellent reliability (Intra-class correlation coefficient = 0.90; 95% CI 0.80–0.95), high construct validity with the validated Quick-DASH and VAS score (r = 0.85 with Quick-DASH, r = 0.75 with VAS-function and r = 0.78 with VAS-pain) and high responsiveness.

Conclusion

The PRWHE-DLV provided reliable and adequate information for primary care clinical practice.

Congenital Bimelic Hypertrophy of the Hands

Congenital hypertrophy of the hand is a rare phenomenon. The condition is characterized by hypertrophy of muscles, varies in severity and has been reported under different names. Some patients also have aberrant muscles. Electromyography is unremarkable, and the signal intensity on MRI and ultrasound is normal. The etiology is unknown and does not seem to be confined to a peripheral nerve, part of the plexus or nerve root. The condition is assumed to be congenital. We report a 28-year-old male with asymmetric hypertrophy of both hands and give a review of the 4 other cases known so far.

Incidence of hand and wrist disorders in primary care: a retrospective cohort study

BACKGROUND

The incidence of different types of hand and wrist disorders in primary care is unknown since there are no specific encodings for it.

AIM

To determine the overall incidence and the incidence of specific types of hand and wrist disorders in primary care.

DESIGN & SETTING

A retrospective cohort study was undertaken, using a healthcare registration database from Dutch general practice, which contains medical records of more than 200 000 patients, and included approximately 25% of the population of the area of Rotterdam in The Netherlands.

METHOD

Patients aged ≥18 years with a new diagnosis of hand or wrist disorder from 1 January 2015-31 December 2019 were extracted using a search algorithm based on International Classification of Primary Care (ICPC) coding and search terms in free text.

RESULTS

The mean incidence over the study period of a hand disorder was 5.9 per 1000 persons-years and of a wrist disorder 0.3 per 1000 persons-years. The incidence of trigger finger or thumb, hand or finger fracture, tendon or ligament tendinopathy, mallet finger, and hand or finger ligament injury were 3 (95% confidence interval [CI] = 2.69 to 3.15), 1 (95% CI = 1.03 to 1.33), 1 (95% CI = 0.98 to 1.28), 0.6 (95% CI = 0.48 to 0.69), and 0.1 (95% CI = 0.06 to 0.14) per 1000 persons-years, respectively. The incidence of a wrist fracture and ligament injury were 0.2 (95% CI = 0.13 to 0.25) and 0.1 (95% CI = 0.04 to 0.12) per 1000 persons-years, respectively.

CONCLUSION

There is a large difference between the number of patients presenting to the GP with hand and wrist complaints and the number of hand and wrist diagnoses reported in the medical files. Introducing specific ICPC codes for different types of hand and wrist disorders could (potentially) lead to a more accurate registration of a diagnosis and determination of the incidence figures.

Increased temporal binding during voluntary motor task under local anesthesia

Temporal binding refers to a systemic bias in the perceived time interval between two related events, most frequently voluntary motor actions and a subsequent sensory effect. An inevitable component of most instrumental motor actions is tactile feedback. Yet, the role of tactile feedback within this phenomenon remains largely unexplored. Here, we used local anesthesia of the index finger to temporarily inhibit incoming sensory input from the finger itself, while participants performed an interval-estimation task in which they estimated the delay between a voluntary motor action (button press) and a second sensory event (click sound). Results were compared to a control condition with intact sensation. While clear binding was present in both conditions, the effect was significantly enhanced when tactile feedback was temporarily removed via local anesthesia. The results are discussed in light of current debates surrounding the underlying mechanisms and function of this temporal bias.

Incidence and management of mallet finger in Dutch primary care: a cohort study

BACKGROUND

A mallet finger (MF) is diagnosed clinically and can be managed in primary care. The actual incidence of MF and how it is managed in primary care is unknown.

AIM

To determine the incidence of MF in primary care and to obtain estimates for the proportions of osseous and tendon MF. An additional aim was to gain insight into the management of patients diagnosed with MF in primary care.

DESIGN & SETTING

A cohort study using a healthcare registration database from general practice in the Netherlands.

METHOD

Patients aged ≥18 years with a new diagnosis of MF from 1 January 2015-31 December 2019 were selected using a search algorithm based on International Classification of Primary Care (ICPC) coding.

RESULTS

In total, 161 cases of MF were identified. The mean incidence was 0.58 per 1000 person-years. A radiograph was taken in 58% (n = 93) of cases; 23% (n = 37) of cases had an osseous MF. The most applied strategies were referral to secondary care (45%) or conservative treatment in GP practice (43%). Overall, 7% were referred to a paramedical professional.

CONCLUSION

On average, a Dutch GP assesses ≥1 patient with MF per year. Since only a minimal number of patients required surgical treatment and a limited number of GPs requested radiography, the recommendation in the guidelines to perform radiography in all patients with MF should potentially be reconsidered. The purpose of requesting radiographs should not be to distinguish between a tendinogenic or osseous MF, but to assess whether there is a possible indication for surgery.

Unilateral fusion of the scaphoid and the trapezium

Fusion of the carpal bones is a rare anatomical abnormality, caused by a defect in the separation and cavitation during embryonic development. It has a prevalence of about 0.1% and most of the time, patients do not present with symptoms. Symptoms are usually caused by wear and tear of the ligaments attached to the fused carpal fragments. We present a case in which a woman aged 36 years experiences pain caused by a lunato-triquetral instability which in turn is caused by a unilateral complete fusion of the scaphoid and the trapezium. A unilateral complete fusion of the scaphoid and trapezium has not been reported before.

Diagnostic tests recommended for the clinical assessment of patients with wrist complaints, an e-Delphi study

BACKGROUND

Evidence-based practice for history-taking and physical examination in the evaluation of wrist complaints is limited.

PURPOSE

To create a set of recommended diagnostic tests for the clinical assessment of patients with undifferentiated wrist complaints.

STUDY DESIGN

An e-Delphi study, following the recommendations on conducting and reporting Delphi studies, was performed.

METHODS

In this e-Delphi study, a national multidisciplinary panel of experts was invited to inventory diagnostic tests, based on several case scenarios, for the probability diagnosis in patients (age ≥18 years) with undifferentiated wrist complaints. Four case scenarios were constructed and presented to the expert panel members, which differed in age of the patient (35 vs 65 years), location (radial vs ulnar), and duration (6 vs 10 weeks) of the complaints. In consecutive rounds, the experts were asked to rate the importance of the inventoried diagnostic tests. Finally, experts were asked to rank recommended diagnostic tests for each case scenario.

RESULTS

Merging all results, the following diagnostic tests were recommended for all case scenarios: ask whether a trauma has occurred, ask how the complaints can be provoked, ask about the localization of the complaints, assess active ranges of motion, assess the presence of swelling, assess the difference in swelling between the left and right, assess the deformities or changes in position of the wrist, and palpate at the point of greatest pain.

CONCLUSIONS

This is the first scientific study where experts clinicians recommended diagnostic tests when assessing patients with undifferentiated wrist complaints, varying in age of the patient (35 vs 65 years), location (radial vs ulnar), and duration (6 vs 10 weeks).