VOLCON: a randomized controlled trial investigating complications and functional outcome of volar plating vs casting of unstable distal radius fractures in patients older than 65 years.

BACKGROUND: Primary aim: to compare complications of operative vs non-operative treatment of unstable distal radius fractures (DRF) fulfilling national clinical guidelines for operative treatment. Secondary aim: to compare the functional outcomes. MATERIALS AND METHODS: A single-centre randomized controlled trial of unstable DRF. 50 patients: volar locking plate, 2 weeks casting + 3 weeks orthosis. 50 patients: 5 weeks casting. PRIMARY OUTCOME: complications assessed after 2 and 5 weeks and 6 and 12 months. SECONDARY OUTCOMES: Quick-DASH, PRWHE, range of motion, grip strength, EQ-5D-3L. RESULTS: 148 patients were screened from November 2019 to March 2021. 48 patients did not want to participate or were unable to participate in the follow-up. 100 patients were randomized and 85 patients were available for full analysis due to there being 4 deaths, 6 withdrawals, 1 wrong inclusion, 1 emigration, 1 refracture, 1 patient with compartment syndrome, and 1 who was advised to undergo surgery after being randomized to non-operative treatment. Median age was 74 years (range 65-92), 81 women/19 men, 42 right/58 left side, 87 retired, 11 smokers, 86 ASA class 1 or 2. Complication rates did not statistical significantly vary between the operative and non-operative group: 20.9% (9/43) vs 16.6% (7/42), p = 0.78 (Fisher's exact test). Complications were driven by sensory disturbances. Four reoperations were performed: two in the non-operative group: carpal tunnel syndrome; two in the operative group: one carpal tunnel syndrome, one protruding screw causing extensor tendon irritation. Mean difference in Quick-DASH varied from 2.3 (95% CI - 3 to 8) pre-injury to 4.2 (- 4 to 12) at 12 months. Quick-DASH and PRWHE were neither statistically nor clinically-relevant different between groups. CONCLUSIONS: Complication rates after operative and non-operative treatment of DRF were similar. Volar plating did not improve the functional outcome after 5 weeks, 6 months, and 12 months. These findings are in line with recent RCTs and mandate a revision of guidelines towards more conservative treatment. TAKE HOME MESSAGES: (1) consider non-operative treatment in elderly patients sustaining unstable DRFs; (2) choosing operative treatment in patients older than 65 years should not be the gold standard; (3) however, non-operative treatment still carries a risk for complications. LEVEL OF EVIDENCE: II. Trial registration Clinicaltrials.gov NCT03716661, registered 23rd Oct 2018; Published protocol PMC6599306.

A protocol for a single-center, single-blinded randomized-controlled trial investigating volar plating versus conservative treatment of unstable distal radius fractures in patients older than 65 years.

BACKGROUND: Distal radius fractures (DRF) are very common in elderly patients, who present at the Emergency Department. Surgical treatment with open reduction and internal fixation using volar locking plates is widely prevalent despite the lack of evidence proving its superiority to conservative treatment with closed reduction and plaster immobilization. The purpose of this study is to investigate whether conservative treatment is superior to volar plating in terms of number of complications and results in a comparable or superior functional outcome in patients ≥65 years. METHODS: In this single-center, single-blinded randomized-controlled trial, patients ≥65 years with distal radius fractures will be invited to participate. A total of 50 patients per treatment arm is required to provide 80% statistical power at a 5% alpha level assuming a difference of 20% in complication rate between operatively and conservatively treated patients. Primary outcome measures will be complication rate, Quick DASH score (Quick Disabilities of the Arm, Shoulder and Hand), PRWE (Patient rated Wrist evaluation), and range of motion of the wrist. Secondary outcome measures will be grip strength, pinch gauge, pain, use of pain medication EQ5D score (European Quality of life - 5 dimensions), standardized radiographs. One year of follow-up is planned with data collection at the day of injury, after 2 weeks, after 5 weeks, after 6 months, and after 12 months. An intention-totreat and per-protocol analysis will be performed. DISCUSSION: This prospective trial helps to clarify the best treatment strategy for displaced DRF patients ≥65 years. TRIAL REGISTRATION: This trial is approved by the Danish Scientific Ethical Committee (ID: 1-10-72-420-17) and registered at Clinicaltrials.gov (Trial registration number NCT03716661 ).

Hemiarthroplasty vs Total Hip Arthroplasty for the Management of Displaced Neck of Femur Fractures: A Systematic Review and Meta-Analysis.

BACKGROUND: Displaced femoral neck fractures (DFNF) are common and can be treated with osteosynthesis, hemiarthroplasty (HA), or total hip arthroplasty (THA). There is no consensus as to which intervention is superior in managing DFNF. METHODS: Studies were identified through a systematic search of the MEDLINE database, EMBASE database, and Cochrane Controlled Trials. Included studies were randomized or controlled trials (1966 to August 2018) comparing THA with HA for the management of DFNF. (https://www.crd.york.ac.uk/PROSPERO Identifier: CRD42018110057). RESULTS: Seventeen studies were included totaling 1364 patients (660 THA and 704 HA). THA was found to be superior to HA in terms of risk of reoperation, Harris Hip Score and Quality of Life (Short Form 36). Overall, the risk of dislocation was greater in THA group than HA in the first 4 years, after which there was no difference. There was no difference between THA and HA in terms of mortality or infection. CONCLUSION: Overall, THA appears to be superior to HA. THA should be the recommended intervention for DFNF in patients with a life expectancy >4 years and in patients younger than 80 years. However, both HA and THA are reasonable interventions in patients older than 80 years and with shorter life expectancy.

Tension band versus locking plate fixation for patella fractures - a protocol of a randomised controlled trial.

INTRODUCTION: Following surgical management of patella fractures, patients commonly report pain; difficulties with weight-bearing tasks such as walking, running and climbing stairs; and restrictions in quality of life. Recently, a locking plate system for surgical management of patella fractures has been introduced. To date, no studies have compared standard treatment with tension band wiring with locking plate fixation in a randomised study design. We aim to compare the one-year patient-reported Knee Injury and Osteoarthritis Outcome subscale scores (KOOS5-subscales) after standard care tension band fixation with locking plate fixation for patients with patella fractures. METHODS: This is a multicentre randomised and prospective clinical trial. A total of 122 patients will be included in the study, and the primary outcome will be the KOOS subscales at 12 months after surgery. CONCLUSIONS: Findings from the present study are expected to advance our understanding of outcome following surgical treatment of patella fractures. FUNDING: This study is funded, in part, by the Novo Nordisk Foundation, Denmark. CLINICALTRIALS: gov ID: NCT04891549.

Hemodynamic Instability After Axillary Artery Rupture Following Inferior Glenohumeral Joint Dislocation: A Case Report.

BACKGROUND Inferior shoulder dislocation is a rare type of glenohumeral joint dislocation. A serious complication to shoulder dislocation is axillary artery injury, which should be taken into consideration early to avoid potentially permanent damage. Literature on artery injury following inferior shoulder dislocation is sparse. CASE REPORT We report the case of a 71-year-old man with a traumatic inferior shoulder dislocation due to a fall. The patient had a medical history of stroke, and thus had a daily intake of 10 mg Warfarin. Previously, he had reported 2 anterior shoulder dislocations. The shoulder reduction was conducted under general anaesthesia after reduction with intravenous morphine sedation. Six hours after reduction, the patient showed signs of hemodynamic instability and a CT scan with contrast showed a suspected axillary artery rupture with a large hematoma in the right axilla. The artery rupture was confirmed with an arteriogram. The patient was successfully treated with an endovascular stent. After 3 months, the patient had normal neurovascular status in the right upper extremity and was continuing rehabilitation of the shoulder. CONCLUSIONS This case emphasizes the importance of proper recognition and awareness of artery injury after inferior shoulder dislocation. The symptoms of artery rupture after inferior shoulder dislocation can be immediate or have a late onset. The diagnostic modalities of CT scan with contrast or arteriogram should be performed with a low threshold of suspicion after reduction. With symptoms such as enlarging hematoma in the axilla, diminished radial and ulnar pulse, sudden pain from the axilla, or signs of hemodynamic instability after reduction, diagnostic modalities should be considered.

Mortality in patients with trochanteric hip fractures (AO/OTA 31-A) treated with sliding hip screw versus intramedullary nail: A retrospective national registry study of 9547 patients from the Danish Fracture Database.

BACKGROUND: Whether trochanteric hip fractures (AO/OTA 31-A) should be treated with an intramedullary nail (IMN) or sliding hip screw (SHS) is debated. Recent studies suggest an association between IMN and excess mortality rates compared to SHS, but higher quality studies fail to show this association. Furthermore, there is an increased usage of IMN with sparse evidence supporting this rise. Our aim was to compare mortality rates between IMN and SHS in patients with AO/OTA 31-A fractures. Secondarily, to investigate choice of implant in relation to fracture subtype. METHODS: This national registry study is based on data from the Danish Fracture Database (DFDB). Data were retrieved on patients aged ≥65 years treated for a non-pathological AO/OTA type 31-A fracture with IMN or SHS from January 1, 2012 to December 31, 2018. Data from DFDB were merged with data from the Danish Civil Registration System (CRS) for time of death. Mortality rates were recorded at 30 days, 90 days, and 1 year and presented as crude mortality and adjusted for age, gender, ASA-class, and AO/OTA-subtype. RESULTS: A total of 9,547 patients were included. The mean age was 83 years, 69% were female, and 55% were ASA-class 3-5. We found higher mortality rates for IMN-patients at 30 days, 90 days, and 1 year. The crude relative mortality risk for IMN was also significantly higher at both 30 days (1.20) and 90 days (1.11). Adjusted relative mortality risk for IMN was 1.12 [0.96; 1.31] at 30-days, 1.03 [0.91; 1.17] at 90-days, and 1.01 [0.92; 1.11] at 1 year. Most patients suffered a 31-A2 fracture (56%) and, overall, 74% of patients were treated with IMN. CONCLUSION: We found significantly increased crude relative mortality risk at 30 days and 90 days in patients treated with IMN. However, when adjusting for confounders the two groups had similar mortality risks. In total, 74% of all patients in this cohort were treated with IMN. LEVEL OF EVIDENCE: This study has level of evidence: III.

Prospective Evaluation of Two Cohorts of Non-Operatively Treated Patients with Displaced vs. Minimally and Non-Displaced Distal Radius Fractures.

BACKGROUND: Distal radius fractures (DRFs) in the elderly are common. Recently, the efficacy of operative treatment of displaced DRFs in patients above 65 years of age has been questioned and it has been suggested that non-operative treatment should be the gold standard. However, the complications and functional outcome of displaced vs. minimally and non-displaced DRFs in the elderly has not been evaluated yet. The aim of the present study was to compare non-operatively treated displaced DRFs vs. minimally and non-displaced DRFs in terms of complications, PROMs, grip strength and range of motion (ROM) after 2 weeks, 5 weeks, 6 months and 12 months. METHODS: We used a prospective cohort study that compared patients with displaced DRFs (n = 50), i.e., >10 degrees of dorsal angulation after two reduction attempts, with patients with minimally or non-displaced DRFs after reduction. Both cohorts received the same treatment of 5 weeks of dorsal plaster casting. Complications and functional outcomes (quick disabilities of the arm, shoulder and hand (QuickDASH), patient-rated wrist/hand evaluation (PRWHE), grip strength and EQ-5D scores) were assessed after 5 weeks, 6 months and 12 months post-injury. The protocol of the VOLCON RCT and present observational study has been published (PMC6599306; clinicaltrials.gov: NCT03716661). RESULTS: One year after 5 weeks of dorsal below-elbow casting of low-energy DRFs in patients ≥ 65 years old, we found a complication rate of 6.3% (3/48) in minimally or non-displaced DRFs and 16.6% (7/42) in displaced DRFs (p = 0.18). However, no statistically significant difference was observed in functional outcomes in terms of QuickDASH, pain, ROM, grip strength or EQ-5D scores. DISCUSSION: In patients above 65 years of age, non-operative treatment, i.e., closed reduction and dorsal casting for 5 weeks, yielded similar complication rates and functional outcomes after 1 year regardless of whether the initial fracture was non-displaced/minimally displaced or still displaced after closed reduction. While the initial closed reduction should still be attempted in order to restore the anatomy, failure to achieve the stipulated radiological criteria may not be as important as we thought in terms of complications and functional outcome.

Posttraumatic arthritis and functional outcomes of nonoperatively treated distal radius fractures after 3 years.

Recent studies have shown that distal radius fractures (DRFs) in elderly patients can be treated nonoperatively with good functional results after 1 year. However, scientific evidence regarding longer follow-up to assess posttraumatic arthritis (PA), complications, and functional outcomes is scarce. This prospective case series aimed to evaluate these outcomes in a cohort of patients ≥ 65-year-old with nonoperatively treated DRFs after a minimum of 3 years. The primary outcome was PA. Secondary outcomes were complications, Quick Disabilities of the Arm, Shoulder and Hand Outcome Measure (QuickDASH), Patient-Rated Wrist/Hand Evaluation (PRWHE), pain, range of motion and grip strength. The full data of 32 patients with a mean follow-up of 3.3 years were available: 10/32 patients had radiological signs of PA, but only 2 of these patients reported pain. A total of 11/32 fractures healed in malunion (> 10° dorsal angulation). There was no significant difference in QuickDASH or PRWHE from 1 year to the latest follow-up after more than 3 years. This study thus adds to the literature stating that radiological signs, including PA and malunion, do not necessarily result in symptoms. Moreover, it underpins that nonoperative treatment of these patients results in good functional outcomes after 1 and 3 years.

Epidemiology and incidence of paediatric orthopaedic trauma workload during the COVID-19 pandemic: A multicenter cohort study of 3171 patients.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has a major influence on all parts of society. AIM: To examine the consequences of the national lockdown and political initiatives during the first surge of the COVID-19 pandemic expressed by changes in incidences of musculoskeletal paediatric injuries. METHODS: Study design was a retrospective multicenter cohort study. A 'pandemic' cohort was established from 16 March 2020 to 21 April 2020, where all institutions including day care and schools were closed. A 'pre-pandemic' cohort was established from the same period in 2019 for comparison. Included were all patients admitted at the emergency departments with paediatric musculoskeletal injuries (aged 0-15 years) identified by a relevant musculoskeletal ICD-10 diagnosis (DSxxx), concussions (DZ033D), or burns (DT2xx). RESULTS: The 'pre-pandemic' cohort consisted of 2101 patients, and the 'pandemic' cohort consisted of 1070 patients, indicating a decrease of paediatric musculoskeletal injuries of 51%. The incidence of paediatric injury in the 'pre-pandemic' cohort was 10460/100000/year. In the 'pandemic' cohort, the incidence was 5344/100000/year. CONCLUSION: A resource re-allocation to help serve the COVID-19 patients might be possible without reducing the level of care for injury-related paediatric patients.

The Effectiveness and Safety of Direct Oral Anticoagulants Following Lower Limb Fracture Surgery: A Systematic Review and Meta-analysis.

OBJECTIVES: Venous thromboembolism (VTE) is a well-established complication after many orthopaedic injuries, such as hip and lower limb fractures. The use of direct oral anticoagulants (DOACs, previously termed novel oral anticoagulants) is well-established as thromboprophylaxis after major elective orthopaedic surgery, but not in the nonelective setting. The aim of this study was to investigate the effectiveness and safety of DOACs after nonelective lower limb fracture surgery. DATA SOURCES: A systematic literature search of the MEDLINE, EMBASE, CINAHL, and CENTRAL databases was conducted. No limitation was placed on publication date, with only manuscripts printed in English were eligible. STUDY SELECTION: Included studies were either randomized controlled trials or prospective and retrospective comparative studies. Included studies compared DOACs to conventional methods of thromboprophylaxis in the postoperative period after surgical management of lower limb fractures. DATA EXTRACTION: Outcomes included VTE, bleeding, wound complications, mortality, and adverse events. Eight studies met inclusion criteria, of which 7 compared direct factor Xa inhibitors (XaIs) with conventional VTE prophylaxis and one study compared a direct thrombin inhibitor with conventional VTE prophylaxis. DATA SYNTHESIS: Revman 5.3 (Nordic Cochrane Centre, Denmark) was used to complete the meta-analysis and generate forest plots. CONCLUSIONS: XaIs were shown to have lower rates of deep vein thrombosis (Odds ratio 0.59; 95% confidence interval, 0.46-0.76; P < 0.0001) and less pharmacologically attributable adverse events (Odds ratio 0.62; 95% confidence interval, 0.46-0.82; P = 0.0007). There was difference between DOACs and conventional VTE prophylaxis regarding mortality, PE, symptomatic deep vein thrombosis, or bleeding events. The results generally support the use of DOACs for VTE prophylaxis after nonelective lower limb fracture surgery, such after hip fracture. The results more strongly support the use of XaIs; however, more evidence is needed to fully assess DOACs' role in clinical practice. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Objective Outcome Measures Continue to Improve from 6 to 12 Months after Conservatively Treated Distal Radius Fractures in the Elderly-A Prospective Evaluation of 50 Patients.

Distal radius fractures (DRF) in the elderly population above 65 years represent 18% of all fractures and are thereby the second most frequent fracture in the elderly. Fracture dislocation and comminution are often used to determine whether non-operative or operative treatment is indicated. The purpose of this prospective case series of minimally displaced DRF treated with a dorsal cast was to assess the complication rate and patient-reported outcome measures. This single-centre, single-blinded, prospective case series followed 50 conservatively treated DRF patients for one year. Primary outcomes were complications and Quick Disability of Arm Shoulder and Hand (qDASH) score. Secondary outcomes were range of motion (ROM), grip strength and pain, and Patient-Rated Wrist/Hand Evaluation (PRWHE). Results showed only minor complications with a return to prior ROM, qDASH, and pain after 12 months and improvement in outcomes after 6-12 months. In conclusion, the majority of DRF patients who were treated non-operatively with five-week dorsal casting recover fully after minimally displaced DRF. This standard approach is thus considered safe, and the present results provide a reference for other studies.

Trauma team training at a "high-risk, low-incidence" hospital.

INTRODUCTION: Trauma is the leading cause of death in younger people in the Western world. It is of great importance that smaller trauma centres with "high-risk, low-incidence" trauma resuscitations maintain high standards in trauma resuscitation, as severely injured patients are occasionally treated. We aimed to evaluate the effect of implementing trauma team training (TTT). Additionally, we investigated the incidence of severe traumas using the Injury Severity Score (ISS). METHODS: Data on process times were collected in a three-month period before and after implementation of TTT at the Regional Hospital Randers, Denmark. Process times from arrival of the patient in the trauma room until chest X-ray, trauma CT, CT description and transfer were registered. ISS was calculated as trauma severity. RESULTS: A total of 43 trauma patients were registered. ISS values were not significantly different between the two cohorts. 5/43 (12%) had an ISS > 15 as an expression of severe traumas. A tendency to reduced process times was found, but results were not statistically significant. CONCLUSIONS: Despite limitations in this study, our results point towards a reduced process time after the implementation of TTT. At an organisational level, TTT can draw attention to challenges, inappropriate local procedures and allocation of material and staff in order to improve trauma resuscitations. Only 12% of patients had an ISS > 15, emphasising the need to simulate trauma resuscitations using TTT. FUNDING: none. TRIAL REGISTRATION: The study was registered with the Danish Data Protection Agency.

[Fracture of os capitatum and os triquetrum in a child].

This is a case report of a seven-year-old boy with fractures of the capitate and triquetral bone. An X-ray revealed fractures of the capitate and triquetral bone, and a CT scan showed non-dislocated fractures suitable for conservative treatment. The patient was treated with a shin cast for four weeks and had full recovery. Fractures of both the capitate and triquetral bone in children under the age of ten have not previously been reported. Fractures of the carpal bones should be suspected and examined in children with relevant trauma and symptoms.

Distal radius fractures are difficult to classify.

BACKGROUND: Traditionally, distal radius fractures (DRFs) have been described using eponyms, e.g. Colles, Smith, Barton, Chauffeur. During the last half of the 20th century several classification systems for DRF have emerged. We evaluated the inter- and intra-observer agreement of the AO/OTA, Frykman and Older classification systems. METHODS: Four observers, an intern, an orthopaedic registrar, an orthopaedic consultant and a radiology consultant, independently evaluated DRF radiograms and classified the fractures according to the AO/OTA, Frykman and Older classification systems. After an interval of 6 months, radiograms of 30 randomly chosen patients were re-evaluated by the same observers. RESULTS: Radiograms of 573 DRF patients were evaluated in the study. The inter-observer reliability of the AO/OTA fracture types (A, B and C) was 'weak' (kappa = 0.45). The agreement dropped to 'minimal' (kappa = 0.24) regarding the AO/OTA groups (A2, A3, B1, B2, B3, C1, C2 and C3). The reliability of the Frykman classification system was 'weak' (kappa = 0.41), and we observed the lowest inter-observer reliability for the Older classification system (kappa = 0.10). The kappa values for the intra-observer reproducibility of the AO/OTA fracture types (A, B and C) ranged from 0.58 to 0.87. For the AO/OTA groups (A2, A3, B1, B2, B3, C1, C2 and C3) the reproducibility was lower ranging from 'minimal' to 'weak'. The intra-observer reproducibility of the Frykman system was 'weak' to 'moderate' and even worse for the Older classification system. CONCLUSION: Based on these findings the AO/OTA classification system seems to be most reliable for routine use, however, with lower kappa values concerning the agreement for the groups. The Frykman and Older classification systems cannot be recommended because of less convincing results.

Volar plating of distal radius fractures does not restore the anatomy.

INTRODUCTION: The objective of this study was to evaluate whether volar locking plating can restore the anatomical volar tilt of 12° and the anatomical length of the radius relative to the ulna. We retrospectively reviewed the radio-graphic outcome of distal radius fractures treated with two different first-generation locking plate systems; VariAx (Stryker) and Acu-Loc (Acumed). METHODS: Three independent observers evaluated radial volar tilt and ulnar variance (> 2 mm) on radiographs taken preoperatively, immediately after the operation and five weeks later. In addition, the radial inclination, distal radio-ulnar joint incongruity and articular step-off were assessed in order to describe the personality of the fracture. RESULTS: A total of 576 fracture cases were included in the study. Preoperatively, the mean volar tilt was 18 ± 6° and -15 ± 11° for volarly and dorsally displaced fractures, respect-ively. After operation, the mean volar tilt was 4.5 ± 6° without any significant changes after five weeks, p = 0.79 and no significant differences with respect to fracture type or type of plate. Thus, the anatomical angulation of 12° was not achieved at any point in time after surgery (p < 0.001). Shortening of the radius (> 2 mm ulnar variance) was still seen in 9% of the cases immediately after surgery and in 22% after five weeks. CONCLUSIONS: Volar locking plating did not restore the anatomy after distal radius fractures. The clinical implication of these findings is unclear because the functional outcome of the patients was not available. Level of evidence, level IV. FUNDING: none. TRIAL REGISTRATION: not relevant.

[Secondary dislocation of primarily unnoticed fracture of the medial clavicle].

This is a case report of a 16-year-old boy with a bipolar fracture of the left clavicle. The patient crashed into a car on a moped with 40 mph. In the accident & emergency department (A&E) the patient was examined physically and by X-ray. There was no protruding bone or threatened skin. The X-ray showed a lateral clavicle fracture, but there were no clinical or radiological signs of medial fracture. The treatment was conservative. Three days later the patient was referred to A&E due to increasing pain and bone protruding of the medial clavicle. A computed tomography revealed a displaced medial and lateral clavicle fracture. The treatment was altered to operative treatment.

[Scaphoid fracture in a seven-year-old girl].

We report a case of a seven-year-old girl, who had a scaphoid fracture, which occurred when she fell off her bicycle. She was examined in the emergency room. X-ray did not show any sign of fracture of the scaphoid, but the fracture was later verified with a magnetic resonance imaging scan. She wore a shin cast for eight weeks and recovered completely. Very few cases of children aged under eight years and diagnosed with scaphoid fracture have been reported in the literature. Scaphoid fracture should be suspected and examined for in all children with relevant trauma and symptoms, regardless of age.

Complications of volar locking plating of distal radius fractures in 576 patients with 3.2 years follow-up.

BACKGROUND: Volar plating of unstable distal radius fractures (DRF) has become the favoured treatment. The complication rates vary from 3 to 36%. The purpose of the study was to estimate the complication rate of volar plating of DRF and its association with AO/OTA fracture type, surgeon experience and type of volar plate. METHODS: Retrospectively, all patients treated with volar plating of a DRF between February 2009 and June 2013 at Aarhus University Hospital, Denmark were included. AO/OTA fracture type, surgeon experience (1st year, 2nd-5th year resident or consultant), type of plate (VariAx®, Acu-Loc®) and complications were extracted from the electronic medical records. Complications were categorized as carpal tunnel syndrome, other sensibility issues, tendon complications including irritation and rupture, deep infections, complex regional pain syndrome and unidentified DRUJ or scapholunar problems. Reoperations including hardware removal were also charted. RESULTS: 576 patients with a median age of 63 years (min: 15; max: 87) were included. 78% were female and the mean observation time was 3.2 years (min: 2.0; max: 5.4). 78% (n=451) of the patients were treated with VariAx® and 22% (n=125) with Acu-Loc®. The overall complication rate was 14.6% (95% CI 11.8-17.7) including carpal tunnel syndrome or change in sensibility in 5.2% and tendon complications in 4.7%. Five flexor tendon ruptures and 12 extensor tendon ruptures were observed. The reoperation rate was 10.4% including 41 cases of hardware removal. A statistically significant association between AO/OTA fracture type C and complications was found. No statistically significant association between complication rate and surgeon experience and type of plate was observed. CONCLUSION: The majority of DRF patients treated with a volar plate suffer no complications. However, the overall complication rate of 14.6% is substantial. Intra-articular fractures, e.g. AO/OTA-type 23C1-3, had significantly higher complication rates. Neither surgeon experience, nor type of volar plate was able to predict complications.

Hypomelanosis of Ito presenting with pediatric orthopedic issues: a case report.

INTRODUCTION: Hypomelanosis of Ito was originally described as a purely cutaneous disease. Extracutaneous manifestations were described later, forming a neurocutaneous syndrome including skeletal, muscular, ocular and central nervous system symptoms.Hypomelanosis of Ito is characterized by a depigmentation along the lines of Blaschko on the trunk and extremities in certain patterns.The aim of this article was to report another case and give an overview of the related orthopedic symptoms that have been previously described. It was also our wish to contribute with recommendations for consideration with regard to bandages on eczematous rashes, especially on clubfeet. CASE PRESENTATION: A one-and-a-half-month-old boy of Caucasian background born with talipes equinovarus, or clubfoot, on his right foot presented with an eczematous rash after surgical correction and plaster bandaging. CONCLUSIONS: It is the appearance of hypopigmentation, either alone or in combination with a congenital malformation, particularly central nervous system or musculoskeletal anomalies, which should form the basis of a presumptive diagnosis. This should then lead to further investigations and should always include skin biopsies and a test for chromosomal mosaicism.We report the case of a boy with a clinical picture consisting of a depigmented skin pattern, mental retardation, pes cavus, talipes equinovarus, clinodactyly, eczema, inverted cilia of the eye, strabismus, reduced hearing, ventral hernia, glomerulonephritis, missing testicles, leg length discrepancy with scoliosis, back pain and a syrinx.It is perhaps impossible to make any conclusions about extracutaneous symptoms. However, some symptoms such as retardation, cramps and seizures, delayed development and hypotonia cannot be ignored.Because of the possibility of creating an undesirable and long postoperative period with complications, it is very important to have this diagnosis in mind when deciding to do surgery or not if there are signs of dermatological problems before surgery. In this case, it could also be good clinical practice to test the patient's reaction to plaster or other bandages.