Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial.

BACKGROUND: Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. The use of immediate surgical fixation to manage this type of fracture has increased, despite insufficient evidence of improved outcomes over non-surgical management. The SWIFFT trial compared the clinical effectiveness of surgical fixation with cast immobilisation and early fixation of fractures that fail to unite in adults with scaphoid waist fractures displaced by 2 mm or less. METHODS: This pragmatic, parallel-group, multicentre, open-label, two-arm, randomised superiority trial included adults (aged 16 years or older) who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear bicortical fracture of the scaphoid waist on radiographs. An independent remote randomisation service used a computer-generated allocation sequence with randomly varying block sizes to randomly assign participants (1:1) to receive either early surgical fixation (surgery group) or below-elbow cast immobilisation followed by immediate fixation if non-union of the fracture was confirmed (cast immobilisation group). Randomisation was stratified by whether or not there was displacement of either a step or a gap of 1-2 mm inclusive on any radiographic view. The primary outcome was the total patient-rated wrist evaluation (PRWE) score at 52 weeks after randomisation, and it was analysed on an available case intention-to-treat basis. This trial is registered with the ISRCTN registry, ISRCTN67901257, and is no longer recruiting, but long-term follow-up is ongoing. FINDINGS: Between July 23, 2013, and July 26, 2016, 439 (42%) of 1047 assessed patients (mean age 33 years; 363 [83%] men) were randomly assigned to the surgery group (n=219) or to the cast immobilisation group (n=220). Of these, 408 (93%) participants were included in the primary analysis (203 participants in the surgery group and 205 participants in the cast immobilisation group). 16 participants in the surgery group and 15 participants in the cast immobilisation group were excluded because of either withdrawal, no response, or no follow-up data at 6, 12, 26, or 52 weeks. There was no significant difference in mean PRWE scores at 52 weeks between the surgery group (adjusted mean 11·9 [95% CI 9·2-14·5]) and the cast immobilisation group (14·0 [11·3 to 16·6]; adjusted mean difference -2·1 [95% CI -5·8 to 1·6], p=0·27). More participants in the surgery group (31 [14%] of 219 participants) had a potentially serious complication from surgery than in the cast immobilisation group (three [1%] of 220 participants), but fewer participants in the surgery group (five [2%]) had cast-related complications than in the cast immobilisation group (40 [18%]). The number of participants who had a medical complication was similar between the two groups (four [2%] in the surgery group and five [2%] in the cast immobilisation group). INTERPRETATION: Adult patients with scaphoid waist fractures displaced by 2 mm or less should have initial cast immobilisation, and any suspected non-unions should be confirmed and immediately fixed with surgery. This treatment strategy will help to avoid the risks of surgery and mostly limit the use of surgery to fixing fractures that fail to unite. FUNDING: National Institute for Health Research Health Technology Assessment Programme.

Selective blockade of tumor necrosis factor receptor I inhibits proinflammatory cytokine and chemokine production in human rheumatoid arthritis synovial membrane cell cultures.

OBJECTIVE: To determine whether selective blockade of tumor necrosis factor receptor I (TNFRI) affects spontaneous proinflammatory cytokine and chemokine production in ex vivo-cultured human rheumatoid arthritis synovial membrane mononuclear cells (MNCs) and to compare this response to that of TNF ligand blockade using etanercept. METHODS: A bispecific, single variable-domain antibody (anti-TNFRI moiety plus an albumin binding moiety [TNFRI-AlbudAb]) was used to selectively block TNFRI. Inhibition of TNFα-mediated responses in cell lines expressing TNFRI/II confirmed TNFRI-AlbudAb potency, human rhabdomyosarcoma cell line KYM-1D4 cytotoxicity, and human umbilical vein endothelial cell (HUVEC) vascular cell adhesion molecule 1 (VCAM-1) upregulation. Eighteen RA synovial membrane MNC suspensions were cultured for 2 days or 5 days, either alone or in the presence of TNFRI-AlbudAb, control-AlbudAb, or etanercept. Proinflammatory cytokines and chemokines in culture supernatants were measured by enzyme-linked immunosorbent assays. A mixed-effects statistical analysis model was used to assess the extent of TNFRI selective blockade, where the results were expressed as the percentage change with 95% confidence intervals (95% CIs). RESULTS: TNFRI-AlbudAb inhibited TNFα-induced KYM-1D4 cell cytotoxicity (50% inhibition concentration [IC50 ] 4 nM) and HUVEC VCAM-1 up-regulation (IC50 12 nM) in a dose-dependent manner. In ex vivo-cultured RA synovial membrane MNCs, selective blockade of TNFRI inhibited the production of proinflammatory cytokines and chemokines to levels similar to those obtained with TNF ligand blockade, without inducing cellular toxicity. Changes in cytokine levels were as follows: -23.5% (95% CI -12.4, -33.2 [P = 0.004]) for granulocyte-macrophage colony-stimulating factor, -33.4% (95% CI -20.6, -44.2 [P ≤ 0.0001]) for interleukin-10 (IL-10), -17.6% (95% CI 3.2, -34.2 [P = 0.0880]) for IL-1ß, and -19.0% (95% CI -3.4, -32.1 [P = 0.0207]) for IL-6. Changes in chemokine levels were as follows: -34.2% (-14.4, -49.4 [P = 0.0030]) for IL-8, -56.6% (-30.7, -72.9 [P = 0.0011]) for RANTES, and -24.9% (2, -44.8 [P = 0.0656]) for monocyte chemotactic protein 1. CONCLUSION: In ex vivo-cultured RA synovial membrane MNCs, although a limited role of TNFRII cannot be ruled out, TNFRI signaling was found to be the dominant pathway leading to proinflammatory cytokine and chemokine production. Thus, selective blockade of TNFRI could potentially be therapeutically beneficial over TNF ligand blockade by retaining the beneficial TNFRII signaling.

Surgical complications: errors and adverse events.

Complications are a recognized hazard of surgery. The term is confusing; it has multiple meanings, including surgical error and adverse surgical outcomes. I propose the latter two terms are used. Grading of 'complications' is difficult but made easier by grading errors and outcomes separately, though they are not always linked. The exact grades are not established.Error avoidance requires efforts at a personal (surgeon) level, including training, learning and preparation, and at a systems level. Understanding human factors is important.The perspective of patients about adverse outcomes is not well understood. There is evidence that, unsurprisingly, patient perspectives may be different to surgeon perspectives. There are a range of surgeon responses to error and adverse outcomes; many are negative. These need to be understood better in order to protect patients and surgeons in the immediate aftermath and in the potentially prolonged 'recovery time', both for patients and surgeons.Level of evidence: V.

The distal radioulnar joint after distal radial fractures: when and how do we need to treat pain, stiffness or instability?

The importance of distal radioulnar joint problems associated with distal radial fractures is recognized increasingly. But there remains considerable disagreement about how to treat these problems both acutely and chronically. This review outlines the knowledge about the natural history of ulnar-sided wrist problems with distal radials fractures. In particular, the recent increased understanding of the almost inevitable joint instability associated with distal radial fractures is highlighted, including the unreliability of clinical assessment and hence why there has been so much misunderstanding. Provided there is reasonable bony alignment, most ulnar-sided wrist problems can be treated non-operatively initially (typically for over a year) in anticipation of substantial improvement with time. The exception is early marked subluxation of the distal radioulnar joint (DRUJ) blocking forearm rotation, which needs urgent (typically closed) reduction.

Thalidomide upper limb embryopathy - pathogenesis, past and present management and future considerations.

This review article provides a comprehensive overview of thalidomide upper limb embryopathy including updates about its pathogenesis, a historical account of the management of the paediatric thalidomide patient, experience with management of the adult patient, as well as creating awareness about early onset age-related changes associated with limb differences. Despite its withdrawal from the market in November 1961, novel discoveries have meant thalidomide is licensed again and currently still in use to treat a variety of conditions, including inflammatory disorders and some cancers. Yet, if not used safely, thalidomide still has the potential to cause damage to the embryo. Recent work identifying thalidomide analogues that retain clinical benefits yet without the harmful effects are showing great promise. Understanding the problems thalidomide survivors face as they age can allow surgeons to support their unique healthcare issues and translate these principles of care to other congenital upper limb differences.

Preventable hand injuries: A national audit.

Little is known of the scale of avoidable injuries presenting to medical services on a national level in the UK. This study aimed to assess the type and incidence of preventable wrist and hand injuries (as defined by the core research team) at a national level in the UK. 28 UK hospitals undertook a service evaluation of all hand trauma cases presenting to their units over a 2 week period in early 2021 identifying demographical and aetiological information about injuries sustained. 1909 patients were included (184 children) with a median age of 40 (IQR 25-59) years. The commonest five types of injury were fractures of the wrist; single phalangeal or metacarpal fractures; fingertip injuries; and infection, with the most common mechanisms being mechanical falls and manual labour. This is the first extensive survey of preventable hand injuries in the UK, identifying a need for further work into prevention to reduce healthcare burden and cost. 50% of injuries presenting to hand surgeons are preventable, with the most common injuries being single fractures of the wrist, phalanx and metacarpal. Few preventable injuries were related to alcohol or narcotic intoxication. Further research is needed to identify how to initiate injury prevention measures for hand injuries, particularly focussed towards hand fracture prevention.

Nonoperative Versus Operative Treatment for Displaced Finger Metacarpal Shaft Fractures: A Prospective, Noninferiority, Randomized Controlled Trial.

UPDATE: This article was updated on January 18, 2023, because of a previous error, which was discovered after the preliminary version of the article was posted online. On page 103, in the first column of Table III, the continuous outcomes, which had been given as "Median" and "(range)", are now given as "Mean" and "(95% CI)", respectively.

Finger metacarpal fractures represent up to 31% of all hand fractures, and most can be treated nonoperatively. Whether operative treatment is superior to nonoperative treatment for oblique and/or spiral finger metacarpal shaft fractures (MSFs) is unknown. Forty-two patients with displaced oblique and/or spiral finger MSFs were randomized to either nonoperative treatment with unrestricted mobilization or operative treatment with screw fixation. The primary outcome was grip strength in the injured hand compared with the uninjured hand at the 1-year follow-up. Secondary outcomes were the Disabilities of the Arm, Shoulder and Hand score, range of motion, metacarpal shortening, complications, sick leave duration, patient satisfaction, and costs. All patients attended the 1-year follow-up. Mean grip strength relative to that in the contralateral hand was 104% (95% confidence interval [CI], 89% to 120%) in the nonoperative group and 96% (95% CI, 89% to 103%) in the operative group (p = 0.34). Mean metacarpal shortening was 5.3 mm (95% CI, 4.2 to 6.4 mm) in the nonoperative group and 2.3 mm (95% CI, 0.8 to 3.9 mm) in the operative group. In the nonoperative group, 1 minor complication was observed; in the operative group, there were 4 minor complications and 3 reoperations. The costs were estimated at 1,347 U.S. dollars (USD) for nonoperative treatment compared with 3,834 USD for operative treatment. Sick leave duration was significantly shorter in the nonoperative group (12 days [95% CI, 5 to 21 days] versus 35 days [95% CI, 20 to 54 days]) (p = 0.008). When treated with unrestricted mobilization, patients with a single displaced spiral and/or oblique finger MSF have outcomes comparable to those treated operatively, despite metacarpal shortening. Costs are substantially higher (2.8 times) and sick leave is significantly higher in the operative group. Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

'Skating on thin ice?' Consultant surgeon's contemporary experience of adverse surgical events.

Concerns about patient safety have prompted studies of adverse surgical events (ASEs), but descriptive classification of errors and malpractice claims have overshadowed qualitative investigations into the processes that lead to expert errors and their solutions. We studied consultant surgeon's perspectives on how and why events occurred through semi-structured interviews about general and specific events. The sample contained heterogeneous cross-section of ages, gender and specialists, with >2 years consultant status and working within a 25-mile radius. Overarching findings included (1) pressures to work harder, faster and beyond capability within a blaming culture; (2) optimism bias from over-confidence and complacency; and (3) multiple pressures to 'finish' an operation or list, resulting in completion bias. Seven high order themes were identified on the healthcare system, adverse event types, contributing factors, emotions, cognitive processes, error detection, and strategies, solutions and barriers. The process of classifying event types guided solution selection, and the decision about whether to formally report it. How serious consequences were for patients and their temporal effects, defined an adversity continuum. Minor events arose routinely i.e. technical discrepancies, side-effects. More problematic were sub-optimal outcomes and avoidable events. Despite their expertise, consultants were vulnerable to unavoidable, uncontrollable events which were major concerns. Most serious were near-misses, errors and mistakes. However, major errors did not inevitably lead to a catastrophe and minor errors could be extremely serious. A 'cascade' of minor events exacerbated by negative emotions can precipitate major events, and interception methods need investigation. Consultants felt powerless and helpless to change environmental, organisational and systemic problems; new communication and action channels are desirable. Confidence building in team leadership would promote 'flatter' hierarchies, facilitating appropriate warnings. Although implementing the WHO Checklist averts important problems, social, environmental and organisational contributing factors are largely overlooked here and in existing models.

Mallet Finger: Two Different Injuries.

Mallet injuries, either tendinous or bony, are common. They are often studied together and typically treated in the same way with extension splintage for 6 to 8 weeks. Yet the evidence clearly shows there are different injuries that present in the same way. Tendinous mallet injuries present in older patients usually following a low energy injury; they are often painless. The commonly injured fingers are the middle and ring. The injuries are almost always single digit without concomitant injuries. There is an extensor lag of a mean of 310 (range 3°-590) in the patients treated in my unit. In contrast, bony mallet injuries occur at a younger age (mean 40 years) and are always due to high energy injuries. The injuries are always painful. The commonly injured fingers are the ring and little fingers. There are multiple injuries in 3% (range 2%-5%) and in 4% to 8% of cases, there are concomitant (nondigital) injuries according to data in my unit. Radiologically there is an appreciably smaller extensor lag; mean 130 (range 0°-400). In particular, bony mallet injuries are extension compression, not avulsion, fractures which should not logically be treated with an extension splint which will reproduce the direction of injury.

Discussions About Obstetric Brachial Plexus Injuries.

Although patients with obstetric brachial plexus injuries (OBPI) have been recognized and treated for greater than 100 years there is much that is not understood or is mis-understood. I address 6 areas for discussion: the cause of OBPI and whether it matters to nerve surgeons; the value of the Narakas grading; whether surgeons should perform primary nerve surgery, especially in patients with incomplete OBPI; the cause and treatment of shoulder tightness; the cause and treatment of elbow contracture; and whether patients with OBPI need surgery in adulthood.

Risk of tendon failure with repeated passage of Kirschner wires or hypodermic needles: an experimental study.

During hand surgery, tendons may be at risk of damage. This biomechanical study aims to assess the risk of tendon rupture due to passage of Kirschner wires or hypodermic needles. Porcine extensor tendons were divided into four groups. Group 1: a control group was tested to ensure that repeated stress alone did not cause failure. Group 2a: 1.1-mm Kirschner wires were hand pushed through tendons 50 times and then stressed to 40 N, repeated until tendon failure. In Group 2b, K-wires were passed while rotating using a drill. Group 3: the experiment was repeated using a 20 G hypodermic needle. Group 2a tendons required a median of 2450 passes (1150-3500) to propagate failure, Group 2b a median of 2250 (1200-3850) and Group 3a median of 200 passes (150-450). The risk of tendon rupture from wires or hypodermic needles in procedures appears very low.

Shapes and Sizes of Common Silicone Metacarpophalangeal Arthroplasties: Clinical Implications.

Background: Silastic metacarpophalangeal joint (MCPJ) arthroplasty is a recognised treatment for painful finger arthritis. There are two commonly used, albeit different, designs; the Swanson and the NeuFlex©. Which design is optimal is unclear. The purpose of this study was to evaluate the radiological differences relative to the bones following implantation. Methods: We examined the radiological features of these implants up to 1 year of follow-up. We reviewed the postoperative radiographs of 42 patients with 113 MCPJ arthroplasties and assessed the implant body anatomical 'fit' relative to the widths of the cut metacarpals and proximal phalanges and resection lengths of the metacarpal heads. We also looked for potential axial implant rotation. Results: The Swanson implants were consistently and statistically significantly wider than the NeuFlex© implants and almost always overhung the margins of the native MCPJ. Four of 33 (12%) of the Swanson and 1 of 80 NeuFlex© implants had rotated axially, the difference was statistically significant. One NeuFlex© implant had fractured at its hinge. Conclusions: The appreciable difference in the positions of the implant bodies relative to the bones may be important. The overhang of the Swanson implants may confer some stability to the arthroplasty helping to resist lateral deviation forces, but concomitant ligament reconstruction may increase the risk of implant rotation which is likely to reduce the postoperative ranges of motion. Axial silastic implant rotation has not previously been reported. It may influence joint biomechanics; future implant designs should consider the risks of implant rotation. Level of Evidence: Level IV (Therapeutic).

In vivo measurement of distal radioulnar translation following distal radius fracture.

The incidence of distal radioulnar joint instability following a distal radius fracture is estimated around one in three based upon clinical examination. Using a validated rig, we objectively measured distal radioulnar joint translation in vivo following distal radius fracture. Dorsopalmar translation of the distal radioulnar joint was measured in 50 adults with previous distal radius fractures. Measurements were compared with the uninjured wrist and against a database of previous measurements within healthy and clinically lax populations. Translation at the distal radioulnar joint was greater in injured wrists at 12.2 mm (range 10-15, SD 1.2) than the uninjured wrists at 6.4 (range 4-9, SD 0.8) (p < 0.001) and was always outside the established normal range. There was no statistically significant link between translation and the severity of the injury. Instability appears almost inevitable following a distal radius (wrist) fracture, albeit subclinical in the vast majority.

How many acute orthopaedic injuries are preventable?

PURPOSE: Injury prevention is important. Injury as a result of an accident carries with it huge cost to the individual and society including health services costs. Understanding the mechanism of injury is important to identify those injuries that are preventable. The aim of this study was to assess how many acute orthopaedic injuries were preventable should reasonable human interventions have been taken METHODS: This prospective study was performed in a UK district general hospital that serves a population of 500,000 people. All patients referred to the Orthopaedic department over 4 weeks between 16th November and 14th December 2020 were reviewed. Data was collected about the mechanism of injury, patient demographics, injury type, injury location, treatment and length of stay in hospital. The mechanisms of injury were analysed thematically. RESULTS: We assessed 605 patient attendances. 502 patients sustained 516 acute traumatic injuries. Preventable injuries were common, accounting for 23.9% of all referrals. The upper limb was most commonly injured with the hand and forearm being injured 33% of the time. Of the preventable injuries 35% were treated operatively. Thematic analysis identified common mechanisms of: occupational related, stairs, RTA, cycling, alcohol related, trampoline, DIY and assault. CONCLUSION: This study identifies that a large proportion of acute orthopaedic injuries are potentially preventable meaning this is an important area for further study. Occupation injuries were identified as an area in which there is the greatest scope to reduce the number of preventable accidents.

The reliability of clinical assessment of distal radioulnar joint instability.

Accurate assessment of distal radioulnar joint (DRUJ) stability is increasingly recognized as an important part of clinical examination of the wrist. The ability of 30 specialist UK hand surgeons to clinically determine the stability of four volunteers' wrists was assessed. Volunteers' wrist stability had previously been confirmed with a validated measurement rig. Use of the wrist ballottement test as the primary examination technique yielded a positive predictive value of 81%, a negative predictive value of 55%, a specificity of 94% and a sensitivity of only 24%, for the detection of DRUJ instability. No correlation between background speciality (orthopaedic versus plastic surgery), nor years of clinical experience was found. Clinical assessment of DRUJ instability among experienced clinicians appears unreliable and instability is typically under recognized. Previous research to date using this clinical assessment method as a parameter of success is therefore brought into question.Level of evidence: IV.

Wrist and hand postures when falling and description of the upper limb falling reflex.

INTRODUCTION: Falling studies, i.e. assessing what happens when an individual falls, have been conducted in controlled environments but not in field studies for ethical reasons; this potentially limits the validity and applicability of previous studies. We performed field studies on existing YouTube © videos of skateboarders falling. The aims of these studies were to measure the wrist angle at impact on videos of real unprotected falls and to study the dynamics of the upper limbs when falling. METHODS: Youtube © videos of skateboarders falling were studied assessing the direction of the fall, the positions of both upper limbs and especially the wrists on impact quantitatively and qualitatively. This study would not be ethical by other means. RESULTS: In study one (the more quantitative study) there were 48 men and 50 falls. The mean elbow flexion was 300 (range 00 to 800) and the mean maximal wrist extension was 800 (range 500 to 1100). The second wrist extended less or the same in > 90%. The second wrist only once (of 31) extended > 900 which should minimise the risk of toppling. Falls onto only one wrist gave significantly greater maximal wrist extension. In the second more qualitative study we observed the "upper limb falling reflex" where the response to falling is for the upper limb(s) to align the upper limb with the direction of falling of the body with the elbow mostly but not fully extended. Initially the wrists extend c. 400-500 with the fingers held mildly flexed. Immediately before impact the fingers hyper-extend with some compensatory wrist flexion to c. 300 of extension. The fingertips impact the ground first followed by the hand. CONCLUSION: These studies confirm wrist extension at impact around 800 but the wrist(s) may hyper-extend risking toppling. Falls on both wrists minimise the risk of toppling. The "upper limb falling reflex" is defined; it is a rapid dynamic response leading to the fingers impacting the ground first on falling. Abnormalities with the upper limb falling reflex may indicate problems with development in young children and may increase the risk of injury in older people.

Articular cartilage and soft tissue damage from radiofrequency thermal ablation wands at wrist arthroscopy.

We report six cases of complications from use of a thermal wand at wrist arthroscopy. Complications included skin necrosis, extensor tendon lesions and thermal articular cartilage damage, one with a catastrophic outcome. Thermal wands have the potential for substantial soft tissue damage causing severe harm to patients. The damage could be related to the design of the wands. User error poses an additional risk. These risks need to be appreciated and should be minimized. The complications indicate the need for careful use of the thermal wands to minimise risk including using only short bursts of thermal energy, the use of high flow irrigation with an outflow and trying to ensure that the collar of the device and not just the tip is within the joint. In addition, the design of thermal wands for use in the wrist may need to be reviewed.Level of evidence: IV.

Common hand and wrist conditions: creation of UK research priorities defined by a James Lind Alliance Priority Setting Partnership.

OBJECTIVE: Prioritisation of important treatment uncertainties for 'Common Conditions Affecting the Hand and Wrist' via a UK-based James Lind Alliance Priority Setting Partnership. SETTING: This process was funded by a national charitable organisation and based in the UK. PARTICIPANTS: Anyone with experience of common conditions affecting the adult hand and wrist, including patients, carers and healthcare professionals. All treatment modalities delivered by a hand specialist, including therapists, surgeons or other allied professionals, were considered. INTERVENTIONS: Established James Lind Alliance Priority Setting Partnership methods were employed.Electronic and paper questionnaires identified potential uncertainties. These were subsequently confirmed using relevant, up-to-date systematic reviews. A final list of top 10 research uncertainties was developed via a face-to-face workshop with representation from patients and clinicians. Impact of research was sought by surveying hand clinicians electronically. OUTCOME MEASURES: The survey responses and prioritisation-both survey and workshop based. RESULTS: There were 889 individually submitted questions from the initial survey, refined to 59 uncertainties across 32 themes. Eight additional uncertainties were added from published literature before prioritisation by 261 participants and the workshop allowed the final top 10 list to be finalised. The top 10 has so far contributed to the award of over £3.8 million of competitively awarded funding. CONCLUSIONS: The Common Conditions in the Hand and Wrist Priority Setting Partnership identified important research questions and has allowed research funders to identify grant applications which are important to both patients and clinicians.

Functional outcomes after surgery for thumb carpometacarpal joint arthritis.

There are a number of possible assessments of functional outcomes for thumb carpometacarpal joint arthritis. The most important and easiest to measure is pain, but it is not the only material outcome. Functional scores for measuring the outcome of the treatment of thumb carpometacarpal joint arthritis have been recommended for some time, but are still not widely used even in published studies. It is also unclear which functional scores are the most valuable. Easily used scores, such as the Disabilities of the Arm Shoulder and Hand questionnaire, are freely available, but may not be sensitive enough to assess outcomes especially of thumb carpometacarpal joint arthroplasty. The optimal functional outcome measurement would be weighted for the individual patient. A minimum dataset needs to be defined in order to compare studies and derive meaningful data.