The Interobserver Reliability of Grading of Distal Radius Volar Plate Prominence.

PURPOSE: The 3-category rating of volar plate prominence in relation to the most volar edge of the distal radius (the watershed line) on lateral radiographs was reliable among a small group of surgeons and associated with the probability of flexor tendon irritation and potential rupture. Classifications are often less reliable when tested among a large group of practicing surgeons in different environments. METHODS: In this survey-based experiment, an international group of 115 fracture and upper extremity surgeons viewed 1 of 4 sets of 24 lateral radiographs (96 unique lateral radiographs) of patients with distal radius fractures who underwent volar plating in the practice of a single surgeon using 2 types of plates. Surgeons were asked to rate the following metrics: (1) the grade of plate prominence according to Soong, (2) whether the plate was more prominent than the watershed line, (3) whether the plate was separate from the bone distally, and (4) whether there is more than 5° of dorsal angulation of the distal radius articular surface. RESULTS: The interobserver agreement of the classification was "fair" (κ = 0.32; 95% confidence interval [CI] = 0.27-0.36), and grading was more reliable among surgeons who do not supervise trainees. Volar prominence was less reliable (κ = 0.034; 95% CI = 0.013-0.055) than plate separation from bone (κ = 0.50; 95% CI = 0.42-0.59) and more than 5° of dorsal angulation (κ = 0.42; 95% CI = 0.35-0.48). CONCLUSIONS: Among a large number of international practicing surgeons, the classification of volar plate prominence in 3 categories was fair. CLINICAL RELEVANCE: The diagnosis of plate prominence might develop toward criteria with moderate reliability, such as separation of the plate from the bone and residual angulation of the distal radius.

Evaluation of flexor pollicis longus tendon attrition using color Doppler imaging after volar plate fixation for distal radius fracture.

PURPOSE: Early diagnosis of attritional wear of the flexor pollicis longus (FPL) tendon is essential in preventing subsequent tendon rupture. There are currently few objective methods of assessing FPL attrition. We hypothesized that color Doppler imaging could visibly detect FPL tendon attrition, and analyzed our results. METHODS: We evaluated ultrasound imaging of the contact between the FPL tendon and a volar locking plate using the real-time B-mode and Doppler waveforms of the FPL tendon using the continuous Doppler wave mode in 40 patients who underwent fixation of the distal volar locking plate for distal radius fracture. Twenty out of 40 patients underwent plate removal surgery after ultrasound evaluation. We also assessed the relationship between the Doppler waveforms and attrition of the FPL tendon in these 20 patients. RESULTS: Based on the ultrasound findings (n = 40), we divided Doppler waveforms of the FPL tendon into three categories: type 1, spindle wave; type 2, spindle wave with spike; and type 3, spike wave. There were 23, 11, and six patients with type 1, 2, and 3 waveforms in the affected hand, respectively. There were 37 patients with type 1, three with type 2, and no patient with type 3 waveforms in the contralateral wrist. Of the 20 patients who underwent plate removal, five had type 3 waveforms. We found tendon fraying or partial tears in three of these five patients. In addition, all five patients showed changes to type 1 or 2 waveforms after plate removal. None of the other 15 patients with type 1 or 2 waveforms had any tendon injuries during plate removal. CONCLUSIONS: Spike Doppler waveform can indicate abnormal findings, and may be a useful method to predict tendon attrition, because of its visibility. DIAGNOSTIC STUDY: Level III evidence.

Volar locking plate versus external fixation for the treatment of unstable distal radial fractures: a meta-analysis of randomized controlled trials.

BACKGROUND: The choice between volar locking plates (VLP) and external fixation (EF) for unstable distal radius fractures have not reached a consensus. The meta-analysis of randomized controlled trials was performed to compare VLP with EF to determine the dominant strategy. MATERIALS AND METHODS: Meta-analysis was performed with a systematic search of studies conducted by using the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. The randomized controlled trials that compared VLP with EF was identified. Characteristics, functional outcomes, radiological results, and complications were manually extracted from all the selected studies. RESULTS: Six studies encompassing 445 patients met the inclusion criteria. There was significant difference between two procedures in disabilities of the arm shoulder and hand scores at 3,6, and 12 mo, visual analogue scale at 6 mo, grip strength at 3 mo, supination at 3 and 6 mo, extension at 3 mo, ulnar variance at 12 mo, and reoperation rate at 12 mo, postoperatively. However, there was no significant difference between flexion, pronation, radial deviation, and ulnar deviation at all follow-up points postoperatively and overall complications at 12 mo, postoperatively. CONCLUSIONS: EF had less reoperative rate due to complications, however, VLP had advantages in functional recovery in the early period after surgery, but two methods had similar functional recovery at 12 mo, postoperatively. Clinician should make the treatment decision with great caution for the patients who sustained unstable distal radial fractures.

A Review of Published Radiographic Indicators of Carpometacarpal Dislocation Including Their Application to Volar Dislocations Through a Case Study.

BACKGROUND: Carpometacarpal joint dislocation is an uncommon injury that is at risk of being overlooked on initial presentation. Dislocation in a volar direction is rare, with a number of case reports published in the literature. CASE REPORT: We report a case of volar dislocation at our institution, and review the application of two reported radiographic signs of carpometacarpal dislocation to volar dislocation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Radiographic signs provide an aid to the emergency physician in the busy department. These are particularly helpful to rule out rare injuries. Carpometacarpal dislocations in a volar direction risk being missed by one radiographic sign reported in the literature, as this article highlights.

Sonographic evaluation of effects of the volar plate on trigger finger.

BACKGROUND: We evaluated trigger fingers ultrasonographically and clarified differences between fingers with and without continuous locking or snapping symptoms according to the thicknesses of the A1 pulley, flexor tendon and volar plate. METHODS: We evaluated 26 trigger fingers, divided into two groups: Group 1, 14 fingers with locking or snapping; and Group 2, 12 fingers without such symptoms. We also evaluated 26 contralateral fingers as controls (Control 1 and 2 groups). We compared each group to the respective control group according to thickness of the A1 pulley and volar plate, and cross-sectional area of the flexor tendon. In addition, nine fingers with locking or snapping and treated using corticosteroid injection were evaluated according to symptoms and sonographic findings 3-4 weeks after treatment. RESULTS: Thickness of the A1 pulley and cross-sectional area of the flexor tendon were greater in both Groups 1 and 2 than in controls. Thickness of the volar plate was greater in Group 1 than in Control 1, although no significant difference was seen between Group 2 and Control 2. In Group 1, eight of the nine fingers showed an alleviation of locking or snapping symptoms with corticosteroid injection, and sonographic findings showed that thickness of the volar plate was significantly decreased with corticosteroid injection, in addition to reduced thickness of the A1 pulley. CONCLUSION: In addition to thickening of the A1 pulley, thickening of the volar plate may represent an important contributor to continuous snapping or locking symptoms.

A comparative study about ionizing radiation emitted during radiological "skyline" view of the wrist in pronation versus supination.

The dorsal tangential view to the distal radius or "skyline," used to control the length of the screws for the ORIF with volar plates, is carried out in supination (fluoroscope vertical) or in pronation (fluoroscope horizontal). The purpose of this study was to compare the dose of ionizing radiation emitted during a "skyline" view in supination versus pronation. A "skyline" was performed on 14 fresh cadaveric wrists. In group 1, the fluoroscope was positioned vertically and the wrist was held in supination. In group 2, the fluoroscope was positioned horizontally and the wrist held in pronation. The average dose of ionizing radiation was 0.9286 cGy/cm(2) (group 1) and 0.8751 cGy/cm(2) (group 2). The difference was not statistically significant. Overall, the emitted dose for the "skyline" is negligible compared to that of a standard wrist radiography with no difference between the vertical and horizontal positioning. Peroperatively, the vertical "skyline" seems easier to setup, less time consuming and less prone to asepsis faults.

Bony palmar ridges of the phalanges of the human fingers.

PURPOSE: On imaging studies, bony ridges can be seen at the palmar aspect of the phalanges of the fingers. Our purpose was to address the following: (1) which structures insert on to the ridges and what is the histological appearance? (2) Is there a difference between the different fingers? (3) Is there a correlation between the ridges and age? MATERIALS AND METHODS: Two observers retrospectively evaluated 270 radiographs (135 men; 135 women; mean age 44 years), and 33 CT scans (22 men; 11 women; mean age 46 years). Three cadaveric hands were also studied. The ridges were graded using a 4-point scale. A Chi-square test was used to compare the different fingers (p < 0.05) and to study the prominence of the ridges in relation to age (p < 0.05). RESULTS: On histology with routine stains the A2 pulley was inserted on the ridges of the proximal phalanx, and the flexor superficialis and A4 pulley on the ridges of the middle phalanx. On histology, the insertion showed a transition zone consisting of fibrocartilage. The prominence of the ridges was significantly different between fingers with III and IV categorized higher than II and III. There was a significant correlation with age for all fingers except for the middle phalanx of II and III. CONCLUSION: The bony palmar ridges have characteristics of enthesophytes. They correspond to the insertion site of the A2 pulley, and the flexor superficialis tendon and A4 pulley, at the proximal and middle phalanx, respectively. The ridges become more prominent with age, and their prominence is different between the fingers with III and IV categorized higher than II and V.

Imaging finger joint instability with ultrasound.

Closed injuries affecting the metacarpophalangeal and interphalangeal joints and their stabilizers in the thumb and fingers occur very commonly in athletes, possibly leading to finger joint instability and long-standing or permanent disability. This article reviews the spectrum of joint injuries of the thumb and fingers that are common in the athletic population with a main focus on the ultrasound features of collateral ligament tears, palmar plate injuries, and thumb sesamoid fractures. A thorough understanding of the complex anatomy, mechanism of injury, soft tissue abnormalities, and imaging findings is critical in the diagnostic work-up of closed finger joint trauma and may help improve outcomes.

Volar dislocation of second, third, and fourth carpometacarpal joints: a rare and easily missed diagnosis.

Volar carpometacarpal dislocation is a rare form of hand injury that can be easily missed without applying a high level of suspicion and performing a meticulous examination. In this case report, we present a rare case of compound volar dislocation of the second, third, and fourth carpometacarpal joints in a 40-year-old male. This was managed by closed reduction and the use of a mini external fixator. The patient regained a good range of motion in 6 weeks with no pain. It is important to diagnose and treat this injury in order to avoid the considerable morbidity associated with this condition.

Biomechanical differences of the proximal interphalangeal joint volar plate during active and passive motion: a dynamic ultrasonographic study.

PURPOSE: To define the biomechanical differences of the volar plate (VP) of the proximal interphalangeal joint during active and passive motion, which may provide clues to understanding the functional importance of the volar elevation of the VP. METHODS: We imaged the volar aspect of the proximal interphalangeal joint in 10 healthy middle fingers using ultrasonography. Cine videos recorded the movements of the VP during joint motion from full extension to more than 60° of flexion both actively and passively. We plotted 5 points on the volar surface of the VP and traced them for motion analysis. We statistically analyzed the volar distances and volar angulation of the VP in full extension, 30°, 45°, and 60° of flexion to determine the differences between active and passive flexion. RESULTS: In active flexion, the VP showed significantly higher volar distances in 45° and 60° and changed its configuration from the original flattened figure to an inverted U shape, with a significant higher angulation at 45° compared with passive flexion. Conversely, in passive flexion, we did not observe the volar elevation of the VP and the flattened configuration was maintained throughout the motion arc. CONCLUSIONS: From an anatomical viewpoint, volar elevation of the VP seen in active flexion could provide dynamic stresses on the adjacent ligaments and contribute to the stability and smooth gliding of the joint.

Comparison of 4 fluoroscopic views for dorsal cortex screw penetration after volar plating of the distal radius.

PURPOSE: To determine whether use of the dorsal tangential view improves the diagnostic accuracy of intraoperative fluoroscopy compared with conventional views in detecting dorsal screw penetrations during volar distal radius plating. METHODS: Dorsal cortices of 10 cadaveric distal radii were penetrated in each of the second, third, and fourth dorsal extensor compartments at 0, 1, 2, and 3 mm penetration. We obtained 4 standardized fluoroscopic images of the wrist: lateral, supination, pronation, and dorsal tangential views. Using high-definition digital images, 2 observers blinded to the experimental paradigm determined whether screws were penetrating the dorsal cortex. RESULTS: For screws that penetrated the floor of the second dorsal compartment, the 45° supination view was 92% sensitive for detecting screw penetration of 2 mm, and 98% for 3 mm. For screws that penetrated the third dorsal compartment, the lateral view was 68% and 80% sensitive in detecting screw penetrations of 1 and 2 mm, respectively. However, the dorsal tangential view showed 95% sensitivity for 1 mm and 98% for 2 mm penetrations. On the floor of the fourth dorsal compartment, pronation and dorsal tangential views were both 88% sensitive for 1 mm screw penetration and 90% and 93% for 2 mm, respectively. CONCLUSIONS: The standard lateral view of the wrist failed to detect all screw penetrations. The dorsal tangential view increased the accuracy of detecting screw penetrations on the floor of the third dorsal compartment, whereas we needed oblique views to detect screw penetrations on the floors of second and fourth dorsal compartments. CLINICAL RELEVANCE: Routine clinical use of the dorsal tangential view has the potential to increase accuracy in detecting dorsal screw penetration during volar plating of the distal radius.

Use of standard and anatomic-tilt lateral X-rays to determine distal radius volar angulation.

PURPOSE: To determine the reliability of measurements of distal radius volar tilt using either standard lateral or anatomic tilt lateral (ATL) radiographs, and to compare the mean values obtained using each radiographic method. METHODS: We obtained standard and 23° ATL plain radiographs of the distal radii of 20 patients with a distal radius fracture treated with a volar locking plate, and of 20 healthy individuals without a history of fracture of the wrist. Three orthopedic surgeons measured volar tilt twice with an interval of 4 weeks. We analyzed intraobserver and interobserver reliability and compared intraobserver means of volar tilts obtained using standard and ATL radiographs. RESULTS: The volar tilts measured using ATL radiographs in patients and healthy controls showed moderate to excellent intraobserver and interobserver reliability, whereas those determined using standard lateral radiographs showed poor to moderate intraobserver and interobserver reliability in patients and controls. However, the mean values of volar tilts measured in standard lateral radiographs and in ATL radiographs were similar in patients and not significantly different in healthy controls. CONCLUSIONS: Volar tilt measurements obtained using anatomic tilt lateral radiographs provided moderate to excellent reliability. However, we found no statistically significant difference between volar tilts determined using ATL and standard lateral radiographs. Accordingly, standard lateral and ATL radiographs are interchangeable with respect to volar tilt measurements. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Sonographic appearance of the flexor tendon, volar plate, and A1 pulley with respect to the severity of trigger finger.

PURPOSE: To evaluate trigger digits with sonography to determine morphological changes in the A1 pulley, flexor tendon, and volar plate in relation to the severity of triggering. METHODS: We evaluated 67 trigger digits and graded them into 1 of 4 groups. We compared the groups according to severity and to contralateral fingers, which served as controls. RESULTS: The thickness of the flexor tendons under the A1 pulley was proportional to the severity of triggering. The anteroposterior thickness of the flexor tendon increased significantly among the grades exhibiting triggering regardless of the affected digit. However, in digits other than the thumb, tendon thickness increased even in the absence of active triggering. Thickening tended to be greater with finger flexion. The A1 pulley exhibited the greatest thickness and the volar plate exhibited significant thickening in the group that exhibited continuous triggering that was easily reduced with active extension (grade III). CONCLUSIONS: The flexor tendon thickened significantly before patients experienced triggering except in the thumb. In the thumb, the flexor tendon and A1 pulley thickened significantly only after patients exhibited triggering. Thickening of the volar plate appears to have an important role in continuous triggering. Although most clinicians can easily determine the severity of a trigger digit by clinical examination, ultrasound might be helpful for objectively understanding the severity and response to treatment, by examining the thickness of the flexor tendon and A1 pulley. In particular, sonographic measurement of the A1 pulley might be useful in judging the progression of trigger finger severity. In cases where a Doppler signal is detected inside the A1 pulley, more conservative therapies might be worth considering before surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic ΙΙΙ.

Distal radial fracture arthroscopic intraarticular gap and step-off measurement after open reduction and internal fixation with a volar locked plate.

PURPOSE: A persistent articular gap and a step-off of ≥1 mm after a distal radial fracture (DRF) may lead to post-traumatic arthritis of the radiocarpal joint. This study aims to arthroscopically assess the reduction in the articular surface in patients requiring volar locked-plate fixation for DRF via fluoroscopy-guided open reduction and internal fixation (ORIF). METHODS: Seventy consecutive patients with DRF were prospectively enrolled. Posteroanterior and lateral radiographs and axial, coronal, and sagittal computed tomography (CT) scans were obtained before ORIF for DRF. The widest articular gap (pregap) and step-off (prestep-off) at the radiocarpal joint surface of the distal radius were measured on all radiographs and CT images. Total predisplacement was defined as the sum of all pregaps and prestep-offs. The DRF was reduced under fluoroscopic guidance, and a volar locked-plate was applied after fluoroscopic ORIF. The residual maximum articular gap and step-off (postgap and poststep-off) were measured arthroscopically with a calibrated probe. Total incongruity was defined as the sum of postgap and poststep-off. The receiver operating characteristic curve was applied within the pregaps, prestep-offs and total incongruity in order to identify the cutoff values of pregap and prestep-off beyond which total incongruity would exceed 1 mm. RESULTS: Of the 70 patients, 40 had a postgap of ≥1 mm, and 15 had a poststep-off of ≥1 mm. All pregap and prestep-off cutoff values were judged to be unsuitable as the screening criteria for arthroscopic reduction of DRF because of their low sensitivity and specificity. The cutoff value obtained from total predisplacement was 7.85 mm, and its sensitivity and specificity were 90 and 70 %, respectively. CONCLUSIONS: Since the cutoff value of 7.85 mm derived from total predisplacement is a good indicator of post-ORIF residual total incongruity of ≥1 mm, it is also a good indicator of the need for arthroscopic reduction.

Locking distal radius plate--early results from India.

BACKGROUND: Restoration of wrist function to close to preinjury levels of patients with intra-articular distal end radius fractures is of concern. Open reduction and internal fixation with angular stable screw fixation implants is coming in vogue but little literature evidence supports it. The objectives of this study are to assess the ability of volar locking plates to maintain fracture reduction when used to treat dorsally displaced intra-articular distal radial fractures and to assess the patient-related outcome after this procedure. METHODS: In a prospective study from March 2008 to September 2009, 23 cases of intra-articular distal radius fractures were included in the study. All these fractures underwent open reduction and internal fixation with 2.4 volar locking distal radius plates. Every patient was reviewed with a minimum follow-up of 36 weeks (9 months to 2 years). Radiographs were taken to assess fracture union or for any potential loss of fracture reduction. Functional outcome was assessed with evaluation of range of movements of the wrist and pain as per the Visual Analog Scale. RESULTS: Radiologic union was noted by the end of 18 weeks in 3 subjects, at the end of 24 weeks in 13 subjects and by 30th week in 6 patients. As for overall functional outcome, 4 patients had excellent outcome, 18 had good outcome, and 1 patient had poor outcome. None of our patients had neurovascular injuries or tendon ruptures during this period. CONCLUSION: Volar locking plate is a viable option for treating intra-articular distal radius fractures.

Biomechanics of the volar plate of the proximal interphalangeal joint: a dynamic ultrasonographic study.

PURPOSE: To study the biomechanics of the volar plate of the proximal interphalangeal (PIP) joint using ultrasonography. METHODS: The subjects were 20 normal and 5 pathological digits. We included as normal subjects 20 digits (10 index and 10 middle fingers) of 10 hands of 10 volunteers who had no history of trauma or any other hand-related pathological conditions. To clarify the biomechanical effect of the A3 pulley for the volar plate motion, we included a total of 5 digits (1 index, 2 middle, and 2 ring) of 4 hands of 4 consecutive patients who had flexor tendon repair surgeries in zone II with the A3 pulley left open as pathological subjects. Transducers were applied volarly to the PIP joint and the ultrasonographic plane was kept in the central axis of the digits to display the volar plate and the flexor tendons in the same image. We recorded cine videos during active joint motion. We also obtained sequential static images for morphological analysis. RESULTS: The motion of the volar plate of the normal PIP joint was as follows: when joint flexion started, the volar plate slid proximally to lie parallel to the condylar slope of the proximal phalanx. In 30° of flexion, the flexor tendons tightened and the distal portion of the volar plate moved volarward. In 45° or more of flexion, the distal portion protruded over the lip of the middle phalanx. The lip rolled dorsalward in the recess in return. In the flexor tendon repair cases, the distal portion of the volar plate did not move volarward at all, even when the joint flexed 45° or more. The main body of the volar plate showed a marked wavelike or sigmoid deformity. CONCLUSIONS: To characterize the biomechanics of the volar plate of the PIP joint, we propose the following 3 sequential phases: sliding, elevating, and rolling in the recess. The A3 pulley may serve as an elevator of the volar plate, triggering the next phase of rolling in the recess. The recess can provide some articulation which the lip of the middle phalanx can roll in.

Predictors of distal radioulnar joint instability in distal radius fractures.

PURPOSE: A tear of the triangular fibrocartilage complex (TFCC) is the most frequent soft tissue injury associated with fractures of the distal radius, and repair of the deep ligamentous portion of the TFCC is considered when the tear contributes to instability of the distal radioulnar joint (DRUJ). The purpose of this prospective cohort study was to identify predictors of DRUJ instability accompanying unstable distal radius fractures. METHODS: Between 2002 and 2007, we prospectively treated 163 consecutive patients with unstable distal radius fractures with the volar locking plating system. Complete radioulnar ligament tears representing DRUJ instability were present in 11 of 163 distal radius fractures. We tested univariate associations between DRUJ instability and potential predictors and conducted multivariate analysis to establish independent predictors of instability. We applied receiver operating characteristics curves within the significant risk factors to determine threshold values. RESULTS: In univariate analyses, only the radial and sagittal translation ratios of the fracture site were significant predictors of DRUJ instability. Multivariate logistic regression analysis confirmed that the radial translation ratio, which corresponds to a normalized DRUJ gap, was a significant risk factor. According to the receiver operating characteristics curve for the radial translation ratio, the area under the curve was 0.89. A cutoff value of 15% for the radial translation ratio showed the highest diagnostic accuracy rate. CONCLUSIONS: A radiographic finding of a normalized DRUJ gap on posteroanterior views was the most important predictor to identify DRUJ instability accompanying unstable distal radius fractures. The relative risk of instability increases by 50% when the ratio of DRUJ widening increases by 1%.

Rotatory subluxation of the proximal interphalangeal joint: an easily missed diagnosis.

We present a case of volar rotatory subluxation of index finger proximal interphalangeal joint (PIPJ) following a skiing accident. The injury was initially perceived to be a central slip rupture and treatment was directed as such. After the initial delay in the diagnosis, the patient underwent surgery during which his radial collateral ligament was found to be avulsed from the proximal origin, the radial lateral band palmarly subluxed and was interposed in the joint space. This structure was also adhered to the uninjured volar plate.PIPJ volar rotatory subluxation could be readily missed in the acute setting. Without surgery, the functional outcome could be mediocre and to the patient's detriment.

Distal radius fracture arthroscopic intraarticular displacement measurement after open reduction and internal fixation from a volar approach.

BACKGROUND: The purpose of this study was to assess articular surface reduction arthroscopically after volar locked-plate fixation of distal radius fractures (DRFs) via fluoroscopyguided open reduction/internal fixation. We also aimed to develop preoperative radiographic criteria to help assist in determining which DRFs may need arthroscopic evaluation. METHODS: A total of 31 consecutive patients with DRF were prospectively enrolled. Posteroanterior (PA) and lateral radiographs as well as axial, coronal, and sagittal CT scans were obtained just after attempted reduction of the DRF. The widest articular displacement at the radiocarpal joint surface of the distal radius (preopD) was then measured using a digital radiography imaging system. The DRF was reduced under fluoroscopy, and a volar locked plate was applied. The degree of residual articular displacement was then measured arthroscopically, and the maximum displacement (postopD) was measured with a calibrated probe. RESULTS: Of the 31 patients, 7 had an arthroscopically assessed maximum postopD of > or = 2 mm after internal fixation. The correlation coefficients between each preopD and postopD of all radiographs and CTs were statistically significant. The cutoff values were 0.5 mm for PA radiographs, 2.10 mm for lateral radiographs, 2.15 mm for axial CT scans, 3.15 mm for coronal CT scans, and 1.20 mm for sagittal CT scans. All cutoff values for PA and lateral radiographs and for axial, coronal, and sagittal CT scans were unsuitable as screening criteria for arthroscopic reduction of DRF because of their low sensitivities and specificities. The cutoff value of the new preopD (the sum of the preopDs determined by lateral radiography and coronal CT scan) was 5.80 mm, and its sensitivity and specificity were 100% and 83.3%, respectively. CONCLUSIONS: Because a new preopD cutoff value of 5.80 mm is a good indicator for residual articular displacement after internal fixation of >2 mm, it is also a good indicator for the need for arthroscopic evaluation after internal fixation.

Uncommon hand injury to the batsman in 'gully cricket': report of two cases.

Volar plate injuries are typically caused by hyperextension of the proximal interphalangeal joint. These injuries are usually seen in sports where the ball comes in direct contact with the hands. Forceful dorsiflexion of the finger caused by the speeding ball leads to volar plate avulsion. In cricket, such finger injuries predominantly occur in fielders trying to catch or stop the speeding ball with bare hands. We report two unusual cases of volar plate avulsion injury occurring in batsmen that occurred during 'gully cricket' (street-cricket). We propose the possibility of a novel contrecoup-type mechanism causing this type of injury in the two cases. Both were successfully managed with splinting and had excellent recovery without any residual deformity or instability.