Recurrence of Scaphoid Stress Fracture: A Case Report.

Background Scaphoid stress fractures are rare and typically present in young, elite male athletes. Due to the infrequency in which these injuries are encountered, the optimum management is not established. Case Description We present the case of a 20-year-old male gymnast with bilateral stress fractures of the scaphoid waist. Following conservative treatment, clinical and radiological signs of union were seen bilaterally. Eight months after return to normal activities, a unilateral recurrence of the stress fracture occurred. This was successfully treated with internal fixation and bone grafting. Literature Review Scaphoid stress fractures are most frequently seen in gymnasts but also occur in participants of other sports involving repetitive loading of an extended wrist. This action conveys force predominantly through the waist of the scaphoid. Most case studies have reported high union rates, whether treated operatively or conservatively, and the patients returned to high-level sport with no further problems. Stress fracture recurrence has been reported in other bones such as the metatarsal and tibia but never before in the scaphoid. Our case is unusual in that the patient suffered ongoing problems due to a recurrence of the scaphoid stress fracture after returning to normal activities. Clinical Relevance Clinicians should be aware that scaphoid stress fracture recurrence can occur, counsel patients accordingly, and remain vigilant after apparent union. We would recommend early fixation to allow a quicker return to function and prevention of recurrence.

Change in capitate shift after osteotomy for distal radial fracture malunion.

Loss of anterior tilt after a distal radial fracture can lead to carpal malalignment, which may cause functional impairment. The aim of this study was to establish whether distal radial osteotomy for malunion, which primarily restores the dorsal tilt, will also improve carpal malalignment as measured by capitate shift. Radiographs of 67 patients who underwent osteotomy after malunion of a distal radial fracture were reviewed. Measurements of capitate shift and dorsal tilt were recorded. Linear regression modelling was used to assess the relationship between dorsal tilt and capitate shift. Change in capitate shift was strongly associated with change in dorsal tilt following osteotomy. This relationship was maintained on long-term radiographs. Capitate shift is strongly related to dorsal tilt following a distal radial fracture. Correcting the dorsal tilt during an osteotomy, therefore, will improve capitate shift and carpal malalignment. Capitate shift is unrelated to age, sex and is easy to visually assess.Level of evidence: IV.

The effectiveness of cognitive behavioural therapy for patients with concurrent hand and psychological disorders.

We investigated the effectiveness of cognitive behavioural therapy (CBT) for patients with psychological disorders thought to be influencing recovery from elective and traumatic hand conditions. Demographic data and psychological assessment scores (Primary Health Questionnaire 9 (PHQ9), General Anxiety Disorder Assessment (GAD7), Impact of Event Scale (IES)) were prospectively collected before and after CBT treatment. One hundred and fourteen patients underwent CBT with 81 completing treatment. Full data was available for 78 (68%) patients. Mean age was 43 (range 13-84) and 63% were women. Sixty-one per cent had sustained a traumatic hand injury. PHQ9, GAD7 and IES scores decreased significantly following treatment. Many patients with hand conditions have associated psychological problems that may influence outcome. CBT in a hand unit setting appears to be an effective treatment. Further research with a control group should investigate whether CBT improves psychological health or if this may occur as patients recover from their physical hand disorder regardless of CBT.Level of evidence: IV.

One-year outcome of surgery compared with immobilization in a cast for adults with an undisplaced or minimally displaced scaphoid fracture : a meta-analysis of randomized controlled trials.

AIMS: There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures. METHODS: A systematic review of seven databases was performed from the dates of their inception until the end of March 2021 to identify eligible RCTs. Reference lists of the included studies were screened. No language restrictions were applied. The primary outcome was the patient-reported outcome measure of wrist function at 12 months after injury. A meta-analysis was performed for function, pain, range of motion, grip strength, and union. Complications were reported narratively. RESULTS: Seven RCTs were included. There was no significant difference in function between the groups at 12 months (Hedges' g 0.15 (95% confidence interval -0.02 to 0.32); p = 0.082). The complication rate was higher in the operative group and involved more serious complications. CONCLUSION: We found no difference in functional outcome at 12 months for fractures of the waist of the scaphoid with ≤ 2 mm displacement treated operatively or nonoperatively. The complication rate was higher with operative treatment. Cite this article: Bone Joint J 2022;104-B(8):953-962.

Factors Associated with Timely Surgery for Semi-elective Distal Radius Fracture Fixation.

Background In the United Kingdom, national guidance recommends intra-articular distal radius fractures should undergo surgery within 72 hours and extra-articular fractures within 7 days. Purpose We investigated if hospitals can provide timely surgery and meet national guidelines in patients who are sent home following distal radius fracture (DRF) to return for planned surgery. The influence of patient, hospital, and seasonal factors on wait to surgery are investigated. Patients and Methods We reviewed Hospital Episode Statistics (HES) data between April 2009 and March 2013. Proportion of procedures being performed within 3 and 7 days was calculated. A linear regression model was created to investigate the relationship between wait for surgery and patient and hospital factors. Results A total of 9,318 patients were sent home to return for planned acute DRF surgery during the 4-year study period. Mean time to surgery was 3.04 days (range 1-days, standard deviation [SD] 3.14). A total of 6,538 patients underwent surgery within 3 days (70.2%) and 8,747 within 7 days (93.9%). Patients listed for surgery and sent home to return waited longer if listed toward the end of the week. Less surgery was performed at weekends, and patients were less likely to be listed for semielective trauma surgery. Conclusions Acute semielective DRF fixation is generally performed within targets for extra-articular fractures but there is scope for improvement for intra-articular fractures. Day of presentation and increasing number of comorbidities increase wait for surgery. Hospital trusts should focus on improving pathways for patients with multiple comorbidities and strategies to improve accessibility of these services at weekends.

Ulnar variance in distal radial fractures: assessment and interpretation.

We explored patterns of shortening of the distal radius and investigated the effect of displacement on 'ulnar variance' in 250 patients with distal radial fractures. A small number of patients (5%) had a fracture that resulted in true shortening. Thirty-two per cent had fractures that appeared short, but lateral radiographs revealed that the articular surface was tilted, with either the anterior or dorsal rim of the articular surface being proximal to the distal ulna but the other rim was distal to it. We recommend initial assessment of variance on lateral radiographs. If the anterior and dorsal rims of the distal radial articular surface are proximal to the distal ulna, then true shortening is present and lengthening and stabilization, to hold the radius distracted, should be considered. If only one rim is proximal to the distal ulna, then correction of the tilt will lessen the apparent positive variance.Level of evidence: IV.

Origins of the threshold for surgical intervention in intra-articular distal radius fractures.

AIMS: The aim of this study was to identify the origin and development of the threshold for surgical intervention, highlight the consequences of residual displacement, and justify the importance of accurate measurement. METHODS: A systematic review of three databases was performed to establish the origin and adaptations of the threshold, with papers screened and relevant citations reviewed. This search identified papers investigating functional outcome, including presence of arthritis, following injury. Orthopaedic textbooks were reviewed to ensure no earlier mention of the threshold was present. RESULTS: Knirk and Jupiter (1986) were the first to quantify a threshold, with all their patients developing arthritis with > 2 mm displacement. Some papers have discussed using 1 mm, although 2 mm is most widely reported. Current guidance from the British Society for Surgery of the Hand and a Delphi panel support 2 mm as an appropriate value. Although this paper is still widely cited, the authors published a re-examination of the data showing methodological flaws which is not as widely reported. They claim their conclusions are still relevant today; however, radiological arthritis does not correlate with the clinical presentation. Function following injury has been shown to be equivalent to an uninjured population, with arthritis progressing slowly or not at all. Joint space narrowing has also been shown to often be benign. CONCLUSION: Knirk and Jupiter originated the threshold value of 2 mm. The lack of correlation between the radiological and clinical presentations warrants further modern investigation. Measurement often varies between observers, calling a threshold concept into question and showing the need for further development in this area. The principle of treatment remains restoration of normal anatomical position. Cite this article: Bone Joint J 2021;103-B(9):1457-1461.

The association between surgery for carpal and cubital tunnel syndrome: analysis of incidence and risk factors within a geographical area.

The relationship between surgery for cubital tunnel and carpal tunnel syndrome was examined in this retrospective study. Between 1997 and 2018, data from consecutive patients who underwent carpal tunnel release (8352 patients), cubital tunnel release (1681 patients) or both procedures (692 patients) were analysed. The relative risk of undergoing cubital tunnel release in the population who had carpal tunnel release compared with those with no carpal tunnel release was 15.3 (male 20.3; female 12.5). The relative risk of undergoing carpal tunnel release in the population who had cubital tunnel release compared with those who did not undergo carpal tunnel release was 11.5 (male 16.5; female 9.1). Our study showed that men and women who undergo carpal tunnel release are over 20 times and 10 times more likely to have cubital tunnel release than those who did not undergo carpal tunnel release, respectively. These findings suggest that the two conditions may share a similar aetiology.Level of evidence: IV.

Scaphoid alignment in dorsally displaced distal radial fracture: a radiographic study.

We aimed to establish if fracture reduction will correct scapholunate angle in dorsally displaced distal radial fractures and to identify the relationship with other measures of distal radial position and carpal alignment. Radiographs of 131 patients with a distal radial fracture and of 50 patients with normal radiographs were reviewed. We measured the scapholunate, radiolunate, capitolunate and metacarporadial angles on the lateral views. Linear regression modelling showed that all parameters measured were significantly associated with scapholunate angle on the first radiograph following injury. Scapholunate angle increased following distal radial fracture. Reduction of the fracture improved scapholunate angle, and this was most strongly related to change in dorsal tilt. We conclude that scaphoid flexion is likely to compensate for the dorsal tilt of the lunate as an attempt to counter its dorsal tilt, and to stabilize the wrist to maintain hand function.Level of evidence: IV.

The effect of social deprivation on the incidence rate of carpal and cubital tunnel syndrome surgery.

We sought to establish whether carpal and cubital tunnel syndrome requiring surgery is associated with deprivation in England. Data from 10,496 adult patients who were treated in our hand unit over a 20-year period were reviewed. The Index of Multiple Deprivation was used to measure deprivation from the patients' postcode. The mean age at surgery in the most deprived three quintiles was significantly lower than in the least deprived two quintiles for carpal tunnel release (55 vs 59 years, respectively) and cubital tunnel release (52 vs 57 years, respectively). The incidence rate was significantly lower for the three least deprived quintiles when compared with the most deprived quintile for both conditions. The incidence rate ratio of the least deprived quintile compared with the most deprived quintile for carpal tunnel release was 0.70 for men and 0.76 for women. The incidence rate ratio of the least deprived quintile compared with the most deprived quintile for cubital tunnel release was 0.79 for men and 0.49 for women. Carpal tunnel and cubital tunnel syndrome requiring surgery is more common in deprived patients and occurs at an earlier age.Level of evidence: IV.

Tool and machinery-related hand injuries: a review of national Hospital Episodes Statistics and data from a tertiary hand unit.

We sought to identify national trends in tool and machinery-related hand injuries. Hospital Episodes Statistics data in England from 1998 to 2017 were analysed. Data from our hand unit from 2011 to 2017 were also reviewed to establish the types of tool and machinery causing injury. During the 19-year study period 210,291 admissions occurred as a result of tool and machinery-related injuries. The overall incidence rate and mean age increased. The largest increase in incidence rate was in the oldest age group (75 years+). The incidence rate in children fell. During the period studied, 2150 patients underwent surgery in our unit for tool and machinery-related injuries. The hand was involved in 2069 (96%) of the injuries. Adult injuries were caused by a similar proportion of types of tool or machinery in all age groups. This study demonstrates a clear and sustained trend of increasing incidence of tool and machinery-related injuries in adults. The largest increase is in older patients.Level of evidence: IV.

The current evidence-based management of distal radial fractures: UK perspectives.

Distal radial fractures are extremely common injuries, yet many basic questions remain unanswered about their optimum management. Recently in the United Kingdom several guideline development groups have produced national standards and best-practice guidelines based on review of the best available evidence and expert knowledge. All guideline groups agree that when surgery is needed for dorsally displaced distal radial fractures, that can be reduced closed, K-wire fixation and cast immobilization, should be offered. Further research questions have been identified. The important findings and recommendations are summarized in this article.

The effect of mean annual temperature on the incidence of distal radial fractures.

We investigated the relationship between the incidence of distal radial fractures and mean annual temperature. Data for all adult patients presenting to our unit with a distal radial fracture from 2007-2014 were analysed. Incidence rates were compared with meteorological records. A Poisson regression model was used to analyse trends. Distal radial fractures were sustained by 8831 adults. The only significant change in fracture incidence occurred in 2010, in women only. This was the coldest year in the United Kingdom for over 20 years. Analysis by age bands during 2010 showed fracture incidences were significantly higher for women aged 40-69 with a higher percentage of injuries occurring in the street. These women are likely to remain mobile during bad weather but frequently have underlying osteoporosis. Falls prevention programmes should address this group with specific strategies. Simple measures, such as walking aids, appropriate footwear and avoidance of non-essential travel in slippery conditions, may reduce risk. Level of evidence: IV.

Epidemiology of distal radius fractures in a geographically defined adult population.

Distal radial fractures are the most common adult orthopaedic fracture. We sought to determine whether the incidence of this injury is changing and identify trends in its occurrence. We analysed data for all adult patients presenting to University Hospitals of Leicester with a distal radial fracture from 2007-2016. Incidence rates were calculated using United Kingdom population data. Poisson regression techniques were used to analyse weekly, seasonal and annual variation in fracture incidence. There was no significant change in average age or incidence of fracture. Increased incidence was associated with inclement weather conditions. Younger patients more commonly sustain fractures on weekends. We predict a 23% rise in the number of fractures in the United Kingdom in the next 20 years. The incidence of fracture does not appear to be changing, although the number of fractures is growing. Weekly and seasonal trends are apparent. Level of evidence: III.

Extraction of a rectal foreign body - an alternative method.

We present a case report of trans-anal extraction of a foreign body from the rectum using an unconventional instrument. Our patient presented with impacted retained rectal foreign bodies. As the patient suffered from psychosis, a laparotomy with a stoma would have been difficult to manage. It was thus decided to make every effort to retrieve the objects transanally. After failed attempts with retractors and endoscopy, Kielland obstetric forceps were used successfully to retrieve the foreign body transanally. The authors have found no other report describing use of Kielland obstetrical forceps to retrieve foreign bodies from the rectum.