Immediate mobilization of distal radius fractures stabilized by volar locking plate results in a better short-term outcome than a five week immobilization: A prospective randomized trial.

OBJECTIVE: To evaluate the impact of immediate (first day after surgery) mobilization compared to standard five weeks cast immobilization on the functional outcome after volar locking plate fixation of distal radius fractures. DESIGN: Prospective randomized parallel group comparative trial. SETTING: Trauma Hospital, Austria. PARTICIPANTS: Patients with isolated unstable distal radius fractures, stabilized with volar angular stable locking plate. INTERVENTIONS: The immediate mobilization group received a removable forearm splint for one week and active supervised group physiotherapy and home exercises for the shoulder, elbow, wrist, and fingers from the first postoperative day. The cast immobilization group received a non-removable cast for five weeks. In the first five weeks supervised group physiotherapy and home exercises were performed for shoulder, elbow, and fingers. Thereafter additional supervised and home exercises for the wrist were started. MAIN MEASURES: At regular intervals of six and nine weeks, three and six months, and one year post surgery range of motion, grip strength, and x-rays were evaluated. Additionally, the shortened disabilities of the arm, shoulder and hand (QuickDASH) score, Patient-rated Wrist Evaluation, Mayo Wrist score, and pain according to the Visual Analog Scale score were analyzed. RESULTS: One hundred and sixteen patients were prospectively randomized into two study groups. At the one-year follow-up, patients in the immediate mobilization group showed a significantly higher range of motion in extension/flexion (mean difference 10.2°, 99% confidence interval 0.6-19.8), grip strength (mean difference 5.1 kg, 99% confidence interval -0.5 to 10.7), and Mayo Wrist score (mean difference 7.9 points, 99% confidence interval 2.3-13.5) than the cast immobilization group. Range of motion in supination/pronation (mean difference 13.4°, 99% confidence interval 1.5-25.3) and in radial/ulnar deviation (mean difference 6.3°, 99% confidence interval 0.9-11.7) differed significantly up to nine weeks favoring the immediate mobilization group. The Patient-rated Wrist Evaluation revealed significantly better scores after three months (mean difference 9.3 points, 99% confidence interval 0.5-18.1) and QuickDASH after six months (mean difference 7.3 points, 99% confidence interval 0.3-14.3) in the immediate mobilization group. All other subsequent follow-up examinations indicated no significant differences in respect of pain, range of motion, and patient-reported outcome measurements between the study groups. There were no significant differences in respect of radiological loss of reduction and complications between the groups. CONCLUSIONS: Immediate mobilization in combination with supervised physiotherapy of the wrist after volar locking plate fixation of unstable distal radius fractures results in a significantly improved range of motion and grip strength after one year compared to cast immobilization. No increased risk for loss of reduction and other complications was observed.

Open reduction and fixation with a locking plate without bone grafting is a reasonable and safe option for treating proximal humerus nonunion.

AIM OF THE STUDY: The aim of this study was to evaluate union rate and clinical outcome in patients with proximal humeral nonunions treated by open reduction and locking plate fixation without bone grafting. METHODS: From 2011 to 2016, nine patients were treated using open reduction and locking plate stabilization without bone grafting. They were examined both clinically and radiologically, with a mean follow-up period of 31 months. Outcome was evaluated using pain and range of motion (ROM) parameters. In addition, self-assessment by patients was registered on the Disability of the Arm, Shoulder and Hand score, Constant-Murley Score, Oxford Shoulder Score, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form. A CT scan of the shoulder was performed to analyze union. RESULTS: At checkup, all patients showed union in the CT scans, where the mean ROM in abduction was 139° (SD 50°), in adduction 39° (SD 8°), in forward flexion 136° (SD 40°), in extension 44° (SD 11°), in internal rotation 62° (SD 15°), and external rotation 54° (SD 31°). ROM improved significantly in all planes of motion, except for adduction, post-surgery (p < 0.05). Plate removal was necessary in three patients. No complications were reported. CONCLUSION: Open reduction and locking plate fixation without bone grafting is a reasonable and safe option for treating proximal humerus nonunion. It leads to a high union rate, significant improvement in ROM, and in the majority of the cases to an "excellent" and "good" functional outcome without an increased risk of complications.

Computed Tomography and Pathobiomechanical-Based Treatment of Volar Distal Radius Fractures.

Today, there are various classifications for distal radius fractures (DRF). However, they are primarily based on plain radiographs and do not provide sufficient information on the best treatment option. There are newer classifications that simultaneously consider the pathobiomechanical basis of the fracture mechanism and analysis of computed tomography images. Main determinants of which type of DRFs occurs are the strength/direction of the applied forces on the carpus and radius, and the position of the wrist relative to the radius during the fall. Reconstruction of the mechanism of injury provides information about which anatomic structures are involved, such as torn ligaments, bone fragments, and the dislocated osteoligamentous units. This article attempts to combine and modify current pathobiomechanically oriented classifications with an improved understanding of the "key fragments" to subsequently offer a treatment approach to stabilize these critical fragments through specific types of internal fixation.

[Palmar radioscapholunate arthrodesis with distal scaphoidectomy]. / Radioskapholunäre Arthrodese mit Entfernung des distalen Skaphoidpols von palmar.

OBJECTIVE: Radioscapholunate (RSL) arthrodesis with distal scaphoidectomy using an angular stable plate and palmar access in post-traumatic or degenerative osteoarthritis limited to the radiocarpal joint. INDICATIONS: Osteoarthritis limited to the radiocarpal joint with intact mediocarpal joint after malunited intra-articular distal radius fractures, rheumatoid osteoarthritis, scapholunate advanced collapse (SLAC) up to stage II. CONTRAINDICATIONS: Mediocarpal osteoarthritis, poor patient compliance, SLAC from stage III, osteitis. SURGICAL TECHNIQUE: The palmar RSL arthrodesis is performed using the palmar approach between the flexor carpi radialis tendon and the radial artery. After releasing the pronator quadratus muscle, a longitudinal capsulotomy is performed and the radiocarpal joint is inspected. After correction of a volar or dorsal intercalated segmental instability of the lunate, the lunate is temporarily fixed to the scaphoid using a K-wire. The distal quarter of the scaphoid and the palmar rim of the distal radius is resected and the cartilage between the scaphoid, lunate and distal radius is removed. The scaphoid and lunate are temporarily fixed to the distal radius using K­wires. Under image intensifier control the angular stable low-profile plate (e.g., volar 2.5 Trilock RSL Fusion plate [Medartis® Aptus® Basel, Switzerland]) is fixed to the distal radius in the long-leg hole. The scaphoid and lunate are fixed distally with two screws each. The carpus is pushed distally using a Codeman distractor and the cancellous bone graft is impacted. Finally, the shaft is fixed with angular stable screws. POSTOPERATIVE MANAGEMENT: Immobilization using a plaster cast or thermoplastic short-arm orthosis for 5 weeks. After 2 weeks, the orthosis can be removed during hand therapy with active wrist and finger exercises. Normal activities permitted after 12 weeks. RESULTS: Palmar RSL arthrodesis and distal scaphoidectomy using angular stable plate fixation shows a high union rate and pain relief while maintaining good residual mobility of the wrist.

A combined approach using transporter-flux assays and mass spectrometry to examine psychostimulant street drugs of unknown content.

The illicit consumption of psychoactive compounds may cause short and long-term health problems and addiction. This is also true for amphetamines and cocaine, which target monoamine transporters. In the recent past, an increasing number of new compounds with amphetamine-like structure such as mephedrone or 3,4-methylenedioxypyrovalerone (MDPV) entered the market of illicit drugs. Subtle structural changes circumvent legal restrictions placed on the parent compound. These novel drugs are effectively marketed "designer drugs" (also called "research chemicals") without any knowledge of the underlying pharmacology, the potential harm or a registration of the manufacturing process. Accordingly new entrants and their byproducts are identified postmarketing by chemical analysis and their pharmacological properties inferred by comparison to compounds of known structure. However, such a heuristic approach fails, if the structures diverge substantially from a known derivative. In addition, the understanding of structure-activity relations is too rudimentary to predict detailed pharmacological activity. Here, we tested a combined approach by examining the composition of street drugs using mass spectrometry and by assessing the functional activity of their constituents at the neuronal transporters for dopamine, serotonin, and norepinephrine. We show that this approach is superior to mere chemical analysis in recognizing novel and potentially harmful street drugs.