Introduction

Literature is scarce regarding the management of soft-tissue coverage for open tibia fractures, while the current BOAST standards stipulate fixation within 24 hours of injury

Background
This audit aimed to assess compliance with BOAST standards for managing open fractures, focusing on time to theatre. Post-operative complications and return to surgery rates were also evaluated.

Patient and Methods
A retrospective audit was conducted over 3 years, identifying 29 patients (aged 23-93) with 20 in the geriatric population, 24 males and 5 females, and 26 with co-morbidities. All injuries were classified using the Gustilo classification (ranges I to IIIa). All patients received intravenous antibiotics and clear documentation of neurovascular status. The average time to surgery was 47 hours, with all patients having a single definite surgical procedure involving debridement, fracture fixation (K-wires, locking plates, and/or screws), and soft tissue coverage. 27 patients had primary wound closure and 2 required split-thickness skin grafts. Post-operatively, no superficial or deep infections were reported, and 2 patients required further surgery. One patient had a loss of fracture reduction requiring the removal of metalwork and an application of a dorsal spanning plate, while the other had a displacement of the ulna styloid requiring further open reduction internal fixation.

Conclusion
This audit shows despite not adhering to BOAST standards a delay in patient presentation to theatres, did not result in adverse clinical outcomes for patients. This suggests that delayed management of open distal wrist fractures might be safe under the care of a skilled hand/trauma surgeon.

Background: This study evaluates the effectiveness of magnetic resonance imaging (MRI) versus computerised tomography (CT) scans for persistent wrist pain at the thumb base following injury in adults and children during covid. This was part of a pathway introduced as access to MRI scan was limited. Methods: Patients were identified as having possible scaphoid fractures within the emergency department but had no fracture identified on initial imaging over a 3-month period. These were triaged to a scaphoid pathway during the covid pandemic from a virtual clinic. Patients were reviewed clinically and radiographically within the hand clinic using further imaging with CT or MRI scan. Results: During the study time 45 patients with scaphoid fractures were detected on initial radiography in ED and 187 with suspected scaphoid fractures were selected for further review. Ninety (48%) were referred to the hand clinic where 2 (1%) scaphoid fractures were diagnosed on a second radiograph and ninety-seven (52%) were to be seen in an upper limb clinic where 2 (1%) further fractures were detected. 92% of scaphoid fractures were identified on radiography either in ED or orthopaedic clinic. Of the remaining 178 with two negative radiographs further imaging was requested in 45 cases (25%). Pathology was found in 17 (58%) MRI scans and in 7 (39%) CT scans. Conclusions: Imaging needs to be timely to enable effective treatment. Obtaining MRI scans while diagnostically superior is not always achievable especially in times of resource depletion. Back up pathways using alternative imaging can be effective.

Volar barton fractures are very rare,accounting for 1,3 % of all distal radius fractures.This fracture is unstable because the distal fracture is accompanied by subluxation of the volar carpus,requiring fixation that is stable enough,anatomical reduction and immediate mobilization.Internal fixation is an option,with open repositioning,selecting a fairly extensive soft tissue area followed by internal fixation with plate screws,k-wire, multiple pinning.Minimal incision and closed reduction as well as fixation with screws are expected to obtain stable anatomical reduction without extensive soft tissue dissection,thereby preventing instability and greater tissue damage.The case of a 41 y.o man with complaints of pain and swelling in the right wrist after falling from a height of 5 meters,radiography of the right wrist showed a Volar Barton fracture.Surgery was performed with a minimal dorsal incision of the right distal radius ,closed reduction of the fracture,evaluation with c-arm radiography showing repositioned fracture fragments followed internal fixation with a 4,0 partial threaded concellous screw and washer.Post operative evaluation, minimal incision to maintain aesthetics,physiotherapy moving the right wrist gradually.Evaluation of 4 weeks,right wrist range of motion approached normal and reduction was achieved

Abstract: Distal radius fractures, stemming from both high and low-energy trauma, are commonplace. Rather than fixating solely on radiological parameters, the primary treatment objective is functional recovery. Adherence to the British Orthopaedic Association Standards for Practice (BOAST) guidelines is pivotal in this context. Key recommendations encompass documenting the injury mechanism, assessing skin integrity, circulation, and sensation, and obtaining posteroanterior and lateral radiographic views of the wrist. For stable fractures, early mobilization with a removable support is advisable once pain permits. Surgical intervention should be contemplated for unstable fractures, adhering to specific timing criteria. This abstract underscores the critical role of BOAST guidelines in managing distal radial fractures.

Methods: A retrospective audit identified 125 cases of distal radius fractures to assess adherence to the National guidelines set by the BOA for trauma management. Criteria included the date of injury in relation to surgery, fracture type, and tourniquet time. We included all closed distal radius fractures treated with open reduction and internal fixation (ORIF) and excluded patients without recorded time or unused tourniquet. Cases involving distal radius fixation using percutaneous wires were also excluded.

Results: Our findings revealed suboptimal adherence to the BOAST guidelines. However, no statistically significant difference in tourniquet time was observed between intra-articular cases fixed exceeding three days and extra-articular cases fixed exceeding seven days. Interestingly, approximately half of the cases exceeded the average time (70 minutes).

Conclusion: We recommend adhering to BOAST guidelines when managing distal radius fractures, as it can reduce tourniquet time and enhance theatre efficiency.

Introduction: Spaghetti wrist injuries pose a significant challenge in surgical treatment and rehabilitation, and are mostly caused by household and industrial machines, knives, sharp tools and glass shards. Definitions of the term differ from injuries affecting one nerve and two other structures to injuries of ten structures in total. The aim of this study is to evaluate the functional outcomes following surgery in patients with spaghetti wrist injuries. Methodology: At a single center, 72 patients with spaghetti wrist injuries were surgically treated between 2020 and 2022. They were followed up for approximately 22 months. Functional outcomes were measured by DASH score, Handgrip strength (HGS), range of motion using the Total Active Motion (TAM) scale and sensory recovery using Medical Research Council (MRC) scale. Results: The mean age was 26+/- 4 years. Commonly affected structures were the superficial flexors of the fingers, flexor pollicis longus and the median nerve. The average value of HGS was 69.1% compared to the uninjured hand, the average TAM values were 74.75%, while the mean value of the DASH score was 24.1. On MCR scale, most patients (15, 35%) were in the S2 group. The average time for return to daily activities was 9 months. Conclusion: With a timely diagnosis, adequate treatment, and intensive physical therapy, it’s possible to achieve good functional results even in the most severe hand injuries. It is notable that older patients and those with a higher number of damaged structures, particularly involving nerves, tended to experience poorer outcomes.

Introduction: It’s hard to estimate the incidence of wrist injuries in polytrauma patients, as they carry a high risk of being overlooked. Although these injuries are not life-threatening, their delayed management can lead to a significant functional deficit. Therefore, it is extremely important to be aware of the possibility of associated wrist injuries in polytrauma patients and to assess them accordingly. The aim of this study was to determine the type of wrist injuries in polytrauma patients, mechanisms of injury and the most common concomitant injuries. Material and methods: In two years, 31 polytrauma patients with wrist injuries were surgically treated at a single center. Patient information was recorded and analyzed. Patients with isolated wrist injuries were not included. Results: Patients were predominantly male (95%). The age range was between 17 and 59 years. Wrist injuries recorded were divided into non-dissociative and complex carpal injuries (CCI). Concomitant injuries were mostly orthopedic (spine, pelvis, and extremities: 22 cases), ribs and chest injuries (20 cases), head (facial and cranial bones: 16 cases), brain (14 cases) and abdominal injuries (9 cases). Dominant mechanism of injury were traffic accidents (motorcycle 39%, car 26% and pedestrian 16%), followed by fall from heights (19%). All patients required surgery. All patients survived. Conclusion: Wrist injuries of variable severity are often seen in polytrauma patients, especially in those with major bone fractures. Detailed clinical examination is required, as overlooking wrist injuries can lead to delays in diagnosis and treatment and subsequently to a poor functional outcome.

Introduction: The scaphoid fracture is the most common type of wrist fracture. Delayed treatment after fracture often leads to nonunion. Because of its irregular shape, closed reduction and internal fixation is often difficult to achieve a good needle position and direction. With the rapid development of robotic navigation technology in recent years, it provides a better therapeutic effect for the treatment of scaphoid fracture with closed reduction and internal fixation. Methods: There were 14 patients with scaphoid fracture (Herbert B 2) . From March 2020 to March 2023, all patients were closed reduction and internal fixation assisted by navigation robot. The time of operation was recorded, and the X-ray films were reexamined at 1,2,3 and 6 months after operation. The patients were evaluated with Cooney wrist score at 6 months after operation. Results: All patients were followed up. At 2 months after operation, 13 patients were healed, 1 patient was unhealed. At 3 months after operation, all patients were healed. The mean Cooney wrist score was 92.4 at 6 months postoperatively. Conclusion: The navigation robot can locate and plan the direction of the needle and the point of insertion more accurately, and the operation time is shortened, and the fixation effect is reliable.

Background: This study was to analyze the clinical follow-up results (minimum, 2 years) in patients with nonunions of the scaphoid with minimal sclerosis treated with arthroscopically assisted percutaneous internal fixation augmented by injection of demineralized bone matrix (DBM) and bone marrow aspirated concertation (BMAC). Method: From January 2021 through November 2022, a consecutive series of 17 patients with fibrous union or early stage of nonunion of a scaphoid fracture with sclerosis or resorption at the nonunion site were treated with arthroscopic osteosythesis with DBM and BMAC combine percutaneous internal fixator. Preoperative and postoperative evaluations included measurement of clinical (grip strength and range of motion), radiographic, and functional (Mayo Modified Wrist Score) parameters, as well as satisfaction.
Result: The sample included 15 men and 2 women with a mean age of 30.5 years (range, 20 to 45 years). We recorded union and return to activity and analyzed data with regular clinical follow-up at a mean of 26 months (range, 24 to 30 months). We confirmed union in 15 of 17 patients (88%) at a mean of 15.4 weeks according to clinical examinations and standard radiography. For the Mayo Modified Wrist Score, there were 11 excellent and 4 good results. A total of 15 of 17 patients (88%) returned to work or sports activities at their preinjury level.
Conclusions: Arthroscopic osteosythesis with DBM and BMAC with percutaneous internal fixation is a reliable and minimally invasive method to achieve union and scaphoid healing in early stage of nonunion.

Introduction: A conservative approach is preferred for closed or minimally displaced phalangeal fractures, while surgical fixation is necessary for open, comminuted, unstable, and irreducible fractures. Mini external fixators can achieve the desired results with reduced complications. This study aims to evaluate the functional outcome of using mini external fixators for phalangeal fractures of the upper limb. Method: We included 30 patients with phalangeal fractures from October 2021 to October 2023 at the Department of Orthopaedics, Chettinad Hospital and Research Institute. The total active flexion (TAF) was measured pre-operatively. The patients underwent mini external fixation for the phalangeal fractures following which, functional outcome was measured during the immediate post-operative period, at 4 weeks, 6 weeks, 8 weeks, 12 weeks and 6 months post-operatively. The ASSH TAF Score was used for evaluating the functional outcome. Results: Comparison of the pre and post-operative functional outcomes was done using the ASSH TAF score. All the patients had a fair outcome during the immediate post-operative period, whereas 76.9% had an excellent outcome at 6 months post-operatively. One incidence each of pin tract infection and pin loosening were observed. Conclusion: Mini external fixation is a highly effective treatment option for phalangeal fractures, delivering functional outcomes ranging from good to excellent. In spite of their unattractive appearance, these constructs allow the patient to return to their daily routines sooner, compared to other fixation methods. It is therefore recommended that external fixation be considered as a viable and valuable treatment modality for patients with phalangeal fractures.

Introduction：The Pilon fracture of the middle phalanx is a complex fracture of the hand. Although there are many treatment methods, the treatment of this kind of fracture is still challenging. The purpose of this study was to evaluate the effect of cement combined with Kirschner wire in the treatment of middle phalangeal Pilon.Methods: A total of 14 patients with Pilon fracture of the middle phalanx from January，2021 to January，2023 were treated in our department.All patients were treated with cement and Kirschner wire with self-made external fixator.First, we inserted a 1.2 mm Kirschner wire laterally from the proximal phalanx and then a 1.2 mm Kirschner wire from the middle phalanx. After bending the two ends of the Kirschner wire in opposite directions, the two ends of the Kirschner wire are fixed with bone cement to form a fixator.After the surgery,X-ray films were taken at2,4, 6 and 12 weeks, and motions of metacarpophalangeal joint (MCP) , proximal interphalangeal joint (Pip) and distal interphalangeal joint (DIP) were measured. VAS scores were recorded. Results:All patients were followed up and all fractures healed 6 weeks after operation,At 12 weeks after operation, the mean range of motion of MCP, PIP and DIP was 84 ° , 80 ° and 74 ° respectively. The average VAS score was 2.3.Conclusion: The technique is simple. This technique can provide traction, provide strong fixation.This technique allows the patient to perform early rehabilitation exercises

Severe intraarticular fractures at the base of the middle phalanges in the proximal interphalangeal joints are one of the most challenging fractures when it comes to treatment, and the results are usually not satisfying leading mainly to a loss of productivity due to subsequent stiffness of the joint, loss of the overall strength of the hand, inability to form the fist and residual pain. They are mostly the results of injury in younger population during sport activity.
Different ways of treatment have been proposed beginning from non-operative, open or closed reduction and fixation with K wires with less probability of proper reduction which will most probably lead to stiffness or arthrosis of the joint to arthrodesis or arthroplasty of the joint. Other options include the dynamic immobilization with transfixation to the neighbouring finger or dynamic external fixation with ligamentotaxor like the Suzuki frame. The role of Suzuki frame resides in the early mobilization of the injured joint while intervening in the reduction during healing of the fracture, preventing the stiffness of the periarticular structures and has the advantage of being less invasive. The aim of this study is to show the results using the Suzuki frame, indications, protocols and eventual complications that are related to the use of the frame. Overall, excellent results were obtained with satisfactory range of motion of the fingers. Key words: Suzuki frame, intraarticular fracture, interphalangeal joint, hand.

Introduction: Treatment of scaphoid fracture sequelae is still an unsolved problem in hand surgery. Custom-made 3D-printed titanium partial and total scaphoid prosthesis and scaphoid interosseous ligament reconstruction (SLIL) are performed in cases of non-union and isolated aseptic necrosis of the proximal scaphoid pole and when it is impossible to save the scaphoid bone, respectively. This study aims to evaluate the clinical, functional and radiographic results after these two prosthesis implantations.
Method: Between January 2019 and July 2020, nine partial and ten total scaphoid prostheses were implanted using custom-made 3D-printed titanium implants. Evaluation criteria included carpal height ratio (CHR), radioscaphoid angle, wrist extension and flexion, radial deviation and ulnar deviation of the wrist, grip strength and pinch strength, Visual Analogue Scale (VAS), the Disabilities of Arm, Shoulder, and Hand (DASH) score, and the Patient-Rated Wrist Evaluation (PRWE).
Result: Clinical, functional, and radiographic improvements were found in all outcomes analyzed for both patient groups. The VAS pain scale obtained the most remarkable improvement at the one-year follow-up. The results of the DASH scores and the PRWE were good, with a great rate of patient satisfaction at the end of the follow-up. SLIL reconstruction also provided excellent stability and prevented a mid-carpal bone collapse in the short- and medium-term follow-up.
Conclusion:A custom-made 3D-printed titanium partial or total scaphoid prosthesis is a viable solution for patients with scaphoid non-union and necrosis or complete scaphoid destruction in whom previous conservative or surgical treatment has failed.

Background: Tendinous mallet finger lacks high-level evidence of optimal treatment. In this study, we compared the results of thermoplastic splints with those of surgical treatment using Kirschner wire fixation in the management of tendinous mallet fingers, with the aim of providing evidence-based guidance for clinical treatment. Method: Forty-eight patients were enrolled and randomly assigned to the thermoplastic splint group (n=23) and Kirschner wire group (n=25). An evaluation was performed at 16- weeks after treatment, mainly focusing on DIPJ extension and flexion angles, and extension lag. The results were graded using the Abouna-Brown and Crawford scores, and factors affecting the outcomes were analyzed. Results: There was no significant difference in the outcomes between the groups in terms of final extension and extension lag after 16 weeks. The final extension of the DIPJ in both groups correlated with the extension degree under fixation and the maximal extension of the contralateral fingers. Slight extension loss was observed in the early stage after the removal of the fixators, which was partially improved by routine active exercise. Conclusions: Both treatments using kirschner wire and thermoplastic splint for the tendinous mallet fingers are equally effective. Active exercise after the removal of fixators plays a key role in the final outcomes, indicating the significance of tendon remodeling.