Aims: To measure the time taken for patients with distal radius fractures to have their operation before and after the introduction of a dedicated hand and wrist trauma list. Methods:
A retrospective analysis of trauma lists of all distal radius fractures operated on over a 6 month period. BOAST guidelines were used as the standard. These included: 1) intra-articular fractures operated on within 72 hours of injury; 2) extra-articular fractures operated on within one week; 3) offer K-wire fixation for dorsally displaced fractures if the radial carpal joint can be reduced closed. A twice weekly hand and wrist trauma list was introduced halfway through the data collection in an attempt to improve this service. Results:
53% (6/30) of intra-articular fractures were operated on within 72 hours prior to the intervention compared to 60% (25/42) after. All of the extra-articular fractures were operated on within one week before and after the intervention (23/23 before and 32/32 after). 27% (9/34) of dorsally displaced fractures with a radial carpal joint amenable to closed reduction were managed with K-wires prior to the opening of the hand unit compared to 13% (6/45) after. Conclusion: The introduction of a hand unit can improve waiting times for distal radius fracture surgery. ORIF was preferable over K-wire fixation for dorsally displaced fractures with a radial carpal joint amenable to closed reduction.

INTRODUCTION: Distal radioulnar joint (DRUJ) is a di-arthrodial trochoid synovial joint involved in pronation-supination and stabilizes the wrist. Poor outcomes after distal radius surgery are due to untreated/unrecognized DRUJ injuries. As per current literature, little evidence supports the efficacy of immobilizing the unstable DRUJ. MATERIALS & METHODS: We carried out a prospective study in a tertiary center. We randomized 60 patients in two comparison groups of 30 each- DRUJ fixed in neutral position using k-wires for 6weeks and DRUJ not fixed. Patients in both groups were followed up for a period of 12months at serial intervals. Evaluation was done using parameters: grip strength, range of wrist motion, supination, pronation, Sarmiento improved Gartland-Werley scoring system (GW score) and serial radiographs RESULTS: AO-OTA Class C and Frykman’s Class VII and VIII were the predominant class in both the groups. In 1.5 and 3 months follow-up, the fixed group had significantly better grip strengths, VAS scores and range of motion. At the 6 and 12 months follow-up, no statistically significant difference was noted. At final follow-up, all 30 patients in the fixed group had excellent outcomes (GW score 0-2). In not fixed group, 28 patients had excellent and 2 had good outcomes (GW score 3-6). No major complications were noted. CONCLUSION: We conclude, fixing the DRUJ in distal radius fractures with an unstable DRUJ operated with volar locking plate has no benefit in functional and radiological outcomes in the long term although it may help early recovery of range of motion and pain.

Introduction: Distal radius fracture are the most common orthopaedic injury in adults, with almost half of cases involving the intra-articular surface. These fractures often require surgical management, where timing of surgery plays an important role in the overall outcome. National Institute of Clinical Excellent (NICE) guidelines recommend surgical fixation of intra-articular fractures to occur within 72 hours following injury, while extra-articular fractures should be managed within a 7 day time frame. The aim of our audit was to assess compliance with NICE guidelines and review our short-term complication rates at 6 weeks post-operatively.

Method: Retrospective data collection was performed using local theatre programme (Bluespier) to identify all surgically managed distal radius fractures across the trust. Furthermore, notes from initial clerking, operation, clinic letters and x-ray images were reviewed to collate data. Three cycle audits were completed with each looking at 3 months data.

Results: Our sample size and cohorts were similar in all three audits (29 – 35 patients in each audit). Compliance rate with NICE guidelines improved from 37% (audit 1) to 45.7% (audit 2) to now 74.3% (audit 3). Moreover, complication rate at 6 weeks post-operatively was reduced from 41% (audit 1) to 19.4% (audit 2) to now 8.82% (audit 3).

Conclusion: Through implementation of simple interventions including addition of an extra weekly upper limb trauma list – operated by an orthopaedic hand surgeon and increasing consultant supervision for fixation of intra-articular fractures, we were able to improve both our compliance with national guidelines and reduce complication rates.

Introduction: We conducted a retrospective study on the management of wrist fractures in a District General Hospital before and during the COVID-19 pandemic. In light of the restrictions on available NHS resources caused by the COVID-19 pandemic, more wrist injuries are managed non operatively. Methods: A retrospective review of all patients seen in the Accident and Emergency (A&E) department with a radiologically confirmed wrist fracture between the imposition of lockdown measures in the United Kingdom on 23rd March and 24rd May 2020, and a control group of patients with the same injury seen in the same time period the previous year (the 23rd of March and 24rd of May 2019) was undertaken. The clinical information was obtained from the Trust Lorenzo software and radiographs from the Trust PACS system. Results: Out of a total of 34 patients seen in the Covid-19 year, 85% were female patients and had an average age was 70.4 years. 23% of these patients underwent surgical fixation at an average of 5.2 days from the time of injury. This is in contrast to 30% of 56 adult patients during the year 2019 underwent surgical fixation with an average duration of 6.5 days from the time of injury. Conclusion: Patients with wrist fractures who are considered too high-risk due to the COVID-19 pandemic were managed conservatively, in line with new guidelines. Pre- and post-COVID-19 data did not show any significant change in the epidemiology or surgical fixation method for patients with wrist fractures in this study.

Objective: To evaluate the safety of the modified direct lateral approach in patients with proximal 3rd fracture of the radius treated with a 3.5mm AO dynamic compression plate.
Methods: Forty patients aged between 18 to 70year with closed displaced extra-articular fractures, proximal 1/3rd of radius without elbow instability, were enrolled. Patients with radial nerve injury, pathological fracture, and previous injuries to the affected arm were excluded. We recorded side of the injury, duration of surgery, postoperative posterior interosseous nerve injury (Extension of thumb and metacarpophalangeal joint) and superficial branch of radial nerve injury (sensory loss of area of nerve distribution), hematoma formation, infection, implant failure, resisted supination and pronation clinically and radiological union using radiographic union scale (RUST) criteria and functional outcome using Quick DASH score till the last follow-up.
Results: Out of the total 40 patients, the mean age was 42±10.85year. Their was no case of posterior-interosseous-nerve (PIN) or the superficial branch of radial nerve injury. Only 01 (2.5%) patients had hematoma formation. Superficial infection was noted in 01 (2.5%) patients. Their was no case of implant failure. Union was achieved in all cases till the last follow-up. The mean postoperative Quick DASH score, 12th, 24th, and 36th week was 51.7±12.01, 36.2±10.57, and 10.2±8.6, respectively. The resisted supination and pronation were normal in all cases.
Conclusion: It is safe to treat proximal 3rd radius fractures using MDLS treated with a dynamic compression plate without nerve injury, less hematoma, and infection with the excellent union and functional outcome.

BACKGROUND: Radial head fractures are quite common with incidence 1.5-4% of all adult fractures. Treatment for these fractures depends upon age and type of injury. AIM: Comparison between radial head excision versus radial head fixation vs radial head replacement based on mayo elbow scoring and handgrip strength test in radial head fractures. MATERIAL AND METHODS: We did a prospective study comprising 60 patients between ages 20-60 years with Mason type III/IV radial head fractures. The patients were randomized, placing 20 patients each in arthroplasty, excision, and fixation groups, and were followed-up for 18-24 months postoperatively. Results were analyzed using Mayo’s elbow performance and Handgrip strength score at 6 and 18 months. RESULTS: As per Mayo’s score at 6 months follow-up, the mean for arthroplasty was 83.25, 75.75 for excision, and 68.75 for fixation. At 18 months, the mean was 90 for arthroplasty, 83 for excision, and 75.75 for fixation. As per the handgrip strength score at 6 months follow-up, the mean was 31.1 for arthroplasty, 28.75 for excision, and 26.47 for fixation. At 18 months, the mean was 32.95 for arthroplasty, 30.7 for excision, and 27.63 for fixation. According to both Mayo’s score and the Handgrip strength test, the difference between the results was statistically significant (p < 0.05). CONCLUSION: Our study shows that long and short-term radial head replacement results are better than radial head excision and radial head fixation based on mayo elbow scoring and handgrip strength score, particularly for dominant upper limbs.

Introduction: Plate osteosynthesis is the most common technique for the treatment of diaphyseal forearm fractures in adults but can be disruptive to surrounding soft tissues. An alternative method is intramedullary nailing. This study aims to explore the demographics, inpatient stay and pre- and post-operative function of patients managed with intramedullary nailing.
Methods: A retrospective cohort study of all adult patients managed with intramedullary nailing at a level 1 major trauma centre was conducted over a 3-year period. Electronic patient records were used to obtain information. QDASH and Eversmann scores were calculated.
Results: A total of 13 forearm bones (11 ulna and 2 radius) in 11 patients were treated with intramedullary nailing. 73% were male with an average age of 54 (17-92 years). 55% of injuries were sustained as a result of RTC or assault. 82% were independent with activities of daily living (ADLs) pre-injury. 88% (7/8) felt that the procedure was fully explained. Mean time to theatre was 9.4 (1-30 days). Mean operative time was 102 minutes (61-190 minutes). Average length of stay was 18.3 (1-59 days). 55% had no postoperative complications with only one patient requiring reoperation for wound seroma. 71% (4/7) were dissatisfied with their postoperative range of movement. Average QDASH score was 33.3.
Conclusion: Intramedullary nailing for forearm fractures is an appropriate option in complex cases with high energy trauma. Postoperative range of motion and return to baseline is poor in the context of polytrauma. Further studies should evaluate optimisation of postoperative rehabilitation in these patients.

Introduction: Floating elbow in adults is rare, resulting from a high-energy trauma and often associated with neurovascular injury and bone exposure, leading to poor clinical outcomes. Methods: A thirty-six year-old male fell from ten meters in height and presented with direct elbow trauma. On physical examination, deformity of the upper limb and radial nerve palsy were noted, but no vascular compromise. Radiographically: transverse diaphyseal humerus fracture (AO: 12A3) with intra-articular extension (AO: 13C2) plus a comminuted fracture of the olecranon (AO: 2U1B1). A posterior approach through the olecranon fracture was chosen. Open reduction and fixation of the humerus with a medial short plate and posterolateral long anatomic plate, with fixation of both diaphyseal and intra-articular fractures, plus fixation of the olecranon with an anatomical plate were made. Results: Surgical intervention and postoperative care elapsed without complications. Radial nerve palsy recovered within the first weeks and active motion of the elbow was progressively recovered. At twelve months postoperative, radiographic consolidation was noted and good clinical outcomes with just five degrees of limitation in elbow flexion and ten degrees on pronation - Dash Score of six (Good). Discussion: The presence of nerve damage and intra-articular involvement are generally associated with a worse long-term functional outcomes and prognosis. The approach chosen by the surgeon allowed to effectively treat three different fractures using simply one incision, taking advantage of the olecranon fracture. Due to its complexity, unusual radiological pattern, the surgical approach chosen and good clinical outcomes, the exposure of this case is noteworthy.

Galeazzi fracture-dislocations consist of a fracture of the distal part of the radius with dislocation of distal radioulnar joint (DRUJ). This pattern is relatively rare and bilateral association is even more unusual. The objectives are to review the literature on a bilateral case and to present a method for stabilization of the DRUJ. A 40-year-old with a car accident resulting in a bilateral Galeazzi fracture-dislocations. She underwent open reduction and internal fixation with a locking plate and as the DRUJ remained unstable, it was stabilized bilaterally with a cortical fixation button system (syndesmopexy) in supinated position. In the postoperative period, she maintained the reduction of both Galeazzi fractures with stable DRUJs. She had mild pain, without neurovascular compromise and started physiotherapy. There are few cases reported in the literature of bilateral Galeazzi fracture-dislocations, being considered extremely rare. Radiographic predictors of DRUJ instability have been reported, such as shortening >5mm or distal radius fracture within 7.5cm of the articular surface. However, the verification of instability must be done intraoperatively after reduction and fixation of the radius fracture, according to Tsismenakis. It is essential to obtain an anatomical reduction of the DRUJ, as the persistent subluxation is related to poor results. There are several management of DRUJ instability described, since open or arthroscopic reduction, to closed reduction and percutaneous Kirschner wire fixation, with the latter being the most used. We report a cortical fixation button system (syndesmopexy), placed from the radius to the ulna in supination, with an excellent functional outcome.

Radial head (RH) is an important stabilizer of the elbow. RH fractures are commonly associated with injury to the ligamentous structures of the elbow, leading to instability. RH fractures and dislocations have been treated by closed and open methods. Conservative treatment resulted in stiffness and loss of function. Surgical methods include excision of fracture fragments; replacement; open reduction and internal fixation (ORIF). Clinical case of an open Gustilo Anderson type I and Mason type IV RH fracture. Male, 33 years-old, motorcycle accident, was taken to the emergency department with right elbow and left wrist excruciating pain and deformity. There were spotty wounds throughout the right antebrachial anterior side. No neurovascular impairment. X-rays: type IV Mason RH fracture (right elbow); distal comminuted metaphyseal extra-articular radial fracture (left). CT: highly comminuted head and neck radial fracture with diaphyseal extension. Simultaneously, it was performed a radial head arthroplasty (RHA) with an extra-long stem on the right elbow through a Kaplan approach, and ORIF with a long volar plate of the left distal radius. Immediate post-op complication: posterior interosseous nerve neuropraxia, with complete recovery 2 months later. At 4 months post-op, he has no pain, no elbow instability or stiffness, full range of motion. Treatment of Mason type IV fractures is controversial. Many authors report ORIF, while others advocate RHA. No functional differences between the two options were found. Common complications include overstuffing/stiffness, instability, and posttraumatic osteoarthritis; as such, these injuries can lead to significant disability in young, active patients if not managed appropriately.

Galeazzi fractures are rare, representing 3 to 7% of the fractures of the forearm. They include distal diaphyseal fracture of the radius and dislocation of the DRUJ (Distal Radio-Ulnar Joint). They result from high energy trauma and are frequent in young males. Galeazzi fractures are also named “fractures of necessity” because surgical treatment is obligatory. Firstly, reduction and rigid fixation of the radius diaphyseal fracture is performed, which can spontaneously reduce the DRUJ. If unstable, then integrity must be restored and fixated with Kirschner wires. DRUJ instability is suggested by radiographic widened PA articular space, ulnar styloid fracture, dorsal displacement of ulna, and a minimal 5 mm radius shortening. A male of 41 years old, who fell over the stairs at work complained of forearm and wrist pain, numbness, functional incapacity for active motion. Galeazzi Fracture was diagnosed. Open Reduction and Fixation of Diaphyseal Fracture of the Left Radius with Compressing Plating and screws was performed. DRUJ was fixed in supination with a Kirschner wire. The patient remained immobilized postoperatively with a forearm splint in supination for 6 weeks. At 12 weeks: no pain, successful active range of motion of wrist and forearm, and no notion of instability. QuickDASH (Disabilities of Arm, Shoulder and Hand) Score and PRWE (Patient-Rated Wrist Evaluation) Score with a corresponding result of 2.3 and 1. This case report shows that a Galeazzi fracture with postoperative period of forearm splinting and a transfixing distal radio-ulnar Kirschner wire results in a favorable functional outcome of the DRUJ.