Background: flexor tendons injuries are challenging in management, In this study, assessment of clinical results a new technique of modified technique six strands core suture method in acute flexor tendon injury.
Patients and methods: prospective study on 22 patients with 46 fingers was conducted at orthopedic department, Al-Zahraa University Hospital, From January 2020 - October 2021 those patients suffering from cut of flexor tendons (zone II – V) repaired by a modified technique of six-strands core sutures (modified cruciate repair).
Results: 91% of cases achieved dependent on Strickland evaluation [7], 85 - 100% (34 fingers) return of active motion (excellent results), 70-84% (8 fingers) return of active motion (good results), Fair results achieved in 1 finger, Poor results were achieved in 3 fingers.
Conclusion: a modified technique of six-strands core sutures (modified cruciate repair added two core suture assembly M of Tang) has comparable result, promoting early physiotherapy and rehabilitation that affect the outcome later on
Keywords: Flexor tendon, six strands, Strickland.

Introduction: Post traumatic Gap Non-union of distal radius is rare entity but not uncommon . If this defect remains uncorrected for a longer time, secondary deformities develop which results in limited movement of elbow and wrist. Usual treatment of gap grafting is practicable in case with minimum manus valgus deformity and stable elbow joint with near normal functional wrist joint. But in case where massive gap non-union of distal radius is present with secondary deformity, gap grafting is not practicable. In such cases, ulnar transposition (at the lower end) resulting in a one bone forearm is an option. This paper critically analysed both the procedures and presenting results of our experience.
Material and Method: Seven cases of post traumatic gap nonunion of distal radius were treated in the last 8 years. Out of 7 cases 5 were treated by the creation of ‘one bone forearm’ and 2 cases by Gap Grafting (Modified Nocolus graft). Male to female ratio was 5:2 with age ranging from 16 years to 35 years.
Results: The functional and clinic- radiological results were excellent in all except one. One case of ‘One bone forearm’ had fair result due to post operative infection.
Conclusion: Autogenous bone grafting (using any technique) is the choice of surgery for gap non-union. Though the outcome of Modified Nicoll’s gap grafting in distal radius is highly encouraging but massive gap and severely deformed DRUJ & Wrist then Creation of ‘One Bone Forearm’ is still a Dependable, Effective and Economical procedure.

introduction:Buckle fractures, also known as torus fractures, are commonly caused by a fall on the outstretched hand and are most often seen in the paediatric population. NICE (NG38) recommend that children with torus forearm fractures should not have rigid casts and should be discharged from hospital after assessment and reassurance.Our initial audit reviewed the practice in our unit between August-October 2017 and it showed that 95% of patients were treated with a cast and 86.2% attended for a follow-up visit. Following this, recommendations were made including education regarding management as per NICE guideline with application of wrist splints in the Emergency Department (ED) or Fracture Clinic and discharging the children after providing carers with information leaflets and reassurance. Methodology & Theoretical Orientation: Retrospective audit of all buckle fractures referred to the Fracture Clinic between July–September 2018 (inclusive). Clinic letters and images reviewed using MediSec and PACS, respectively.Findings: Thirty-six patients were included (63% male; mean age 9 years).In ED, 19% of patients were given a splint compared to 0%. In fracture clinic, 54% were given a splint and of those only 38.9% were discharged at first visit.A further 55.6% of patients were brought back for a second visit.Four patients were given a cast due to size issues or patient preferences. Conclusion & Significance: Despite the improvement seen regarding compliance with NICE guidelines, work is needed to further enhance compliance. Staff education and optimising splint availability will be a priority to reduce the burden on fracture clinic resources by unnecessary follow-up appointments.

Purpose
To compare the arthroscopic wafer procedure (AWP) and ulnar shortening osteotomy (USO) for treatment of idiopathic ulnar impaction syndrome (UIS) in terms of clinical, functional improvement, and time of return to work.
Methods
This single-center study was conducted at an academic level 1 referral center between 2014 and 2020. Sixty patients with idiopathic UIS were prospectively randomized to treatment with either AWP or USO. At the final follow-up, patients were evaluated by the Disabilities of the Arm, Shoulder, and Hand (DASH) score, the Modified Mayo Wrist Score (MMWS), the visual analogue scale (VAS) for pain, wrist range of motion (ROM), and grip strength. Also, the time of return to work and complications were reported. Results
The mean follow-up period was 22 ± 5.7 months in the AWP group and 21.1 ± 5.3 months in the USO group. All patients in the USO group achieved union by 12 weeks. At the final follow-up period, there were no statistically significant differences in the outcome measures (DASH score, MMWS, VAS, ROM, and grip strength) in both groups. Fewer complications and earlier return to work were observed in the AWP group.
Conclusions
Both techniques yielded comparable outcomes with earlier return to work, less incidence of complications, and secondary procedures in the AWP group.
Type of study/level of evidence Therapeutic, Randomized controlled trial, level II.

Introduction: Treatment of fractures around interphalangeal joint (IP), ranges from conservative (strapping) to surgical (k wire, screws, miniplate) which leads to stiffness due to prolonged immobilization. Suzuki frame a dynamic traction, by using principle of ligamentotaxis help to align the fragments as well as allows immediate movement. Material and methods: 60 patients of fractures around the proximal interphalangeal joint were treated by Suzuki frame and were evaluated by quick DASH and belesky score. Results: The mean was 31 years (range 17 to 49 years). Ring finger was most commonly involved as seen in 24 cases. The mean quick DASH score was 13, with almost 38 (95%) cases having no or only mild difficulty. 52 patients (87%) had excellent to good results as per belesky grade. The mean PIP range at immediate postoperative, 2 weeks, 1 month and 3 month was 28.500±5.590, 55.270±9.560, 74.500±12.060 and 94.330±10.320 respectively. 2 (3.3%) patient had pin tract infection and 6 (10.0%) patients had stiffness. Conclusion: Suzuki frame is closed, cost effective, day care and easy procedure, which gives excellent to good outcome in fractures around proximal interphalangeal joints, owing to allowing permitting immediate joint mobility while maintaining the reduction.

Introduction: The predominant method for Blauth type ⅢA thumb hypoplasia is pollicization. However, the four-digits hand presented after pollicization is not perfect, and it is also a pity to amputate the deformed thumb. This study tried to reconstruct a five-digits hand by reshaping the hypoplastic thumb with a sectional toenail flap. Methods: A ‘L’ shaped incision along the tip and ulnar side of the deformed thumb were designed. According to the difference in circumference and length between the contralateral thumb and the deformed thumb, the ipsilateral partial toenail flap with toe tip and phalangeal bone were accurately harvested, and transplanted to fit with the deformed thumb, forming a new thumb similar to the contralateral thumb. Results: Two boys aged 12 years and 18 years with Blauth type ⅢA thumb hypoplasia received surgery. the flaps survived. With an average follow-up of 11 months, the reconstructed thumbs had acceptable functional and aesthetic outcomes and the donor foot presented in decent appearance without signs of impaired function. Patients and parents had good acceptance of the new thumb. Conclusions: Reconstruction of an hypoplastic thumb (Blauth type ⅢA) with a sectional toenail flap is an effective strategy. It offers an alternative solution for parents insisting on saving the five-digits hand.
Keywords: Thumb hypoplasia; toenail flap; Donor site morbidity; Microsurgery

The Extension-block fixation is a popular surgical treatment method for bony mallet fractures but is associated with several pitfalls. Transfixation Kirschner wires used in the extension-block pinning may cause iatrogenic nail bed injury, chondral damage may lead to osteoarthritis, the need for prolonged immobilization may cause flexion contracture of the DIP joint. The objective of this study was to determine clinical outcome of the Novel delta(Δ) wiring technique in bony mallet fractures which can permit early joint motion and give strong compression force on the fracture fragment continuously. 10 Patient with bony mallet fractures were treated with delta wiring technique with good functional and radiologic outcomes. The mean time between the injury and surgery was 7 days (range 3-9 days), and the mean follow-up period was 7.2 months (range 8 to 10 months). Radiographic bone union was achieved in all patients within an average of 7.1 weeks (range 6 to 8 wk.). At the final follow-up, the distal interphalangeal joint had an average degree of flexion of 72 degrees (range, 70 to 76 degrees) and an average extension deficit of 4.60 (range, 0 to 7 degrees). According to Crawford’s criteria, 4 patient had excellent results and 6 patients had good results. No patient reported pain at the final follow-up. Satisfactory clinical and radiologic outcomes were obtained with the delta wiring technique. Delta(Δ) wiring technique may therefore, be a useful alternative method for the treatment of bony mallet fractures when properly applied.

Introduction: Fracture of the base of the ulnar styloid has shown to have higher incidence of TFCC tears and DRUJ instability leading to nonunion and impaired function. Poorer functional outcomes of the distal radius fracture have been attributed to the untreated associated ulnar styloid fractures while others have shown no difference. Thus, the treatment remains controversial. Although, fixation of ulnar styloid is recommended, there are no studies comparing the outcomes of surgically and conservatively treated patients. Methods: A retrospective analysis of 14 surgically treated and 28 age and fracture pattern matched conservatively treated ulnar styloid fractures in patients with intra-articular distal radius fractures treated with LCP fixation with a minimum follow up of 2 years. Radiological parameters such as union and amount of displacement, VAS score of ulnar-sided wrist pain, functional assessment using the modified Mayo score and the quick DASH questionnaire and complications were analyzed. Results: At the final follow-up, mean VAS score, modified Mayo score, Quick DASH score, non-union rate between the groups were statistically insignificant(p >0.05). Patients with non union had a higher VAS score, post-operative displacement of the styloid, poorer functional outcomes which were statistically significant (p <0.05). Discussion: Although there is no difference in ulnar sided wrist pain and functional outcomes between the groups, conservatively treated cases have higher risk of non-union. If the displacement is >2.1mm after fixation of the distal radius fracture, open reduction and fixation of the styloid minimizes the incidence of non-union, ulnar sided wrist pain and provides better functional outcomes.

Introduction: Preservation of the quadratus pronator is explained by preservation of bone vascularity, improvement of the bone healing process, reduction of the infection rate, and early functional recovery.

MATERIALS AND METHODS: This is a prospective study of 18 patients, performed at the Trauma-Orthopedics Department, of Chu Ibn Rochd , over a 3-year (2018-2020), all victims of articular or extra-articular fractures of the distal radius, surgically treated with a screwed plate locked by a minimally invasive approach with conservation of the quadratus pronator.

RESULTS: The mean age of our patients was 54 years. All patients in our series were treated with a screw plate using a minimally invasive anterior approach to the distal radius with preservation of the pronator quadratus. Each patient was evaluated by the Green O'brien score, a joint range of motion study, and a frontal and lateral wrist radiograph was also performed. The mean Green and O'brien score was 85 at 6 months, and the mean scar size was 50 mm.

DISSCUSSION: The pronator quadratus muscle plays an important role in wrist biomechanics. Preservation of the pronator quadratus in the MIPO technique improves the bone healing process, reduces the rate of infection, accelerates functional recovery, provides a better aesthetic result. The relative contraindications to the MIPO technique are comminuted joint fractures in elderly osteoporotic patients. The results of our series are consistent with the literature.

CONCLUSION: Conservation of the pronator quadratus in distal radius fractures is an attractive technique, which requires a learning curve and adequate equipment.

The wide-awake local anesthesia no tourniquet technique is used in Distal end radius fracture fixation. We studied the perioperative variables, clinical outcomes and limitations of open reduction and internal fixation (ORIF) for distal radius fractures under WALANT.

Methods

From June 2021 to Jan 2022, 25 patients with distal radius fractures were treated. Of these 25 patients, 20 radius fractures were fixed with a volar plate, and the other 5 were fixed with a dorsal plate.. Radiographs; range of motions; visual analog scale (VAS); quick disabilities of the arm, shoulder, and hand (Quick DASH) questionnaire; and time to union were evaluated.

Results

In 24 patients, distal radius ORIF under WALANT procedure done successfully. In 1/25 patients we had to go for GA. The average age is 36.28 (18-72) years. The average operation time was 75 ( 45-110) minutes, the average blood loss was 33.8 (15-50) ml. The average postoperative day one VAS was 1.52 (1-3). The average time of union was 18 (15-32) weeks. Functional 1-year postoperative outcomes revealed an average Quick DASH score of 6.9 (4.8-12.6). There was no wound infection, neurovascular injury, or other major complication noted.

Conclusions

WALANT for distal radius fracture ORIF is a method to control blood loss by the effects of local anesthesia mixed with hemostatic agents and an alternative to regional block or general anesthesia. It eliminates the requirements of multiple preoperative examinations, postoperative anesthesia care, and side effects of the sedation. However, patients who are not amenable to the awake procedure are contraindications.

Introduction
The fifth metacarpal neck fracture is the most common metacarpal fracture. However, there is no consensus regarding the angulation measurement method of the fracture. This study aimed to identify a reliable measurement method for assessing palmar angulation.
Materials and methods
We identified surgically treated patients for acute fifth metacarpal neck fracture between January 1, 2008, and December 31, 2020, and obtained preoperative, opposite hand, and final follow-up oblique X-rays and sagittal computed tomography (CT) radiograms. The metacarpal neck palmar angulation was measured using the metacarpal neck-shaft center (MNSC) angle and the shaft articular surface (SAS) angle methods by three orthopedic surgeons in two sessions.
Results
The study included 51 patients; the average age was 32.5 (range 18–73) years, with 46 men and 5 women. Intraclass coefficients (ICCs) for the MNSC angle demonstrated an excellent inter-observer agreement among the three measurers in both session [first:0.93 second:0.88] compared to ICCs for the SAS angle [first: 0.81, second: 0.87] The MNSC angle intra-observer reliability was also better than the SAS angle, with higher ICCs. In terms of preoperative CT radiograms measurements, the MNSC angle inter-observer reliability was higher than that of the SAS angle [MNSC: 0.83; SAS: 0.35], second [MSNC: 0.85; SAS: 0.81] as well as the intra-observer reliability.
Conclusions
The palmar angulation measurement in oblique X-ray using the MNSC angle method had good-to-excellent reliability, with superior results to sagittal CT radiograms. As a results, the method is reliable for judging the fracture degree and reduction adequacy after surgery.

A common problem after volar plate fixation of distal radius fractures is screw protrusion through the dorsal radius cortex leading to extensor tendon irritation and tendon rupture. The aim of this study was to compare lateral x-ray views and intraoperative skyline views to detect dorsal screw penetration using ultrasonography as the reference standard. Three different surgeons analysed the postoperative lateral images of 49 patients treated with volar plate fixation. In the first assessment, images were reviewed regarding dorsal penetration according to the surgeons' experience. In the second determination, screws that protruded beyond a vertical auxillary line drawn on the dorsal edge of the distal radius were assessed as protruding. The accuracy of the intraoperative Skyline view detecting dorsal screw penetration was also evaluated. All patients included in this evaluation had an ultrasound examination 6 months postoperatively. The first analysis showed interobserver agreement in 32 out of 49 cases (65.3%). Utilizing the auxiliary line on the lateral x-ray views increased this ratio to 83.7%. Analysis of the intraoperative skyline view, which was available in 30 patients, resulted in an unanimous response in 19 cases (63.3%). Ultrasound examination showed dorsal screw protrusion in 33 out of 49 cases (67.3%). Using the auxiliary line on the lateral images, the accuracy of screw penetration detection increased from 51.0% to 79.6%. Skyline view assessment shows agreement with ultrasound in 20 out of 33 cases (60.6 %). These findings highlight the difficulty detecting dorsal screw penetration after volar plate osteosynthesis in distal radius fractures.