Epidemiology of Distal Radius Fixations and Functional Outcomes in the Superelderly Population

Background: Superelderly patients (defined as 80 years old and older) account for 18% of all distal radius fractures in our institution and this number is increasing with the ageing population. When faced with the option of surgery, patients in this age group have concerns with regards to the long term outcomes including functional outcomes and the time to fracture union. Therefore, the aim of this study was to evaluate the functional outcomes in this specific population. Methods: Patient selection for surgery was determined by the fracture stability, the patient's premorbid function and underlying comorbidities. Post operatively, the time to fracture union after surgical fixation, surgical complications and patients' functional outcome scores were recorded. The method of anaesthesia and any anaesthesia-related complications were also included. Results: There were 76 superelderly patients who underwent surgical fixation of their distal radius fractures identified from our institution's prospective database from 2009 to 2016. Overall there were good functional outcome scores. The DASH scores at 3 months and 6 months were 17 and 10 respectively. Furthermore, the mean time to fracture union in our population was 47 days (approximately 7 weeks). There were only 2 post-operative surgical complications but no anaesthesia-related complications. Conclusions: Surgical fixation of distal radius fractures in appropriately selected patients in the superelderly population yields good functional outcomes.

Flap Related Complications Requiring Secondary Surgery in a Series of 851 Local Flaps Used for Fingertip Reconstruction

BACKGROUND

Local flaps are widely used to cover fingertip defects. Errors in design or technical execution of the flap may lead to morbidity and additional surgical procedure. The purpose of this study was to review flap related complications requiring unplanned secondary surgery to characterize preventable issues.

METHODS

851 local flaps were used to reconstruct fingertip defects during a 9-year period. Patients requiring unplanned secondary surgery to address flap related complications were subjected to analysis.

RESULTS

31 of 851 flaps (3.6%) required unplanned secondary surgery because of flap related complications. The most reliable flap was VY advancement flap with only one (0.3%) re-operation. The reverse vascular island flap, cross finger flap, and neurovascular island flap were associated with the comparable number of complications (8.0%; 6.3%; and 3.8% respectively). Total or partial necrosis was the cause for re-operation in 6 patients (0.7%). The typical reason for secondary surgery was inadequate soft tissue cover of the tip with homodigital neurovascular island flap and flexion contracture with reverse vascular island flap. Cross finger flaps were revised because of poor graft take at the donor site, bulky flap or flap necrosis.

CONCLUSIONS

Local flaps are reliable operations to cover fingertip defects. Each flap has potential pitfalls, which may be avoided if the surgeon is aware of them.

Proposed Guidelines for Treatment of Concomitant Distal Radius and Distal Ulna Fractures

BACKGROUND

Concomitant distal radius and distal ulna metaphysis or head fractures (DRUF) are uncommon and acceptable results have been reported from cast immobilisation and internal fixation.

METHODS

We reviewed the charts of 1094 patients treated for distal radius fracture at our institution in a two year period from 2009 to 2010. 24 patients with concomitant DRUF with were treated by cast immobilisation (group 1, n = 11), internal fixation of both bones (group 2, n = 7), internal fixation of radius alone (group 3, n = 2), and internal fixation of radius with distal ulna resection (group 4, n = 4). Patients treated by surgery underwent intraoperative assessment of distal ulna stability to determine the indication for ulna fixation. Post surgical range of motion, clinical parameters, and functional outcome scores (Gartland-Werley and modified Mayo) were measured.

RESULTS

Wrist motion was comparable in each group. Radiographic parameters were better in surgical groups. 23 of 24 patients achieved excellent/good outcomes based on Gartland-Werley scores, while 12 of 24 achieved good modified Mayo wrist score. There was a case of distal ulna non-union in group 1, and another case of delayed distal radius union in group 2.

CONCLUSIONS

By evaluating patients' functional requirement, and dynamic fluoroscopy examination, satisfactory outcomes can be achieved for various presentations of DRUF.

Antipronation spiral tenodesis--a surgical technique for the treatment of perilunate instability

Perilunate dislocations involve avulsion or rupture of both intrinsic and extrinsic ligaments around the lunate. If inadequately treated, these ligaments may not heal properly, inducing a particular type of carpal instability characterized by the loss of the ability of the carpus to resist pronation torques. Six ligaments protect the carpus against excessive intracarpal pronation: long radiolunate, palmar and dorsal lunotriquetral, dorsal scapholunate, dorsal intercarpal, and palmar scaphocapitate ligaments. Collectively, these antipronation ligaments have a spiral configuration around the carpus. This article describes a technique to reconstruct this spiral arrangement of ligaments using a strip of flexor carpi radialis. To illustrate the technique, we describe 1 clinical case with a follow-up of 34 months. The so-called antipronation spiral tenodesis is only indicated if the instability is easily reducible, without cartilage damage.

General practitioners' knowledge of hand surgery in Singapore: a survey study

INTRODUCTION

Hand surgery is a subspecialty with a dedicated training programme in Singapore. Currently, Singapore is one of two countries in the world that still provides dedicated advanced hand specialty training. As hand surgeons depend on referrals from institutions and general practitioners, appropriate hand surgical referral requires the referring physician to have knowledge and understanding of common hand conditions as well as less common but more urgent surgical conditions, and their available surgical treatments. This study aimed to determine the knowledge of hand surgery and hand surgical conditions among general practitioners.

METHODS

A questionnaire survey was conducted during a continuing medical education symposium on hand surgery in Singapore. Participants responded to 12 questions on hand trauma by keying the answers into a computer database system. The results were then analysed.

RESULTS

A total of 35 general practitioners responded to our survey, and they were able to answer 53% of the questions correctly. We found knowledge gaps among the participants regarding hand surgical conditions, and identified areas where increased education during medical school, postgraduate training and continuing medical education may be beneficial. Areas that were found to be weak included recognising injuries that pose a high risk for developing wound infection, complications of topical steroid injection in trigger finger treatment and hand tumours.

CONCLUSION

Improving hand surgery knowledge among general practitioners not only leads to improved primary care, but it can also facilitate prompt recognition of surgical problems and subsequent referral to appropriate hand surgeons for treatment. This may possibly reduce the load of tertiary institutions in treating non-urgent hand conditions.