Aims

Assessment of bone mineral density (BMD) with dual-energy X-ray absorptiometry (DXA) is a well-established clinical technique, but it is not available in the acute trauma setting. Thus, it cannot provide a preoperative estimation of BMD to help guide the technique of fracture fixation. Alternative methods that have been suggested for assessing BMD include: 1) cortical measures, such as cortical ratios and combined cortical scores; and 2) aluminium grading systems from preoperative digital radiographs. However, limited research has been performed in this area to validate the different methods. The aim of this study was to investigate the evaluation of BMD from digital radiographs by comparing various methods against DXA scanning.

Introduction. With advances in artificial intelligence, the use of computer-aided detection and diagnosis in clinical imaging is gaining traction. Typically, very large datasets are required to train machine-learning models, potentially limiting use of this technology when only small datasets are available. This study investigated whether pretraining of fracture detection models on large, existing datasets could improve the performance of the model when locating and classifying wrist fractures in a small X-ray image dataset. This concept is termed “transfer learning”. Method. Firstly, three detection models, namely, the faster region-based convolutional neural network (faster R-CNN), you only look once version eight (YOLOv8), and RetinaNet, were pretrained using the large, freely available dataset, common objects in context (COCO) (330000 images). Secondly, these models were pretrained using an open-source wrist X-ray dataset called “Graz Paediatric Wrist Digital X-rays” (GRAZPEDWRI-DX) on a (1) fracture detection dataset (20327 images) and (2) fracture location and classification dataset (14390 images). An orthopaedic surgeon classified the small available dataset of 776 distal radius X-rays (Arbeidsgmeischaft für Osteosynthesefragen Foundation / Orthopaedic Trauma Association; AO/OTA), on which the models were tested. Result. Detection models without pre-training on the large datasets were the least precise when tested on the small distal radius dataset. The model with the best accuracy to detect and classify wrist fractures was the YOLOv8 model pretrained on the GRAZPEDWRI-DX fracture detection dataset (mean average precision at intersection over union of 50=59.7%). This model showed up to 33.6% improved detection precision compared to the same models with no pre-training. Conclusion. Optimisation of machine-learning models can be challenging when only relatively small datasets are available. The findings of this study support the potential of transfer learning from large datasets to improve model performance in smaller datasets. This is encouraging for wider application of machine-learning technology in medical imaging evaluation, including less common orthopaedic pathologies

Aims

The aim of this study was to create artificial intelligence (AI) software with the purpose of providing a second opinion to physicians to support distal radius fracture (DRF) detection, and to compare the accuracy of fracture detection of physicians with and without software support.

In Asia, traditional bands are placed around limbs of children to ward off evil spirits and ensure good health. This practice may lead to the Rubber Band Syndrome (RBS) a rare paediatric condition described mainly in Asia which results from a forgotten thread or elastic band applied to the limb of a child. Because pressure necrosis beneath the band is slow, rapid healing of tissues over the band can obscure its presence. This makes the condition difficult to diagnose and distinguish from other infective conditions. This study presents the first case of RBS reported in South Africa. Case: The patient aged 18 months presented with a swollen hand, circumferential scar and discharging sinus on the wrist. A radiograph was negative. In theatre the volar wound was explored. Debridement revealed a yellow rubber band deep to the wrist flexors and neurovascular bundles but superficial to the extensor retinaculum. Complete removal of the rubber band and antibiotics was followed by rehabilitation with Occupational Therapy. At a 3 month follow up, there was no evidence of infection, sensation was normal and motor function of the hand restored. In this case, the structures through which the band had already passed were intact and overlay the band. It would appear that as the band slowly eroded the underlying structures it was followed by healing along the tract until the band exited deep to these structures. The band may come to rest on bone causing osteomyelitis if allowed to progress. A high index of suspicion of RBS is needed in children presenting with a circumferential scar and a non-healing wound, especially on the wrist or ankle. Careful debridement and complete removal of the band are essential to resolve symptoms and restore function

Introduction: The assessment of bone age using the standard Gruel and Pyle chart based on hand and wrist radiographs is usually carried out by Senior Radiologists. We performed a study to look at both intra and inter observer variability with different grades of clinicians. Materials and Methods: 30 sets of wrist radiographs were selected at random. The investigators included a Senior Radiographer, a Consultant and Registrar Radiologist an Orthopaedic Consultant and Senior Orthopaedic Fellow. Discussion: The Radiology team appear to be more consistent in their readings for the assessment of skeletal bone age than the Orthopaedic team. Howevr, it is interesting to note that although the Orthopaedic team are less consistent, when looking at the inter-observer variability, it suggests that both teams are equally well equipped to perform the task. Conclusion: Our study suggests that we should not cross professional boundaries. Render unto Caeser what is Ceaser’s!

Osteoporosis is an increasing problem due to increasing age and inactivity. Distal radial fractures are often the first symptom of this disease. Medical treatment can reduce the risk of further fractures (including hip fractures with the associated mortality and morbidity). To develop a method for accurate assessment of bone density from routine wrist radiographs:. Various bone substitutes were tested until one was found that gave reasonable density matches with fresh bone over a limited X-ray kV range;. Twenty patients with distal radius fractures had the bone substitute placed beside the wrist being X-rayed. Wrist and radius thickness were measured from the radiograph. This was combined with the optical density of the distal radius (relative to the bone substitute) to calculate a value for the bone density. The patients subsequently underwent a DEXA scan of the contralateral (uninjured) wrist. [The X-ray calculated bone density and the DEXA density compare well. (R> 0.5]. Conclusion: This technique gives reasonably accurate results. It is not yet ready for clinical practice. A larger study is required to improve the accuracy of this technique, perhaps comparing results with lumbar spine DEXA

Aim. In an earlier study we identified severe Vitamin D deficiency as a problem in institutionalised children with cerebral palsy (CP), which resulted in rickets and a high incidence of fractures. The purpose of this study was to establish whether a cohort of non-ambulatory children with CP, living at home, presented with Vitamin D deficiency. Method. The participants were a consecutive sample (N=100) of non-ambulatory children with CP attending a CP outpatient clinic. Their ages ranged from 2 to 15 years (mean 5.8, SD 3.3 years). There were 57 males and 43 females. Nineteen were on Level IV of the Gross Motor Function Classification System (GMFCS), and 81 were on Level V. 66% were on anticonvulsant therapy (ACT). Basic demographic data was collected, and measurements included blood sample analysis and wrist radiographs. There was radiographic evidence of osteopenia and delayed ossification of the carpal bones. Results. Three participants had Vitamin D deficiency rickets confirmed by wrist changes and serology. There was a significantly higher level of Alkaline Phosphatase (p=0.04) in children on ACT than in those who did not receive ACT. Preliminary results show that one third of the children had Vitamin D deficiency. Conclusion. Non ambulatory children with CP are at risk of developing rickets. We recommend regular exposure to sunlight or Vitamin D supplementation as preventative measures. NO DISCLOSURES

Various radiological classification systems exist for rheumatoid wrist progression but few have been evaluated for reliability and clinical application. In order to research these three sets of wrist radiographs of 35 rheumatoid patients, with an average duration of disease of 11 years, were classified according to four different classification systems (Larsen, Simmen, Wrightington and Modified Wrightington). The inter- and intraobserver reliability of each was calculated. The reliability of the Larsen and both Wrightington systems were good but the Simmen system had poor interobserver and intraobserver reproducibility. None of the classification systems satisfactorily assessed the distal radioulnar joint (DRUJ) and the Modified Wrightington system could not classify DRUJ disease in 6 of the 35 wrists

Purpose: In pediatric orthopedics, Risser sign is used to assess skeletal maturity. Two grading system exist for the Risser sign, one US and one European. In adolescent idiopathic scoliosis (AIS) the curve acceleration phase begin at a digital skeletal age (DSA) score between 400 – 425. The objective was to asses the disagreement between both grading system and evaluate the best estimator of the curve acceleration phase. Method: One hundred twenty-one AIS patients had a PA and lateral X-rays of the spine and a left hand and wrist X-ray. Risser sign was measured according to both grading system and bone age was calculated according to Tanner-Whitehouse III method. Kappa statistics were done to evaluate concordance between US and Euro-pean grading system and 2 multiple linear regression models were performed to find which stage best predicts the beginning of the rapid acceleration phase. Results: Kappa statistic between the US and European system was 0.517 (moderate agreement). US Risser 1 was the best predictor of the curve acceleration phase. DSA scores predicted with Risser 1 were 425 and 445 for US and European system respectively. Conclusion: American and European Risser grading system use different criteria to define 6 stages of a same sign. This is reflected in our study with a moderate agreement between both grading systems. US Risser 1 is the stage that best predicts the beginning of the rapid acceleration phase and a close follow up should be made at the beginning of the iliac apophysis ossification

Introduction: Osteoporosis is an increasing problem due to increasing age and inactivity. Distal radial fractures are often the first symptom of this disease. Medical treatment can reduce the risk of further fractures (including hip fractures with the associated mortality and morbidity). Aims: To develop a method for accurate assessment of bone density from routine wrist radiographs. Material and Methods: 1. Various bone substitutes were tested until one was found that gave reasonable density matches with fresh bone over a limited X-ray kV range. 2. Patients with distal radius fractures had the bone substitute placed beside the wrist being X-rayed. Wrist and radius thickness were measured from the radiograph. This was combined with the optical density of the distal radius (relative to the bone substitute) to calculate a value for the bone density. The patients subsequently underwent a DEXA scan of the contralateral (uninjured) wrist. Results: 20 patients. The X-ray calculated bone density and the DEXA density compare well. (R> 0.5)Discussion and Conclusion: This technique gives reasonably accurate results. It is not yet ready for clinical practice. A larger study is required to improve the accuracy of this technique, perhaps comparing results with lumbar spine DEXA

We aim to assess the AP distance and teardrop angles in a cohort of normal wrists and to assess their possible use as prognostic indicators in fractures of the distal radius. Two hundred standardised PA and lateral wrist radiographs from uninjured wrists and 95 patients with fractures of the distal radius were assessed and anatomic parameters measured, including the Teardrop angle and AP distance. Clinical assessment at a mean of 6 years post fracture included an assessment of grip strength and range of motion along with the DASH score. The mean teardrop angle in 200 normal wrists was 68 degrees (95%CI:67–69 degrees) and did not differ significantly between sexes (p=0.148). The average teardrop angle at presentation in 95 fractures of the distal radius was 47 degrees (95%CI:41–50 degrees), improving significantly to 58 degrees (95%CI:56–61 degrees, p< 0.0001) post-reduction, and this improvement was maintained at 56 degrees (95%CI:54–59 degrees) at union. The final position was significantly better than at presentation (p< 0.0001). Loss of teardrop angle between the fractured and uninjured wrist was significantly related to reduced grip strength (p=0.04) and worse DASH score (p=0.03). The mean AP distance in 200 normal wrists was 19.6mm (95%CI:19.4–19.9mm) in males and 17.6mm (95%CI:17.2–18.0mm) in females, which is significantly different (p< 0.0001). The mean AP Distance at presentation in 95 fractures of the distal radius was 21.0mm (95%CI:20.4–21.7mm), which improved significantly to 19.6 (95%CI:19.1–20.2mm, p< 0.0001), but subsequently worsened to 20.8mm (95%CI:20.2–20.4mm) at union. This is not significantly better than at presentation (p=0.397). An increase in AP distance in the fractured wrist correlated to loss of range of motion (p< 0.01). The value of these parameters is that they offer quite detailed assessment of the articular surface of the distal radius in the absence of more detailed imaging. They appear to be of prognostic value

The major aim of this presentation is to introduce the complex medical procedure concerning wrist fractures, luxations and wrist ligaments injuries based up-to date literature and author’s own experience. In scaphoid fractures the most common one – the diagnostic problems (proper X-ray projection, repete X-ray, CT, bone scan, e.t.c.) are presented as well as the right treatment based on the bone healing pathology (different vascular topography, fracture type e.t.c.). Also the medical procedure algorithm of the fresh scaphoid fractures (Herbert’s screw, Matti-Russe method), prolonged union or pseudoarthroses (bone transplant according to Matti-Russe or Fisk-Fernandes) is suggested. The treatment ways concerning lunar fractures (blood supply disorders and Kienböck disease), capitatum fractures (unstable fractures - open reposition + bone graft), triquetrum fracture (a mirror Bennet or ridge fracture), trapezoideum fracture, hamatum fracture (most common one – the hook) and posiforme fracture (usually coexists with other fractures) one also discussed based on clinical examples. Due to the wrist ligaments injuries author presents the most common luxations and instabilities; the treatment of perilunar luxations, either quicke hand reposition or open repositions with simultaneous tunnel decompression is described. The wrist instabilities are presented mainly due to diagnostic problems. According to static instabilities (dissociations) the author compares static X-ray and a healthy wrist X-ray (three arcs estimation, interbone space asymmetry) while dynamic instabilities require forced position X-ray scans. The most common instabilities – VISI and DISI – are also presented from wrist biomechanical point of view

Purpose of the study: Since 2001, we have used arthroscopy systematically to control the treatment of distal radius fractures. We report our three years experience. Material and methods: Arthroscopic control was used for all patients aged less than 65 admitted to our unit for treatment of an articular fracture of the distal radius. The same operator performed all procedures. Fixation methods were: K-wire pinning, locked plating (Synthes) or a combination of these two methods. The arthro-scope had a 2.4 mm optic. Bony lesions were noted according to the Cataign, Fernandez and AO classifications. The DASH, Green and O’Brien, and PWRE scores were noted. Results: Intraoperative arthroscopic control was performed for 61 patients between November 2001 and November 2004. Mean follow-up was 17 months (range 6–36 months). Arthroscopic exploration revealed: scapholunate ligament tears (n=11), lunotriquetral ligament injuries (n=3), pathological perforations of the triangle complex (n=4), damage to the radial cartilage (n=15), and mirror involvement of the carpal cartilage (n=4). An arthroscopic procedure was necessary to treat a bone or ligament lesion in 28 cases. At last follow-up, the DASH score was 19.3 and the PWRE 37.6. Discussion: Arthroscopic evaluation of articular fractures of the distal radius, a routine practice in English-speaking countries, remains a limited practice in France. There is nevertheless a real advantage of using intraoperative arthroscopy. The particular anatomy of the radial surface makes it impossible to achieve proper assessment on the plain x-ray for a quality reduction of the fracture. Recent ligament injuries are rarely detectable on a wrist x-ray. An intra-articular stair-step or an untreated ligament injury can pave the way to short-term development of osteoarthritic degeneration. Intraoperative arthroscopic control is the only way to diagnosi and treat these osteoligamentary lesions observed in patients with an articular fracture of the distal radius. For us, non use of intraoperative arthroscopy constitutes a lost chance for patients with an articular fracture of the distal radius

Purpose: The purpose of this study was to determine the impact of an ulnar styloid fracture (USF) associated with a nonsurgically or surgically treated distal radius fracture (DRF) in adult Patients under 65 years of age. Method: This was a cohort study involving 170 DRF patients aged 18 to 64 years old that presented to a single tertiary care center from 2004 to 2008. At initial presentation, three, six, 12 and 24 months follow up, patients were asked to complete a standardized pain and disability self-report measure, Patient Rated Wrist Evaluation (PRWE). All participants had posterior-anterior and lateral wrist radiographs performed at initial presentation and at each visit. Radiographs were reviewed at initial presentation, post treatment and at final follow up for DRF alignment as well as USF information. USFs were classified by size into tip, middle and base. Results: There were 170 DRF patients with two patients having bilateral injuries giving a total of 172 DRFs. Age ranged from 20 to 64 years old with a mean age of 50. There were 113 females and 57 males. Eighty-four of the DRFs were not associated with an USF and 88 were. Of these 88, 42 were tip, 18 were middle and 28 were base USFs. Thirty-two of these USFs (36%) were united at final follow up. One-hundred and one patients were treated nonoperatively and 69 treated operatively for their DRFs. The PRWE scores of DRF patients with an associated USF of any size was significantly better than those without an associated USF only at 24 month follow up (10 vs. 23, p=0.04). Patients with an USF in the middle or at the base had better PRWE scores at both 12 and 24 months (17 vs. 23, p=0.05 at 12 months & 10 vs. 20, p=0.01 at 24 months). An ulnar head fracture had no influence on PRWE scores. There was no difference in PRWE scores between united and nonunited ulnar styloid fractures at all follow up time points. Conclusion: We found that an USF was associated with better PRWE scores at 24 months and that the larger USFs, middle and base fractures, were associated with better scores at as early as 12 months. A fall onto the outstretched hand includes a component of force transmission through the ulnar side of the wrist. Without a bony ulnar styloid injury, we hypothesize that this force is transmitted through the soft tissues, creating an associated occult ligamentous, TFCC or other undetected soft tissue injuries resulting in higher pain and disability among those without a fracture. This hypothesis will require further attention in future studies. Union of the USFs also did not show an effect on outcome

It is generally appreciated that the internal structure and external shape of living bone adapt to mechanical stimuli according to Wolff’s law. However, the precise details of bone adaptation to external forces are not fully understood and there has been no previous investigation of the association between specific loading conditions and the skeletal architecture of a particular anatomical area using case-specific observations in a group of individuals. The aim of the present study was to investigate a previously unreported correlation between the maximum wrist joint reaction force and the volar tilt angle of the distal radius using parameters radiographically obtained parameters from normal wrist joints. Using free body analysis of the forces acting on the distal radius for the loading condition that corresponds to the lift of a weight using the supinated hand, the wrist joint reaction force F and the angle formed between the vector of F and the long axis of the radius have been expressed as a function of the lifted weight, the lever-arm of the wrist flexor tendons and that of the lifted weight. Measurements of the volar tilt angle of distal radius and the lever-arms of the flexor tendons and the lifted weight were performed from lateral wrist radiographs of 30 normal wrists. Subsequently, using the equations obtained from free body analysis, the maximum wrist joint reaction force F and the angle that the latter forms with the long axis of the radius were calculated for each the cases. Statistical analysis compared the angle of the maximum wrist force and the volar tilt of the distal radius (two-tailed paired t-test) and correlated (a) the angle of the maximum wrist force and the volar tilt angle and (b) the maximum joint reaction force and the volar tilt angle. Results showed no significant difference (p=0.33, 95% confidence interval −0.64° to 0.22°) but a statistically significant correlation (R. 2. = 0.74, r = 0.86, p < 0.001) between the angle of the maximum wrist force and the volar tilt angle of the distal radius. Additionally, an inverse relationship between the volar tilt angle and the magnitude of the maximum wrist force (R. 2. = 0.71, r =−0.84, p< 0.001) was found. These observations may explain the mechanism of the phylogenetical development of the volar tilt angle and support the ‘minimum effective strain’ theory of adaptive bone remodeling. 1. The importance of accurate restoration of the volar tilt during treatment of distal radius fractures, especially in wrists that are normally characterised by a low volar tilt angle, is also emphasized by the results of the present study

Aims

The primary aim of this study was to describe long-term patient-reported outcomes after ulna shortening osteotomy for ulna impaction syndrome.

Aims

Displaced distal radius fractures were investigated at a level 1 major trauma centre during the COVID-19 2020 lockdown due to the implementation of temporary changes in practice. The primary aim was to establish if follow-up at one week in place of the 72-hour British Orthopaedic Association Standards for Trauma & Orthopaedics (BOAST) guidance was safe following manipulation under anaesthetic. A parallel adaptation during lockdown was the non-expectation of Bier’s block. The secondary aim was to compare clinical outcomes with respect to block type.

Aims

To assess the proportion of patients with distal radius fractures (DRFs) who were managed nonoperatively during the COVID-19 pandemic in accordance with the British Orthopaedic Association BOAST COVID-19 guidelines, who would have otherwise been considered for an operative intervention.