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International Journal of Clinical... Dec 2021Fifteen potentially low value practices in adult orthopaedic trauma care were previously identified in a scoping review. The aim of this study was to synthesise the...
OBJECTIVES
Fifteen potentially low value practices in adult orthopaedic trauma care were previously identified in a scoping review. The aim of this study was to synthesise the evidence on these practices.
METHODS
We searched four databases for systematic reviews, randomised controlled trials (RCTs), cohort studies and case series that assessed the effectiveness of selected practices. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2) for systematic reviews and the Critical Appraisal Checklist for Case Series. We evaluated risk of bias with the Cochrane revised tool for RCTs and the risk of bias in non-randomised studies of interventions tool for observational studies. We summarised findings with measures of frequency and association for primary outcomes.
RESULTS
Of the 30,670 records screened, 70 studies were retained. We identified high-level evidence of lack of effectiveness or harm for routine initial imaging of ankle injury, orthosis for A0-A3 thoracolumbar burst fracture in patients <60 years of age, cast or splint immobilisation for suspected scaphoid fracture negative on MRI or confirmed fifth metacarpal neck fracture, and routine follow-up imaging for distal radius and ankles fractures. However, evidence was mostly based on studies of low methodological quality or high risk of bias.
CONCLUSION
In this review, we identified clinical practices in orthopaedic injury care which are not supported by current evidence and whose use may be questioned. In future research, we should measure their frequency, assess practice variations and evaluate root causes to identify practices that could be targeted for de-implementation.
Topics: Adult; Delivery of Health Care; Fractures, Bone; Humans; Orthopedics; Wrist Injuries
PubMed: 34816530
DOI: 10.1111/ijcp.15009 -
Medicina (Kaunas, Lithuania) Sep 2021The term acrometastases (AM) refers to secondary lesions sited distally to the elbow and knee, representing 0.1% of all bony metastases. By frequency, pulmonary cancer... (Review)
Review
The term acrometastases (AM) refers to secondary lesions sited distally to the elbow and knee, representing 0.1% of all bony metastases. By frequency, pulmonary cancer and gastrointestinal and genitourinary tract neoplasms are the most responsible for the reported AM. Improvements in oncologic patient care favor an increase in the incidence of such rare cases. We performed a systematic review of acrometastases to the hand to provide further insight into the management of these fragile patients. We also present a peculiar case of simultaneous acrometastasis to the ring finger and pathological vertebral fracture. A literature search according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement was conducted using the PubMed, Google Scholar, and Scopus databases in December 2020 on metastasis to the hand and wrist, from 1986 to 2020. MeSH terms included acrometastasis, carpal metastasis, hand metastasis, finger metastasis, phalangeal metastasis, and wrist metastasis. In total, 215 studies reporting the follow-up of 247 patients were analyzed, with a median age of 62 years (range 10-91 years). Overall, 162 out of 247 patients were males (65.6%) and 85 were females (34.4%). The median reported follow-up was 5 months (range 0.5-39). The median time from primary tumor diagnosis to acrometastasis was 24 months (range 0.7-156). Acrometastases were located at the finger/phalanx (68.4%), carpal (14.2%), metacarpal (14.2%), or other sites (3.2%). The primary tumors were pulmonary in 91 patients (36.8%). The average interval from primary tumor diagnosis to acrometastasis varied according to the primary tumor type from 2 months (in patients with mesenchymal tumors) to 64.0 months (in patients with breast cancer). Acrometastases usually develop in the late stage of oncologic disease and are associated with short life expectancy. Their occurrence can no longer be considered rare; physicians should thus be updated on their surgical management and their impact on prognosis and survival.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Bone Neoplasms; Child; Female; Finger Phalanges; Fingers; Humans; Lung Neoplasms; Male; Middle Aged; Prognosis; Young Adult
PubMed: 34577873
DOI: 10.3390/medicina57090950 -
Hand Surgery & Rehabilitation Oct 2021Intramedullary screw (IMS) fixation is increasingly used as an alternative treatment option in metacarpal and phalangeal fractures of the hand. However, this technique...
Intramedullary screw (IMS) fixation is increasingly used as an alternative treatment option in metacarpal and phalangeal fractures of the hand. However, this technique is currently the subject of controversy among hand surgeons. The aim of this systematic review was to gain insight on radiological, functional and patient-rated outcomes reported in literature. A comprehensive literature search of PubMed, Embase, CENTRAL and CINAHL databases was conducted on March 1st, 2021. All studies reporting on fracture union, complications, and functional and patient-rated outcome in IMS fixation of metacarpal and/or phalangeal fractures were selected. Two prospective and 16 retrospective cohort studies were included, encompassing a total of 837 patients with 958 fractures (693 metacarpal, 222 proximal phalangeal and 43 middle phalangeal). Mean surgery duration was 26.4 min (range 5-60 min). Union was ultimately achieved in all fractures in a mean of 5.7 weeks (range 2-12 weeks). The procedure-related complication rate was 3.2%. The most frequently reported complication was limitation of joint motion, occurring in 2.0% of cases. Incidence of other complications, including loss of reduction, infection and screw protrusion did not exceed 1%. Overall mean total active motion averaged 243° and grip strength reached 97.5% of the contralateral side. The Disabilities of the Arm, Shoulder and Hand (DASH) score averaged 3.7 points. Duration of sick leave was 7.3 weeks. According to the findings of this systematic review, IMS fixation is a time-saving and safe minimally invasive solution for both metacarpal and phalangeal fractures, with a low rate of complications and promising functional and patient-rated results.
Topics: Bone Screws; Fracture Fixation, Internal; Humans; Metacarpal Bones; Prospective Studies; Retrospective Studies; Upper Extremity
PubMed: 33933635
DOI: 10.1016/j.hansur.2021.04.009 -
Hand (New York, N.Y.) Jan 2023Common forms of fixation of metacarpal fractures have historically included percutaneous Kirschner wire fixation, plates and screws, and, more recently, intramedullary... (Review)
Review
Common forms of fixation of metacarpal fractures have historically included percutaneous Kirschner wire fixation, plates and screws, and, more recently, intramedullary screw fixation. Retrograde intramedullary screws (RISs) are a novel modality first described 10 years ago. The purpose of this review is to critically evaluate the published literature assessing outcomes of RIS fixation for metacarpal fractures and create a complication profile for this novel technique. A comprehensive literature search was performed using electronic databases for both clinical and biomechanical studies in relation to RIS fixation published from 2000 to 2020. A total of 19 studies (13 clinical and 6 biomechanical) met the inclusion criteria. The clinical studies examined 603 metacarpal fractures and demonstrated adequate functional outcomes in terms of grip strength, total active motion, and time to return to work. The biomechanical studies examined 80 metacarpal fractures, finding that load to failure in RISs was often equal to or higher than Kirschner wires but less than plate and screws. The complication rate in reviewed studies was 2.8%, with the most prevalent complications being stiffness and extension lag. RIS use in metacarpal fractures appears to provide adequate stability with satisfactory clinical outcomes and minimal complications, although more high-quality studies are needed to fully examine this modality.
Topics: Humans; Fracture Fixation, Internal; Metacarpal Bones; Fractures, Bone; Bone Screws; Bone Wires; Hand Injuries
PubMed: 33530708
DOI: 10.1177/1558944720988073 -
Hand (New York, N.Y.) Sep 2022Metacarpal shaft fractures are common hand injuries that predominantly affect younger patients. There is wide variability in their treatment with no consensus on best...
Metacarpal shaft fractures are common hand injuries that predominantly affect younger patients. There is wide variability in their treatment with no consensus on best practice. We performed a systematic review to assess the breadth and quality of available evidence supporting different treatment modalities for metacarpal shaft fractures of the finger digits in adults. A comprehensive search was conducted across multiple databases, in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 1600 records were identified; 7 studies fulfilled eligibility criteria and were included. No randomized controlled trials directly comparing surgery with nonsurgical treatment were found. One retrospective study compared nonsurgical with surgical treatment, whereas 6 compared surgical or nonsurgical treatments. Considerable heterogeneity between studies along with a high or critical risk of bias restricts direct comparison and conclusions. There is a lack of high-quality evidence to guide treatment, supporting the need for well-designed, multicenter trials to identify the most effective and cost-efficient treatment for metacarpal shaft fractures in adults.
Topics: Adult; Fracture Fixation, Internal; Fractures, Bone; Hand Injuries; Humans; Metacarpal Bones; Retrospective Studies
PubMed: 33252278
DOI: 10.1177/1558944720974363 -
The Journal of Hand Surgery, European... Jan 2021Cadaveric studies suggest that the acceptable deformity in fifth metacarpal neck fractures is maximally 30° palmar angulation. This systematic review verifies the...
Cadaveric studies suggest that the acceptable deformity in fifth metacarpal neck fractures is maximally 30° palmar angulation. This systematic review verifies the validity of these threshold values. Eighteen prospective comparative studies on operative and/or conservative treatment options in adults were included. None of the studies demonstrated any correlation between the residual or initial angulation and the clinical results despite accepting more severe angular deformities. Closed reduction and immobilization without internal fixation improved the palmar angle by 5° to 9° in three studies and 29° in a fourth. Operative treatments compared with non-reducing conservative treatments showed no benefit of the surgery other than aesthetic issues. The synthesis of this review indicates that 90% of fractures of the metacarpal neck with apex angulation up to 70° can be treated successfully with a functional metacarpal brace without reduction. Disability of the Arm, Shoulder and Hand questionnaire scores <10 are uniformly reported. I modified my own practice accordingly a decade ago to treating these fractures conservatively regardless of the palmar angulation, except in patients with exceptional demands or other fracture deformities.
Topics: Adult; Fracture Fixation, Internal; Fractures, Bone; Hand Injuries; Humans; Metacarpal Bones; Prospective Studies
PubMed: 33135525
DOI: 10.1177/1753193420968040 -
Orthopedic Reviews Jun 2020Aneurysmal bone cysts are benign, rare bony tumours frequently observed among children and young adults principally located in the long bones, pelvis, and spine and...
Aneurysmal bone cysts are benign, rare bony tumours frequently observed among children and young adults principally located in the long bones, pelvis, and spine and rarely in other anatomical district such as the hand. We report the case of a 12-year-old girl with an aneurysmal bone cyst, in active stage, involving the still-open epiphysis of the fourth metacarpal of the right hand, which was in a first time treated by curettage, and 3 months later, occurring a recurrence, by a radically excision of the bone and reconstruction with a graft from the iliac crest. At 10-year follow-up the patient had good cosmetic results and a functioning hand. We also performed a systematic Literature review in order to retrieve the key information regarding: the diagnosis, the clinical features and the treatment.
PubMed: 32913594
DOI: 10.4081/or.2020.8658 -
Hand (New York, N.Y.) May 2022Ulnar metacarpal base fractures can destabilize the carpometacarpal (CMC) joint, prompting surgical stabilization. Studies investigating this injury are limited by small...
BACKGROUND
Ulnar metacarpal base fractures can destabilize the carpometacarpal (CMC) joint, prompting surgical stabilization. Studies investigating this injury are limited by small case volumes. Our purpose is to review the surgical techniques, outcomes, and complications of ulnar CMC joint stabilization.
METHODS
A literature search was performed of all articles published on the surgical treatment and outcomes of ulnar CMC fracture dislocations using PubMed and Google Scholar databases between the years 2014 and 2019. Data were pooled and analyzed, assessing surgical techniques and hand outcome measures: union, recurrent dislocations, range of motion, grip strength, and complications.
RESULTS
Six studies met inclusion criteria. All surgical patients, regardless of technique, went on to union with no incidents of recurrent instability. Grip strength was significantly decreased postoperatively (82.7% of uninjured side). Patients with CMC dislocations of both the fourth and fifth ray had similar postoperative outcomes to those with CMC dislocations of the fifth ray alone. One third of plate and screw constructs required plate removal, due to breakage (2) or implant-related pain (4). Plate-related symptoms resolved after removal in all cases. Delayed treatment decreased the effectiveness of nonoperative treatment, and increased the likelihood of postoperative pain, chronic deformity, malunion, and CMC osteoarthritis.
CONCLUSIONS
Closed reduction percutaneous pinning, open reduction percutaneous pinning, and open reduction internal fixation with CMC joint bridging or dorsal buttress plating are all well described, safe techniques with low complication rates. Early, accurate diagnosis of fourth and fifth CMC joint fracture-dislocations is crucial for optimizing hand function and postoperative outcomes.
Topics: Bone Plates; Carpometacarpal Joints; Fracture Dislocation; Fracture Fixation, Internal; Humans; Joint Dislocations; Metacarpal Bones; Ulna Fractures
PubMed: 32772579
DOI: 10.1177/1558944720948241 -
The Journal of Hand Surgery... Sep 2020The little finger metacarpal neck fracture, also known as boxer's fracture, is a commonly encountered upper limb fracture in orthopaedics. There are multiple ways of... (Meta-Analysis)
Meta-Analysis
The little finger metacarpal neck fracture, also known as boxer's fracture, is a commonly encountered upper limb fracture in orthopaedics. There are multiple ways of managing this fracture, ranging from immediate mobilization to rigid internal fixation. However, there is still a lack of consensus on the best management option. The aim of this study is to review all comparative studies, either randomized trial or cohort studies, on little finger metacarpal neck fracture management, meta-analyze the radiological and functional outcome between conservative and operative management. A systematic search of the literature was conducted between year 1987 to 2018 on MEDLINE and EMBASE. To be included, studies needed to have shown comparison between conservative against operative management, assessing the radiological (palmar angulation) and the patient reported functional outcomes. The data were pooled using fixed-effect method. The methodology was adapted from the Cochrane Handbook for Systematic Review of Interventions and compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO CRD42018099168). 5 full papers were included in our study. Our meta-analysis showed that compared to operative management, conservative management report worse radiological palmar angulation at follow-up; but equivalent functional outcome in terms of Quick-DASH and grip strength. Conservative studies also showed fewer mean days off in comparison to operative management. Conservative management also showed equivalent Total Active Motion (TAM) and Visual Analogue Score for Pain (VAS), but some studies had insufficient data to be pooled. Regardless of palmar angulation, conservative treatment of little finger metacarpal neck fracture provides an equivalent functional outcome to surgical intervention with an earlier return to work and no risk of surgical complications. Larger, randomised controlled trials are required.
Topics: Conservative Treatment; Disability Evaluation; Fracture Fixation, Internal; Fractures, Bone; Hand Strength; Humans; Metacarpal Bones; Visual Analog Scale
PubMed: 32723052
DOI: 10.1142/S2424835520500290 -
BMC Musculoskeletal Disorders Jan 2020The standard diagnostic work-up for hand and wrist fractures consists of history taking, physical examination and imaging if needed, but the supporting evidence for this...
BACKGROUND
The standard diagnostic work-up for hand and wrist fractures consists of history taking, physical examination and imaging if needed, but the supporting evidence for this work-up is limited. The purpose of this study was to systematically examine the diagnostic accuracy of tests for hand and wrist fractures.
METHODS
A systematic search for relevant studies was performed. Methodological quality was assessed and sensitivity (Se), specificity (Sp), accuracy, positive predictive value (PPV) and negative predictive value (NPV) were extracted from the eligible studies.
RESULTS
Of the 35 eligible studies, two described the diagnostic accuracy of history taking for hand and wrist fractures. Physical examination with or without radiological examination for diagnosing scaphoid fractures (five studies) showed Se, Sp, accuracy, PPV and NPV ranging from 15 to 100%, 13-98%, 55-73%, 14-73% and 75-100%, respectively. Physical examination with radiological examination for diagnosing other carpal bone fractures (one study) showed a Se of 100%, with the exception of the triquetrum (75%). Physical examination for diagnosing phalangeal and metacarpal fractures (one study) showed Se, Sp, accuracy, PPV and NPV ranging from 26 to 55%, 13-89%, 45-76%, 41-77% and 63-75%, respectively. Imaging modalities of scaphoid fractures showed predominantly low values for PPV and the highest values for Sp and NPV (24 studies). Magnetic Resonance Imaging (MRI), Computed Tomography (CT), Ultrasonography (US) and Bone Scintigraphy (BS) were comparable in diagnostic accuracy for diagnosing a scaphoid fracture, with an accuracy ranging from 85 to 100%, 79-100%, 49-100% and 86-97%, respectively. Imaging for metacarpal and finger fractures showed Se, Sp, accuracy, PPV and NPV ranging from 73 to 100%, 78-100%, 70-100%, 79-100% and 70-100%, respectively.
CONCLUSIONS
Only two studies were found on the diagnostic accuracy of history taking for hand and wrist fractures in the current review. Physical examination was of moderate use for diagnosing a scaphoid fracture and of limited use for diagnosing phalangeal, metacarpal and remaining carpal fractures. MRI, CT and BS were found to be moderately accurate for the definitive diagnosis of clinically suspected carpal fractures.
Topics: Carpal Bones; Finger Phalanges; Fractures, Bone; Hand Injuries; Humans; Medical History Taking; Metacarpal Bones; Physical Examination; Predictive Value of Tests; Reproducibility of Results; Wrist Injuries
PubMed: 31910838
DOI: 10.1186/s12891-019-2988-z