To Örebro University

INTRODUCTION: Distal radial fractures are the most common fractures in adults. Maltreatment of distal radial fractures can result in pain and disability. The most common complications and maltreatment after distal radial fractures are malunion, tendon injury, infection and nerve injury. The Swedish Patient Insurance Company (LÖF) indemnifies approximately 90% of all healthcare providers in Sweden. The aim of this study was to assess maltreated distal radius fractures using data from the LÖF-register in combination with data from the Swedish Fracture Register.

METHOD: All insurance claims relating to patient-reported maltreatment of distal radial fractures in adults in Sweden, as well as data from the Swedish Fracture Register regarding fracture type and patient-reported outcome measures during the period 2011-2021 were analysed.

RESULTS: Of the total of 1393 claims relating to distal radial fractures during the study period, the frequency of reported maltreatment claims was 1.4%. Eighty-two per cent of the claimants were female and the median age was 60 years. Malunion was the most common overall complication, carpal tunnel syndrome was the most common nerve-related complication and extensor pollicis longus tendon rupture following anterior plating was the most common tendon-related complication. Sixty-four per cent of the claims were accepted and reimbursed. The total direct cost for maltreated distal radial fractures was €4,980,000.

CONCLUSION: Reducing the number of symptomatic malunions, ensuring correct anterior plate placement and identifying other critical steps in treatment would likely improve patient safety and decrease the additional financial burden for the society.

LEVEL OF EVIDENCE: IV.

Finger fractures are among the most common fractures of the upper limb. The number and cost of maltreated and misdiagnosed finger fractures in Sweden is unknown. The aim was to study the number, complications, causes, and cost of maltreated and misdiagnosed finger fractures, 2011-2021, in Sweden.

Claims matching the prespecified ICD-10-SE codes S62.6-7 (finger fractures) and T92.2 (sequelae after finger fracture) during the 2011-2021 timeframe were identified. The data were extracted from the Swedish National Patient Insurance Company Register and analyzed in terms of epidemiology and cost.

Of the 1621 assessed cases, 384 reported maltreated and misdiagnosed finger fractures were found. The mean age was 41 years (range 2-88). Thirty-one percent of the healthcare-related injuries occurred in emergency care, primarily due to maltreatment leading to malunion after non-operative treatment. Thirty-six percent of healthcare-related injuries occurred in specialist departments, mostly due to malunion after surgical intervention. In primary care, the leading cause was misdiagnosis, often due to inadequate examination and lack of X-ray examination. The total aggregated direct and indirect costs amounted to SEK 25 557 200 (USD 2 505 608, Euro 2 165 864, Yen 424 249 520).

CONCLUSION: Finger fractures affect people of all ages and can lead to significant socioeconomic and medical invalidity. Maltreated fractures mainly occur in emergency care (due to malunion after immobilization) and specialist care (due to malunion after surgery). Misdiagnosed fractures were more common in primary care. A suggestion for claims prevention would be improved physician education, updated guidelines regarding the use of X-rays, seeking specialist opinions in uncertain cases, evaluating surgical technique, and optimizing postoperative care could probably help reduce the number of these injuries.

Introduction: The mobilization regime after triangular fibrocartilage complex (TFCC) reinsertion is under debate, and there is no consensus in the literature. It would be desirable to mobilize patients more rapidly than traditional mobilization protocols; however, there are concerns regarding the risk of reinstability. During the last decade, our department developed and used a more accelerated rehabilitation protocol. The aim of this retrospective study was to evaluate the outcome and reinstability rate after TFCC reinsertion with this accelerated rehabilitation protocol.

Methods: A total of 74 patients (30 women/44 men) operated with foveal reinsertion of the TFCC (63 mini-open surgery, 11 arthroscopic surgery), who underwent the accelerated rehabilitation protocol, were evaluated after 1 year for stability, range of motion (ROM), grip strength, pain and function, using Patient Satisfaction Functional Score (PSFS), Visual Analog Scale (VAS), Patient-Rated Wrist Evaluation (PRWE), as well as Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) and Satisfaction grade.

Results: One patient needed surgery due to reinstability. Seven patients were assessed as semi-unstable in one of three directions (four mini-open and three arthroscopic surgeries). Twenty-one patients had additional surgery at the index operation. There was a statistically significant improvement in grip strength, wrist flexion, PSFS, VAS, PRWE, and Quick-DASH scores. The median Satisfaction grade was 4 (very satisfied).

Conclusion: Early mobilization with ROM exercises initiated 1 week after TFCC reinsertion results in high patient satisfaction, consistently good outcomes, and a low frequency of reinstability.Level of evidence III.

PURPOSE: The purpose of this study was to compare the clinical and radiographic outcomes 5 years after randomization to volar plating or combined plating for surgical treatment of an AO (Arbeitsgemeinschaft für Osteosynthesefragen) type C distal radius fracture (DRF).

METHODS: A total of 150 patients were previously randomized to a volar locking plate or combined plating for treatment of an AO type C DRF with strict inclusion and exclusion criteria. All participating patients were invited for a 5-year postoperative follow-up. Radiographs, pain (visual analog scale), grip strength, and range of motion were documented, along with the Patient-Rated Wrist Evaluation, Quick Disabilities of the Arm, Shoulder, and Hand, and EuroQol 5-Dimension questionnaires. Arthritis in the radiocarpal and distal radioulnar joint was graded on radiographs by a senior radiologist according to the Knirk and Jupiter classification.

RESULTS: There were 135 patients (66 in the volar plate group and 69 in the combined plating group), corresponding to a 90% follow-up rate. Median age at follow-up was 67 years (interquartile range 57-75). There was no difference in radiographic arthritis between the two groups. The volar plate group had significantly better outcomes in flexion, extension, radial deviation, and Patient-Rated Wrist Evaluation (P < .05). There were no significant between-group differences in the Quick Disabilities of the Arm, Shoulder, and Hand, EuroQol 5-Dimension index, or EuroQol Visual Analog Scale (P > 05). Hardware removal was significantly more common in the combined plating group (64%) than in the volar plate group (30%) (P < .001).

CONCLUSIONS: Among surgically treated patients with AO type C DRF, those operated with volar plating had better clinical outcomes 5 years after surgery compared to those treated with combined plating, but the minimal clinically important difference was not reached. These findings support volar plating as the preferred method for AO type C DRFs.

TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Wrist ligament injuries are common after trauma, especially when concomitant dislocated radius fractures are present. The diagnostics of scapholunate (SL), lunotriquetral (LT) and triangular fibrocartilage complex (TFCC) injuries are challenging and most often dependent on magnetic resonance imaging (MRI) examination or invasive arthroscopy. In some circumstances, missed ligament injuries can lead to devastating sequelae, in terms of pain, reduced grip strength, range of motion and subsequent degenerative arthritis. In certain cases and under certain conditions, the choice of treatment for wrist ligament injuries can sometimes be the subject of debate. An updated review of diagnostic accuracy, a higher awareness of the injuries among orthopaedic surgeons, a surgically adaptable classification of the injuries and objective and clinically easily adapted diagnostic tools are essential. This thesis demonstrates that a negative result from MRI cannot rule out the possibility of a clinically relevant injury to the SL ligament, the LT ligament or the TFCC. Clinical provocation wrist tests are of limited diagnostic value. The current gold standard, wrist arthroscopy, remains the preferred diagnostic technique with sufficient conclusive properties when it comes to wrist ligament injuries. Due to low accuracy and high costs, MRI can most often be abandoned, when it comes to wrist ligament injuries. The cost of wrist MRI is three times higher than that of a clinical examination at the Hand Surgery Department, Sahlgrenska University Hospital. The thesis emphasises the increased diligence required when dealing with wrist trauma in children and adolescents, as a substantial amount of delayed presentation of distal radio-ulnar joint (DRUJ) instability after wrist fractures or sprains in children and adolescents is found. The most striking finding is that several children and adolescents present with DRUJ instability with isolated TFCC tears. The long delay from injury to diagnosis and the severity of the injury in terms of solving the DRUJ instability problem among young people is also interesting and somewhat surprising. Four distinct SL injury types can be identified and classified. This classification can be used in both open and arthroscopic surgery and in acute, subacute and chronic injuries. An arthroscopically assisted SL capsuloplasty and suture may not be possible in all patients, particularly not when the ligament has been completely avulsed from the bone (in approximately 60% of patients; Andersson-Garcia-Elias Type 1 and 2), leaving no ligament remnant on one side. Most patients with an SL injury will require ligament re-attachment techniques using transosseous sutures, bone anchors, or ligament reconstruction. Distal radio-ulnar joint instability with an arthroscopically confirmed TFCC injury is associated with a 30% loss of pre-operative peak torque strength in pronation and supination – a measurement technique easily adapted in the clinical pre-operative setting.