III.

The authors of this study noticed that the elastic garters of below knee anti-embolism stockings (AES) were indenting the proximal calves of patients after application and feared this might be interrupting venous return. This was lower on one ward which had a rigorous standardized protocol for sizing and checking stockings. Hypotheses were that proximal indentation caused higher proximal than distal pressures (reverse gradients) and that by adopting the standardized protocol throughout the unit, proximal indentation could be reduced. Fifty-seven patients were recruited after total hip replacement (THR) or total knee replacement (TKR) in a regional orthopaedic centre. The authors implemented the standardized protocol for sizing stockings and measured the pressures under them. After implementation of the standardized protocol, proximal indentation fell from 53% to 19% (p<0.05), incorrectly sized stockings from 74% to 34% (p<0.05) and removal of stockings by patients from 32% to 0% (p<0.05). In total, 21% of patients had reverse gradients which occurred in 41% of legs with proximal indentation and 8% without. When reverse gradients or proximal indentation exist, AES may not be as effective and may be counterproductive. A standardized protocol of nursing practice is critical to optimizing AES after THR and TKR. More in-vivo research is needed on AES after hip and knee replacement.

Accurate assessment of distal radioulnar joint (DRUJ) stability is increasingly recognized as an important part of clinical examination of the wrist. The ability of 30 specialist UK hand surgeons to clinically determine the stability of four volunteers’ wrists was assessed. Volunteers’ wrist stability had previously been confirmed with a validated measurement rig. Use of the wrist ballottement test as the primary examination technique yielded a positive predictive value of 81%, a negative predictive value of 55%, a specificity of 94% and a sensitivity of only 24%, for the detection of DRUJ instability. No correlation between background speciality (orthopaedic versus plastic surgery), nor years of clinical experience was found. Clinical assessment of DRUJ instability among experienced clinicians appears unreliable and instability is typically under recognized. Previous research to date using this clinical assessment method as a parameter of success is therefore brought into question. Level of evidence: IV

The incidence of distal radioulnar joint instability following a distal radius fracture is estimated around one in three based upon clinical examination. Using a validated rig, we objectively measured distal radioulnar joint translation in vivo following distal radius fracture. Dorsopalmar translation of the distal radioulnar joint was measured in 50 adults with previous distal radius fractures. Measurements were compared with the uninjured wrist and against a database of previous measurements within healthy and clinically lax populations. Translation at the distal radioulnar joint was greater in injured wrists at 12.2 mm (range 10–15, SD 1.2) than the uninjured wrists at 6.4 (range 4–9, SD 0.8) ( p < 0.001) and was always outside the established normal range. There was no statistically significant link between translation and the severity of the injury. Instability appears almost inevitable following a distal radius (wrist) fracture, albeit subclinical in the vast majority.

No abstract