Purpose of Review High energy distal radius are commonly multi-fragmentary with significant comminution and/or bone loss. They can also be associated with ligamentous and soft tissue injury and neurovascular compromise. As such, reconstruction of these injuries can be challenging. This paper will review the relevant anatomy, different methods of fixation, and present techniques for difficult fractures. Recent Findings Volar locked plating is a successful, very common method of treatment for distal radius fractures, but dorsal plating, fragment specific fixation, spanning bridge plating, and external fixation are sometimes necessary, particularly in higher energy injuries characterized by metaphyseal comminution, small volar fragments, intra-articular free fragments or lunate facet subsidence. Extended flexor carpi radialis (FCR), dorsal, and flexor carpi ulnaris (FCU) exposures can assist in visualizing the fracture site. Summary There are many different modes of fixation for distal radius fractures, and successful outcome depends on selection of appropriate fixation based on the fracture pattern and status of the soft tissues. Keywords Distal radius. Hand trauma. Comminuted fracture. Articular fracture. Open reduction internal fixation This article is part of the Topical Collection on Distal Radius and Wrist Fractures

Summary: Targeted muscle reinnervation (TMR) is an evolving technique with promising results for prevention and treatment of neuropathic pain, as well as modulation of control for myoelectric prostheses. The previously described and most commonly used technique for transhumeral TMR combines both an anterior and posterior approach to access the major peripheral nerves of the upper extremity. In this article, we review the literature for transhumeral TMR and describe a more expeditious and efficient anterior-only approach that offers safe access through a single incision.

Aims We quantitatively compared the 3D bone density distributions on CT scans performed on scaphoid waist fractures subacutely that went on to union or nonunion, and assessed whether 2D CT evaluations correlate with 3D bone density evaluations. Methods We constructed 3D models from 17 scaphoid waist fracture CTs performed between four to 18 weeks after fracture that did not unite (nonunion group), 17 age-matched scaphoid waist fracture CTs that healed (union group), and 17 age-matched control CTs without injury (control group). We measured the 3D bone density for the distal and proximal fragments relative to the triquetrum bone density and compared findings among the three groups. We then performed bone density measurements using 2D CT and evaluated the correlation with 3D bone densities. We identified the optimal cutoff with diagnostic values of the 2D method to predict nonunion with receiver operating characteristic (ROC) curves. Results In the nonunion group, both the distal (100.2%) and proximal (126.6%) fragments had a significantly higher bone density compared to the union (distal: 85.7%; proximal: 108.3%) or control groups (distal: 91.6%; proximal: 109.1%) using the 3D bone density measurement, which were statistically significant for all comparisons. 2D measurements were highly correlated to 3D bone density measurements (Spearman’s correlation coefficient (R) = 0.85 to 0.95). Using 2D measurements, ROC curve analysis revealed the optimal cutoffs of 90.8% and 116.3% for distal and proximal fragments. This led to a sensitivity of 1.00 if either cutoff is met and a specificity of 0.82 when both cutoffs are met. Conclusion Using 3D modelling software, nonunions were found to exhibit bone density increases in both the distal and proximal fragments in CTs performed between four to 18 weeks after fracture during the course of treatment. 2D bone density measurements using standard CT scans correlate well with 3D models. In patients with scaphoid fractures, CT bone density measurements may be useful in predicting the likelihood of nonunion. Cite this article: Bone Joint J 2020;102-B(9):1200–1209.

Objectives:Surgical performance is a highly intellectual activity that involves the processing of perceptual information from the five senses. Strategies to process, organize, and retain this perceptual information may benefit learning techniques. Once such strategy, cognitive rehearsal, is the activity where a skill is rehearsed in memory prior to the actual performance. This study aimed to develop and validate a cognitive rehearsal strategy for arthroscopic knee surgery in orthopaedic residents. We hypothesized that this training tool will lead to increased comfort and confidence with arthroscopic surgery performance.Methods:An expert surgeon was filmed performing an arthroscopic ACL reconstruction using patellar bone-tendon-bone autograft. An instructional training video was then created incorporating the extracorporeal and arthroscopic footage with voice over and subtitles. Following the surgery, cognitive recall of the procedure was conducted with the surgeon to identify key visual, cognitive, and kinesthetic cues to develop a mental imagery script to enhance rehearsal of arthroscopic surgery. Orthopaedic residents from two academic training programs were invited to participate. Demographic information including training level, previous musical experience, organized sports participation, and preferred learning style was collected. The training session consisted of a relaxation exercise, instructional video of an expert performing the procedure, learning the mental imagery script, and rehearsing the procedure out loud with a partner. The residents’ ability to rehearse the procedure was assessed before and after the training session with a modified version of a previously validated questionnaire, and a post-training session survey was administered to define which components of the rehearsal seemed most beneficial. Statistical analysis included a reliability analysis for internal consistency, and a nonparametric Wilcoxon test to compare the composite cognitive rehearsal scores of the junior and senior residents. A nonparametric Mann-Whitney test was used to evaluate performance of each group before and after the training session on each item of the questionnaire.Results:53 of 62 (85%) residents completed the demographics survey prior to the training session, while 44 of 62 (71%) residents were available to complete the training exercise. A Cronbach alpha of 0.9494 for the pre-training (n=44) and 0.9394 (n=44) for the post-training suggested that the cognitive rehearsal questionnaire was internally consistent, allowing for the reliable summation of individual items to a composite score. The median composite cognitive rehearsal scores of the junior residents significantly improved from 24 pre- to 42 post-training exercise (p = 0.002). Senior resident median composite scores improved after training from 38 pre- to 46 post-exercise (p = 0.041). Those with previous musical training and kinetic / visual learners performed better during the training session. Both groups found the entire process valuable.Conclusion:Thi...

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