Session 2: Hand/wrist and Pediatrics

Rasmus Wejnold Jørgensen¹, Kiran Annette Anderson¹, Anders Odgaard², Claus Hjorth Jensen¹
1) Dept of Orthopedic Surgery, Copenhagen University Hospital - Herlev and Gentofte, Gentofte, Denmark; 2) University of Copenhagen/Department of Orthopaedic Surgery Rigshospitalet, Copenhagen, Denmark

Background: New and improved surgical techniques are warranted to treat osteoarthritis of the thumb carpometacarpal joint. The Pyrocardan® implant yields striking results but only few series exist making the evidence scarce.
Aim: The aim of this study was to conduct a prospective series using the Pyrocardan® implant.
Materials and Methods: We compared the outcomes to a matched historical control group of patients operated on with ligament reconstruction and tendon interposition. The hypothesis was that the Pyrocardan® implant would yield better patient reported outcomes. Moreover, that the procedure would be safe and effective in relieving symptoms of CMC-1 osteoarthritis. In total, 30 patients were included in the prospective series. These 30 patients were compared, in a 1:3 design, to a matched historical group.
Results: Results were promising with VAS 0.7 (rest), 2.1 (function), key-pinch 5.1 kg and Quick-DASH of 14.3 after one year when using the Pyrocardan® implant. The revision rate was 10%. We found no differences in patient reported outcomes between the two groups.
Interpretation / Conclusion: In conclusion, the Pyrocardan® implant is a viable option in the treatment of CMC-1 osteoarthritis but with a significant revision rate. When comparing the Pyrocardan® implant to a historical control group we failed to find any differences in patient reported outcomes.

Janni K Thillemann¹ ², Sepp De Raedt², Emil T Petersen² ³, Katriina B Puhakka4, Torben B Hansen¹, Maiken Stilling² ³
Department of Orthopaedics, University Clinic for Hand, Hip and Knee Surgery, Gødstrup Hospital¹; AutoRSA Research Group, Orthopaedic Research Unit, Aarhus University Hospital²; Department of Orthopaedic Surgery, Aarhus University³; Department of Radiology, Regional Hospital Horsens4.

Background: Foveal triangular fibrocartilage complex (TFCC) lesion may cause distal radioulnar joint (DRUJ) instability. Dynamic radiostereometry (dRSA) has been validated for objective measurement of DRUJ kinematics.
Aim: We aimed to evaluate the stabilizing effect of open foveal TFCC reinsertion surgery in patients, by use of dRSA.
Materials and Methods: In a prospective cohort study, 21 patients (11 men) at mean age 34 years (range 22- 50) with arthroscopically confirmed foveal TFCC lesion were evaluated preoperatively, 6 and 12 months after open foveal TFCC reinsertion with QDASH, PRWE, pain on NRS, and dRSA imaging during a patient active Press test motion cycle, including a force-loaded downstroke and a release phase.
Results: Preoperatively, the force-loaded part (>2.3 kg (CI 1.6–3.0)) of the Press test motion cycle (from 15-75%) revealed increased volar position of the ulnar head in the sigmoid notch (DRUJ position ratio) and increased distance in DRUJs with foveal TFCC lesion compared to the patients’ contralateral non-injured DRUJ (p<0.05). Six months postoperatively, the DRUJ position was generally normalized and remained normalized at 12 months. However, the DRUJ distance remained higher on the injured side 6 and 12 months after surgery. Twelve months postoperatively, patients reported less pain during activities, improved QDASH and PRWE scores (p<0.007).
Interpretation / Conclusion: DRUJs with foveal TFCC lesion revealed more instability during a patient active Press test using paired comparison with the contralateral non-injured DRUJ. Open foveal TFCC reinsertion had a stabilizing effect on DRUJ kinematics towards normalization, 6 and 12 months after surgery.

Thomas Colding-Rasmussen¹, Peter Schwarzenberg², Daniel Hutcinson³, Dominic Mischler², Peter Horstmann¹, Michael Mørk Petersen4, Christian Nai En Tierp-Wong¹, Peter Varga²
¹Department of orthopedic Surgery, Hvidovre Hospital, Denmark ²AO Research Institute, Switzerland ³KTH Royal Institute of Technology, Sweden 4Dep. Of orthopedic tumor surgery, Rigshospitlet, Denmark

Background: Traditional metal hardware is not easily customized for a specific fracture. Accordingly, an in situ customizable osteosynthesis material, AdhFix, might be an adjuvant in the treatment of specific complex bone fractures.
Aim: To investigate the biomechanical performance of AdhFix compared to a metal plate when loaded in torsion and four-point bending.
Materials and Methods: 41 ovine proximal phalanges were stripped of soft tissue and cut transversely before osteosynthesis with either AdhFix or a metal plate (1.5mm DePuy Synthes). 3D printed specimen specific cut/drill guides were used for standardization. AdhFix was applied around conventional 1.5mm bicortical screws for anchorage and UV-light cured in a plate- like construct, on an either perfect reduced fracture or with a 3mm gap. Groups were further defined by loading modality (see results). An Instron 5866 was used for biomechanical testing: 3mm/min until failure in bending and 6°/sec until failure in torsion. Descriptive statistics and One-Way ANOVAs were performed in SPSS 27 (IBM Corp.).
Results: In bending, AdhFix 0mm gap (N=8) was stiffer than 0mm gap metal plate (N=3); 1884.2 ± 415.8; 1246 ± 114.2N/mm, p<0,05. The metal plate 3mm gap (N=3) was stiffer than AdhFix 3mm gap: 795.5 ± 84.3; 372.6 ± 99.9 N/mm, p<0,05. In max bending load to failure, metal plate 0mm gap (N=3): 2634.7 ± 324.9N and 3mm gap (N=3): 3020.4 ± 71.9 N, was stronger than AdhFix in both 0mm gap (N=8): 731.2 ± 93.1N and 3mm gap (N=8): 168.5 ± 41.1, p<0,05. The torsional stiffnesses of AdhFix and metal plate constructs were 39.1 ± 6.2, and 16.2 ± 3.0 Nmm/° respectively, p<0,05. In max torque, AdhFix (N=8) was not as robust as the metal plate (N=3): 424 ± 72; 579 ± 20 Nmm, p<0,05. However, when AdhFix was applied as a wide patch (25x10mm) no significant difference was observed: 600 ± 120; 579 ± 20 Nmm, p=0,76.
Interpretation / Conclusion: The stiffness of the composite was higher than in metal plates in both the 0mm gap group in bending and in torsion. The max loads of metal plates were higher than in AdhFix. However, for specific complex fractures, such a high max load might not be necessary. Accordingly, AdhFix might be a valuable adjuvant in the management of specific complex bone fractures.

Robert Gvozdenovic1,2, Martina Ageskov1, Lars Solgaard1, Lars Vadstrup1, Niels Søe1
1 Department of Hand Surgery, Herlev/Gentofte University Hospital of Copenhagen, Hellerup, Denmark. 2 University of Copenhagen, Faculty of Health and Medical Sciences, Institute of Clinical Medicine, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.

Background: Comparing Proximal Row Carpectomy with Four Column Fusion, PRC results in a better range of motion, while 4CF gives better grip strength. Nevertheless, 4CF has far more complications due to hardware issues. Recently, 1 or 2CF techniques have been developed as a limited carpal fusion. A comparative study between PRC and 1/2CF was needed.
Aim: The present study compares the clinical, radiological, and patient-reported results between PRC and less invasive, 1/2 Column Fusion, in the treatment of SLAC and SNAC conditions of the wrist.
Materials and Methods: We included 45 1/2 Column Fusion patients and 15 Proximal Row Carpectomy patients. Besides gender proportions (1/3 in 1/2CF vs 2/3 in PRC group were female), no demographic differences existed between the groups. Postoperative outcomes for the pain, range of motion, grip strength, Quick-DASH, and satisfaction were assessed, and a radiological assessment was performed.
Results: With a mean age of 58 years (range 35-76), the 1&2 CF cohort had a mean follow-up of 35 months. With a mean age of 60 years (range 31-77), the PRC cohort had a mean follow-up of 42 months. The 1/2 CF group performed significantly better regarding pain, grip strength, radial-ulnar motion, and the q- DASH: (p-value = 0.002), (p-value = 0.008), (p-value = 0.003), (p-value = 0.002), respectively. Differences in volar-dorsal motion between the groups were insignificant (p-value = 0.525). A higher conversion rate to total wrist fusion was observed in the PRC Group. All the PRC patients had osteoarthritis at follow-up, whereas it was seen in 19% of the 1/2 CF patients. The patient-reported satisfaction was substantially better in the 1 & 2 Colum Fusion group.
Interpretation / Conclusion: The findings of pain, grip strength and qDASH are in favour of 1 and 2 Column Fusion compared to Proximal Row Carpectomy, among patients treated for SNAC and SLAC wrist conditions. The ROM for the radial-ulnar movement was superior in the 1 / 2 CF group, while the ROM for the volar-dorsal movement was surprisingly no different.

Søren Sørensen¹, Peter Larsen ¹ ², Lærke R Korup¹, Adriano A Ceccotti¹, Mia B Larsen¹, Jonas T Filtenborg¹, Karen P Weighert¹, Rasmus Elsøe¹
Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg Denmark¹; Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital, Aalborg Denmark ²

Background: Despite intensive investigation of the epidemiology of adult fractures of the distal forearm existing literature is limited.
Aim: The aim of this study was to provide a full overview of adult epidemiology including incidence, fracture classification, mode of injury and trauma mechanism in patients sustaining a distal forearm fracture, based on an accurate at-risk population with manually validated data leading to a high quality in data.
Materials and Methods: Population-based cohort study with manual review of X-rays and charts. The primary outcome measure was incidence of adult distal forearm fractures. The study was based on an average at-risk population of 522.607 citizens. A total of 5,426 adult distal forearm fractures were included during the study period. Females accounted for 4,199 (77%) and males accounted for 1,227 (23%) of fractures.
Results: The overall incidence of adult distal forearm fractures was 207,7/100.000/year. Female incidence was 323,4/100,000/year and male incidence was 93.3/100.000/year. A marked increase in incidence with increasing age was observed for female gender after the age of 50. The incidence of DRF incidence was 203.0/1000.000/year and incidence of isolated ulna fractures was 3.8/100.000/year. The most common fracture type was an extra articular AO type 2R3A(69%), and the most common modes of injury was fall from own height (76%). A small year-to-year variation <5% was observed during the 5-year study period.
Interpretation / Conclusion: Results show that adult distal forearm fractures are very common in women after the postmenopausal period. The overall incidence of adult distal forearm fractures was 207,8/100.000/year. Female incidence was 323,4/100,000/year.

Robert Gvozdenovic 1,2, Kiran Andersen 1
1 Department of Hand Surgery, Herlev/Gentofte University Hospital of Copenhagen, Hellerup, Denmark. 2 University of Copenhagen, Faculty of Health and Medical Sciences, Institute of Clinical Medicine, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.

Background: Treatment of large skin defects on the hand and the forearm varies depending on the localization of the injury. Different flap techniques have been introduced, most containing split-skin flap as a transplant or as a supplement for the donor site coverage.
Aim: The study aimed to evaluate the feasibility of several flap options without using the split skin, thus improving the cosmetic result, and minimizing donor- site morbidity.
Materials and Methods: Between November 2018 and February 2022, 15 patients, of these, six women were included. Three patients had skin cancer, one pyogenic granuloma. Seven patients sustained sharp lacerations, two patients had combustions, one patient had osteomyelitis in the finger, and one was bitten by a domestic cat. Overall, six patients had infections of the soft tissue before the flap surgery. 7/15 patients sustained additional injuries. The evaluation included the size of the defects, the type of the skin flap, the number of postoperative visits, an assessment of antibiotic uses, the necessity for the additional flap surgery and the complication rate.
Results: All 15 patients were eligible for the follow-up, with a mean of six months [1-14]. The size of the defects varied from 1.5 x 1.5 cm up to 7 x 8 cm. (mean, 14.6 cm2). Four Kite-, four Thenar-, three Brunelli – and one Homo-digital Adipo-, Tendo- Fascial Reversed Flap was used on the hand/digits. Two Becker flaps and a Reversed Adipo-Fascial Forearm Flap was used on the wrist/forearm. The mean number of postoperative visits was 10, (range 3-17). Eight patients needed postoperative antibiotics. Of these, six patients received prophylactic coverage, and two patients sustained postoperative infection. One patient with supplemental nerve injury still had neural pain, postoperatively. One patient sustained partial necrosis of the primary transplant and underwent revision surgery with split skin coverage. Poor health conditions and high comorbidity might have contributed to this outcome.
Interpretation / Conclusion: All presented skin grafting techniques allowed primary closure of the skin. Although this case series lacks a larger number of patients, the techniques can be successfully used for most skin defect conditions on the hand and forearm.

Christopher Emil Jønsson¹ ², Lotte Poulsen¹ ², Jan Duedal Rölfing³, Harpreet Chhina4, Anthony Cooper4, Jens Ahm Sørensen¹ ²
Research Unit for Plastic Surgery, Odense University Hospital, Odense, Denmark¹; University of Southern Denmark, Odense, Denmark²; Department of Orthopaedics, Aarhus University Hospital³; Department of Orthopaedics, BC Children’s Hospital, Vancouver, BC, Canada4

Background: Lower Limb deformities is a term that includes many conditions such as: Lower limb deficiency, leg length discrepancy, rotational and angular deformities of the hips, knees, ankles, and feet. Pain and physical limitations are often a part of the lives of children with these deformities. The ideal way to assess the impact of these deformities impact on a child’s health-related quality of life, is by using a Patient Reported Outcome Measure (PROM). Such a disease- specific PROM is currently under development, called LIMB-Q Kids.
Aim: The aim of this study was to perform an advanced translation and cultural adapt (TCA) of the LIMB-Q Kids for use in Danish children.
Materials and Methods: To undertake a TCA of the LIMB-Q Kids, the guidelines from World Health Organization and the Professional Society for Health Economics and Outcomes Research were used. This process can be divided into: Two independent Forward translations, a reconciliation meeting, a Backward translation, assessment of the Backward translation, an expert meeting, Cognitive interviews with patients and a proof reading. As it is an advanced translation, results from this translation process will influence the development of the original LIMB-Q Kids.
Results: The different steps of the TCA process contributed to the Danish version of LIMB-Q Kids. The reconciliation meeting resulted in a Danish version, with no major discrepancies between the two forward translations. The revision of the backward translation compared with the original version resulted in 12 corrections to the Danish version and the expert meeting resulted in 26 changes. The results from the cognitive interviews will be presented at the congress.
Interpretation / Conclusion: The rigorous advanced translation process has led to a linguistically validated and cultural adapted Danish version of LIMB-Q Kids. Next step is international field-testing and using this data to look at the psychometric properties of LIMB-Q Kids and conduction of the item reduction.

Nicolas Borghegn 1, Rasmus Hansen 1, Per Gundtoft 1,2, Katrine Nielsen 3, Andreas Balslev-Clausen 4, Bjarke Viberg 1,5
Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital Kolding, University Hospital of Southern Denmark 1: Department of Orthopaedic Surgery and Traumatology, Aarhus University Hospital 2: Department of Orthopaedic Surgery and Traumatology, Zealand University Hospital 3: Department of Orthopaedic Surgery and Traumatology, Hvidovre Hospital 4: Department of Orthopaedic Surgery and Traumatology, Odense University Hospital 5

Background: Diaphyseal forearm fractures in children have limited remodeling potential and the choice between surgery and no surgery can be difficult. The gold standard treatment has been closed reduction and casting for a long time, but studies suggest there is an upcoming trend in managing these fractures surgically.
Aim: This study investigates the trend in choice of treatment after a diaphyseal forearm fracture in children up to 15 years over a 20- year period and as a secondary aim trend in choice of treatment in relation to age.
Materials and Methods: This is a population-based register study with data retrieved from the Danish National Patient Registry between 1997 and 2016 using ICD-10 codes for diaphyseal ulna and/or radius fractures in children 0-15 years. Surgical treatment was defined as one of the following procedure codes within one week of fracture diagnosis: closed reduction and casting, intramedullary nailing (IN), and open reduction with internal fixation (ORIF). Non-surgical treatment was defined as no recorded code within one week of fracture diagnosis or with a code for casting. Age groups were determined to give the best representation of pediatric growth development. Groups were made of four- year age intervals as followed: 0-3 years, 4- 7 years, 8-11 years, and 12-15 years.
Results: A total of 36,244 diaphyseal forearm fractures were investigated yielding a mean fracture incidence of 172/ 100,000/year. The proportion between surgical and non- surgical treatment changed from 2007 to 2016, where surgery increased from 22% to 30%. Closed reduction and casting dropped from 83% of all performed surgery in 1996 to 22% in 2016. IN increased from 7% to 75% while ORIF decreased from 11% to 3%. The same changes were also evident in all four age groups with the largest change in 8-11 years and 12-15 years while the smallest changes were in the 0-3 years group.
Interpretation / Conclusion: This study found an increase in the surgical treatment of pediatric diaphyseal forearm fractures with intramedullary nailing becoming the predominant choice of surgical treatment. There are no RCT’s supporting the advantage of more fractures being treated invasively and further studies of national guidelines are recommended.

Lærke Riis Korup, Rasmus Elsoe¹, Peter Larsen¹ ², Kumanan Rune Nanthan ¹, Marie Arildsen ¹, Nikolaj Warming ¹, Søren Sørensen ¹, Hanne Dalsgaard ¹, Ole Rahbek ¹
Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg Denmark.¹ Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital, Aalborg Denmark.

Background: At present, the reported incidence and epidemiology of pediatric distal forearm fractures are inconsistent, and the literature lacks a large-scale population-based study of all distal forearm fractures, based on an accurate at-risk population including all children and adolescents, reporting fracture classifications, and associated mode of injury. Such accurate data are essential to identify potential safety issues and develop potential prevention strategies to reduce the risk of distal forearm fractures in children. Furthermore, accurate data is essential in the allocation of healthcare resources in the emergency department and may be a strong predictor in determining cost of injury and associated consequences in society.
Aim: The aim of the present study was to report a complete overview of both incidence, fracture distribution, mode of injury, and patient baseline demographics of pediatric distal forearm fractures to identify age of risk and types of activities leading to injury.
Materials and Methods: Population-based cohort study with manual review of X-rays and charts. The primary outcome measure was incidence of pediatric distal forearm fractures. The study was based on an average at-risk population of 116,950 citizens. A total number of 4,316 patients sustained a distal forearm fracture in the study period. Females accounted for 1,910 (44%) and males accounted for 2,406 (56%) of the fractures
Results: The overall incidence of pediatric distal forearm fractures was 738.1/100,000 persons/year (95%CI 706/100,000 persons/year to 770/100,000 persons/year). Female incidences peaked with an incidence of 1,578.3/100,000 persons/year at 10 years of age. Male incidence peaked at 13 years of age with an incidence of 1,704.3/100,000 persons/year. The most common fracture type was a greenstick fracture to the radius (48%), and the most common modes of injury were sports and falls from =1 m. A small year-to-year variation was reported during the 5- year study period but without any trends.
Interpretation / Conclusion: Results show that pediatric distal forearm fractures are very common throughout childhood in both genders, with almost 2% of boys aged 13 sustaining a forearm fracture each year.

Ahmed Abood¹, Sara Faartoft¹, HC Bang², Jan Duedal Rölfing², Søren Kold¹, Ole Rahbek¹, Per Gundtoft²
¹Department of Orthopaedics, Aalborg University Hospital ²Department of Orthopaedics, Aarhus University Hospital

Background: The choice of management of paediatric forearm fractures has been associated with controversies. Most fractures are either managed by Elastic Stable Intramedullary Nails (ESIN) or Closed Reduction and Casting (CR). Neither option has proven to be superior to the other.
Aim: To estimate the re-fracture rate of pediatric forearm fractures managed by ESIN and CR.
Materials and Methods: Retrospective multi-center study of 0-16- year-old children sustaining a diaphyseal forearm fracture that was surgically treated with ESIN or CR at Aalborg or Aarhus University Hospital from 2012 until 2021. Patients were identified using the ICD-10 codes DS52*, KNCJ0* and KNCJ4/5/9*. Exclusion criteria were: Lack of follow-up, physeal closure, non-diaphyseal fractures (distal/proximal fractures, Monteggia/Galeazzi/Essex-Lopresti fracture luxations), other treatment modalities (LCP/k-wire). Re-fracture rates were estimated based on chart review of each patient’s electronic patient journal and assessment of all related radiographs. The re-fracture rate of management by ESIN was compared to CR using Fischer’s exact test.
Results: A total of 848 patients fulfilling these criteria were analyzed. 745 patients (88%) were treated by ESIN and 103 patients (12%) by CR. Mean age was 8.9 years (CI 95% 8.67; 9.1). The re-fracture rate of ESIN treatment was 6% and 22% for CR (p<0.001). Mean time from injury to re-fracture was 413 days (CI 95% 279; 548) for the children treated by ESIN compared to 117 days (CI 95% 47; 185) days for the children treated by CR (p=0.03). The mean age at re-fracture did not statistically significantly between the two groups (p=0.3). Mean age difference of children managed by ESIN and CR was 2.0 years (p<0.001).
Interpretation / Conclusion: Children treated with ESIN were significantly older than CR-treated children. The re-fracture rates were 6% vs. 22%, respectively. This indicates an increased risk of re-fracture when managing paediatric forearm fractures with CR. However, we did neither explore injury severity, initial fracture dislocation, nor quality and time of casting.