Narrow Results

Distal radius fractures are common, and surgeons have in their armament a variety of ways of treating them. In this study, 50 orthopaedic surgeons in the UK were shown five clinical scenarios and radiographs from patients with various fracture patterns of the distal radius, and were asked for their preferred management. There was a wide variation in the preferred treatment for each scenario presented. Across all of the cases, 52% of surgeons preferred to use a volar locking-plate compared with 21% who chose fixation with Kirschner wires. There was very little consensus among surgeons with regard to the optimal method of fixation for patients sustaining dorsally displaced fractures of the distal radius. This disagreement is not surprising as there is currently no high level evidence to guide surgeons as to the best management option for this common and potentially debilitating injury.

Kienbock’s disease remains a condition of uncertain etiology and our understanding about the pathogenesis is still evolving. However, a lack of consensus on the treatment is the most striking as there are wide array of treatment options described ranging from ‘doing nothing’ to a free vascularized bone graft reconstruction of the lunate. Furthermore, most treatment modalities report equivalent success rate but cumulative evidence is lacking. This ‘black hole’ in the literature presents difficulties to surgeons treating the condition and even patient’s confidence with the treatment. All the treatment options described reliably relieve pain, thus improving function and patient satisfaction. However, the disease process is not reliably altered by any of the treatment options described till date. The operative treatment chosen depends on the stage of the disease, ulnar variance, age of the patient and surgeon preference. The treatment options in early stage (before lunate collapse) aim to preserve the lunate while once the lunate is collapsed its removal is performed. The lunate preserving operations basically are either decreasing the load on the lunate to possibly permit its revascularization or are the procedures which are aimed at augmenting the vascularity of the lunate. Radius shortening osteotomy is the most popular treatment in the early stages especially in the patients’ with negative ulnar variance and the proximal row carpectomy is most popular in the advanced stages of the disease. Authors present their algorithm of management of Kienbock’s disease and discuss the various treatment options described in the literature in an attempt to find the apt in 2020.

About 30% of patients treated for their cancer will develop lymphoedema, most within the first two years of their treatment. Early attention to tissue and limb changes and acknowledging patients' comments about how the limb feels are crucial to control the onset of lymphoedema and/or reduce its severity. Both treatment-related (extent of surgery, radiotherapy and wound management) and patient-related (arm dominance, age, skin condition weight) risk factors need attention. The management of issues such as CCF, and hypertension may help reduce lymph loads, while improving skin care and undertaking physical activity can help improve lymph flow. In order to halt or reverse lymphoedema progression, it is critical to reduce the lymphatic load to below the lymphatic transport capacity. Involvement of a lymphoedema therapist at this stage may help with risk management and be able to provide enhanced lymph flow as part of their treatment.

For patients with lymphoedema, treatment should be targeted and sequenced, beginning with an intensive phase, followed by a maintenance phase. Compression garments and bandaging are still the mainstay of treatment, but compliance issues arise in hot climates. For some patients the main problem is not the size of the affected limb, but how the limb feels, so dealing with subjective issues is equally important. There are many new treatment options available for its treatment and lymphoedema therapists will be aware of those suitable for your patient.