Background: To restore distal radioulnar joint stability following injury to the Triangular Fibrocartilage Complex (TFCC), foveal repair surgery may be necessary. Post-surgery rehabilitation is prescribed to restore wrist and hand function; however, no universally accepted or definitive rehabilitation protocol currently exists. The aim of this study was to survey hand and wrist surgeons regarding their recommended postoperative rehabilitation protocols following TFCC foveal repair surgery. Methods: Australian hand and wrist surgeons were invited to complete a descriptive survey containing 10 questions. Questions included clinical recommendations for wrist and forearm immobilisation, range of motion (ROM) exercise timeframes and surgeon experience of TFCC rupture. Descriptive statistics and between-group (TFCC rupture vs. no-rupture) comparisons (Pearson\'s Chi2) were calculated. Results: Thirty-one surgeons completed the survey. Recommendations for post-surgery immobilisation ranged from \'not required\' to 8 weeks (mode 6 weeks). Wrist and forearm ROM commencement time ranged from \'immediately\' to \'later than 8 weeks\' (mode 6 weeks). The most recommended orthosis was a \'sugar-tong\' (57%). Thirty-seven percent (37%) reported experience of post-surgery re-rupture. Conclusions: While surgeon recommendations varied, the majority recommended 4- to 6-week timeframe for immobilisation and ROM exercise commencement. Additional clinical research is recommended to evaluate whether postoperative rehabilitation decisions influence patient outcomes. Level of Evidence: Level V (Therapeutic).

OBJECTIVE: The purpose of this agreement was to establish evidence-based consensus statements on imaging of distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) injuries by an expert group using the Delphi technique.
METHODS: Nineteen hand surgeons developed a preliminary list of questions on DRUJ instability and TFCC injuries. Radiologists created statements based on the literature and the authors\' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panelists consisted of twenty-seven musculoskeletal radiologists. The panelists scored their degree of agreement to each statement on an 11-item numeric scale. Scores of \"0,\" \"5,\" and \"10\" reflected complete disagreement, indeterminate agreement, and complete agreement, respectively. Group consensus was defined as a score of \"8\" or higher for 80% or more of the panelists.
RESULTS: Three of fourteen statements achieved group consensus in the first Delphi round and ten statements achieved group consensus in the second Delphi round. The third and final Delphi round was limited to the one question that did not achieve group consensus in the previous rounds.
CONCLUSIONS: Delphi-based agreements suggest that CT with static axial slices in neutral rotation, pronation, and supination is the most useful and accurate imaging technique for the work-up of DRUJ instability. MRI is the most valuable technique in the diagnosis of TFCC lesions. The main indication for MR arthrography and CT arthrography are Palmer 1B foveal lesions of the TFCC.
CONCLUSIONS: MRI is the method of choice for assessing TFCC lesions, with higher accuracy for central than peripheral abnormalities. The main indication for MR arthrography is the evaluation of TFCC foveal insertion lesions and peripheral non-Palmer injuries.
CONCLUSIONS: • Conventional radiography should be the initial imaging technique in the assessment of DRUJ instability. CT with static axial slices in neutral rotation, pronation, and supination is the most accurate method for evaluating DRUJ instability. • MRI is the most useful technique in diagnosing soft-tissue injuries causing DRUJ instability, especially TFCC lesions. • The main indications for MR arthrography and CT arthrography are foveal lesions of the TFCC.

OBJECTIVE: The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique.
METHODS: Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors\' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of \'0\', \'5\' and \'10\' reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of \'8\' or higher for 80% or more of the panellists.
RESULTS: Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available.
CONCLUSIONS: Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability.
CONCLUSIONS: • Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability. • Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability. • Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects.

The ulnar head attachment of triangular fibrocartilage complex is divided into 2 sections: the distal radioulnar ligament consists of superficial and deep bundles on both the palmar and dorsal sides, which attach at the fovea and the base of the ulnar styloid. A tear on the ulnar side of triangular fibrocartilage complex inevitably occurs at these attachments. Both magnetic resonance imaging and distal radioulnar joint (DRUJ) arthroscopy are crucial. DRUJ arthroscopy can clarify the tear location. An ulnar styloid tear can be treated by capsular repair. However, a foveal tear should be reattached to the fovea because this tear could cause gross DRUJ instability. There are several ways to reattach the bundles to the fovea, including single- or double-tunnel or bone anchors, and open versus arthroscopic.

BACKGROUND: Although Guyon\'s canal syndrome is not highly prevalent, a considerable knowledge of anatomy is needed to localise and treat the pathology. Data on the effectiveness of interventions for this disorder are lacking.
OBJECTIVE: To achieve consensus on a multidisciplinary treatment guideline for this disorder based on experts\' opinions.
METHODS: A European Delphi consensus strategy was initiated. In total, 35 experts (hand surgeons/hand therapists selected by the national member associations of their European federations and Physical Medicine and Rehabilitation physicians) participated in the Delphi consensus strategy. Each Delphi round consisted of a questionnaire, an analysis and a feedback report.
RESULTS: After three Delphi rounds, consensus was achieved on the description, symptoms and diagnosis of Guyon\'s canal syndrome. The experts agreed that patients with this disorder should always receive instructions and that these instructions should be combined with another form of treatment. Instructions combined with splinting or with surgery were considered as suitable treatment options. Details on the use of instructions, splinting and surgery were described. Main factors for selecting one of the aforementioned treatment options were identified: severity and duration of the syndrome and previous treatments given. A relation between the severity/duration and choice of therapy was indicated by the experts and reported in the guideline.
CONCLUSIONS: Although this disorder is less prevalent and not easy to diagnose, this guideline may contribute to better insight into and treatment of Guyon\'s canal syndrome.

METHODS: A Delphi study was conducted to obtain consensus on the most important criteria for the radiological evaluation of the reduction and fixation of the wrist and ankle. The Delphi study consisted of a bipartite online questionnaire, focusing on the interpretation of radiographs and CT scans of the wrist and the ankle. Questions addressed imaging techniques, aspects of the anatomy and fracture reduction and fixation. Agreement was expressed as the percentage of respondents with similar answers. Consensus was defined as an agreement of at least 90%.
RESULTS: In three Delphi rounds, respectively, 64, 74 and 62 specialists, consisting of radiologists, trauma and orthopaedic surgeons from the Netherlands responded. After three Delphi rounds, consensus was reached for three out of 14 (21%) imaging techniques proposed, 11 out of the 13 (85%) anatomical aspects and 13 of the 22 (59%) items for the fracture reduction and fixation. This Delphi consensus differs from existing scoring protocols in terms of the greater number of anatomical aspects and aspects of fracture fixation requiring evaluation and is more suitable in clinical practice due to a lower emphasis on measurements.

The first edition of the practice guideline for general practitioners (GPs) on hand and wrist symptoms was published in January 2010 by the Dutch College of General Practitioners. This practice guideline provides GPs with pointers for the diagnosis and treatment of hand and wrist symptoms. Carpal tunnel syndrome (CTS) can be diagnosed on its typical clinical presentation alone. The treatment of mild symptoms of CTS, trigger finger and De Quervain\'s tenosynovitis is conservative, or sometimes a corticosteroid injection: more severe or persistent symptoms require referral to hospital. Mallet finger is treated with a splint for 6 weeks, surgical intervention is necessary for large avulsion fractures or persisting symptoms after treatment with a splint.

Better detection and management of osteoporosis will reduce unnecessary health expenditure. A number of high quality guidelines are available to support early detection and best practice management of osteoporosis in hospital settings. However, sustainable implementation of guidelines poses practical issues in terms of structure and processes in hospitals. This paper describes an investigation into guideline compliance in one large tertiary metropolitan hospital and discusses practical elements of guideline implementation. Given the evidence of poor practice across the two audit periods, we recommend that a coordinated clinical pathway be implemented in the fracture clinic, supported by a targeted and discipline-specific training program. Small steps towards improving awareness and management of osteoporosis in patients presenting for the first time with non-trauma wrist fracture may well produce large cost savings by future fracture prevention.

BACKGROUND: The British Orthopaedic Association published guidelines on the care of fragility fracture patients in 2003. A section of these guidelines relates to the secondary prevention of osteoporotic fractures. The objective of this audit was to compare practice in our fracture clinic to these guidelines, and take steps to improve our practice if required.
METHODS: We retrospectively audited the treatment of all 462 new patients seen in January and February 2004. Using case note analysis, 38 patients who had sustained probable fragility fractures were selected. Six months\' post-injury, a telephone questionnaire was administered to confirm the nature of the injury and to find out whether the patient had been assessed, investigated or treated for osteoporosis. A second similar audit was conducted a year later after steps had been taken to improve awareness amongst the orthopaedic staff and prompt referral.
RESULTS: During the first audit period, only 5 of 38 patients who should have been assessed and investigated for osteoporosis were either referred or offered referral. This improved to 23 out of 43 patients during the second audit period.
CONCLUSIONS: Improvements in referral and assessment rates of patients at risk of further fragility fractures can be achieved relatively easily by taking steps to increase awareness amongst orthopaedic surgeons, although additional strategies and perhaps the use of automated referral systems may be required to achieve referral rates nearer 100%.

The treatment aim is restoration of adequate length of the radius, adjustment of the distal radioulnar joint, alignment of the distal radius joint surface, and prevention of reflex dystrophy syndrome. Stable fractures are treated by close reduction and a cast for 3-4 weeks, depending on bone stock quality. Instable extra-articular fractures are treated by K-wiring using various methods. In case of a comminuted dorsal or palmar area, K-wiring is unstable, so additional fixation is necessary (autogeneous bone graft + external fixator + plate or cast). The external fixator alone or in combination with K-wires is the appropriate fixation method all intra- or extra-articular comminuted fractures. Palmar or dorsal plate osteosynthesis is highly recommended in palmar or dorsal rim fractures (B 3, B 2 type), whereas in C 2 to C 3 fractures additional autogeneous graft and/or K-wires or screws are necessary should be used in combination with autogeneous graft, according to the fracture pattern. Ligament injuries or luxation in the carpal row must be looked for precisely and treated according to the injury pattern.