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OBJECTIVES: Current studies on the treatment of adolescent patients with disc displacement without reduction (DDWOR) are limited by short follow-up periods and small sample sizes, and there are few comparative studies on the efficacy of conservative treatment with and without disc reduction for acute DDWOR. This study compared the therapeutic effects of two conservative treatment methods: physical therapy alone and physical therapy combined with non-surgical manual disc reduction and anterior repositioning splints (ARS), in adolescent patients with acute DDWOR. MATERIALS AND METHODS: This retrospective study included adolescent patients with DDWOR who underwent physical therapy at the Temporomandibular Joint Rehabilitation Department of the Shanghai Ninth People's Hospital from January 2018 to December 2021. Patient assessment data were collected before and after treatment. Patients were followed up through telephone and online questionnaires from March to August 2023. RESULTS: The results indicate that compared to physical therapy alone, the combination of physical therapy and non-surgical manual disc reduction with ARS showed better short-term efficacy, improved mouth opening, and better long-term pain control. Also, it may be effective in preventing degenerative joint disease. CONCLUSIONS: This combination therapy is recommended for clinical application in adolescent patients with acute DDWOR. CLINICAL RELEVANCE: The present research demonstrates the superior efficacy of physical therapy and non-surgical manual disc reduction combined with anterior repositioning splint in adolescent patients with acute DDWOR.

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BACKGROUND: It is currently unknown to what degree surgical or nonoperative treatment of acromioclavicular (AC) dislocation influences the development of osteoarthritis (OA). The aim of this study was to evaluate AC OA after surgical and nonoperative treatment for AC dislocations, compare OA prevalence between treatment options, and compare OA prevalence between the injured and contralateral shoulder. METHODS: Articles reporting on the prevalence of OA after surgical or nonoperative treatment of an AC dislocation with a minimal 2-year follow-up were included. AC OA presence was extracted for the injured and contralateral shoulder. Treatment categories were defined based on anatomical variation in the reattachment of ligaments: AC fixation, coracoclavicular (CC) fixation, AC and CC fixation, Bosworth screw synthetic graft, tendon graft, and conservative. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: Ninety-four articles were included for qualitative analysis, and 7 articles were included for meta-analysis (n = 3,812; follow-up = 2.0-24.2 years; mean age 37.6 ± 10.4 years). A total of 3,483 patients underwent surgical treatment, and 329 patients underwent conservative treatment. OA prevalence ranged from 6.7%-29.3% between 7 pooled treatment categories. Most included studies had a follow-up <10 years (94%) and OA prevalence increased with time, regardless of treatment option. There was no difference in OA prevalence between the injured and contralateral shoulder (p = 0.120). MINORS scores were varied, ranging from poor to very good. CONCLUSION: The pooled AC OA prevalence of the 7 treatment categories ranged from 6.7% for the CC fixation surgical group to 29.3% for the conservative treatment group. However, the included studies were predominantly of low quality and had varying follow-up periods, with most having relatively short follow-up durations. No difference in AC OA prevalence was found between the injured and contralateral shoulder. Based on the available evidence, treatment choice for AC dislocation should not be influenced by the potential development of AC AO. LEVEL OF EVIDENCE: Level IV. See Instructions for Authors for a complete description of levels of evidence.

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Skeletal disorders encompass a wide array of conditions, many of which are associated with short stature. Among these, Desbuquois dysplasia is a rare but severe condition characterized by profound dwarfism, distinct facial features, joint hypermobility with multiple dislocations, and unique vertebral and metaphyseal anomalies. Desbuquois dysplasia is inherited in an autosomal recessive manner, with both the DBQD1 (MIM 251450) and DBQD2 (MIM 615777) forms resulting from biallelic mutations. Specifically, DBQD1 is associated with homozygous or compound heterozygous mutations in the CANT1 gene, while DBQD2 can result from mutations in either the CANT1 or XYLT1 genes. This review synthesizes the findings of 111 published case reports, including 54 cases of DBQD1, 39 cases of DBQD2, and 14 cases of the Kim variant (DDKV). Patients in this cohort had a median birth weight of 2505 g, a median length of 40 cm, and a median occipitofrontal circumference of 33 cm. The review highlights the phenotypic variations across Desbuquois dysplasia subtypes, particularly in facial characteristics, joint dislocations, and bone deformities. Genetic analyses revealed a considerable diversity in mutations, with over 35% of cases involving missense mutations, primarily affecting the CANT1 gene. Additionally, approximately 60% of patients had a history of parental consanguinity, indicating a potential genetic predisposition in certain populations. The identified mutations included deletions, insertions, and nucleotide substitutions, many of which resulted in premature stop codons and the production of truncated, likely nonfunctional proteins. These findings underscore the genetic and clinical complexity of Desbuquois dysplasia, highlighting the importance of early diagnosis and the potential for personalized therapeutic approaches. Continued research is essential to uncover the underlying mechanisms of this disorder and improve outcomes for affected individuals through targeted treatments.

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CASE: Odontoid fractures with atlantoaxial dislocations are rare injuries. We report a case of a 41-year-old man with a Type 2 odontoid fracture with locket facet and posterolateral dislocation. He underwent single-stage C1-C4 posterior fixation and fusion, and at 2-year follow-up, he is symptom-free without any residual pain. Follow-up radiograph and CT scan show healed odontoid fracture with posterior fusion. CONCLUSION: This case highlights successful management of a complex odontoid fracture by a single-stage posterior surgery. Closed reduction is usually unsuccessful, and open reduction using posterior approach is preferable.

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BACKGROUND: Early and accurate diagnosis is critical to preserve function and reduce healthcare costs in patients with hand and wrist injury. As such, artificial intelligence (AI) models have been developed for the purpose of diagnosing fractures through imaging. The purpose of this systematic review and meta-analysis was to determine the accuracy of AI models in identifying hand and wrist fractures and dislocations. METHODS: Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Diagnostic Test Accuracy guidelines, Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from their inception to October 10, 2023. Studies were included if they utilized an AI model (index test) for detecting hand and wrist fractures and dislocations in pediatric (<18 years) or adult (>18 years) patients through any radiologic imaging, with the reference standard established through image review by a medical expert. Results were synthesized through bivariate analysis. Risk of bias was assessed using the QUADAS-2 tool. This study was registered with PROSPERO (CRD42023486475). Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation. RESULTS: A systematic review identified 36 studies. Most studies assessed wrist fractures (27.90%) through radiograph imaging (94.44%), with radiologists serving as the reference standard (66.67%). AI models demonstrated area under the curve (0.946), positive likelihood ratio (7.690; 95% confidence interval, 6.400-9.190), and negative likelihood ratio (0.112; 0.0848-0.145) in diagnosing hand and wrist fractures and dislocations. Examining only studies characterized by a low risk of bias, sensitivity analysis did not reveal any difference from the overall results. Overall certainty of evidence was moderate. CONCLUSION: In demonstrating the accuracy of AI models in hand and wrist fracture and dislocation diagnosis, we have demonstrated that the potential use of AI in diagnosing hand and wrist fractures is promising. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

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Dislocations of the fourth and fifth carpometacarpal joints (CMCJs) are rare and often misdiagnosed via radiography. Moreover, treatment strategies have not yet been standardized. Herein, we report a case of chronic dislocations of the fourth and fifth CMCJs with delayed diagnosis and successful treatment via ligament repair. A 29-year-old male patient who was initially diagnosed with contusion at another center following a fall on the stairs was referred to our hospital one month later due to persistent pain and swelling. Fourth and fifth CMCJ dislocations were diagnosed using radiography and computed tomography. Closed reduction attempts were unsuccessful, prompting open reduction. The operative findings included rupture of the dorsal carpometacarpal ligament and hamate cartilage injury. Using two mini anchors, the fourth and fifth dorsal carpometacarpal ligaments were repaired, and Kirschner-wire (K-wire) pinning was performed. The K-wire was extracted after four weeks. At the eight-month follow-up, the only remaining symptom was mild discomfort, and the range of motion and grip strength was fully recovered. Our findings highlight the difficulties in diagnosing CMCJ dislocation and suggest ligament repair as a treatment option for chronic cases of CMCJ dislocation.

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BACKGROUND: The clinical diagnosis of atlantoaxial joint subluxation (AJS) in traditional Chinese medicine (TCM) is characterized by an unequal distance between the lateral mass of the atlas and the odontoid process on imaging, resulting in neck pain accompanied by symptoms such as dizziness, headache, and limited cervical mobility. In Shanghai, Shi cervical rotational manipulation (SCRM) is a commonly employed TCM manual therapy for treating this condition. Nevertheless, there is a lack of evidence-based medical information regarding the clinical efficacy and safety of this technique. OBJECTIVE: The principal aim of this study is to evaluate the efficacy and safety of SCRM in patients diagnosed with AJS. METHODS: This study is a prospective randomized controlled clinical trial that will be conducted at a single center and that has a follow-up period of 24 weeks. A total of 96 patients diagnosed with AJS will be recruited from outpatient and inpatient clinics at Shanghai Baoshan Hospital of Integrated Traditional Chinese and Western Medicine. These patients will be randomly assigned to either the experimental group (SCRM) or the comparison group (basic cervical manipulation [BCM]). Treatment sessions consisting of SCRM or BCM will be administered twice a week for a duration of 4 weeks. Clinical monitoring indicators include the presence or absence of clinical symptoms as recorded on a symptom recording form, cervical imaging examination findings using cervical computed tomography, degree of neck pain measured by a visual analog scale (VAS), cervical range of motion assessed through cervical mobility measurement, degree of vertigo evaluated using the Vertigo Symptoms Scale-Chinese Version (VSS-C), and adverse events that may occur during the follow-up period. The time points for data collection and follow-up are baseline and postintervention (weeks 4, 8, 12, 16, 20, and 24). RESULTS: This paper presents an overview of the reasoning and structure of a prospective randomized controlled trial with the objective of investigating the clinical efficacy and safety of SCRM in patients with AJS by assessing improvements in clinical symptoms, neck pain severity, and vertigo severity and evaluating changes in cervical imaging findings. Recruitment was started in March 2023. By the end of May 2024, 76 patients were included in this project. The last follow-up data are predicted to be collected by the end of February 2025. CONCLUSIONS: This investigation will yield dependable evidence regarding the efficacy and safety of SCRM in patients with AJS. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2300068510; https://www.chictr.org.cn/showprojEN.html?proj=186883. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/57865.

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Grisel's syndrome is a non-traumatic atlantoaxial (C1-C2) subluxation and one of the causes of torticollis in children. The subluxation occurs in the context of an infection in the ENT ("Ear Nose and Throat") region or following surgery. Diagnosis is based on clinical examination and radiological assessment. Treatment is typically medical and conservative, with surgical interventions reserved for recurrences and late presentations. We discuss here two cases of C1-C2 subluxation. The first case involves a 10-year-old child with subluxation following a rhinopharyngitis. This presentation is the classical manifestation of Grisel's syndrome. Prompt management led to correction of the subluxation using medical treatment and a soft Philadelphia collar. The second case involves a 34-year-old adult who developed posterior headaches after sphenoidotomy surgery. Grisel's syndrome is less common in adults, leading to clinical challenges and delayed diagnosis (> 1 month). Reduction combined with a halo vest treatment failed, and the patient required cervical arthrodesis.

Le syndrome de Grisel est une subluxation atlanto-axoïdienne (C1-C2) non traumatique et l'une des causes de torticolis chez l'enfant. La subluxation survient dans le cadre d'une infection de la sphère ORL ou à la suite d'une chirurgie. Le diagnostic est basé sur la clinique et l'examen radiologique. Le traitement est le plus souvent médical et conservateur. Les prises en charge chirurgicales sont limitées aux récidives et aux présentations tardives.Nous discutons ici deux cas de subluxation C1-C2. La première chez un enfant de 10 ans faisait suite à une rhinopharyngite. Cette présentation correspond à la présentation typique du syndrome de Grisel. Une prise en charge rapide a permis une correction de cette subluxation à l'aide d'un traitement médical et d'une minerve souple de type Philadelphia. Le second cas concerne une adulte de 34 ans qui a présenté des céphalées postérieures à la suite d'une chirurgie de sphénoïdotomie. Le syndrome Grisel est moins fréquent chez l'adulte, ce qui a engendré une errance clinique et un diagnostic retardé (> 1 mois). La réduction associée à un traitement par haloveste a échoué et la patiente a nécessité une arthrodèse cervicale.

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PURPOSE: The study aimed to report the results of the Delphi survey conducted by the Shoulder, Elbow Society India (SESI), to achieve consensus on ambiguous topics in managing type III acromioclavicular joint (ACJ) dislocations. METHODS: This study was based on responses from the Shoulder Elbow Society India (SESI) panel of peer-selected twenty senior surgeons practicing shoulder orthopedics. They participated in two rounds of the survey to obtain consensus on several topics pertaining to the management of type III ACJ dislocations. Consensus was achieved when at least 70 % of the panel members selected at least a 4-point on a 5-point Likert scale. RESULTS: Our Delphi survey reached a consensus on seven topics of ambiguity. An anteroposterior and axillary view of the shoulder without any traction or weight in hand is sufficient in the setting of a suspected type III ACJ dislocation. Magnetic resonance imaging (MRI) is not routinely indicated in type III ACJ dislocation. Either cross-arm adduction X-rays or clinical examination may be used to distinguish between ISAKOS (International Society of Arthroscopy, Knee surgery and Orthopaedics Sports medicine) IIIA and B classification of ACJ to identify stable and unstable injuries. Conservative treatment can be offered to patients who have stable injuries and who are not high-demand individuals in acute type III ACJ dislocations. In conservative management of type III ACJ dislocation, a two-week sling suffices. Jones strapping has no clear advantage over a shoulder sling. Coracoclavicular reconstruction with an autograft is an acceptable way to treat symptomatic, chronic grade III ACJ dislocation. CONCLUSION: The survey helped achieve consensus on several controversial issues related to type III ACJ dislocations. However, there remains ambiguity on the definition of chronicity of such dislocations, the necessity of bilateral Zanca views, and the duration of conservative trial before switching to a surgical line of management.

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OBJECTIVE: to compare the combined effect of Prolotherapy and Deep Dry Needling (DDN) versus DDN effect on relieving the symptoms of Temporomandibular joint (TMJ) anterior disc displacement. PATIENTS AND METHODS: The clinical trial randomly allocated forty patients. The (control group) patients received four intraarticular and masseteric DDN sessions, while the (study group) patients were subjected to the exact technique followed by Prolosolution injection. The baseline preoperative measurements included Maximal interincisal opening (MIO), auscultation of the presence of clicking, and Visual Analogue Scale (VAS), which were repeated for postoperative measurements after one, two, five, and eight months. RESULTS: By the end of the study, all patients expressed apparent improvement in pain MIO and clicking. The inter- and intragroup comparison revealed that the pain score values of the control group after five and eight months were significantly higher than those of the study group. The study group demonstrated more significant MIO calibration than the control group, with insignificant differences between both groups regarding the presence of clicking at any time interval. The associations between clicking and VAS values, between clicking and MIO, and between VAS values and increased MIO were positive in the test group and negative in the control group. CONCLUSIONS: Dextrose Prolotherapy and DDN were beneficial. However, Prolotherapy demonstrated more significant, sustained, and correlated long-term alleviation of symptoms and increased MIO. CLINICAL RELEVANCE: The study assesses the sole effect of dextrose prolotherapy on relieving the signs of TMJ anterior disc displacement apart from the impact of the penetrating needle. CLINICAL TRIAL REGISTRATION: The study was registered on www. CLINICALTRIALS: gov (#: NCT05821985) by Ahmed Nagi Alghandour.

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OBJECTIVE: To assess the influence of unilateral open disc repositioning surgery (ODRS) of the temporomandibular joint (TMJ) on the internal derangement (ID) of the contralateral joint. METHODS: Patients with bilateral ID of TMJ who underwent unilateral ODRS were enrolled and followed-up for one year. They were divided into two groups based on the contralateral disease: the anterior disc displacement with reduction (ADDWR) and without reduction (ADDWoR). Postoperative evaluation included clinical and MRI evaluation. Indices measured were unilateral intermaxillary distance (UID), visual analogue scale (VAS), disc length (DL), condylar height (CH), and disc-condyle angle (DCA). Paired t tests were used to compare the clinical and MRI indices between different time points. RESULTS: Ninety-six patients were enrolled, including 47 in the ADDWR group and 49 in the ADDWoR group. One-year post-surgery, ODRS led to significant increases in MMO, DL, and CH, and decrease in VAS and DCA on the operated side (P < 0.05). In ADDWR group, UID, DL, and CH increased significantly, and VAS decreased (P < 0.05), with no significant change in DCA (P > 0.05). In ADDWoR group, clinical and MRI variables worsened slightly, except for UID, which remained unchanged (P > 0.05). CONCLUSIONS: ODRS is a promising method for correcting TMJ ID and may improve condition of ADDWR and decrease progress of ADDWoR at the contralateral joint. Preoperative bilateral TMJ evaluation is essential for better outcomes. CLINICAL RELEVANCE: ODRS can effectively treat TMJ ID and produce adaptive changes in the contralateral ID, for which continuous monitoring of the contralateral joint is essential.

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Objective: To compare the effectiveness of robot-assisted and traditional freehand screw placement in the treatment of atlantoaxial dislocation. Methods: The clinical data of 55 patients with atlantoaxial dislocation who met the selection criteria between January 2021 and January 2024 were retrospectively analyzed. According to different screw placement methods, they were divided into the traditional group (using the traditional freedhand screw placement, 31 cases) and the robot group (using the Mazor X robot-assisted screw placement, 24 cases). There was no significant difference in gender, age, body mass index, etiology, and preoperative visual analogue scale (VAS) score, cervical spine Japanese Orthopaedic Association (JOA) score between the two groups ( P>0.05). The operation time, intraoperative blood loss, operation cost, and intraoperative complications were recorded and compared between the two groups. The VAS score and cervical spine JOA score were used to evaluate the improvement of pain and cervical spinal cord function before operation and at 1 month after operation. CT examination was performed at 3 days after operation, and the accuracy of screw placement was evaluated according to Neo grading criteria. Results: All the 55 patients successfully completed the operation. The operation time, intraoperative blood loss, and operation cost in the robot group were significantly higher than those in the traditional group ( P<0.05). A total of 220 C 1 and C 2 pedicle screws were inserted in the two groups, and 94 were inserted in the robot group, with an accuracy rate of 95.7%, among them, 2 were inserted by traditional freehand screw placement due to bleeding caused by intraoperative slip. And 126 pedicle screws were inserted in the traditional group, with an accuracy rate of 87.3%, which was significantly lower than that in the robot group ( P<0.05). There were 1 case of venous plexus injury in the robot group and 3 cases in the traditional group, which improved after pressure hemostasis treatment. No other intraoperative complication such as vertebral artery injury or spinal cord injury occurred in both groups. All patients were followed up 4-16 months with an average of 6.6 months, and there was no significant difference in the follow-up time between the two groups ( P>0.05). Postoperative neck pain significantly relieved in both groups, and neurological symptoms relieved to varying degrees. The VAS score and cervicle spine JOA score of both groups significantly improved at 1 month after operation when compared with preoperative scores ( P<0.05), and there was no significant difference in the score change between the two groups ( P>0.05). Conclusion: In the treatment of atlantoaxial dislocation, the accuracy of robot-assisted screw placement is superior to the traditional freedhand screw placement.

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Objective: To investigate the effectiveness of computer-assisted and robot-assisted atlantoaxial pedicle screw implantation for the treatment of reversible atlantoaxial dislocation (AAD). Methods: The clinical data of 42 patients with reversible AAD admitted between January 2020 and June 2023 and met the selection criteria were retrospectively analyzed, of whom 23 patients were treated with computer-assisted surgery (computer group) and 19 patients were treated with Mazor X spinal robot-assisted surgery (robot group). There was no significant difference in gender, age, T value of bone mineral density, body mass index, etiology, and preoperative Japanese Orthopaedic Association (JOA) score, Neck Dysfunction Index (NDI) between the two groups ( P>0.05). The operation time, screw implantation time, intraoperative blood loss, hand and wrist radiation exposure, and complications were recorded and compared between the two groups. Gertzbein classification was used to evaluate the accuracy of screw implantation. JOA score and NDI were used to evaluate the function before operation, at 3 days after operation, and at last follow-up. At last follow-up, the status of screws and bone fusion were observed by neck three-dimensional CT. Results: The operation time and hand and wrist radiation exposure of the computer group were significantly longer than those of the robot group ( P<0.05), and there was no significant difference in the screw implantation time and intraoperative blood loss between the two groups ( P>0.05). All patients were followed up 11-24 months, with an average of 19.6 months. There was no significant difference in the follow-up time between the two groups ( P>0.05). There was no significant difference in the accuracy of screw implantation between the two groups ( P>0.05). Except for 1 case of incision infection in the computer group, which improved after antibiotic treatment, there was no complication such as nerve and vertebral artery injury, screw loosening, or breakage in the two groups. The JOA score and NDI significantly improved in both groups at 3 days after operation and at last follow-up ( P<0.05) compared to those before operation, but there was no significant difference between the two groups ( P>0.05). At last follow-up, 21 patients (91.3%) in the computer group and 18 patients (94.7%) in the robot group achieved satisfactory atlantoaxial fusion, and there was no significant difference in the fusion rate between the two groups ( P>0.05). Conclusion: Computer-assisted or robot-assisted atlantoaxial pedicle screw implantation is safe and effective, and robotic navigation shortens operation time and reduces radiation exposure.

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CASE: We present a 17-year-old male patient with an initially missed posterior sternoclavicular fracture dislocation who presented with symptoms related to thrombotic emboli arising from a pseudoaneurysm. He was treated 6 weeks after injury with a figure-of-eight tendon allograft repair with good clinical outcomes. CONCLUSION: This is a unique presentation that highlights the significant risk of a missed diagnosis, life-threatening complications that may ensue, and biomechanically superior surgical intervention.

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INTRODUCTION: The development of temporomandibular disorders specifically emphasizes the biochemical changes occurring in the synovial fluid at different stages of temporomandibular joint disease. Research has indicated that inflammation may be a primary reason behind the pain and dysfunction in temporomandibular joint diseases. Since its clearance several years ago, MESNA (sodium 2-mercaptoethanesulfonate) has been used in various formulations as a mucolytic drug in the respiratory domain. It operates by disrupting the disulfide bonds present between polypeptide chains within mucus. MESNA exhibits minimal tissue distribution, with the material being swiftly and thoroughly eliminated via the kidneys. OBJECTIVES: To assess the efficacy of injecting MESNA directly into the Temporomandibular Joint to treat internal derangement. MATERIALS AND METHODS: A randomized clinical trial was conducted on sixty patients who exhibited non-responsiveness to conventional treatment and were diagnosed with TMJ anterior disc displacement with reduction. The patients were chosen from the outpatient clinic of the Oral and Maxillofacial Surgery Department at Tanta University Faculty of Dentistry. Two equal groups of patients were randomly assigned to each other. Group I (Mesna group) received intra-articular injection with MESNA solution. Group II (Standard group) received arthrocentesis with lactated ringer solution followed by injection of Hyaluronic Acid (HA). The data was gathered by functional examinations such as maximum interincisal opening (MIO) and clicking. A Visual Analogue Scale (VAS) assessed pain severity before and after treatments. RESULTS: Both MESNA and HA showed significant improvement up to six months of the follow-up compared to preoperative status, as evidenced by better mouth opening, lateral excursion, lower clicking, and reduced pain score in patients with TMDs. MESNA showed significant improvement during follow-up compared to HA. CONCLUSION: Compared to HA, MESNA showed a more noticeable improvement during the follow-up period.

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OBJECTIVE: This study aims to evaluate the outcomes of open reduction and internal fixation (ORIF) for chronic perilunate dislocations using single-stage, two-stage, and salvage procedures. The study also compares these approaches with each other and with results from existing literature. METHODS: A total of 15 patients with chronic perilunate injuries from 2013 to 2019 were included in the study. Pre-operative and post-operative assessments were conducted using plain radiographs, with CT scans performed selectively for detailed morphology and fracture pattern analysis. Among the patients, 13 underwent ORIF, while 2 underwent salvage procedures. Among the ORIF cases, single-stage procedures were performed in 4 patients, and two-stage procedures in 9 patients. External fixators, including unilateral uniplanar external fixators (UUEF) and bilateral uniplanar external fixators (BUEF), were applied in 5 and 4 patients, respectively. Our methodology of treating chronic perilunate injuries has evolved over the years. We started with single stage ORIF then graduated to a two staged procedure initially using a external fixator as a carpal distractor applied only on the radial side and finally settling down with bilateral carpal distraction using external fixators both on the radial and ulnar sides. RESULTS: Among the 15 patients, 3 were lost to follow-up. Of these, one underwent four-corner fusion, while the remaining two had UUEF. The mean time interval between injury and surgery was 3.60 months. The post-operative mean scapholunate angle measured 52.46°, with a negative radio-lunate angle (indicating flexion) observed in two patients, while others showed a positive angle (indicating extension). Two cases exhibited nonunion and avascular necrosis (AVN) of the scaphoid, while one case presented with lunate AVN. Mid-carpal and radio-carpal arthritis was observed in 4 and 2 patients, respectively. Functional outcomes were evaluated using Mayo's wrist score categorized as good for two-stage BUEF cases and satisfactory for UUEF and single-stage procedures. CONCLUSION: Staged reduction utilizing the BUEF followed by open reduction has demonstrated superior outcomes when compared to UUEF, single-stage open reduction and salvage procedures. LEVEL OF EVIDENCE: 4.

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BACKGROUND: Ultrasound-guided supraclavicular block (UGSCB) is an emerging technique gaining interest amongst emergency physicians that provides regional anaesthesia to the upper limb to tolerate painful procedures. It offers an alternative to the more traditional technique of a Bier block (BB). However, the effectiveness or safety of UGSCB when performed in the emergency department (ED) is unclear. METHODS: SUPERB (SUPraclavicular block for Emergency Reduction versus Bier block) is a prospective open-label non-inferiority randomised controlled trial comparing the effectiveness of UGSCB versus BB for closed reduction of upper limb fractures and/or dislocations. Adult patients presenting with upper limb fracture and/or dislocation requiring closed reduction in ED were randomised to either UGSCB or BB. Once regional anaesthesia is obtained, closed reduction of the injured part was performed and immobilised. The primary outcome is maximal pain experienced during closed reduction measured via a visual analogue scale (VAS). Secondary outcomes include post-reduction pain, patient satisfaction, total opioid requirement in ED, ED length of stay, adverse events and regional anaesthesia failure. RESULTS: Primary outcome analysis will be performed using both the intention-to-treat and per-protocol populations. The between-group difference in maximum pain intensity will be assessed using linear regression modelling with trial group allocation (UGSCB vs BB) included as a main affect. A pre-specified non-inferiority margin of 20 mm on the VAS scale will be used to establish non-inferiority of UGSCB compared to BB. CONCLUSION: SUPERB is the first randomised controlled trial to investigate the effectiveness and safety of UGSCB in the ED. The trial has the potential to demonstrate that UGSCB is an alternative safe and effective option for the management of upper extremity emergencies in the ED.

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BACKGROUND: Total talus dislocation without ankle (malleoli) fracture is a very rare injury with prevalence of only 0.06% of all dislocations and only 2% of talar injuries, and are usually associated with common complications such as infection, avascular necrosis, and posttraumatic arthritis. The treatment usually involves debridement, reduction, stabilization of the ankle joint, and primary or secondary closure of the wound. CASE PRESENTATION: We present the case of a 40-year-old South Asian woman who was involved in an accident. She was rushed to our hospital, whereby subsequent examination revealed an open total talus dislocation with the talus being exposed in its entirety from a contaminated wound in the medial side. Furthermore, radiograph confirmed total talus dislocation without concomitant malleoli fracture. She was immediately taken to the operating theater whereby debridement and immediate reduction was performed under anesthesia, and the ankle was stabilized with external fixator for about 6 weeks. She is now able to bear weight on the affected ankle with minimal tolerable pain and has normal range of motion of the ankle. CONCLUSIONS: Open total talus dislocation without concomitant malleoli fracture is a rare injury. Reduction of the talus in combination with complete wound debridement potentially successfully avoids infection, provides early revascularization preventing avascular necrosis, and preserves the normal ankle anatomy.

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SUMMARY: Monteggia fracture is a complex fracture consisting of a proximal ulna fracture with a dislocation of the radial head. This review article highlights the relevant anatomy, clinical evaluation, classification, surgical management, recent innovation, and advancements with treating these injuries. A thorough understanding of these fractures allows for detailed operative plans and reconstitution of normal anatomy.

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