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Conclusions If surgical treatment for metacarpal shaft fractures is considered, we recommend antegrade intramedullary K-wire fixation. This technique results in low complication rates and excellent functional outcome.

IntroductionRepetitive electrostatic pressurised intraperitoneal aerosol chemotherapy with oxaliplatin (ePIPAC-OX) is offered as a palliative treatment option for patients with isolated unresectable colorectal peritoneal metastases (PM) in several centres worldwide. However, little is known about its feasibility, safety, tolerability, efficacy, costs and pharmacokinetics in this setting. This study aims to explore these parameters in patients with isolated unresectable colorectal PM who receive repetitive ePIPAC-OX as a palliative monotherapy.Methods and analysisThis multicentre, open-label, single-arm, phase II study is performed in two Dutch tertiary referral hospitals for the surgical treatment of colorectal PM. Eligible patients are adults who have histologically or cytologically proven isolated unresectable PM of a colorectal or appendiceal carcinoma, a good performance status, adequate organ functions and no symptoms of gastrointestinal obstruction. Instead of standard palliative treatment, enrolled patients receive laparoscopy-controlled ePIPAC-OX (92 mg/m2body surface area (BSA)) with intravenous leucovorin (20 mg/m2BSA) and bolus 5-fluorouracil (400 mg/m2BSA) every 6 weeks. Four weeks after each procedure, patients undergo clinical, radiological and biochemical evaluation. ePIPAC-OX is repeated until disease progression, after which standard palliative treatment is (re)considered. The primary outcome is the number of patients with major toxicity (grade ≥3 according to the Common Terminology Criteria for Adverse Events v4.0) up to 4 weeks after the last ePIPAC-OX. Secondary outcomes are the environmental safety of ePIPAC-OX, procedure-related characteristics, minor toxicity, postoperative complications, hospital stay, readmissions, quality of life, costs, pharmacokinetics of oxaliplatin, progression-free survival, overall survival, and the radiological, histopathological, cytological, biochemical and macroscopic tumour response.Ethics and disseminationThis study is approved by an ethics committee, the Dutch competent authority and the institutional review boards of both study centres. Results are intended for publication in peer-reviewed medical journals and for presentation to patients, healthcare professionals and other stakeholders.Trial registration numberNCT03246321, Pre-results;ISRCTN89947480, Pre-results; NTR6603, Pre-results; EudraCT: 2017-000927-29, Pre-results.

Injury to the distal radioulnar joint (DRUJ) causes swelling and ulnar-sided wrist pain. The Adams procedure stabilizes the DRUJ and shows promising short-term results. We studied the long-term functional outcome in patients who underwent the Adams procedure. We also tested the null hypothesis that there would be no difference in range of motion (ROM) and grip strength between the operated wrist compared to the unaffected side. We identified 74 consecutive patients that were operated from March 2005 to February 2014. Twenty-three patients responded to our invitation and underwent clinical follow-up. Three patients had a re-do of the Adams procedure after presenting with postoperative DRUJ instability, one was excluded due to additional wrist surgery not related to the initial procedure. Wrist functionality in the remaining 22 patients was examined by measuring ROM in all planes and grip strength of the operated and non-operated hand. Functional outcome was measured by asking patients to complete the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome measure and the Patient-Rated Wrist and Hand Evaluation (PRWHE). After a mean follow-up time of 5.0 years (standard deviation [SD] 2.0), we found that supination, pronation, and grip strength were significantly decreased in the operated wrist. Postoperative DASH and PRWHE-scores averaged 13.1 (SD 18.6) and 20.3 (SD 15.1), respectively. The Adams procedure affects, but largely restores pronation and supination, and clinical examination, DASH, and PRWHE scores indicate that the Adams procedure leaves patients with upper extremity functionality comparable to a healthy population. Level IV.

Background: Untreated bony mallet fingers can cause an array of problems; therefore, adequate treatment is essential. The primary aim of this study was to determine the patient-reported functional outcome of delayed surgical intervention of bony mallet fingers. The secondary aim was to determine the complication rate of delayed surgical intervention. Methods: In this single-center retrospective cohort study, all consecutive patients treated between 2010 and 2016 at our level 2 regional teaching hospital were included. Inclusion criterion was a bony mallet finger injury (excluding the thumb), presenting >21 days after injury, treated with extension block pinning. Indications for surgery were >2 mm fragment displacement or volar subluxation of the distal interphalangeal joint. Six to 82 months postoperatively, patients completed the Patient-Rated Wrist and Hand Evaluation (PRWHE) by phone. Complications were extracted by chart review. Results: Twenty-seven patients were included, and all completed the PRWHE. Median time to surgery was 35 days (interquartile range [IQR] = 29-42; range = 22-61). Reasons for delay in surgical treatment were patient/physician delay in 24 cases and failed conservative treatment in 3 cases. The median PRWHE score was 0 (IQR = 0-5; range = 0-22.5). After retrospective assessment of the outpatient charts, no early symptoms of malunion or nonunion were found. One patient had a loss of Kirschner-wire fixation, which was corrected. Three patients had an infection that required antibiotic treatment. Conclusions: Delayed surgical management of bony mallet fingers demonstrated adequate functional outcome with minimal complications when compared with prior literature.

Case: A 14-year-old girl was diagnosed with nonunion of an isolated capitate fracture 5 months after she first presented to the emergency department. The fracture of the capitate was treated by cancellous proximal bone graft and screw fixation. This current case provides details of the surgical fixation method and long-term functional outcome after nonunion of an isolated capitate fracture after a follow-up of 18 months following fixation. Conclusions: Persisting localized tenderness over the capitate should be an indication to perform an additional computed tomography or magnetic resonance imaging scan. Nonunion of isolated capitate fractures can be treated by means of open reduction and internal fixation, with autologous bone grafting.

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There is little published data to guide management of ulnar neck fractures associated with fractures of the distal radius. As unplanned surgery usually reflects adverse events and this injury combination is relatively uncommon, we used a large database to study the incidence of unplanned surgeries after surgical and nonsurgical treatment of distal metaphyseal ulna fractures associated with a distal radius fracture and identify factors associated with these unplanned surgeries. We identified 277 patients with an ulnar neck fracture associated with a distal radius fracture. Fifty-six (20%) ulnar neck fractures were initially treated operatively and six of them (11%) had a second, unplanned surgery. Of the 221 initially nonoperatively treated fractures, only one (0.45%) had a subsequent unplanned surgery that seemed unrelated to the fracture (ulnar nerve neurolysis). Bivariate analysis showed that younger age, open fracture, multifragmentary fractures, and initial operative treatment of the ulnar neck fracture were significantly associated with unplanned surgery. A multivariable analysis was not feasible due to the small number of unplanned surgeries. Eighty percent of ulnar neck fractures associated with a fracture of the distal radius was treated nonoperatively in our region, and subsequent surgery for problems was very uncommon. Operative treatment and fracture complexity were associated with unplanned surgery, which reflected some measure of injury severity, technical inadequacy, and inherent problems associated with surgery. Level II, prognostic study.