Fracture of the distal radius including sequelae--shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study

Catastrophic Thinking Is Associated With Finger Stiffness After Distal Radius Fracture Surgery

OBJECTIVES

To identify demographic, injury-related, or psychologic factors associated with finger stiffness at suture removal and 6 weeks after distal radius fracture surgery. We hypothesize that there are no factors associated with distance to palmar crease at suture removal.

DESIGN

Prospective cohort study.

SETTING

Level I Academic Urban Trauma Center.

PATIENTS

One hundred sixteen adult patients underwent open reduction and internal fixation of their distal radius fractures; 96 of whom were also available 6 weeks after surgery.

INTERVENTION

None.

MAIN OUTCOME MEASUREMENTS

At suture removal, we recorded patients' demographics, AO fracture type, carpal tunnel release at the time of surgery, pain catastrophizing scale, Whiteley Index, Patient Health Questionnaire-9, and disabilities of the arm, shoulder, and hand questionnaire, 11-point ordinal measure of pain intensity, distance to palmar crease, and active flexion of the thumb through the small finger. At 6 weeks after surgery, we measured motion, disabilities of the arm, shoulder, and hand, and pain intensity. Prereduction and postsurgery radiographic fracture characteristics were assessed.

RESULTS

Female sex, being married, specific surgeons, carpal tunnel release, AO type C fractures, and greater catastrophic thinking were associated with increased distance to palmar crease at suture removal. At 6 weeks, greater catastrophic thinking was the only factor associated with increased distance to palmar crease.

CONCLUSIONS

Catastrophic thinking was a consistent and major determinant of finger stiffness at suture removal and 6 weeks after injury. Future research should assess if treatments that ameliorate catastrophic thinking can facilitate recovery of finger motion after operative treatment of a distal radius fracture.

LEVEL OF EVIDENCE

Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Proposed Guidelines for Treatment of Concomitant Distal Radius and Distal Ulna Fractures

BACKGROUND

Concomitant distal radius and distal ulna metaphysis or head fractures (DRUF) are uncommon and acceptable results have been reported from cast immobilisation and internal fixation.

METHODS

We reviewed the charts of 1094 patients treated for distal radius fracture at our institution in a two year period from 2009 to 2010. 24 patients with concomitant DRUF with were treated by cast immobilisation (group 1, n = 11), internal fixation of both bones (group 2, n = 7), internal fixation of radius alone (group 3, n = 2), and internal fixation of radius with distal ulna resection (group 4, n = 4). Patients treated by surgery underwent intraoperative assessment of distal ulna stability to determine the indication for ulna fixation. Post surgical range of motion, clinical parameters, and functional outcome scores (Gartland-Werley and modified Mayo) were measured.

RESULTS

Wrist motion was comparable in each group. Radiographic parameters were better in surgical groups. 23 of 24 patients achieved excellent/good outcomes based on Gartland-Werley scores, while 12 of 24 achieved good modified Mayo wrist score. There was a case of distal ulna non-union in group 1, and another case of delayed distal radius union in group 2.

CONCLUSIONS

By evaluating patients' functional requirement, and dynamic fluoroscopy examination, satisfactory outcomes can be achieved for various presentations of DRUF.

Is it time to revisit the AO classification of fractures of the distal radius? Inter- and intra-observer reliability of the AO classification

We conducted an observational radiographic study to determine the inter- and intra-observer reliability of the AO classification of fractures of the distal radius. Plain posteroanterior and lateral radiographs of 456 patients with an acute fracture of the distal radius were classified by a consultant orthopaedic hand specialist and two specialist trainees, and the k coefficient for the inter- and intra-observer reliability of the type, group and subgroup classification was calculated. Only the type of fracture (A, B or C) was found to provide substantial intra-observer reliability (k type 0.65). The inclusion of 'group' and 'subgroup' into the classification reduced the inter-observer reliability to fair (kgroup 0.29, ksubgroup = 0.28) and the intra-observer reliability to moderate (kgroup 0.53, ksubgroup 0.49). Disagreement was found to arise between specific subgroups, which may be amenable to clarification.

[Fractures of the distal radius]

The most prevalent fractures managed by trauma surgeons are those involving the distal radius. The injury occurs in two peaks of prevalence: the first peak around the age of 10 years and the second peak around the age of 60 years. Distal radius fracture management requires sensitive diagnostics and classification. The objectives of treatment are the reconstruction of a pain-free unlimited durable functioning of the wrist and avoidance of typical fracture complications. Non-operative conservative management is generally employed for stable non-displaced fractures of the distal radius with the expectation of a good functional outcome. Unstable comminuted fractures with intra-articular and extra-articular fragment zones are initially set in a closed operation and finally by osteosynthesis. An armament of surgical implants is available for instable fractures requiring fixation. Palmar locked plate osteosynthesis has been established in recent years as the gold standard for operative management of distal radius fractures. Complex Working Group on Osteosynthesis (AO) classification type 3 fractures require extensive preoperative diagnostics to identify and treat typical associated injuries around the wrist.

Anatomical and/or pathological predictors for the "incorrect" classification of red dot markers on wrist radiographs taken following trauma

OBJECTIVE

To establish the prevalence of red dot markers in a sample of wrist radiographs and to identify any anatomical and/or pathological characteristics that predict "incorrect" red dot classification.

METHODS

Accident and emergency (A&E) wrist cases from a digital imaging and communications in medicine/digital teaching library were examined for red dot prevalence and for the presence of several anatomical and pathological features. Binary logistic regression analyses were run to establish if any of these features were predictors of incorrect red dot classification.

RESULTS

398 cases were analysed. Red dot was "incorrectly" classified in 8.5% of cases; 6.3% were "false negatives" ("FNs")and 2.3% false positives (FPs) (one decimal place). Old fractures [odds ratio (OR), 5.070 (1.256-20.471)] and reported degenerative change [OR, 9.870 (2.300-42.359)] were found to predict FPs. Frykman V [OR, 9.500 (1.954-46.179)], Frykman VI [OR, 6.333 (1.205-33.283)] and non-Frykman positive abnormalities [OR, 4.597 (1.264-16.711)] predict "FNs". Old fractures and Frykman VI were predictive of error at 90% confidence interval (CI); the rest at 95% CI.

CONCLUSION

The five predictors of incorrect red dot classification may inform the image interpretation training of radiographers and other professionals to reduce diagnostic error. Verification with larger samples would reinforce these findings.

ADVANCES IN KNOWLEDGE

All healthcare providers strive to eradicate diagnostic error. By examining specific anatomical and pathological predictors on radiographs for such error, as well as extrinsic factors that may affect reporting accuracy, image interpretation training can focus on these "problem" areas and influence which radiographic abnormality detection schemes are appropriate to implement in A&E departments.

The effects of ulnar styloid fractures on patients sustaining distal radius fractures

PURPOSE

To determine if ulnar styloid fractures (USF) affect clinical outcome following distal radius fracture (DRF) in adults under 65 years of age.

METHODS

This study involved 312 patients (aged 18-64) with surgically and nonsurgically treated DRFs. Patients were followed prospectively at baseline and 3, 6, and 12 months. The primary outcome was the Patient-Rated Wrist Evaluation (PRWE), and secondary outcomes were range of motion and grip strength. The USFs were classified by location (tip, middle, and base) and union status.

RESULTS

There were 170 patients with isolated DRFs and 142 with associated USF (64 tip, 32 middle, and 46 base fractures). The mean age of the entire cohort was 48 years with 218 (70%) women. All USFs were treated nonoperatively. There was a trend of higher PRWE scores in DRFs associated with USFs compared to isolated DRFs throughout the study. Associated ulnar styloid base fractures had higher but clinically insignificant PRWE scores than isolated DRFs at 6 and 12 months. Patients with an associated USF had a slower recovery of wrist flexion and grip strength compared to isolated DRF, but values were comparable at 12 months. United USFs and nonunited USFs had similar PRWE scores at all time points.

CONCLUSIONS

Adults under 65 years old with DRFs and associated USFs initially have greater pain and disability than those with isolated DRFs; however, this difference dissipated over time and was not significant at one year. No long-term differences in measured impairments were observed, but the presence of an associated USF resulted in a slower recovery of grip strength and wrist flexion. Presence of a USF nonunion did not significantly affect outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Fractures of distal radius: an overview

Fractures of distal radius account for up to 20% of all fractures treated in emergency department. Initial assessment includes a history of mechanism of injury, associated injury and appropriate radiological evaluation. Treatment options include conservative management, internal fixation with pins, bridging and non-bridging external fixation, dorsal or volar plating with/without arthroscopy assistance. However, many questions regarding these fractures remain unanswered and good prospective randomized trials are needed.

The use of plain radiographs in the classification of distal radius fractures

INTRODUCTION

Classification systems guide surgical planning. We reviewed the accuracy of interpreting plain radiographs to classify distal radius fractures.

METHODS

Pre-operative radiographs of 24 consecutive distal radius fractures were classified using Frykman and AO methods. Classification was repeated intra-operatively under direct vision for comparison.

RESULTS

Mean age of the patients was 51 years. Pre-operative Frykman scores and AO grades were underestimated, compared with intra-operative visual classification (p < 0.001). One over-estimate occurred, while only 3 of 24 cases were classified correctly pre-operatively.

CONCLUSION

Sensitivity of radiographs to classify Frykman or AO grades was 12.5%, indicating interpretation using plain radiographs alone is often inadequate.

The importance of epidemiological fracture data: injury epidemiology for the non-epidemiologist

Epidemiological studies enhance clinical practice in a number of ways. However, there are many methodological difficulties that need to be addressed in designing a study aimed at the collection and analysis of data concerning fractures and other injuries. Most can be managed and errors minimised if careful attention is given to the design and implementation of the research.

Ulnar styloid fracture in distal radius fractures managed with volar locking plates: to fix or not?

Distal radius fracture is usually associated with ulnar styloid fracture. Whether to fix the ulnar styloid or not remains a surgical dilemma as some surgeons believe that their repair is imperative while others feel that they should be managed conservatively. This prospective study involved 47 patients with unilateral fracture of the distal radius who met the inclusion criterion and underwent open reduction and internal fixation with volar locking plates; 28 patients (12 males and females = 16) had an associated ulnar styloid fracture (Group A) while 19 (7 males; 12 females) did not have any ulnar styloid fracture (Group B). At the time of final evaluation both the groups were compared clinically by measuring the grip strength and range of motion around the wrist and the radiologically by measuring radial angle, radial length, volar angle and ulnar variance. Subjective assessment was done using DASH score and final assessment using Demerit point system of Saito. In Group A, average time for consolidation was 9.4 weeks, 17 patients developed non-union of the ulnar styloid, average DASH scores was 4.4 and according to Demerit point system of Saito, there were 78.5 % excellent, 17.9 % good and 3.6 % fair results; there were 2 cases of loss of reduction out of which one had persistent ulnar sided wrist pain. In Group B the average time for consolidation was 10.2 weeks, average DASH score was 3.8.and Demerit point system of Saito yielded 78.9 % excellent, 15.8 % good and 5.3 % fair results. There was one case of loss of reduction and one case of carpal tunnel syndrome which was managed conservatively. Both groups attained excellent range of motion, grip strength and well maintained the post operative radiological parameters. The comparison of clinico-radiological parameters in both groups was found to be statistically insignificant. To conclude, ulnar styloid fracture or its non union does not affect the outcome of an adequately fixed distal end radius fracture. We urge caution in electing operative treatment of non-united fracture of the ulnar styloid until better scientific report for treatment of pain associated with these fracture is available.

Distal radial fractures in the superelderly: does malunion affect functional outcome?

Purpose. The management of unstable distal radial fractures in the superelderly (≥80 years old) remains controversial. The aim of this study was to compare the functional outcome of super-elderly patients with and without malunion after a distal radial fracture. Methods. We identified 51 superelderly patients living independently with displaced fractures from a prospective database of 4024 patients with distal radial fractures. Activities of daily living, presence of wrist pain, whether the wrist had returned to its normal level function, grip strength and ROM were recorded. The dorsal angulation was measured radiographically. Results. There were 17 (33.3%) patients defined to have a malunion. The outcomes of the independent patients with and without malunion were compared at a mean follow-up of 15 months. No difference was observed in activities of daily living (P = 0.28), wrist pain (P = 0.14), whether the wrist had returned to its normal level function (P = 0.25), grip strength (P = 0.31), or ROM (P = 0.41). An increasing degree of dorsal angulation correlated with diminished ROM (P = 0.038), but did not correlate with activities of daily living (P = 0.10). Conclusions. Malunion of the distal radius does not influence the functional outcome of independent superelderly patients.

Intra-articular distal radius fractures involving the distal radioulnar joint (DRUJ): three dimensional computed tomography-based classification

PURPOSE

The purpose of this study was to analyze fracture patterns and the magnitude of displacement in the distal radioulnar joint (DRUJ), by three-dimensional (3D) computed tomography (CT), for distal radius fractures with intra-articular displacement of the radiocarpal joint.

METHODS

We reconstructed 3D images for 72 consecutive patients with displaced intra-articular distal radius fracture on the basis of fine-cut axial CT data. The fracture patterns involving the DRUJ were classified on the basis of the location and direction of fracture lines, and the extent of fracture comminution. We measured the maximum spatial distance of the gap and the step between the fragments in each 3D image, and the magnitudes of displacement between the groups were compared by analysis of variance followed by post-hoc analysis by use of Tukey's test.

RESULTS

Sixty wrists had a fracture involving the DRUJ. We classified the 60 wrists into 3 types of fracture pattern. Type 1 was a transverse fracture with minimum displacement. Type 2, in which fracture lines extended into the distal margin of the sigmoid notch, was the most common longitudinal fracture. Type 3 was a fracture with multiple fragments. The step and gap in Type 3 was significantly larger than that in the other types.

CONCLUSIONS

Eighty-three percent of intra-articular distal radius fractures had DRUJ involvement, and 28% of the wrists had multiple fragments. For Type 3 fractures with dorsal or proximal comminution displacement was significantly larger than for simple Type 1 and 2 fractures. Surgical intervention for the DRUJ fragment may be beneficial when there is remarkable intra-articular displacement.

Age and gender effects on the proximal propagation of an impulsive force along the adult human upper extremity

We tested the null hypotheses that neither age, gender nor muscle pre-cocontraction state affect the latencies of changes in upper extremity kinematics or elbow muscle activity following an impulsive force to the hand. Thirty-eight healthy young and older adult volunteers lay prone on an apparatus with shoulders flexed 75° and arms slightly flexed. The non-dominant hand was subjected to three trials of impulsive loading with arm muscles precontracted to 25, 50, or 75% of maximum pre-cocontraction levels. Limb kinematic data and upper extremity electromyographic (EMG) activity were acquired. The results showed that pre-cocontraction muscle level (p < 0.001) and gender (p < 0.05 for wrist and shoulder) affected joint displacement onset times and age affected EMG onset times (p < 0.05). The peak applied force (F1) occurred a mean (± SD) 27 (± 2) ms after impact. The latencies for the wrist, elbow, and shoulder displacements were 21 ± 3, 29 ± 5, and 34 ± 7 ms, respectively. Because the latencies for elbow flexion and lateral triceps EMG were 23 ± 5 and 84 ± 8 ms, respectively, muscle pre-activation rather than stretch reflexes prevent arm buckling under impulsive end loads.

Ligament origins are preserved in distal radial intraarticular two-part fractures: a computed tomography-based study

Background Operative fixation of intraarticular distal radius fractures is increasingly common. A greater understanding of fracture patterns will aid surgical fixation strategy. Previous studies have suggested that ligamentous insertions may less commonly be involved, but these have included heterogeneous groups of fractures and have not addressed Lister's tubercle. Purpose We hypothesize that fracture lines of distal radial intraarticular 2-part fractures have reproducible patterns. They propagate through the cortical bone between ligament origins and do not involve Lister's tubercle. Methods Axial CT scans of two-part intraarticular distal radius fractures were assessed independently by two examiners. The fractures were mapped onto a grid and the cortical breaches expressed as a percentile of the total radial width or length. The cortical breaches were compared with the ligamentous insertions on the distal and Lister's tubercle. Associated injuries were also documented. Results The cortical breaches occurred between the ligamentous insertions in 85%. Lister's tubercle was not involved in 95% of the fractures. Three major fracture patterns emerged: radial styloid, dorsal, and volar. Each major pattern had two subtypes. Associated injuries were common. Scapholunate dissociation was associated with all types, not just the radial styloid fracture pattern. Conclusions The fracture patterns of two-part intraarticular fractures mostly involved the interligamentous zones. Three major groups were identified: dorsal, volar, and radial styloid. Lister's tubercle was preserved with fractures tending to propagate radial or ulnar to this structure. We suggest conceptualizing fracture fragments as osseo-ligamentous units to aid prediction of fracture patterns and associated injury. Study Design Diagnostic III Level of Evidence 3.

Union of the ulnar styloid fracture as a function of fracture morphology on conventional radiographs

OBJECTIVE

In a retrospective radiological study, the authors aimed to detect the influence of fracture morphology on the union rate of ulnar styloid fractures associated with distal radial fractures.

MATERIALS AND METHODS

Eighty-two out of 101 ulnar styloid fractures were included in the final statistical analysis. Initially, they were grouped into six different morphological types based on a novel classification system. They were also classified as per the established Fernández and Frykman classification systems. Furthermore, the initial ulnar styloid displacement was measured in conventional anteroposterior radiographs. Union of the ulnar styloid fracture was evaluated after at least 6 months of follow-up.

RESULTS

The current investigators demonstrated that the various ulnar styloid fracture patterns have no significant predictive value for ulnar styloid union. In contrast, it could be attested, that an initial fragment dislocation of greater than 2.4 mm in the conventional AP radiographs has a significantly lower chance of successful union (p = 0.022).

CONCLUSION

Initial displacement of the ulnar styloid should be measured in each distal radial fracture with a concomitant ulnar styloid fracture. This could be useful to inform the decision regarding surgical fixation of the ulnar styloid fragment in patients with an unstable distal radioulnar joint (DRUJ) or persistent symptoms at the ulnar aspect of the wrist.

Treatment of distal radial fractures with antegrade intra-medullary Kirschner wires

The treatment of unstable Colles-type distal radial fractures remains a challenge. A prospective study was conducted to evaluate the outcomes of the treatment of unstable distal radial fractures using antegrade intra-medullary K-wires. Twenty-eight Colles-type distal radial fractures were selected excluding comminuted intra-articular and Barton’s fractures. The blunt tips of intra-medullary K-wires were introduced in an antegrade direction to support the subchondral bone of the distal fragment. The scoring system of Green and O’Brien modified by Cooney et al. was used for the final clinical evaluation. The radiological outcomes were evaluated using the scale proposed by Stewart et al. After a mean follow-up of 34 months (range 14–46), 17 patients were rated clinically excellent, seven good, three fair and one poor. The mean loss of radial height, radial inclination, volar tilt and ulnar variance was 0.9 mm, 1.9°, 0.5° and 0.4 mm, respectively. These results were comparable with the values reported in other pinning studies. Only one patient complained of skin irritation and painful bursitis in the forearm; otherwise, no complications related to tendon or nerve injury were encountered. One patient had protrusion of K-wire into the wrist joint. The technique proved to be effective in maintaining reduction in distal radial fracture with low rate of soft tissue complications.

Open reduction and internal fixation versus external fixation for unstable distal radial fractures: a meta-analysis

PURPOSE

To compare the clinical outcomes of open reduction and internal fixation (ORIF) versus the ones of closed reduction and external fixation (EF) in the treatment of distal radial fractures.

METHODS

We performed a meta-analysis of randomized controlled trials that compared the clinical results of ORIF to EF in the treatment of distal radial fractures. A systemic retrieve from PubMed, EMBASE, OVID and Cochrane Collaboration CENTRAL database resulted in 11 studies with 824 patients. We thus performed data synthesis using RevMan (version 5.1).

RESULTS

Superior statistical differences were observed for DASH scores (at 3, 6 and 12 months follow-up) grip strength (at 3 months follow-up), volar tilt (at 12 months follow-up), flexion and supination (at 3 months follow-up), and extension (at 3 and 6 months follow-up) in ORIF patients group, compared with those in EF group. We also found a significantly higher risk of infection associated with EF. There was no significant difference in the incidence of malunion and median nerve dysfunction.

CONCLUSION

Regarding surgical fixation of unstable distal radius fractures, ORIF yields significantly better subjective outcome (DASH scores) the first year after operation, restoration of anatomic volar tilt, and forearm flexion and extension at the end of the follow-up period. However, EF results in higher incidence of infection compared to ORIF. ORIF is equal to EF for either grip strength, or range of motion of the injured wrist, or incidence of malunion or median nerve dysfunction at the end of the follow-up period.

LEVEL OF EVIDENCE

Level II. Therapeutic study.

Aspects of current management of distal radius fractures in the elderly individuals

Diatal radius fractures (DRFs) are typical fractures of relatively fit persons with osteoporotic bone who remain active into older age. Traditionally, DRFs in older patients have been treated with closed reduction and cast immobilization. Considering the increasing life expectancy of the elderly population, appropriate management of these fractures is of growing importance. Decision making for surgical or nonsurgical approach to osteoporotic DRFs is difficult. These decisions are often made based on the data from treatments of much younger patients. The current literature concerning the treatment of DRFs in the elderly individuals is more controversial. Some investigators have recommended open reduction internal fixation (ORIF) as treatment for unstable DRFs in older patients, while others have suggested that elderly patients should be treated nonsurgically even if there is an unstable fracture situation because fracture reduction is not associated with functional outcomes as in younger patients. This article reviews the different treatment options for DRFs in the elderly individuals reported in the recent literature.

Impact of ulnar styloid fractures in nonoperatively treated distal radius fractures

PURPOSE

The effect of an ulnar styloid fracture (USF) on the stability of nonoperatively treated distal radius fractures (DRF) is unknown. The aim of this study was to evaluate the influence of USFs on the dislocation of DRFs treated by closed reduction.

METHODS

Standardized radiographs of 100 nonoperatively treated DRFs were evaluated. DRFs with a USF were compared to DRFs without a USF with respect to dorsal tilt, radial inclination, and ulnar variance.

RESULTS

We evaluated the radiographs of 100 DRFs in 99 consecutive patients, of whom 84 were women. An accompanying USF was present in 58 wrists, of which 49 were displaced. On the trauma radiograph, the USF group showed significantly more overall dislocation. After closed reduction, fracture position improved, and no significant differences in dislocation were observed between groups. After a mean of 42 days, radial inclination significantly decreased if a USF was present. When USF displacement was taken into account, significantly more ulnar variance occurred in the displaced USF group on the trauma and follow-up radiograph compared to the nondisplaced USF group and no-USF group.

CONCLUSIONS

The results of this study show that presence of a dislocated USF in patients with a DRF is associated with a worse position directly after trauma, and with recurrence of radial shortening after adequate reduction. These results warrant early radiologic follow-up in patients with reduced combined DRFs and USFs in order to evaluate the redislocation of the distal radius. Early detection of redislocation in these combined fractures may induce early surgical intervention.

Opening wedge osteotomy for distal radius malunion: dorsal or palmar approach?

Background There are various technical variations to consider when performing a corrective osteotomy of a distal radius malunion. We chose two of the more commonly reported techniques and compared the results of volar (palmar) osteotomy and fixation with dorsal osteotomy and fixation. Method Within a continuous cohort of patients who had undergone corrective osteotomy for a malunited Colles fracture, two groups could be identified retrospectively. In 8 patients a dorsal approach was used. A structural trapezoidal graft, subtending the amount of correction, was inserted into the osteotomy gap and stabilization was performed with a thin round-hole mini-fragment plate. In 14 patients a palmar approach and a palmar fixed-angle plate was used for correction of the malunion and for angular stable rigid fixation of the two fragments. The osteotomy gap was loosely filled with nonstructural cancellous bone chips. A retrospective comparison of the two groups was performed to see whether the outcome was affected by the use of either operative technique.The demographics, the preoperative amount of deformity, range of motion, pain, and force were comparable for both groups. All osteotomies healed without loss of correction. After a minimal follow-up of one year, radiographic appearance, objective functional parameters were assessed and subjective data (Disabilities of the Arm, Shoulder, and Hand [DASH] score and special pain and function questionnaire) obtained. Results These data did not show statistical difference for the two groups except for the amount of final wrist flexion. This parameter was significantly better in patients who had palmar approaches and fixed-angle plates. Conclusion Corrective osteotomies of distal radius malunions can be done in either way. It might result in some better flexion, if performed volarly.

Radiographic outcomes of volar locked plating for distal radius fractures

PURPOSE

To assess the ability of volar locked plating to achieve and maintain normal radiographic parameters for articular stepoff, volar tilt, radial inclination, ulnar variance, and radial height in distal radius fractures.

METHODS

We performed a retrospective review of 185 distal radius fractures that underwent volar locked plating with a single plate design over a 5-year period. We reviewed radiographs and recorded measurements for volar tilt, radial inclination, ulnar variance, radial height, and articular stepoff. We used logistic regression to determine the association between return to radiographic standard norms and fracture type.

RESULTS

At the first and final postoperative follow-up visits, we observed articular congruence less than 2 mm in 92% of fractures at both times. Normal volar tilt (11°) was restored in 46% at the first follow-up and 48% at the final one. Radial inclination (22°) was achieved in 44% at the first follow-up and 43% at the final one, and ulnar variance (01 ± 2 mm) was achieved in 53% at the first follow-up and 53% at the final one. In addition, radial height (14 ± 1mm) was restored in 14% at the first follow-up and 12% at the final one. More complex, intra-articular fractures (AO class B and C and Frykman types 3, 4, 7, and 8) were less likely to be restored to normal radiographic parameters. However, because of the small sample size for some fracture types, it was difficult to discover significant associations between fracture type and radiographic outcome.

CONCLUSIONS

Volar locked plating for distal radius fractures achieved articular stepoff less than 2 mm in most fractures but only restored and maintained normal radiographic measurements for volar tilt, radial inclination, and ulnar variance in 50% of fractures. The ability of volar locked plating to restore and maintain ulnar variance and volar tilt decreased with more complex intra-articular fracture types.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A new method for classifying distal radius fracture: the IDEAL classification

OBJECTIVES

To describe the new IDEAL method from classifying distal radius fractures.

METHODS

IDEAL classification system is based on the most important literature evidences about clinical and radiographic characteristics that influence in the treatment and prognosis for patients that suffered from a distal radius fractures. In this method, we classify the fracture in patients first consultation, in which we collect demographical (age and trauma energy) and radiographic characteristics (fracture deviation, articular fracture, and associated lesions). For each feature a score is attributed for grouping purposes. Group I - Stable fractures, good prognosis; Group II - potentially unstable fractures, commonly treated by surgical methods. Prognosis depends on surgeons' success after method choice. Group III - complex and instable fractures, poor outcome is expected.

CONCLUSION

IDEAL classification staging rationale was presented, which is based on the best available evidence. The evidence of its scientific plausibility will be settled with the assessment of the classification reliability and its capacity to aid in therapeutical decisions and as a tool to predict prognosis. Further studies are under development to support these properties.

Treatment of unstable distal ulna fractures associated with distal radius fractures in patients 65 years and older

PURPOSE

To prospectively compare the clinical and radiological outcomes of 2 treatment methods for unstable distal ulna fractures associated with distal radius fractures in patients 65 years of age and older.

METHODS

From February 2008 to March 2010, the first 29 ulnas were treated surgically (group 1) and the next 32 ulnas were treated nonoperatively (group 2). The mean final follow-up period was 34 months (range, 24-56 mo). All radiuses were fixed internally, in both groups. Clinical outcomes were compared between groups using a visual analog scale for postoperative pain; Disabilities of the Arm, Shoulder, and Hand scores; active range of motion; grip strength; and the modified system of Gartland and Werley. Radiological outcomes, including ulnar variance, were evaluated. Arthrosis was evaluated at the radiocarpal joint or distal radioulnar joint (DRUJ) according to the system of Knirk and Jupiter.

RESULTS

There were no significant differences between the groups in any of the clinical outcomes. No significant differences were observed for radiological outcomes including ulnar variance, distal radius, and union rate. There were no patients in either group with symptomatic arthritic changes in the radiocarpal joint or DRUJ at the final follow-up. In group 2, 1 patient had malunion (angulated, 14°) on the anteroposterior view without evidence of arthrosis in the DRUJ, and functional outcomes were good.

CONCLUSIONS

In this population distal ulna fractures can be successfully managed nonoperatively when they occur in combination with distal radius fractures.

Functional results of the Darrach procedure: a long-term outcome study

PURPOSE

To assess long-term functional outcome after ulnar head excision for distal radioulnar joint dysfunction with prior or concomitant wrist trauma. We hypothesized that long-term outcomes would reflect good functional results with satisfactory pain relief.

METHODS

A retrospective chart review identified patients who had undergone the Darrach procedure for traumatic or posttraumatic distal radioulnar joint (DRUJ) pathology. We assessed subjective outcomes using a visual analog scale questionnaire to assess pain, wrist stability, and overall satisfaction. We evaluated objective functional outcomes using the Quick Disabilities of the Shoulder, Arm, and Hand and Patient-Rated Wrist Evaluation measures. Final radiographs were compared with preoperative x-rays to investigate the effect of possible ulnar impingement syndrome (convergent instability).

RESULTS

A total of 98 patients with 99 wrists met our predetermined inclusion criteria. Of these, 27 patients with a total of 27 wrists were available for final follow-up, 15 of whom were available for final in-office follow-up with radiographs (6-20 y). Patients displayed an average Quick Disabilities of the Shoulder, Arm, and Hand score of 17 and a Patient-Rated Wrist Evaluation score of 14. Final average visual analog scale scores for pain (0-4), pain with activity (0-4), overall satisfaction (0-4), and wrist stability (0-10) were 0.1, 0.6, 3.7, and 1.5, respectively. Final average wrist range of motion was 85°/78° and 41°/45° for pronation-supination and flexion-extension, respectively. A total of 7 patients displayed radioulnar impingement based on dynamic radiography. This ulnar impingement was not associated with clinical reports of pain and did not affect outcome measures in a statistically significant manner.

CONCLUSIONS

The Darrach procedure provides reliably good long-term subjective and objective results for the treatment of a symptomatic DRUJ after a distal radius fracture. Patients can expect to have excellent forearm range of motion at long-term follow-up. Nearly one-half of patients had dynamic convergence of the DRUJ when stressed radiographically; however, the presence of radiographic dynamic convergence did not influence clinical outcomes.

Subluxation-related ulnar neuropathy (SUN) syndrome related to distal radioulnar joint instability

Ulnar neuropathy coexistent with distal radioulnar joint (DRUJ) instability has previously been observed in our practice. The aim of this study was to define this phenomenon and investigate the hypothesis that the cause of this intermittent, positional ulnar neuropathy is related to kinking of the ulnar nerve about the DRUJ. Ulna neuropathy was present in 10/51 (19.6%) of a historical cohort of patients who presented with DRUJ instability. Nine subsequent patients with DRUJ instability and coexistent ulnar neuropathy underwent 3-T magnetic resonance imaging to better understand the mechanism of the observed syndrome. Both 3D qualitative and quantitative analyses were used to assess the presence of nerve 'kinking', displacing the nerve from its normal course and causing nerve compression/distraction in the distal forearm and Guyon's canal. Results of the quantitative analysis were statistically significant (p < 0.05). The clinical features of the condition have been delineated and termed subluxation-related ulnar neuropathy or SUN syndrome. The imaging study was a level II diagnostic study.

Use of bone graft substitute in the treatment for distal radius fractures in elderly

INTRODUCTION

Fractures of the distal radius in elderly patients are often associated with metaphyseal defects that can lead to collapse, malunion and therefore decreased function. An alternative approach to simple reduction is to fill the defects with materials that can provide structural support.

METHODS

We used synthetic hydroxyapatite (HA) in unstable fractures of the distal radius in thirty-one elderly patients, of which four patients lost to follow-up, leaving twenty-seven patients for this study. All subjects underwent closed reduction with K-wire fixation and HA augmentation. They were followed up at 8- and 16-week intervals post-operatively to assess the functional outcome using patient-related wrist evaluation [PRWE], clinical outcome and radiological outcome.

RESULTS

At mean 16 weeks, our results show that patients treated with this method showed no metaphyseal defect, no collapse and had satisfactory clinical outcome as assessed by PRWE.

CONCLUSION

We believe that fixation with hydroxyapatite augmentation for fractures of the distal radius in elderly patients is an attractive therapeutic option. This experience has changed our clinical practice.

Conservative treatment of the distal radius fracture using thermoplastic splint: pilot study results

INTRODUCTION

Fractures of the distal radius are common accounting for approximately one-sixth of all fractures treated in the emergency room. This study reviews a series of patients with stable distal radius fractures who have been treated with thermoplastic splint.

METHODS

This study was undertaken between November 2009 and May 2010 in a single orthopaedic fracture outpatient clinic. All patients had undisplaced or minimally displaced distal radius fractures. Children and open fractures were excluded. Patients had been reviewed in the outpatients with radiographs on 1, 2, 6 and 12 weeks after injury. Skin condition and satisfaction were assessed on splint removal. Radiological parameters of radial inclination, radial length and palmer tilt were measured.

RESULTS

In total, 26 patients were treated with the splint. The average age of the patients was 45.1 (range, 21-73), and male/female ratio was 12:14. On average, the splint was removed at 5.1 weeks (mode = 6 weeks). The right- to left-side ratio was 11:15. Eleven of those fractures were on the dominant side. There was no significant difference in the radiological outcomes pre- and post-splinting. Nearly all patients had been satisfied with the splint. Two patients had minor cast complications whilst 23 patients were able to shower whilst in splint.

CONCLUSION

Patients treated with thermoplastic splint showed no deterioration in their radiological outcomes. Nearly all the patients had been satisfied with the splint.

Failure characteristics of the isolated distal radius in response to dynamic impact loading

We examined the mechanical response of the distal radius pre-fracture and at fracture under dynamic impact loads. The distal third of eight human cadaveric radii were potted and placed in a custom designed pneumatic impact system. The distal intra-articular surface of the radius rested against a model scaphoid and lunate, simulating 45° of wrist extension. The scaphoid and lunate were attached to a load cell that in turn was attached to an impact plate. Impulsive impacts were applied at increasing energy levels, in 10 J increments, until fracture occurred. Three 45° stacked strain gauge rosettes were affixed along the length of the radius quantifying the bone strains. The mean (SD) fracture energy was 45.5 (16) J. The mean (SD) resultant impact reaction force (IRFr) at failure was 2,142 (1,229) N, resulting in high compressive strains at the distal (2,718 (1,698) µε) and proximal radius (3,664 (1,890) µε). We successfully reproduced consistent fracture patterns in response to dynamic loads. The fracture energy and forces reported here are lower and the strains are higher than those previously reported and can likely be attributed to the controlled, incremental, dynamic nature of the applied loads.

The effects of pain, supination, and grip strength on patient-rated disability after operatively treated distal radius fractures

PURPOSE

The correlation between physician-observed parameters and patient-rated disability in distal radius fractures is complex and poorly understood. Anecdotal clinical experience suggests that supination is an important factor in the return of functional status after distal radius fracture. To explore this relationship, we conducted a retrospective multivariate linear regression analysis of an existing patient database to evaluate the hypothesis that range of motion and other objective parameters are important determinants of patient-rated disability.

METHODS

We analyzed a prospectively gathered registry of patients undergoing operative fixation of distal radius fractures using physical examination parameters measured at each follow-up visit and patient-based outcomes including Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and visual analog scale for pain. We constructed a multivariate linear regression model to evaluate the association of range of motion, grip strength, and visual analog scale score with the DASH score.

RESULTS

We analyzed data from 190 patients and 611 total clinic visits. Pain, grip strength, and supination were significantly correlated with DASH scores, controlling for all other factors. These 3 variables were able to predict 56% of the variability of the DASH score. Flexion-extension, radial-ulnar deviation, and pronation had no significant correlation to DASH score.

CONCLUSIONS

Pain, strength, and supination appear to be important determinants of patient-rated outcomes after distal radius fracture. Pain and strength continuously improve over time up to 2 years after surgery, whereas supination plateaus more quickly, usually within the first 3 to 6 months.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Common myths and evidence in the management of distal radius fractures

Distal radius fractures (DRFs) are the most common fracture treated by physicians, but questions remain regarding optimal management. Fracture patterns, biomechanics, and treatment strategies have been debated for more than 200 years, and research shows many controversies regarding long-held beliefs. Although these common myths have been propagated and considered fact, they are not based on the best-available evidence. This article illustrates some of the major controversies regarding the management of DRFs. To provide optimal care in a world of evidence-based medicine, clinicians must shift their thinking and accept that some of the indoctrinated ideas may represent a flawed heuristic approach.

Intraoperative imaging of the distal radioulnar joint using a modified skyline view

PURPOSE

Nonanatomic reduction of the sigmoid notch in distal radius fractures may lead to limited motion, instability, or pain with pronation and supination. Standard radiological projections only poorly capture the sigmoid notch contours in the axial plane. The purpose of this study was to find an intraoperatively feasible radiological projection that will facilitate an axial view of the distal radioulnar joint.

METHODS

We modified a previously described radiographic projection termed the skyline view for evaluating the distal radius axially. We created intra-articular steps at the sigmoid notch in solid foam forearm models to identify the best of 12 projections using an image intensifier. Four observers scored each projection based on the clarity of the sigmoid notch contour and indicated the presence and location of an intra-articular stepoff.

RESULTS

The sigmoid notch was best visualized in the modified skyline view with the wrist in extension and 10° to 15° of dorsal forearm angulation relative to the x-ray path. All observers correctly recognized the presence and location of intra-articular steps at the sigmoid notch with this view. The same forearm angulation with the wrist in flexion did not reach equally good visibility of the sigmoid notch. Arm position (wrist flexion, forearm rotation, or forearm angulation) and intra-articular stepoff (none, palmar, or dorsal) were dependent determinates. Elimination of the variable forearm rotation had minimal effect, indicating that forearm rotation is not important for visualization of the sigmoid notch.

CONCLUSIONS

The modified skyline view for visualization of the distal radioulnar joint in an axial plane allows good visibility of the sigmoid notch and reliable identification of stepoffs. Further cadaver and in vivo studies are required to verify the validity of this method.

Evaluation of the sigmoid notch involvement in the intra-articular distal radius fractures: the efficacy of computed tomography compared with plain X-ray

Background

The purpose of this study is to evaluate the efficacy of computed tomography (CT) scans compared with plain radiographs on detecting the involvement of the sigmoid notch.

Methods

This study involved 121 cases diagnosed as the intra-articular distal radius fracture and performed post-reduction CT scans. We determined the presence of the sigmoid notch involvement with both plain radiographs and CT scans and compared findings of plain radiographs with CT scans about the incidence and the pattern of injuries. And the differences of results between arbeitsgemeinschaft für osteosyntheses (AO) type C2 and C3 were compared.

Results

The incidences of sigmoid notch involvement detected in plain radiographs were 81 cases (66.9%), whereas CT scans were 99 cases (81.9%). The sensitivity of plain radiographs compared with CT scans was 74.7%, the specificity was 68.2%, the positive predictive value was 91.4%, the negative predictive value was 37.5%, the false negative value was 25.3%, and the false positive value was 31.8%. In comparison between AO type C2 and C3, the incidence of sigmoid notch involvement was not a significant difference, but the displacement of fracture fragment showed a significant difference.

Conclusions

The intra-articular distal radius fracture usually accompanies the sigmoid notch involvement. Considering that the evaluation of sigmoid notch involvement by plain radiography often results in misinterpretation or underestimation, performing CT scan in intra-articular distal radius fracture is thought to be beneficial.

Distal radioulnar joint injuries

Distal radioulnar joint is a trochoid joint relatively new in evolution. Along with proximal radioulnar joint, forearm bones and interosseous membrane, it allows pronosupination and load transmission across the wrist. Injuries around distal radioulnar joint are not uncommon, and are usually associated with distal radius fractures,fractures of the ulnar styloid and with the eponymous Galeazzi or Essex_Lopresti fractures. The injury can be purely involving the soft tissue especially the triangular fibrocartilage or the radioulnar ligaments. The patients usually present with ulnar sided wrist pain, features of instability, or restriction of rotation. Difficulty in carrying loads in the hand is a major constraint for these patients. Thorough clinical examination to localize point of tenderness and appropriate provocative tests help in diagnosis. Radiology and MRI are extremely useful, while arthroscopy is the gold standard for evaluation. The treatment protocols are continuously evolving and range from conservative, arthroscopic to open surgical methods. Isolated dislocation are uncommon. Basal fractures of the ulnar styloid tend to make the joint unstable and may require operative intervention. Chronic instability requires reconstruction of the stabilizing ligaments to avoid onset of arthritis. Prosthetic replacement in arthritis is gaining acceptance in the management of arthritis.

A three-dimensional analysis of the sigmoid notch

Fractures of the distal radius are among the most common injuries of the upper extremity, though treatment has traditionally focused on restoration of the radiocarpal joint and late sequelae may persist. X-ray imaging underestimates sigmoid notch involvement following distal radius fractures. No classification system exists for disruption patterns of the sigmoid notch of the radius associated with distal radius fractures. This study quantifies the anatomy of the sigmoid notch and identifies the landmarks of the articular surface and proximal boundaries of the distal radioulnar joint (DRUJ) capsule. Computed tomography scans of freshly frozen cadaveric hands were used - followed by dissection, and three-dimensional reconstruction of the distal radius and sigmoid notch. The sigmoid notch surface was divided into two surfaces and measured. The Anterior Posterior (AP) and Proximal Distal (PD) widths of the articulating surface were reviewed, along with the radius of curvature, version angle and depth. The study showed that the sigmoid notch is flatter than previously believed - and only the distal 69% of its surface is covered by cartilage. On average, it has about nine degrees of retroversion, and its average inclination is almost parallel to the anatomical axis of the radius. Clinical implications exist for evaluation of the DRUJ involvement in distal radius fractures or degenerative diseases and for future development and evaluation of hemiarthroplasty replacement of the distal radius.

Dorsally displaced extra-articular distal radius fractures fixation: Dorsal IM nailing versus volar plating. A randomized controlled trial

INTRODUCTION

Fractures of the distal radius are very common and mainly occur in the elderly. There has been an increasing use of locked volar plate fixations which report satisfactory results. However, some authors advocate the use of nail fixation.

HYPOTHESIS

The aim of this study is to compare dorsal nail plate versus locked volar plate fixation in the treatment of distal radius fractures with dorsal tilt.

MATERIALS AND METHODS

The mean age of the patients was over 50 years. The study included extra-articular distal radius fractures with posterior tilt. We conducted a prospective randomized study between December 2007 and February 2009 including a group of 16 patients treated with a dorsal nail fixation (group 1) and a group of 15 patients managed with a locked volar plate fixation (group II). We analyzed both the clinical results (complications, Range of motion [ROM], tightening strength, Disabilities of the Arm, Shoulder and Hand [DASH] and Mayo Clinic scores) and the radiographic results from A/P and lateral radiographs in the early postoperative period and at 6-month follow-up.

RESULTS

ROM toward extension was better in the volar plating subgroup (group I, 42.5°, group II, 57.5°; P<0.05). Pronation mobility was better in the dorsal nail subgroup (group I, 85°; group II, 80°; P<0.05). The locked volar plate fixation subgroup demonstrated a better recovery of the tightening strength as compared with the uninjured side (group I, 78%, group II, 90%, P=0.03). The DASH score was similar in both groups (group I, 22.09±22.9; group II, 20.62±20.3, P>0.05). The Mayo Clinic score was better in the locked volar plate fixation subgroup (group I, 65±13.4; group II, 85.6±19.2; P=0.002). Radiographic results were good in both groups, however anatomical reduction of the volar tilt was significantly better in group II (plate) when compared with the uninjured side. Moreover, we report on two cases of tendinous damages to the long extensor muscle of the thumb in the dorsal nail fixation subgroup despite the use of a minimally invasive implant.

CONCLUSION

The management of distal radius fractures with locked volar plate fixation in active elderly patients has proved successful and leads to better results than nail fixation regarding both reduction quality and objective functional scores.

LEVEL OF EVIDENCE

Level II, prospective, randomized of low-level.

What are the radiological predictors of functional outcome following fractures of the distal radius?

The fracture most commonly treated by orthopaedic surgeons is that of the distal radius. However, as yet there is no consensus on what constitutes an 'acceptable' radiological position before or after treatment. This should be defined as the position that will predict good function in the majority of cases. In this paper we review the radiological indices that can be measured in fractures of the distal radius and try to identify potential predictors of functional outcome. In patients likely to have high functional demands, we recommend that the articular reconstruction be achieved with less than 2 mm of gap or step-off, the radius be restored to within 2 mm of its normal length, and that carpal alignment be restored. The ultimate aim of treatment is a pain-free, mobile wrist joint without functional limitation.

[External fixation with motion capacity and radius fractures. Methods and results]

Both the radiocarpal and distal radioulnar joints are often affected in"distal radius fractures". The incidence of this injury increases markedly among women over the age of 40. Bearing in mind the wide variety of distal radius fractures, a fixation system should be used which permits trans- and extra-articular application and subsequent reduction by means of distraction, as well as wrist mobilization. It is important that both reduction and position of the carpal bones can be checked. The possibility of extra-articular (radioradial) fixation should always be considered. AO group A2 and A3 fractures with sufficiently large fragments are suitable for this procedure. In other cases, transarticular application is advised. Complementary measures are justified in the case where two or more cortices in AP and lateral X-rays are destroyed. Adequate implants are also used to stabilize the articular surface. Large bone defects should be filled with corticocancellous material.

Articular step-off and risk of post-traumatic osteoarthritis. Evidence today

The goal of treatment in intra-articular fractures is to obtain anatomical restoration of the articular surface and stable internal fixation. Studies have attempted to specify how accurately an articular fracture needs to be reduced to minimise the chances of a poor clinical outcome. In this study, the current evidence with regard to articular step-offs and risk of post-traumatic osteoarthritis (POA) is evaluated. A literature review based on pre-specified criteria, revealed 36 articles for critical analysis related to intra-articular injuries of distal radius, acetabulum, distal femur and tibial plateau.In the distal radius, step-offs and gaps detected with precise measurement techniques have been correlated with a higher incidence of radiographic POA, but in the second 5 years after injury, a negative clinical impact of these radiographic changes has not been convincingly demonstrated. Restoring the superior weight-bearing dome of the acetabulum to its pre-injury morphology decreases POA and improves patient outcomes. Involvement of the posterior wall, however, seems to bean adverse prognostic sign. This effect may be independent of articular reduction. In the tibial plateau, articular incongruities appear to be well tolerated, and factors only partially related to articular reduction are more important in determining outcome than articular step-off alone;these include joint stability, retention of the meniscus, and coronal alignment. Based on observational approach and evaluation of the studies, factors other than just the extent of articular displacement affect the management of articular fractures. Different joints and even different areas of the same joint appear to have different tolerances for post-traumatic articular step-offs.

Activation level of extensor carpi ulnaris affects wrist and elbow acceleration responses following simulated forward falls

The main objective of this study was to measure the acceleration response at the wrist and elbow as a function of different levels of isometric forearm muscle activation during the impact phase of a simulated forward fall. A seated human pendulum was designed to impact the hands of 28 participants while maintaining one of four levels of isometric muscle activation (12%, 24%, 36% and 48% maximal voluntary exertion (MVE)) in the extensor carpi ulnaris muscles. The acceleration responses including peak acceleration (PA), acceleration slope (AS) and time to peak acceleration (TPA) were measured at the wrist and elbow along two axes (axial and off-axis) with two low mass surface mounted accelerometers. At the wrist, significant muscle activation effects were found for PA(off), AS(axial), AS(off), such that they increased as muscle activation increased from baseline to 48% MVE. At the elbow, a similar response was noted, with the acceleration variables increasing as muscle activation level increased, except for AS(off). The results suggest that increases in muscle activation from 12% to 48% MVE stiffen the forearm complex and increase the transmissibility of the impact reaction force shock waves through the forearm.

Differential onset patterns and causes of carpal tunnel syndrome after distal radius fracture: a retrospective study of 105 wrists

BACKGROUND

It is well known that carpal tunnel syndrome (CTS) can occur in a wide range of time periods after distal radius fracture (DRF). Few studies have evaluated in detail the relationship between fracture and electrophysiological finding characteristics and time to onset of CTS after DRF. To clarify the characteristics of CTS after DRF, we classified a large number of clinical cases based on the period from the injury to onset of CTS. These cases were analyzed retrospectively.

METHODS

We reviewed 105 wrists with CTS following DRF. Patients' ages ranged from 13 to 89 years. These 105 wrists were divided into three groups according to the period of post-fracture onset of CTS. Twenty-eight wrists were classified into the acute onset group (when the symptoms of CTS occurred within 1 week after fracture). Forty-seven wrists were classified into the subacute onset group (when symptoms of CTS occurred from 1 to 12 weeks after fracture). The remaining 30 wrists were classified into the delayed onset group (when symptoms of CTS occurred more than 12 weeks after fracture). Deformity of the distal radius on X-ray films was evaluated and distal motor latency (DML) of the median nerve was recorded to compare values among these three groups.

RESULTS

In the acute onset group, 68% had an AO C-type fracture and 46% were caused by a high-energy injury. The percentage of this fracture pattern and mechanism was significantly higher in the acute onset group than in the other groups (P < 0.05; Kruskal-Wallis test). In the subacute onset and delayed onset groups, 79% and 63% had an A-type fracture and more than 90% were caused by a low-energy injury. In the delayed onset group, the incidence of prolonged DML in the contralateral wrists was 71%, which was significantly higher than in the other two onset groups (P < 0.05; Kruskal- Wallis test).

CONCLUSIONS

There were three onset patterns of CTS after DRF, and each CTS onset pattern had different etiologic mechanisms and different clinical features of CTS. In the acute onset group, a high-energy fracture pattern was associated with CTS. In the subacute and the delayed onset groups, lowenergy injury in elderly women was associated with CTS. Both deformity of the fracture and preexisting median nerve dysfunction were suggested as predisposing factor for CTS.

[Mountain biking : Breezy ups and traumatic downs]

For more than two decades the popularity of mountain biking as a national pastime as well as a competitive sport has been undiminished. However, its related risks are not monitored as closely as those, for example, of skiing. The injuries caused by mountain biking are specific and cannot be compared with those caused by other cycling sports. This is due not only to the characteristics of the terrain but also to the readiness to assume a higher risk compared to cycle racing.The particular value of radiology is in the acute trauma setting. Most often musculoskeletal lesions must be examined and digital radiography and MRI are the most useful techniques. Severe trauma of the cranium, face, spine, thorax and abdomen are primarily evaluated with CT, particularly in dedicated trauma centers. Therefore, radiology can play a role in the rapid diagnosis and optimal treatment of the trauma-related injuries of mountain biking. Thus, the unnecessarily high economical damage associated with mountain biking can be avoided.

Distal radius fractures--classification of treatment and indications for surgery

Distal radius fractures are common injuries. Multiple classification systems have highlighted the evolution of the understanding of distal radius fractures. Understanding the classifications of distal radius fractures is important in identifying the important aspects that affect their outcome. Surgical indications of distal radius fractures can be divided into the following categories: patient factors, fracture reduction, fracture stability, and the presence of associated injuries.