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

Can Machine Learning Identify Patients Who are Appropriate for Outpatient Open Reduction and Internal Fixation of Distal Radius Fractures?

Purpose

This study aimed to identify which patients were "unsafe" for outpatient surgery patients and determine the most predictive demographic and clinical factors contributing to postoperative risk following open reduction internal fixation for distal radius fractures.

Methods

Adult patients (aged ≥18 years) who presented with distal radius fracture and underwent open reduction internal fixation were identified using the American College of Surgeons National Surgical Quality Improvement Program database for years 2016 to 2021. Patients who were deemed "unsafe" therefore contraindicated for outpatient open reduction internal fixation of distal radius fracture if they required admission (length of stay of one or more days) or experienced any complication or required readmission within 7 days of the index operation. The model with optimal performance was determined according to area under the curve on the receiver operating characteristic curve and overall accuracy. Additional model metrics were also evaluated, and predictive factors (ie, features) that were most important to model derivation were identified.

Results

A total of 2,020 eligible patients underwent open reduction and internal fixation for distal radius fractures. The majority (78.6%) were women, with a mean age of 57.5 ± 16.0 years. Of these patients, 21.5% experienced short-term adverse events. Gradient boosting was the optimal model for predicting patients who were "unsafe" for outpatient surgery, with key features including International Classification of Diseases, 10th Revision code, preoperative white blood cell count, age, body mass index, and Hispanic ethnicity.

Conclusions

Using machine learning techniques, a predictive model was developed, which demonstrated good discrimination and excellent performance in predicting which patients were "unsafe" for outpatient operative fixation of distal radius fracture. Findings of this study highlight the predictive value of artificial intelligence and machine learning for the purposes of preoperative risk stratification as well as its potential to better inform shared decision making and guide personalized fracture care.

Level of evidence/type of study

Prognostic IV.

The Fragility of Statistical Findings in Distal Radius Fractures: A Systematic Review of Randomized Controlled Trials

PURPOSE

Probability analysis with reporting of P values is often used to determine the statistical significance of study findings in the orthopedic literature. The fragility index (FI) has been used to evaluate the robustness of a significant result. The purpose of this study was to determine the utility of applying a fragility analysis to randomized controlled trials (RCTs) evaluating distal radius fractures (DRFs).

METHODS

We identified all dichotomous outcome data for randomized controlled trials of distal radius fractures (DRFs) published in 13 orthopedic journals from 2000 to 2020. The fragility index (FI) was determined by the number of event reversals required to change a P value from less than 0.05 to greater than 0.05, or vice-versa. The associated fragility quotient (FQ) was determined by dividing the FI by the sample size. The interquartile ranges (IQR) for the FI and FQ were calculated as the difference between the 25th and 75th percentiles for the overall study.

RESULTS

Of the 7352 studies screened, 221 met the search criteria, with 34 randomized controlled trials evaluating distal radius fractures and 151 total outcome events included for analysis. The overall FI was 9 (IQR 6.5-11) with an associated fragility quotient of 0.097 (IQR 0.060-0.140). However, a majority of outcomes (78.8%) were not significant. Fragility analysis of statistically significant outcomes had an FI of 4 (IQR 1-10). All of the studies reported lost to follow-up (LTF) data where 20.6% reported lost to follow-up of greater or equal to 9.

CONCLUSION

The RCTs in distal radius fracture outcomes have comparable statistical robustness to literature in other orthopedic surgical specialties, are not as statistically stable as previously thought and should be interpreted with caution. We recommend that orthopedic literature report the FI and FQ along with the P values to help the reader draw reliable conclusions based on the fragility of outcome measures.

LEVEL OF EVIDENCE

Level I.

Reduction Techniques in Volar Locking Plate Fixation of Distal Radius Fractures

Distal radius fractures are the most common upper extremity fracture and volar locking plate fixation has become a common modality for operative management of these injuries over the last 2 decades. However, despite the widespread use of volar locking plates, there remains no comprehensive guide detailing the available reduction techniques using these systems. This review aims to consolidate the reduction techniques from the literature along with the authors' experiences into a blueprint for distal radius fracture reduction when using a volar plate. Techniques described include those with and without use of the plate and with supplementary means of fixation for both extra-articular and intra-articular fracture patterns.

Distal radius fractures

The management of distal radius fractures has evolved considerably in the last two decades. Techniques and hardware have improved so much that the surgeon can usually assure good results in these debilitating fractures. Yet no one method can be used for all injuries, as the personality of each fracture demands a customized approach. Furthermore, what works in one age group may not work in another. For this reason, every available treatment has its own space in our options. The need for surgeons to be well versed in all techniques is critical. We offer a concise update of important evolutionary and current treatment guidelines for this common fracture.

EPIDEMIOLOGY, CLASSIFICATION, AND TREATMENT OF BILATERAL FRACTURES OF THE DISTAL RADIUS

Objective:

To study epidemiology, fracture pattern, associated injuries, and treatment of individuals with bilateral distal radius fracture, in a tertiary hospital.

Methods:

Retrospective cross-sectional study developed based on patients with bilateral distal radius fracture from January 2012 to November 2017. Demographic data, trauma mechanism, radiological patterns, degree of deviation, associated injuries, classification of fractures according to the Association of Osteosynthesis (AO), the Salter-Harris (SH) and Frykman scales, and type of treatment used in each case.

Results:

13 cases were included in the trial, 10 adults and three children. In infants, the mean age was 9.6 years (7-11 years), and low-energy trauma was described in all these cases. In total, 66.6% of the children presented the SHII classification . In adult patients, the mean age observed was 43.5 years (27-56 years), with high-energy trauma reported in four (40%) cases. The AO 23C.3 and 23B.2 classifications were the most prevalent in adults.

Conclusion:

In adult individuals, there was a higher incidence of open fractures, wrist joint involvement, ulna fracture, and concomitant injuries, with high-energy trauma observed only in this group, corresponding to half of the cases. Level of Evidence IV, Case Series.

A post-surgical rehabilitation program for women over 60 years old who underwent surgery in trauma and orthopedic hospital after distal radius fracture

INTRODUCTION

Distal radius fractures (DRFs) are associated with a high economic burden and an impact on quality of life on these patients. Its high prevalence demonstrates the importance of registering functional results, with emphasis on vulnerable population such as elderly females.

METHODS

Thirty-six patients were admitted to a multimodal rehabilitation program. Exercise progressions combined with manual therapy and electrophysical agents were provided, taking into account bone and soft tissues healing stages, protection of surgical intervention and symptoms of each patient. The primary outcome was the Patient Rated Wrist Evaluation (PRWE) questionnaire. The secondary outcomes were wrist and forearm range of motion (ROM), grip strength and lateral and tripod pinch strength. The paired t-test was used to compare mean PRWE, ROM, and strength between 6 and 12 weeks.

RESULTS

An improvement of functionality was observed with a decreased of -20.9 (CI 95%: 25.9 to -15.9) points in the PRWE questionnaire (p < 0.001) between 6 and 12 weeks after DRF surgery. In addition, an increase in the ROM of the wrist (p < 0.001), grip strength (p < 0.001), lateral pinch (p < 0.001) and tripod pinch (p < 0.001) were observed between 6 and 12 weeks after surgery.

CONCLUSIONS

These findings showed a clinically and statistically significant improvement in function, ROM, and strength assessed at weeks 6 and 12 after surgery. However, this study design cannot establish a cause-and-effect relationship. Future randomized controlled clinical trials should investigate the effectivity of similar rehabilitation programs.

Plate Fixation of Distal Radius Fractures: What Type of Plate to Use and When?

There are several options for plate fixation of distal radius fractures. Volar plating has broad applicability and consistent outcomes, and thus is the most commonly used plate type. Dorsal plates are advantageous for specific fracture patterns, and can provide direct fracture reduction and buttressing, but may be prominent and can cause tendon irritation. Bridge plates offer an alternative to external fixation while avoiding the complications with prominent hardware, because they span highly comminuted fractures and can be used for immediate weight bearing; however, they require plate removal. Choice of plate fixation should depend on fracture type, patient factors, and surgeon experience.

Operation time effect on rates of perioperative complications after operative treatment of distal radius fractures

Purpose

The purpose is to identify the impact of operation time length on complications for patients undergoing operative treatment of distal radius fracture.

Methods

Patients who underwent operative treatments for distal radius fractures were identified in a national database. Data collected include patient demographic information, comorbidities, and complications.

Results

Operation time was found to be an independent predictor for return to the operating room. Operation time was not found to be a predictor of other postoperative complications.

Conclusion

Surgeons should work to shorten procedure duration whenever possible to minimize the risks that longer operative times can have on patient outcomes.

The Effect of a PEEK Material-Based External Fixator in the Treatment of Distal Radius Fractures with Non-Transarticular External Fixation

Objective

To explore the effect of a PEEK material‐based external fixator in the treatment of distal radius fractures with non‐transarticular external fixation.

Methods

There were 48 patients in this prospective comparative study. They were divided into two groups according to the materials used: the PEEK group and the titanium group. Wrist dorsiflexion, palmar flexion, pronation, supination, radial deviation, ulnar deviation, grip strength of the palm on the affected side, kneading force, Visual Analogue Scale/Score (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, operation time, frequency of fluoroscopy procedures, and X‐ray results were compared between the two groups. Functional recovery was evaluated at the last follow‐up according to the wrist joint evaluation criteria.

Results

The baseline data were comparable between the two groups, and no significant differences were found in age, sex, fracture types (P > 0.05). There was no significant difference between the two groups in the results of DASH, grip strength, and recovery of pinch force and wrist function (dorsiflexion, clavicle, ulnar deviation, deviation, pronation, and supination) (P > 0.05). Normal limb function was achieved in the two groups of patients at an average of 6 weeks after surgery, and there was no significant difference in X‐ray examination radial height (10.60 ± 1.59 vs 11.00 ± 1.53, P = 0.687), radial inclination (1.11 ± 0.24 vs 1.12 ± 0.24, P = 0.798), volar tilt (10.33 ± 2.13 vs 10.00 ± 2.08, P = 0.660), ulnar variance (20.87 ± 3.00 vs 20.38 ± 3.04, P = 0.748), and step‐off persistence (1.73 ± 0.69 vs 1.68 ± 0.72, P = 0.425) between the two groups (P > 0.05). However, the operation time (54.80 ± 12.20 vs 85.23 ± 15.14, P = 0.033) and number of fluoroscopy procedures (36.93 ± 6.89 vs 64.77 ± 9.74, P = 0.000) in the PEEK group were significantly reduced compared with those in the titanium group.

Conclusion

Compared with the traditional titanium external fixator, the PEEK composite external fixator has advantages, such as a shorter operation time and fewer fluoroscopy procedures when used to treat different types of distal radius fracture.

Surgical treatment of intra-articular distal radius fractures with the assistance of three-dimensional printing technique

BACKGROUND

The aim of this study was to evaluate the effectiveness and safety of surgical treatment of intra-articular distal radius fractures (DRFs) with the assistance of three-dimensional (3D) printing technique.

METHODS

Patients with intra-articular DRFs in our hospital from February 2017 to November 2018 were enrolled in this study, and were randomly assigned to 2 parallel groups to receive surgical treatment with the assistance of 3D printing technique or not. For patients in the 3D printing group, the surgical procedure was simulated with 3D physical model before surgery. Volar plate and K-wire fixation were performed in all patients. Patients in the 2 groups were compared in terms of intraoperative indexes and postoperative function.

RESULTS

A total of 32 patients were included in our study. During surgery, mean operation time in the 3D model group was significantly lower than that in the routine group (P < .001). Besides, significantly less blood was lost in the 3D model group than that in the routine group (P < .001). Furthermore, the 3D model group had a significantly less times of intraoperative fluoroscopy than that in the routine group (P = .002). However, the 3D model group showed no significant difference in visual analog scale (VAS) score, the disabilities of the arm, shoulder, and hand (DASH) score, or active wrist range of motion (ROM) in comparison with the routine group (P > .05).

CONCLUSION

With the assistance of 3D printing technique, the operation time, amount of intraoperative bleeding, and times of intraoperative fluoroscopy can be reduced during the surgical treatment of intra-articular DRFs with volar plating and K-wire fixation. This technique is safe and effective, and is worth spreading in other orthopedic surgeries.

A Novel Technique for Correcting Radial Length and Translation in Distal Radius Fractures

We describe a novel technique in correcting distal radius fractures deformed with significant shortening or coronal plane translation in both the acute or chronic setting. The technique involves using a modified push-pull device to assist the surgeon in correcting length and/or translation of the articular block without the use additional hardware outside of the volar plate.

Do Impairments Predict Hand Dexterity After Distal Radius Fractures? A 6-Month Prospective Cohort Study

BACKGROUND

The relationship of routinely measured grip and motion measures may be related to hand dexterity. This has not yet been thoroughly examined following a distal radius fracture (DRF). The purpose of this study was to investigate if impairments in range of motion (ROM) and grip strength predict hand dexterity 6 months following a DRF.

METHODS

Patients with DRFs were recruited from a specialized hand clinic. Hand grip was assessed with a J-Tech dynamometer; ROM was measured using standard landmarks and a manual goniometer. Multiple regression analyses were performed to identify whether potential predictors (grip, ROM, age, hand dominance, and sex) were associated with 3-month or 6-month outcomes in large- and small-object subtests of the NK dexterity test in the affected hand.

RESULTS

Age, sex, and arc motion for radial-ulnar deviation were significant predictors of large-object hand dexterity explaining the 23% of the variation. For small-object hand dexterity, age and flexion-extension arc motion were significant predictors explaining 11% of the variation at 3 month after the fracture (n = 391). At 6 months post injury (n = 319), grip strength, arc motion for flexion-extension, and age were found to be significant predictors of large-object dexterity explaining 34% of the variance. For the small objects, age, grip strength, sex, and arc motion of radial-ulnar deviation explained 25% of the variation.

CONCLUSIONS

Although this confirms that the impairments in ROM and grip that occur after a DRF can explain almost one-third of the variation in hand dexterity, it also suggests the need for dexterity testing to provide more accurate assessment.

Physical impairments predict hand dexterity function after distal radius fractures: A 2-year prospective cohort study

Introduction

The overall aim of this study was to determine whether physical impairments – loss of range of motion and grip strength – could be used to predict hand dexterity functions in patients at 1 and 2 years after distal radius fracture.

Methods

This was a prospective cohort study. Hand dexterity was assessed at three different levels using the NK hand dexterity test. We used a manual goniometer to measure the active range of motion in the affected hand for wrist flexion and extension movements, and a J-Tech grip strength device to measure patients’ hand grip strength levels. Assessments were performed at 1- and 2-year follow-ups. Separate multivariable regression analyses were performed to determine if range of motion predicts hand dexterity functions at 1 and 2 years after distal radius fracture.

Results

A total of 160 patients with distal radius fracture were included in this study. Range of motion (flexion and extension) and grip strength were both statistically significant (p < 0.05) independent variables in predicting hand dexterity functions at all three levels among patients after distal radius fracture at 1-year follow-up. Range of motion and strength levels accounted for 31%, 33% and 22% of the variance in patients’ large, medium and small hand dexterity functions, respectively. At 2 years, grip strength remained the only statistically significant (p < 0.001) independent variable in predicting hand dexterity functions at all three levels.

Conclusions

Physical impairments (loss of range of motion and grip strength) have higher predictive values for large and medium hand dexterity functions, than small hand dexterity functions, in patients after distal radius fracture, at both 1- and 2-year follow-up periods.

Distal Radius Fractures in a Functional Quadruped: Spanning Bridge Plate Fixation of the Wrist

Patients who require assistive devices with their hands for mobilization are called functional quadrupeds. These patients pose a unique challenge after they have a distal radius fracture, as their injury not only limits the wrist but also compromises ambulation. The authors propose a different treatment strategy for functional quadrupeds to improve mobilization and weight-bearing with the injured limb after a distal radius fracture. In this article, the authors define the functional quadruped and describe their technique of spanning bridge plate fixation with a retrospective review of patient outcomes.

Iatrogenic Injuries of the Palmar Branch of the Median Nerve Following Volar Plate Fixation of the Distal Radius

Background: Our aims were to identify iatrogenous injuries to the palmar branch of the median nerve sustained during volar plate fixation of the distal radius, make the clinician aware of this relatively uncommon complication of distal radius fixation, to emphasise common threads in symptomatology and to propose an algorithm for evaluation and management.

Methods: Retrospectively interrogating our database over a 5 year period, the case records, neurophysiology records, operative records, therapy records were reviewed. The data was analysed with regard to the grade of surgeon performing the procedure, the site of injury, complexity of the fracture, delay to surgery, implant choice and outcome of the treatment. Variations in nerve anatomy were documented during revision surgery and common themes in symptomatology and clinical presentation were identified.

Results: Seven patients with an iatrogenic injury involving the palmar branch of the median nerve associated with volar plate fixation of the distal radius were assessed. The male: female ratio was 1:6 and the mean age of patients was 47.8 years (33-74 years). The initial operative fixation was undertaken by a consultant orthopaedic surgeon at a mean of 7.8 (1-17) days from injury. The mean time from fracture fixation surgery to referral to the peripheral nerve injury service was 8.9 (2-36) months. Six patients presented with pain on attempted wrist extension. Five patients had parasthesia, hyperaesthesia or dysaesthesia in the distribution of the PCBMN. Anaesthesia or hypoaesthesia was present in three patients. Two patients presented with symptoms of complex regional pain syndrome (CRPS) Type 2.

Conclusions: Revising relevant anatomy and possible variations as well as careful placements of retractors in the region of the median nerve could bring down these injuries. We propose an algorithm for their management.

Adult distal radius fractures classification systems: essential clinical knowledge or abstract memory testing?

Classification systems should be tools for concise communication, which ideally can predict prognosis and guide treatment. They should be relevant, reproducible, reliable, properly validated and most importantly simple to use and understand. There are 15 described distal radius classification systems present in the literature in the past 70 years, of which 8 are discussed in this paper. For each classification, we give an insight into its history, strengths and weaknesses, and provide evidence from the literature on reliability and reproducibility. Sadly, on completion of this paper we have not found a distal radius fracture classification that proved to be useful. Failings range from poor reproducibility and reliability, and over-complexity mainly emanating from the inability to classify this spectrum of injury in all of its manifestations. Consequently, we would suggest that classification systems for acute adult distal radius fractures are not useful clinical knowledge but mainly historical and/or research tools. Moreover, we would discourage trainees from spending time learning these classifications, as they serve not as essential clinical knowledge but more as forms of abstract memory testing.

Radiographical measurements for distal intra-articular fractures of the radius using plain radiographs and cone beam computed tomography images

OBJECTIVE

Operative treatment of an intra-articular distal radius fracture is one of the most common procedures in orthopedic and hand surgery. The intra- and interobserver agreement of common radiographical measurements of these fractures using cone beam computed tomography (CBCT) and plain radiographs were evaluated.

MATERIALS AND METHODS

Thirty-seven patients undergoing open reduction and volar fixation for a distal radius fracture were studied. Two radiologists analyzed the preoperative radiographs and CBCT images. Agreement of the measurements was subjected to intra-class correlation coefficient and the Bland-Altman analyses.

RESULTS

Plain radiographs provided a slightly poorer level of agreement. For fracture diastasis, excellent intraobserver agreement was achieved for radiographs and good or excellent agreement for CBCT, compared to poor interobserver agreement (ICC 0.334) for radiographs and good interobserver agreement (ICC 0.621) for CBCT images. The Bland-Altman analyses indicated a small mean difference between the measurements but rather large variation using both imaging methods, especially in angular measurements.

CONCLUSIONS

For most of the measurements, radiographs do well, and may be used in clinical practice. Two different measurements by the same reader or by two different readers can lead to different decisions, and therefore a standardization of the measurements is imperative. More detailed analysis of articular surface needs cross-sectional imaging modalities.

Radiographs Versus Radiographic Measurements in Distal Radius Fractures

Surgeons use radiographic measures of deformity to help make treatment decisions in distal radius fractures. Precise threshold values are sometimes offered as a guide to treatment. The purpose was to evaluate if agreement on treatment recommendations would improve if surgeons were provided with radiographs rather than precise numeric radiographic measurements. We randomized 259 surgeons to review the scenarios of 30 consecutive adult patients with a distal radius fracture treated at our emergency department either with radiographs (135 surgeons) or with radiographic measurements (124 surgeons). Interrater reliability was measured with the Fleiss' generalized Kappa. Factors associated with a recommendation for operative treatment were sought in bivariate and multivariable analyses. Surgeons that received measurements only recommended operative treatment significantly more often, but were less likely to agree than surgeons evaluating actual radiographs. Patient factors - radiographic factors in particular - had a greater influence on treatment recommendation than surgeon factors. Agreement on treatment recommendations improved if surgeons were provided with radiographs instead of just measurements. There may be radiographic factors other than measures of deformity that some surgeons use to determine recommendations for surgery.

Distal radius fractures: Should we use supplemental bone grafts or substitutites in cases of severe osteoporotic or conminution?

OBJECTIVES

The purpose of this study was to assess the need of bone graft or bone substitutes in unstable distal radius fractures (DRF) treated with locking compression plates (LCP) PATIENTS AND METHODS: An observational and prospective study was conducted on 60 patients with DRF AO-type A3 and AO-type C3, treated surgically by LCP plates without bone grafts or substitutes. Ranges of motion in flexion (F), extension (E), pronation (P), and supination (S) were measured in the injured wrist and compared with the healthy contralateral wrist. X-ray parameters: palmar tilt (PT), radial inclination (RI), ulnar variance (UV), and radial height (RH) were calculated in the injured wrist one year after surgery and then compared, with those parameters in the healthy contralateral wrist and in the follow-up postoperative x-ray of the injured wrist. PRWE and DASH scores were used to evaluate patient satisfaction.

RESULTS

The range of motion loss was F 12° ± 16.1°, E 9° ± 13.1°, P 2.5° ± 7.5°, and S 5°±10°, but they remained within functional parameters. Good results were also obtained in the PRWE and DASH scores (DASH 12.6 ± 14.16 and PRWE 9.5 ± 9.5). All the fractures were healed without significant collapse (IP 0.55 ± 1.7°, IR 0.31 ± 1.5°, VC 0.25±0.8mm, and AR 0.1 ± 0.9 mm).

CONCLUSIONS

All fractures healed without problems or with significant loss of reduction. Bone graft and bone substitutes are not mandatory for treatment of unstable DRF with LCP plates. Their use increases the cost and is not exempt of morbidities. This study also reinforces the role of LCP plates in surgical treatment of unstable DRF.

Non-bridging external fixation employing multiplanar K-wires versus volar locked plating for dorsally displaced fractures of the distal radius

BACKGROUND

The aim of this study was to compare non-bridging external fixation to palmar angular stable plating with respect to radiological outcome, wrist function, and quality of life.

METHODS

One hundred and two consecutive patients (mean age: 63 years) were enrolled in the study. Fifty-two patients were randomized for plate osteosynthesis (2.4 mm, Synthes), 50 patients received non-bridging external fixation (AO small fixator). Objective (range of motion, grip strength), patient rated outcomes (quality of life, pain), and radiological outcome were assessed 8 weeks, 6 months, and 1 year after surgery.

RESULTS

Loss of radial length of more than 3 mm was not detected in any group. Volar tilt was better restored by external fixation (7.2°) than by volar plating (0.1°). Wrist function was good in both groups. The external fixator was tolerated very well, and the quality of life assessment revealed comparable results in both groups. Osteoporosis was found in 54 % of patients and had no influence on radiological and functional outcome.

CONCLUSION

Non-bridging external fixation employing multiplanar K-wires is a suitable treatment option in intra- and extra-articular fractures of the distal radius even in osteoporotic bone.

[The significance of displacement in dorsally angled distal radial fractures]

BACKGROUND

Distal radial fractures occur very frequently. Most are dorsally displaced (Colles' fracture). In contrast to previously, approximately a quarter of these patients now undergo surgery. This is more than the number that is reduced and immobilised in a plaster cast. Volar plate osteosynthesis is now the most common type of surgery. There is great uncertainty regarding indications for surgery.

METHOD

The article is based on own research, a search in PubMed and a review of reference lists to identify articles that compare radiological and clinical outcomes after Colles' fractures.

RESULTS

A number of national orthopaedic associations have reviewed the literature in an attempt to draw up guidelines for indications for performing surgery on distal radial fractures, without being able to arrive at definite recommendations based on randomised studies. Our review of the literature indicates a very uncertain correlation between radiological displacement and the final clinical outcome. This applies particularly to elderly patients (over 55-65), where by far the majority of the studies do not find any such correlation. Complications and reoperation are common among patients who have undergone volar plate surgery.

INTERPRETATION

There is surprisingly little correlation between the radiological and clinical outcome after Colles' fractures. A practice where a large proportion of patients undergo surgery is probably not justified. Elderly patients will very seldom benefit from surgery in the longer term.

The relationship between displacement and clinical outcome after distal radius (Colles') fracture

We reviewed 260 patients who had been treated non-operatively for a dorsally displaced distal radius fracture a mean 6.3 (range 2.5-12.7) years earlier, in an attempt to find the limits of displacement compatible with a good clinical outcome. We excluded patients with previous or later injuries to the same limb. Bivariate analysis revealed a highly statistically significant relationship between radiographic displacement at review and clinical outcome scores. Correlation coefficients varied between 0.14 and 0.30. However, multiple linear regression analysis using most factors commonly thought to be of importance in determining the clinical outcome as independent variables explained only 23% of the variability of the clinical outcome. Dorsal angulation, ulnar variance, and radial inclination together accounted for only 11% of the variability. We conclude that the final alignment of the distal radius as shown radiologically has only a minor influence on the clinical outcome of Colles' type distal radius fractures.

WHAT IS THE BEST RADIOGRAPHIC VIEW FOR "DIE PUNCH" DISTAL RADIUS FRACTURES? A CADAVER MODEL STUDY

OBJECTIVE

the aim of this study is try to show the best view for distal radius fractures so called die-punch fractures.

METHODS

There has been used a human cadaver radius bone from the Salvador Arena Tissue Bank. This bone was cleaned up after removing the soft tissues and osteotomies created displaced lunate fossa fractures of 0, 1, 2, 3 and 5 mm. We have fixed this fragment with adhesive tape. Then the joint deviation were significantly increased with step-offs of 1 mm. Radiographs were then taken into 5 different positions: postero-anterior view, lateral view, oblique views and tangencial view for each of the deviations. The resulting lunate fossa depression in each X-ray film was analyzed by the AutoCAD 2010® software.

RESULTS

The tangencial view was the best one to see the 1mm and 3mm bone degrees and the second one view to see the 2mm and 5 mm degrees. The pronated oblique view was the best to see the 2mm degrees and the oblique supinated view wasn't able to see the degrees between 1 and 2mm.

CONCLUSION

The tangencial view was the best one to see the 1mm and 3mm bone degrees and the second one view to see the 2mm and 5 mm degrees.