An Asian perspective on the management of distal radius fractures

Pediatric wrist fractures: variations in management across countries. An evidence-based summary of evidence

INTRODUCTION

Fractures of the distal radius are common in pediatric population, with considerable variation in the management of pediatric wrist fractures across different countries. It is crucial to consider the different approaches to conservative management and surgical intervention. The decision on the appropriate treatment method often depends on the type and severity of the fracture, as well as the available healthcare resources and expertise in each country. This article tries to identify these variations, so the various healthcare systems can work toward implementing best practices in the management of pediatric wrist fractures on a global scale.

SOURCE OF DATA

Published peer-reviewed articles identified in electronic databases, including PubMed Scopus and Google Scholar.

AREAS OF AGREEMENT

The management of pediatric wrist fractures can differ significantly among countries given the high variability in healthcare resources and cultural practices.

AREAS OF CONTROVERSY

The management of pediatric wrist fractures can be challenging in certain countries, especially in developing regions with limited resources.

GROWING POINTS

Challenges such as long therapeutic delays, lack of appropriate anesthesia, and the absence of fluoroscopy can complicate the treatment process. Randomized controlled clinical trials (RCTs) are vital in providing high-quality evidence to guide clinical decision-making, especially in the field of pediatric wrist fractures.

AREAS TIMELY FOR DEVELOPING RESEARCH

Efforts to support and prioritize the conduct and dissemination of RCTs in pediatric wrist fracture management can ultimately lead to more consistent, effective, and evidence-based care for children with wrist fractures worldwide.

Epidemiology and Treatment of Distal Radius Fractures in Finland-A Nationwide Register Study

A distal radius fracture (DRF) is one of the most common fractures in emergency units, the treatment of which requires considerable health care resources. We analyzed the incidence rate for DRFs and the incidence rate of operative treatment over a five-year period, 2015–2019, for the entire population of Finland and all ages. Data was obtained from the Finnish National Care Register for Health Care. The results were counted as cases per 100,000 person/years and standardized with the European Standard Population 2013. The mean annual incidence rate of DRF was 204.90 (203.21–206.59) in specialist care and 69.53 (68.55–70.52) in primary care. It peaked among the pediatric population and among elderly women, in whom it was more than four times as common compared to men of the same age. No increase in the incidence rate of DRFs was found. The mean incidence rate of operative treatment was 45.66 (45.66–45.66)/100,000 person/years, 2015–2019; women were more likely to undergo operative treatment. Altogether, 15–18% of DRFs were operated on over the study period. The annual incidence rate of operations seemed to plateau compared to earlier studies in Finland.

Comparison of bone mineral density and vertebral fracture assessment in postmenopausal women with and without distal radius fractures

Objectives

To compare bone mineral density (BMD) in Thai postmenopausal women with and without distal radius fracture, and to investigate the role of vertebral fracture assessment (VFA) in diagnosing osteoporosis after distal radius fracture.

Methods

A cross-sectional study was conducted in Thai postmenopausal women with and without distal radius fracture. BMDs of the femoral neck (FN), total hip (TH), lumbar spine (LS), and VFA were obtained within 2 weeks of injury. BMD were compared between groups. Participants were classified into osteoporosis, osteopenia or normal using BMD alone, and BMD plus VFA, where a mere presence of vertebral compression fracture indicated osteoporosis.

Results

Fifty postmenopausal women with distal radius fractures and 111 non-fracture postmenopausal women participated. The mean BMD was significantly lower at all sites in the fracture group (FN BMD 0.590 ± 0.075 vs 0.671 ± 0.090, p = 0.007; TH BMD 0.742 ± 0.103 vs 0.828 ± 0.116, P = 0.009; LS BMD 0.799 ± 0.107 vs 0.890 ± 0.111, P = 0.009 in the fracture vs non-fracture group respectively). VFA increased the prevalence of osteoporosis from 16 (32%) to 23 (46%) in the fracture group, and 7 (6.31%) to 17 (16.22%) in the non-fracture group, with a number needed to treat 9.

Conclusions

Postmenopausal women with distal radius fractures had lower BMD. Incorporating VFA into diagnosis of osteoporosis increased the prevalence of osteoporosis in both fracture and non-fracture groups. Postmenopausal women aged 50 years or older with distal radius fracture are a good target for the investigation of osteoporosis.

Therapist's practice patterns for subsequent fall/osteoporotic fracture prevention for patients with a distal radius fracture

STUDY DESIGN

Cross-sectional survey.

INTRODUCTION

Multifactorial risk factor screening and treatment is needed for subsequent falls/osteoporotic fractures prevention (SFOFP), given the elevated risk among patients with distal radius fracture (DRF).

PURPOSE OF THE STUDY

The primary objective was to describe hand therapists' knowledge and clinical practice patterns for assessment, treatment, referral, and education with respect to SFOFP for patients with DRF older than 45 years. Secondary objective was to explore therapist's preferences in content and delivery of knowledge translation tools that would support implementation of SFOFP.

METHODS

A cross-sectional multinational (Canada, the United States, and India) survey was conducted among 272 therapists from August to October 2014. Completed surveys were analyzed descriptively.

RESULTS

Surveys were completed by 157 therapists. Most respondents were from the United States (59%), certified hand therapists (54%), and females (87%). Although 65%-90% believed that they had knowledge about SFOFP assessment, treatment, and referral options, 55% did not include it in their routine practice for patients with DRF. Most assessed medication history (82%) and never used a Fracture Risk Assessment Tool (90%) or lower extremity muscle strength testing (54%) to identify those at risk of secondary fractures. With respect to treatment, approximately 33% always used upper extremity muscle strengthening exercises. Most reported rarely (sometimes to never) using balance (79%), lower extremity muscle strengthening (85%), bone strengthening (54%), or community-based physical activity (72%) programs. Similarly, when surveyed about patient education, therapists rarely (sometimes to never) advised patients about web-based resources (94%), regular vision testing (92%), diet for good bone health (87%), bone density evaluation (86%), footwear correction (73%), and hazard identification (67%). Most hand therapists were interested to receive more information on SFOFP for patients with DRF. Nearly one-half preferred to have Web sites for patients, and two-fifth were in favor of pamphlets for patients.

CONCLUSION

Current practice patterns reveal care gaps and limited implementation with respect to SFOFP for patients with DRF. Future research should focus on web-based educational/knowledge translation strategies to promote implementation of multifactorial fall risk screening and hand therapist's engagement in SFOFP for patients with DRF.

Re-fracture of Distal Radius and Hardware Repair in the Setting of Trauma

Distal radius fractures are one of the most common fractures in the elderly. Falls and motor vehicle collisions lead to increased risk for this type of fracture. A seventy-three year-old female had a previous history of distal radius fracture with repair by open reduction and internal fixation. She was involved in a motor vehicle collision that re-fractured the distal radius. The plate was bent and required removal, which is a very rare but potentially serious complication. Surgery was done to fix the open reduction and internal fixation with volar locking plates while removing damaged hardware. Only a select few cases have reported hardware failure as a cause of complications. Among those cases, high-energy activities and maintained stress on the hardware were likely causes. Distal radius fractures are the most common upper extremity fracture in the elderly. We highlight a unique case of re-fracture in the setting of trauma with prior hardware failure and describe the strategy for hardware repair.

Incidence and Seasonal Variation of Distal Radius Fractures in Korea: a Population-based Study

BACKGROUND

The present study aimed to investigate the incidence and seasonal variation of distal radius fractures (DRFs) in Korea.

METHODS

We analyzed a nationwide database acquired from the Korean Health Insurance Review and Assessment Service from 2011 to 2015. We used International Classification of Diseases, 10th revision codes and procedure codes to identify patients of all ages with newly diagnosed DRFs.

RESULTS

An average of about 130,000 DRFs occurred annually in Korea. The incidence of DRF, by age group, was highest in the 10 to 14-year-old age group for males and the highest in the 70s age group for females, with a rapid increase of incidence after 50 years. The peak incidence of DRF occurred during winter; however, the incidence greatly varied annually when compared with that of other seasons. The incidence of DRFs during the winter season was correlated with the average temperature.

CONCLUSION

The annual incidence of DRF was 130,000 in Korea. The incidence increased under an intense cold surge during winter. Active preventive measures are recommended especially in women exceeding 50 years considering the higher incidence in this age group.

National Surgical Trends for Distal Radius Fractures in Korea

The objective of this study was to investigate national surgical trends for distal radius fractures (DRFs) in Korea and analyze healthcare institution type-specific surgical trends. We analyzed a nationwide database acquired from the Korean Health Insurance Review and Assessment Service (HIRA) from 2011 to 2015. International Classification of Diseases, 10th revision (ICD-10) codes and procedure codes were used to identify patients aged ≥ 20 years with newly diagnosed DRFs. A total of 459,388 DRFs occurred from 2011 to 2015. The proportion of DRF cases treated by surgery tended to increase over time, from 32.6% in 2011 to 38.3% in 2015 (P < 0.001). Open reduction with internal fixation (ORIF) using a plate steadily gained in popularity each year, increasing from 39.2% of overall surgeries in 2011 to 60.9% in 2015. The type of surgery for DRFs differed depending on the type of healthcare institution. ORIF (91%) was the most popular procedure in tertiary hospitals, whereas percutaneous pinning (58%) was most popular in clinics. In addition, general hospitals and hospitals with 30-100 beds used external fixation more frequently than tertiary hospitals and clinics did. Overall, our findings indicate that surgical treatment of DRF, particularly ORIF, continues to increase, and that the component ratio of operation codes differed according to the healthcare institution type.

Epidemiology of distal radius fractures and factors predicting risk and prognosis

STUDY DESIGN

Literature Review.

INTRODUCTION

For optimal Distal Radius Fracture (DRF) rehabilitation and fracture prevention, it is important to understand the epidemiology and factors predictive of injury, chronic pain, chronic disability, and subsequent fracture.

PURPOSE

To summarize the literature reporting on DRF epidemiology, risk factors, and prognostic factors.

METHODS

Literature synthesis.

RESULTS

Although incidence varies globally, DRFs are common across the lifespan and appear to be on the rise. Risk of DRF is determined by personal factors (age, sex/gender, lifestyle, health condition) and environmental factors (population density, climate). For example, age and sex influence risk such that DRF is most common in boys/young men and older women. The most common causes of DRF in the pediatric and young adult age groups include playing/sporting activities and motor vehicle accidents. In contrast, the most common mechanism of injury in older adults is a low-energy trauma because of a fall from a standing height. Poorer health outcomes are associated with older age, being female, poor bone healing (or having an associated fracture of the ulnar styloid), having a compensated injury, and a lower socioeconomic status.

CONCLUSIONS

Risk stratification according to predictors of chronic pain and disability enable therapists to identify those patients who will benefit from advocacy for more comprehensive assessment, targeted interventions, and tailored educational strategies. The unique opportunity for secondary prevention of osteoporotic fracture after DRF has yet to be realized by treating therapists in the orthopedic community.

LEVEL OF EVIDENCE

V.

Morphology of distal radius curvatures: a CT-based study on the Malaysian Malay population

INTRODUCTION

The purpose of this study was to examine the differing curves of the volar distal radius of healthy Malaysian Malays, so as to obtain detailed morphological information that will further the understanding of volar plate osteosynthesis in Malaysian Malays.

METHODS

Computed tomography with three-dimensional reconstruction was performed on the wrists of 16 healthy Malaysian Malay volunteers. Profile measurements were made using a software program. A novel parameter, the pronator quadratus curve angle, was explored and introduced in this study. Interclass correlation coefficients were calculated to assess the level of agreement between the data collected by the principal investigator and that collected by an independent radiologist.

RESULTS

The mean ± standard deviation of the arc radii on the radial aspect was 17.50° ± 5.40°, while the median (interquartile range [IQR]) of the arc radii on the ulnar aspect was 25.27° (IQR 5.80°). The mean ± standard deviation of the curvature of the pronator quadratus line was 40.52° ± 2.48°. The arc radii on the radial aspect was significantly lower than the arc radii on the ulnar aspect (p = 0.001). Different radial and ulnar arcs were observed in 56.25% of the radii; the arc was deeper on the ulnar aspect in 93.75% of the radii.

CONCLUSION

Based on the findings of this study, the likelihood of achieving anatomical reduction with uniformly curved, fixed-angle volar plates is questionable. Changes in the design of these implants may be needed to optimise their usage in the Malaysian Malay population.