A randomized prospective study on the treatment of intra-articular distal radius fractures: open reduction and internal fixation with dorsal plating versus mini open reduction, percutaneous fixation, and external fixation

The Fragility of Landmark Randomized Controlled Trials in the Plastic Surgery Literature

Background

Randomized controlled trials (RCTs) are integral to the progress of evidenced-based medicine and help guide changes in the standards of care. Although results are traditionally evaluated according to their corresponding P value, the universal utility of this statistical metric has been called into question. The fragility index (FI) has been developed as an adjunct method to provide additional statistical perspective. In this study, we aimed to determine the fragility of 25 highly cited RCTs in the plastic surgery literature.

Methods

A PubMed search was used to identify the 25 highest cited RCTs with statistically significant dichotomous outcomes across 24 plastic surgery journals. Article characteristics were extracted, and the FI of each article was calculated. Additionally, Altmetric scores were determined for each study to determine article attention across internet platforms.

Results

The median FI score across included studies was 4 (2-7.5, interquartile range). The two highest FI scores were 208 and 58, respectively. Four studies (16%) had scores of 0 or 1. Three studies (12%) had scores of 2. All other studies (72%) had FI scores of 3 or higher. The median Altmetric score was 0 (0-3).

Conclusion

The FI can provide additional perspective on the robustness of study results, but like the P value, it should be interpreted in the greater context of other study elements.

"Spin" in Plastic Surgery Randomized Controlled Trials with Statistically Nonsignificant Primary Outcomes: A Systematic Review

BACKGROUND

"Spin" refers to a manipulation of language that implies benefit for an intervention when none may exist. Randomized controlled trials (RCTs) in other fields have been demonstrated to employ spin, which can mislead clinicians to use ineffective or unsafe interventions. This study's objective was to determine the strategies, severity, and extent of spin in plastic surgery RCTs with nonsignificant primary outcomes.

METHODS

A literature search of the top 15 plastic surgery journals using MEDLINE was performed (2000 through 2020). Parallel 1:1 RCTs with a clearly identified primary outcome showing statistically nonsignificant results ( P > 0.05) were included. Screening, data extraction, and spin analysis were performed by two independent reviewers. The spin analysis was then independently assessed in duplicate by two plastic surgery residents with graduate-level training in clinical epidemiology.

RESULTS

From 3497 studies identified, 92 RCTs were included in this study. Spin strategies were identified in 78 RCTs (85%), including 64 abstracts (70%) and 77 main texts (84%). Severity of spin was rated moderate or high in 43 abstract conclusions (47%) and 42 main text conclusions (46%). The most identified spin strategy in the abstract was claiming equivalence for statistically nonsignificant results (26%); in the main text, focusing on another objective (24%).

CONCLUSIONS

This study suggests that 85% of statistically nonsignificant RCTs in plastic surgery employ spin. Readers of plastic surgery research should be aware of strategies, whether intentional or unintentional, used to manipulate language in reports of statistically nonsignificant RCTs when applying research findings to clinical practice.

COMBINED PLATE VERSUS EXTERNAL FIXATION FOR DISTAL RADIUS FRACTURES

Objectives

This study aimed to compare the functional and radiological results of patients who had intra-articular comminuted distal radius fractures and were operated on with external fixation percutaneous pinning or the volar-dorsal combined plate osteosynthesis.

Methods

In this study, 49 patients operated on and followed up for the comminuted distal radius fractures between May 2015 and January 2019 were retrospectively evaluated. The surgical outcomes of the patients, who were operated on with combined dorsal-volar plate osteosynthesis or external fixation percutaneous pinning, were compared in this study. Functional and radiological scores were evaluated and analyzed statistically.

Results

There was no statistical difference between external fixation and volar-dorsal combined plate groups regarding the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Visual Analog Scale (VAS), the Mayo scoring system, range of motion, and grip strength values.

Discussion

Although the combined volar-dorsal plate osteosynthesis technique had a longer operation time and a more complicated surgical procedure, the combined volar-dorsal plate osteosynthesis had lower complication rates and permitted early mobilization. The combined volar-dorsal plate osteosynthesis could be an alternative to external fixation percutaneous pinning. Level of Evidence III, Therapeutic Studies Investigating the Results of Treatment.

A Cost-Effectiveness Analysis of the Various Treatment Options for Distal Radius Fractures

Purpose

To conduct a cost-effectiveness study of nonsurgical and surgical treatment options for distal radius fractures using distinct posttreatment outcome patterns.

Methods

We created a decision tree to model the following treatment modalities for distal radius fractures: nonsurgical management, external fixation, percutaneous pinning, and plate fixation. Each node of the model was associated with specific costs in dollars, a utility adjustment (quality-adjusted life year [QALY]), and a percent likelihood. The nodes of the decision tree included uneventful healing, eventful healing and no further intervention, carpal tunnel syndrome, trigger finger, and tendon rupture as well as associated treatments for each event. The percent probabilities of each transition state, QALY values, and costs of intervention were gleaned from a systematic review. Rollback and incremental cost-effectiveness ratio analyses were conducted to identify optimal treatment strategies. Threshold values of $50,000/QALY and $100,000/QALY were used to distinguish the modalities in the incremental cost-effectiveness ratio analysis.

Results

Both the rollback analysis and the incremental cost-effectiveness ratio analysis revealed nonsurgical management as the predominant strategy when compared with the other operative modalities. Nonsurgical management dominated external fixation and plate fixation, although it was comparable with percutaneous fixation, yielding a $2,242 lesser cost and 0.017 lesser effectiveness.

Conclusions

The cost effectiveness of nonsurgical management is driven by its decreased cost to the health care system. Plate and external fixation have been shown to be both more expensive and less effective than other proposed treatments. Percutaneous pinning has demonstrated more favorable effectiveness in the literature than plate and external fixation and, thus, may be more cost effective in certain circumstances. Future studies may find value in investigating further clinical aspects of distal radius fractures and their association with nonsurgical management versus that with plate fixation.

Type of study/level of evidence

Economic/decision analysis II.

Lasso loop technique using bioabsorbable thread to treat intra-articular distal radius fracture

This article introduces our lasso loop technique (LLT) using a bioabsorbable thread for the treatment of intra-articular distal radius fractures with displaced dorsal bone fragment containing articular surface (DBF). We also examined whether the articular gap is sufficiently reduced and maintained by the LLT, along with the results of other radiological and clinical evaluations. We retrospectively reviewed 19 patients who underwent LLT for intra-articular distal radius fracture with a displaced DBF. Patient radiographic images and medical records were used to investigate radiological characteristics, symptoms, physical findings, and the Quick Disabilities of the Arm, Shoulder, and Hand scores. Sagittal-view computed tomography showed that the mean preoperative articular gap was 2.6 mm, but the gap was reduced by LLT, and the gap immediately postoperatively was <1.0 mm in all patients. No re-displacement of the DBF was evident from immediately postoperatively to 6 months postoperatively. Postoperatively, no losses of correction in palmar tilt, radial inclination, or ulnar variance were seen in the evaluation of plain radiographs, and satisfactory joint range of motion, grip strength, and the Quick Disabilities of the Arm, Shoulder, and Hand score were obtained. No significant complications due to LLT were observed. LLT appears to offer a simple and effective procedure to reduce displaced DBF with little risk of complications. LLT may become a useful option in the treatment of intra-articular distal radius fractures with displaced DBF.

Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Operative Distal Radius Fractures

Introduction:

Distal radius fractures are the second most common fracture in the elderly population. The incidence of these fractures has increased over time, and is projected to continue to do so. The aim of this study is to utilize a validated trauma risk prediction tool to stratify middle-aged and geriatric patients with operative distal radius fractures as well as compare hospital quality metrics and inpatient hospitalization costs among the risk groups.

Materials and Methods:

Patients were prospectively enrolled in an orthopedic trauma registry. The Score for Trauma Triage in Geriatric and Middle Aged (STTGMA) was calculated using patient demographics, injury severity, and functional status. Patients were then stratified into minimal-risk, moderate-risk, and high-risk cohorts based on their scores. Length of stay, need for escalation of care, complications, mortality, discharge location, 1-year patient reported outcomes, and index admission costs were evaluated.

Results:

Ninety-two patients met inclusion criteria. Sixty-three (68.5%) patients were managed with outpatient surgery. The mean inpatient length of stay for the high-risk cohort was 2.9x and 2.2x higher than the minimal and moderate-risk cohorts, respectively (2.0 + 2.9 days vs. 0.7 + 0.9 and 0.9 + 1.1 days, P = .019). There were no complications or mortality in any of the risk groups. No patients required intensive care and all patients were discharged home. There was no difference in readmission rates, inpatient cost, or 1-year patient reported outcomes among the risk cohorts.

Discussion/Conclusions:

The Score for Trauma Triage in Geriatric and Middle-Aged is able to risk-stratify patients that undergo operative intervention of distal radius fractures. Middle aged and elderly patients with isolated closed distal radius fractures can be safely managed on an outpatient basis regardless of risk. Standardized pathways can be created in the management of these injuries, thereby optimizing value-based care.

Level of evidence:

Prognostic Level III

What Is the Relative Effectiveness of the Various Surgical Treatment Options for Distal Radius Fractures? A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

BACKGROUND

Many acceptable treatment options exist for distal radius fractures (DRFs); however, a simultaneous comparison of all methods is difficult using conventional study designs.

QUESTIONS/PURPOSES

We performed a network meta-analysis of randomized controlled trials (RCTs) on DRF treatment to answer the following questions: Compared with nonoperative treatment, (1) which intervention is associated with the best 1-year functional outcome? (2) Which intervention is associated with the lowest risk of overall complications? (3) Which intervention is associated with the lowest risk of complications requiring operation?

METHODS

Ten databases were searched from inception to July 25, 2019. Search and analysis reporting adhered to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Included studies were English-language RCTs that assessed at least one surgical treatment arm for adult patients with displaced DRFs, with less than 20% loss to follow-up. We excluded RCTs reporting on patients with open fractures, extensive bone loss, or ipsilateral upper extremity polytrauma. Seventy RCTs (n = 4789 patients) were included. Treatments compared were the volar locking plate, bridging external fixation, nonbridging external fixation, dynamic external fixation, percutaneous pinning, intramedullary fixation, dorsal plating, fragment-specific plating, and nonoperative treatment. Subgroup analyses were conducted for intraarticular fractures, extraarticular fractures, and patients with an average age greater than 60 years. Mean (range) patient age was 59 years (56 to 63) and was similar across all treatment groups except for dynamic external fixation (44 years) and fragment-specific plating (47 years). Distribution of intraarticular and extraarticular fractures was approximately equal among the treatment groups other than that for intramedullary fixation (73% extraarticular), fragment-specific plating (66% intraarticular) [13, 70], and dorsal plating (100% intraarticular). Outcomes were the DASH score at 1 year, total complications, and reoperation. The minimum clinically important different (MCID) for the DASH score was set at 10 points. The analysis was performed using Bayesian methodology with random-effects models. Rank orders were generated using surface under the cumulative ranking curve values. Evidence quality was assessed using Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology. Most studies had a low risk of bias due to randomization and low rates of incomplete follow-up, unclear risk of bias due to selective reporting, and high risk of bias due to lack of patient and assessor blinding. Studies assessing bridging external fixation and/or nonoperative treatment arms had a higher overall risk of bias while studies with volar plating and/or percutaneous pinning treatment arms had a lower risk of bias.

RESULTS

Across all patients, there were no clinically important differences in terms of the DASH score at 1 year; although differences were found, all were less than the MCID of 10 points. Volar plating was ranked the highest for DASH score at 1 year (mean difference -7.34 [95% credible interval -11 to -3.7) while intramedullary fixation, with low-quality evidence, also showed improvement in DASH score (mean difference -7.75 [95% CI -14.6 to -0.56]). The subgroup analysis revealed that only locked volar plating was favored over nonoperative treatment for patients older than 60 years of age (mean difference -6.4 [95% CI -11 to -2.1]) and for those with intraarticular fractures (mean difference -8.4 [95% CI -15 to -2.0]). However, its clinical importance was uncertain as the MCID was not met. Among all patients, intramedullary fixation (odds ratio 0.09 [95% CI 0.02 to 0.84]) and locked volar plating (OR 0.14 [95% CI 0.05 to 0.39]) were associated with a lower complication risk compared with nonoperative treatment. For intraarticular fractures, volar plating was the only treatment associated with a lower risk of complications than nonoperative treatment (OR 0.021 [95% CI < 0.01 to 0.50]). For extraarticular fractures, only nonbridging external fixation was associated with a lower risk of complications than nonoperative treatment (OR 0.011 [95% CI < 0.01 to 0.65]), although the quality of evidence was low. Among all patients, the risk of complications requiring operation was lower with intramedullary fixation (OR 0.06 [95% CI < 0.01 to 0.85) than with nonoperative treatment, but no treatment was favored over nonoperative treatment when analyzed by subgroups.

CONCLUSION

We found no clinically important differences favoring any surgical treatment option with respect to 1-year functional outcome. However, relative to the other options, volar plating was associated with a lower complication risk, particularly in patients with intraarticular fractures, while nonbridging external fixation was associated with a lower complication risk in patients with extraarticular fractures. For patients older than 60 years of age, nonoperative treatment may still be the preferred option because there is no reliable evidence showing a consistent decrease in complications or complications requiring operation among the other treatment options. Particularly in this age group, the decision to expose patients to even a single surgery should be made with caution.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Combined palmar and dorsal plating of four-part distal radius fractures: Our clinical and radiological results

OBJECTIVES

This study aims to investigate the radiological and clinical outcomes of four-part intraarticular distal radius fractures treated with a volar anatomically locked plate and 2 mm low-profile plates using both the volar and dorsal approaches.

PATIENTS AND METHODS

This retrospective study included 20 patients (8 males, 12 females; mean age 47±12.1; range, 25 to 67 years) who received open reduction and internal fixation with combined volar and dorsal plating to treat complex four-part distal radius fractures (shaft, radial styloid area, dorsal medial facet, volar medial facet) between May 2016 and January 2019. According to Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification, all fractures were 2R3-C3. According to Melone classification, one fracture was type 1, seven fractures were type 2a, three were type 2b, three were type 3 and six were type 4. The mean follow-up time was 21±7.5 (range, 12 to 36) months.

RESULTS

Union was achieved in all fractures. The mean tourniquet time was 103±12 (range, 90 to 130) minutes. The mean Disabilities of the Arm, Shoulder, and Hand questionnaire score was 10±9, and the mean Visual Analog Scale score was 2.1±0.9. According to Mayo wrist score, five patients had excellent, six had good, six had satisfactory and three had poor results. The mean grip strength was 25.2±9.2 (range, 15 to 40) kg and 78% of opposite side. Mean wrist flexion was 48.7°±15.3° (range, 30° to 80°), extension was 52.2°±17.2° (range, 25° to 80°), radio-ulnar deviation arc was 40.7°±6.9° (range, 30° to 55°), and mean forearm rotation arc was 152.3°±11° (range, 130° to 170°).

CONCLUSION

Plating method with a dual approach may be an alternative for four-part intraarticular distal radius fractures given its early mobility advantage and satisfactory functional and radiological results.

Combined Plating of Intra-Articular Distal Radius Fractures, a Consecutive Series of 74 Cases

Background  The distal radius fracture (DRF) is the most common fracture in adults. For unstable intra-articular fractures, the choice of treatment is often operative. The optimal choice of fixation remains a matter of discussion. Question/Purpose  Can combined volar and dorsal plating, using a dorsal frame plate, achieve a good functional and radiographic 1-year outcome in intra-articular DRFs? Methods  In a retrospective cohort study, we evaluated 74 consecutive patients operated with combined plating using a volar plate and a dorsal frame plate. The DRFs were operated between 2016 and 2017 and all cases were AO type C intra-articular fractures. The primary outcome was patient-reported outcome measures including radiographic examination 1 year postoperatively. Secondary outcome measures included wrist range of motion, visual analog scale (VAS) pain scores, and hand grip strength. Results  The median patient-rated wrist evaluation score was 18 points; the quick disabilities of the arm, shoulder, and hand score was 14.8 points. The median Batra radiographic score was 88. Wrist extension was 76% of the uninjured side, flexion was 74%, pronation was 94%, and supination was 94%. VAS pain scores were 0 at rest and 2 during activity. Hand grip strength was 82% compared with the uninjured side. The radiographic outcome according to Batra did not correspond to the patient-reported outcome. Patients older than 60 years had significantly better QuickDASH (quick disabilities of the arm, shoulder, and hand) and PRWE scores (patient-rated wrist evaluation scores) and less pain during activity compared with younger patients despite similar radiographic outcome. There were no tendon ruptures; hardware removal was performed in 21 of the 74 patients. Conclusion  The radiographic outcome did not correspond to the functional outcome 1 year postoperatively. Older patients report less pain and better functional outcome compared with younger patients. There were no tendon ruptures and the frequency of hardware removal was acceptable. Complex intra-articular DRFs AO type C can be managed with volar and dorsal frame-plate fixation to restore distal radius anatomy and achieve a good functional outcome.

Comparative results of radius distal AO type C1 fractures of elderly women by two different techniques

ackgrounds: We evaluated clinical and radiographic outcomes of volar locking plates and close reduction with percutaneous pinning treatment approaches for elderly female patients with AO type C1 simple intra-articular distal radius fractures.

PATIENTS AND METHODS

We conducted retrospective studies of 72 elderly female patients with AO type C1 simple intra-articular DRFs treated with VLPs or CRPP, from 2012 to 2018. The patients were divided into two groups: There were 38 patients in VLP group and 34 patients in CRPP group. Periodic clinical and radiological evaluation was performed at 2nd, 4th, 6th, 8th weeks and in 6 and 12 months intervals for all patients. We recorded the patient-rated wrist evaluation scores, flexion, extension, supination and pronation degrees and radiographic outcome scores at the end of 6th and 12 months after surgery.

RESULTS

A total number of 72 patients were studied. 38 patients were treated with VLP and 34 patients were treated with CRPP .The mean age of the patients was 70,5 years. Comparing the PRWE scores, the VAS scores and the ROM degrees between the 2 groups yielded no significant difference at any time point between 6 months and 1 year. There were no differences in radiographic outcomes at the latest reported follow up between the two interventions and there was no significant difference in the complication between the 2 groups (VLP 6 and CRPP 6) complications.

CONCLUSIONS

Complicated surgeries should be avoided because of specific problems in women aged 60 years or older. Our study show that VLP and CRPP techniques had little differences and similar clinical and radiographic results.

Complications after operatively treated distal radius fractures

In the recent years, treatment of distal radius fractures (DRF) has advanced considerably. Surgical fixation with palmar angular stable plate has gained popularity, due to a reported lower complication rate when compared to dorsal fixation. The type of trauma or injury, surgical procedure and impaired bone quality are all contributors to complications in DRF. The main aim of this review is to summarize the most common complications and possible therapeutic solutions. In addition, strategies for minimizing these complications will be discussed.

Integrated Compression Screw Stabilization of the Dorsal Lunate Facet in Intra-Articular Distal Radius Fractures

PURPOSE

To evaluate outcomes of intra-articular distal radius fractures with displaced dorsal lunate facet fragments treated with a combination of volar plating and the use of a dorsal screw that integrates into the plate.

METHODS

We reviewed a retrospective cohort of 22 patients who underwent open reduction and internal fixation of an intra-articular distal radius fracture with a volar plate in conjunction with the Frag-Loc Compression screw. Patient charts and radiographs were reviewed for clinical and radiographic outcomes.

RESULTS

A total of 12 patients with a minimum 6-month follow-up who met all eligibility criteria were included in this study. There were 8 women and 4 men. The mean age was 55.2 years. Mean follow-up was 11.5 months (range, 6-21 months). The most common mechanism of injury was a fall from standing (75.0%). At final follow-up, all patients were able to return to their previous level of function. Bony union was achieved in all patients at the time of final follow-up. Average radiographic parameters at final follow-up were radial inclination 24.2° ± 5.3°, volar tilt 1.3° ± 5.2°, and ulnar variance 0.9 ± 1.7 mm. During the follow-up period, transient median nerve paresthesias were observed in 4 patients, with spontaneous resolution in 3 of 4 patients. Loss of articular reduction was not observed in any case.

CONCLUSIONS

This study demonstrates satisfactory clinical and radiographic results and minimal complications with utilization of a new fixation device for distal radius fractures with displaced dorsal lunate facet fragments.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Deterioration of initially accepted radiological alignment of conservatively treated AO type-C distal radius fractures: mid-term outcome

BACKGROUND AND AIMS

It still remains controversial how often the once-accepted radiological alignment of an AO type-C distal radius fracture deteriorates after conservative treatment, and to what extent this deterioration is perhaps associated with patient-rated outcome measures (PROms). Thus, we aimed to evaluate this radiological deterioration and its association with mid-term functional follow-up.

PATIENTS AND METHODS

We retrospectively reviewed 66 patients (mean age at fracture 53 years, SD 14.1, range 18-73, female 65%) with 68 C-type distal radius fractures at a mean of 6.7 years (SD 0.5 years, range 5.8-7.7 years) after primary closed reduction and cast immobilization. Radiographs of the wrists were taken and analysed for any radial shortening, dorsal tilt or step-off at the joint surface. Range of motion and grip strength were measured. In addition to the radiological result, primary outcome measures included Quick Disabilities of the Arm, Shoulder and Hand (QDash) and Patient-Rated Wrist Evaluation (PRWE).

RESULTS

At mid-term follow-up, an acceptable anatomical radiological result was seen in only 22 wrists (32%). Deterioration of the once-achieved and accepted primary alignment was seen in a majority of cases (68%). Radial shortening of ≥ 2 mm was found in 34 wrists (51%, mean 4 mm, range 2-8 mm), with no association with QDash (12.8 vs. 5.5, p = 0.22) or PRWE (9.1 vs. 5.7, p = 0.40). Only four patients (6%) showed step-off at the joint surface (mean 1.1 mm, range 0.5-2 mm). Twenty-two wrists (32%) showed dorsal tilt of ≥ 10° (five with volar tilt of 15°-25°), with no effect on QDash or PRWE (14.7 vs. 6.5, p = 0.241 and 10.1 vs. 5.8, p = 0.226). Altogether, patients with dorsal tilt, step-off or shortening did not show significantly worse QDash (10.3 vs. 5.7, p = 0.213) or PRWE (8.1 vs. 5.1, p = 0.126) versus those with none. Twenty-nine (43%) of the patients had deficits in range of motion (ROM), either in extension (39%), flexion (43%), supination (16%) or pronation (4%), or combinations of these. Worse extension was associated with worse QDash (15.9 vs. 5.0, p = 0.037), flexion deficit with worse PRWE (11.5 vs. 4.4, p = 0.005) and supination deficit with both QDash (21.7 vs. 6.8, p = 0.025) and PRWE (18.9 vs. 5.2, p = 0.007).

CONCLUSIONS

The initially accepted radiological alignment of AO type-C radius fractures deteriorated in a majority of cases during conservative treatment. However, this deterioration was fairly mild and showed no significant association with functional outcome. Restricted ROM showed some association with PROms.

LEVEL OF EVIDENCE

IV.

Distal Radius Fractures in the Athlete

Although the technical details of distal radius fracture fixation in athletes are largely similar to the general population, the issues surrounding the injury, desire to return to sport, and rehabilitation require specialized attention. Athletes are generally healthy, with a drive to recover and must balance the risk of long-term consequences of returning to play too early with the potential loss of scholarship, salary, or opportunities for advancement. Outcomes after nonoperative and operative treatment of distal radius fractures are generally excellent in athletes and return to the same level of sport occurs in most patients.

Long term outcomes of open reduction internal fixation versus external fixation of distal radius fractures: A meta-analysis

Distal radius fractures are among the most common fractures encountered in the clinical setting. Of these common fractures, it has been said that up to 60% are intraarticular in nature. Intra-articular or unstable and comminuted fractures represent severe and high energy injuries. Despite a large amount of literature, it is surgeon preference which determines the fixation method employed. There are only a few randomised control trials that report 2-year outcomes. There has yet to be a meta-analysis comparing the long-term outcomes of open reduction internal fixation (ORIF) and external fixation (EF). The aim of this metaanalysis is to identify any difference in the outcomes of either fixation method in the long term. We pooled the data of all the available randomised control trials that followed the patients for a minimum of 2 years and compared outcomes of ORIF against EF of distal radius fractures as per PRISMA guidelines from inception of the databases to December 2016. We then performed our meta-analysis using RevMan 5.3 software. Flexion/extension arcs were significantly improved in ORIF, and 7 of the 10 analysed outcomes supported ORIF, although most not to a significant degree. The meta-analysis indicated that there is no difference in outcomes with either form of treatment. Even though the flexion extension arc was statistically better in the ORIF group, the difference is not clinically meaningful.

Combined Volar T-Plate and Dorsal Pi-Plate for Distal Radius Fractures: A Consecutive Series of 80 AO type C2 and C3 Cases

Background  The distal radius fracture (DRF) is the most common fracture among adults. In recent years, there has been a shift toward volar locking plates in the treatment of DRFs, and this shift has taken place with a low degree of evidence. Question/purposes  Can combined volar T-plating and dorsal pi-plating of AO type C fractures yield a good functional and radiographic outcome 1 year postoperatively? Patients and Methods  In a retrospective cohort study, we evaluated 102 consecutive patients operated with combined dorsal and volar plating, of whom 80 completed the 1-year follow-up. The DRFs were operated between 2012 and 2013. All cases were AO type C2 and C3 fractures. The primary outcome was functional scoring including radiographic examination. Secondary outcome measures included range of motion, visual analog scale (VAS) pain scores, and hand grip strength. Results  The median Batra radiographic score was 84.5. Wrist extension was 74% of the uninjured side, flexion was 70%, pronation was 94%, and supination was 90%. The Patient-Rated Wrist Evaluation score was 21 points, and the Disabilities of the Arm, Shoulder, and Hand score was 19.4 points. VAS pain scores were 0 at rest and 3 during activity. Hand grip strength was 80% of the uninjured side. Radiographic outcome did not correspond to a patient-reported outcome. Hardware removal was performed in 15/80 cases. Conclusions  We conclude that a good outcome can be expected after combined dorsal and volar plating of DRFs. Radiographic outcome is not necessarily associated with functional outcome 1 year postoperatively. The rate of hardware removal was acceptable. Level of Evidence  III.

Factors predicting adverse outcome in complete intra-articular distal radius fractures

PURPOSE

To determine risk factors associated with adverse functional and radiological outcome in complete intra-articular distal radius fractures (AO 23 C2-3) with a minimum follow-up of 1 year.

METHODS

Retrospective case series of 87 consecutive patients with a complete intra-articular distal radius fracture (AO/OTA 23 C2-3) and a minimum follow-up of 1 year between 2012 and 2016. Risk factors for adverse clinical [using the Patient-Rated Wrist Evaluation (PRWE) score] and radiological outcome (positive ulnar variance 1 year postoperative) were analysed in a linear regression model.

RESULTS

PRWE scored a median of 4.5 points (range 0-72.5) after a median follow-up of 31 months (range 12-70 months). A concomitant polytrauma was associated with a worse PRWE (β = 23.34, p < 0.01) and was also significantly associated with the use of a temporary external fixator (χ² = 11.93; p < 0.01) and high-energy trauma (χ² = 19.39; p < 0.01). Radiological outcome measures 1 year postoperative did not correlate with clinical outcome measures.

CONCLUSION

This cohort of complete intra-articular distal radius fractures (AO/OTA 23 C2-3) shows a good clinical outcome at medium-term follow-up independent of the radiological outcome. A concomitant polytrauma was associated with worse functional outcome and a higher complication rate. This is most likely due to the associated injury severity. These factors help the treating physician in decision-making and informing patients when treating displaced intra-articular radius fractures.

A technical note on the reduction of distal radius fractures with angular stable plates

Plating of distal radius fractures is a common procedure. Especially in busy practices the procedure is mostly performed by a single surgeon. By the use of a distance holder screw in the most proximal hole of the shaft of an angular stable distale radius plate a Lever arm can be created that allows indirect reduction of a dorsal ly displaced distal radius fracture. The method described here may facilitate the Operation in that the articular block can be securely fixed while the plate is stable centered on the shaft of the radius. Especially for single surgeon operations this may save time. In contrast the costs of an extra angular stable screw must be accepted.

A Long-Term Study of Application of Joshi's External Stabilizing System in Displaced Intra-articular Distal End Radius Fractures

Background  Fractures of the distal end radius are a common upper extremity fracture. Intra-articular distal end radius fractures are recognized as very complex injuries with a variable prognosis. The aim of the study was to assess the long-term functional outcome of patients treated with Joshi's external stabilizing system (JESS) for displaced intra-articular distal end radius fractures. Materials and Methods  A total of 170 patients with intra-articular distal end radius fracture were treated with JESS from 2014 to 2017. The patients were followed up at 2, 6 weeks, 6 months, 1, and 2 years (final) after the surgery. The assessment of pain, range of motion, grip strength, and satisfaction were assessed at 6 months, 1, and 2 years (final) follow-up and scored according to modified Mayo wrist scoring system. Results  The good and/or excellent results were found in 82.2% of cases. We observed that patients with age less than 50 years had greater prognosis as compared with patients with more than 50 years of age. Final outcome was also found better in males as compared with females at 6 months, 1, and 2 years postoperatively. Conclusion  JESS is an effective treatment technique for intra-articular distal end radius fractures in our community. On long-term follow-up of the patients treated with JESS for intra-articular distal end radius fractures, the functional and radiological outcomes were good with low complication rate.

Volar locking plate fixation versus external fixation of distal radius fractures: a meta-analysis

This meta-analysis evaluates reported outcomes of volar locking plates versus external fixation for management of distal radius fractures. A comprehensive literature search was carried out using PubMed, embase, MEDLINE, and the Cochrane Library. Multiple outcomes were analysed: study characteristics, objective/subjective outcome measures, radiographic parameters, and complication rates. Nine studies containing 780 participants met the outlined inclusion criteria. Disabilities of the arm, shoulder, and hand scores significantly favoured volar locking plates, but only at 3 months was the difference clinically meaningful. Grip strength, extension, and supination were better in the volar locking plates group in the early post-operative period, but were similar at 12 months. Ulnar variance was better restored by volar locking plates. The volar locking plates group was associated with higher re-operation rate, and the external fixation group had a higher infection rate. Current literature suggests that volar locking plates can provide better subjective scores and radiographic parameters, especially in the first 3 months, but may be associated with a higher re-operation rate.

Cost and Complications of Percutaneous Fixation of Hand Fractures in a Procedure Room Versus the Operating Room

BACKGROUND

The purpose of this study was to compare closed reduction and percutaneous pinning of metacarpal and phalanx fractures performed in the operating room (OR) versus the procedure room of the emergency department with primary outcomes being infection rate, radiographic union, and monetary cost.

METHODS

From January 2006 to December 2010, all closed reduction and percutaneous pinnings of metacarpal and phalanx fractures (CPT codes: 26608; 26727) by a single board-certified hand surgeon (A.M.H.) were retrospectively reviewed. Patients were placed into 2 groups: Group 1 was patients treated in the OR, and group 2 was patients in an emergency department procedure room. Infection, malunion, and nonunion rates were compared using a chi-square test. Charges were compared using a t-test, and cost of supplies and labor was evaluated.

RESULTS

A total of 189 patients met final inclusion criteria for this study: 130 in group 1 and 59 in group 2. There was no statistically significant difference in infection rates ( P = .13), nonunion ( P = .40), malunion rates ( P = .89), and hardware failure with revision ( P = .94) between the 2 groups. The procedure room patients had an average hospital charge of $1358.55 compared with $3691.85 for OR-treated patients (P = .001). The total cost of supplies and nonphysician labor was $432.31 per OR case and $179.59 per procedure room case.

CONCLUSIONS

Metacarpal and phalanx fractures of the hand amendable to closed reduction and percutaneous pinning can be treated in the procedure room with no increase in risk of infection, malunion, or nonunion rates. In addition, these surgeries can be performed in a procedure room with lower cost and less charges to patients than in the operating room.

Locking plate versus external fixation for type C distal radius fractures: A meta-analysis of randomized controlled trials

PURPOSE

Distal radial fracture is one of the most common fractures. Up to now, locking plates (LP) and external fixation (EF) are two conventional surgical approaches to type C radius fracture. Which method is superior has not yet reached a consensus. We try to assess the clinical effectiveness of the two interventions by this meta-analysis.

METHODS

We used network to search the PubMed, Embase, and Cochrane Medical Library of randomized controlled clinical trials about the type C distal radius fractures performed according to the search strategy mentioned in Cochrane Handbook 5.1.0 from Jan. 2005 to Jan. 2016. Patients in the experimental group were used LP, in the control group were included EF and other surgical approaches. Publication language was restricted to English. Studies that patient population and surgical indication did not define had been excluded. Studies must report at least one of the outcomes as follow: radial inclination, palmar tilt, ulnar variance, range of wrist flexion and extension, and range of wrist supination and pronation. The trials in which participants included children were excluded. We used Jadad study scores to appraise the study.

RESULTS

Seven studies included 162 patients (LP group) and 190 patients (EF group). We compared the radial inclination, palmar tilt, ulnar variance, range of wrist flexion and extension, and range of wrist supination and pronation. The radial inclination were revealed a difference favoring LP over EF [WMD = 1.84, 95% CI (0.17, 3.50), p = 0.03] and the palmar tilt and ulnar variance was no significant difference between the two groups [(WMD = 3.61, 95% CI (0.00, 7.23), p = 0.05; WMD = 0.05, 95% CI (-0.99, 1.09), p = 0.93]. The functional activities of range of flexion and extension and range of supination and pronation between the two groups was no difference [WMD = 10.04, 95% CI (-6.88, 26.96), p = 0.24; WMD = 12.53, 95% CI (-9.99, 35.06), p = 0.28].

CONCLUSION

Locking plate and external fixation is feasible to heal radius type C fracture. We found the small difference between the two groups on imaging examination. The locking plate has the advantage on maintaining reduction, however no significant difference regarding outcomes has been found between the two groups.

Evidence-Based Review of Distal Radius Fractures

Distal radius fractures are one of the most commonly treated fractures in the United States. The highest rates are seen among the elderly, second only to hip fractures. With the increasing aging population these numbers are projected to continue to increase. Distal radius fractures include a spectrum of injury patterns encountered by general practitioners and orthopedists alike. This evidence-based review of distal radius fractures incorporates current and available literature on the diagnosis, management, and treatment of fractures of the distal radius.

Complications following open reduction and internal fixation versus external fixation in treating unstable distal radius fractures: Grading the evidence through a meta-analysis

BACKGROUND

The common fixation techniques for unstable distal radius fractures include open reduction and internal fixation (ORIF) with plates and closed reduction and external fixation (EF). There is controversy over the choice of surgical approach in treating unstable distal radius fractures.

HYPOTHESIS

This meta-analysis was performed to compare complication rates in patients treated with ORIF or EF for unstable distal radius fractures and to develop GRADE (grading of recommendations, assessment, development, and evaluation)-based recommendations for using the procedures to treat unstable distal radius fractures.

MATERIALS AND METHODS

A systematic search of all the studies published was conducted using the Pubmed, ScienceDirect, Embase, BIOSIS, Springer, Cochrane Library databases. The randomized controlled trials (RCTs) that compared ORIF with EF in treating adult patients with unstable distal radius fractures and provided data regarding the complication were identified. The demographic characteristics and adverse events were manually extracted from all of the included studies. RevMan 5.1 was used for data analysis. PRISMA guidelines were followed.

RESULTS

Sixteen studies that included a total of 1280 patients met the inclusion criteria. Compared with ORIF, EF results in higher incidence of total complications, infection and malunion. The overall GRADE system evidence quality was very low, which reduces our confidence in the recommendations of this system.

DISCUSSION

This meta-analysis indicates that ORIF and EF are both effective procedures for treating unstable distal radius fractures. ORIF may be superior to EF in the treatment of unstable distal radius fractures. Because of the low quality evidence currently available, high-quality RCTs are required.

LEVEL OF EVIDENCE

Level II: low-powered prospective randomized trial meta-analysis.

[Not Available]

Zusammenfassung. Mit einfachen Mitteln kann bereits in der Hausarztpraxis entschieden werden, welche Behandlung einer distalen Radiusfraktur angestrebt werden soll. Man soll vor allem keinen Respekt davor haben, sie konservativ zu behandeln. Unsere Empfehlung ist, dass gerade bei Patienten älter als 65 Jahre, die eine nicht bzw. wenig dislozierte oder eine stabil reponierte Fraktur haben, eine Operation oft überflüssig ist. Eine Fraktur, sofern ohne die oben genannte Instabilitätskriterien, soll und darf konservativ in der Hausarztpraxis behandelt werden. Aufgrund meist geringerer funktioneller Ansprüche bei älteren Patienten darf man bei der Beurteilung der Fraktur oft grosszügiger sein in Hinblick auf die anatomischen Verhältnisse sein. Eine solche Fraktur oder Reposition muss nicht in perfekter Stellung ruhiggestellt werden beziehungsweise heilen.

Is a short arm cast appropriate for stable distal radius fractures in patients older than 55 years? A randomized prospective multicentre study

We conducted a prospective randomized, multicentre study to compare short arm and long arm plaster casts for the treatment of stable distal radius fracture in patients older than 55 years. We randomly assigned patients over the age of 55 years who had stable distal radius fracture to either a short arm or long arm plaster cast at the first review 1 week after their injury. Radiographic and clinical follow-up was conducted at 1, 3, 5, 12 and 24 weeks following their injury. Also, degree of disability caused by each cast immobilization was evaluated at the patient's visit to remove the cast. There were no significant differences in radiological parameters between the groups except for volar tilt. Despite these differences in volar tilt, neither functional status as measured by the Disabilities of the Arm, Shoulder and Hand, nor visual analogue scale was significantly different between the groups. However, the mean score of disability caused by plaster cast immobilization and the incidence rate of shoulder pain were significantly higher in patients who had a long plaster cast. Our findings suggest that a short arm cast is as effective as a long arm cast for stable distal radius fractures in the elderly. Furthermore, it is more comfortable and introduces less restriction on daily activities.

LEVEL OF EVIDENCE

II.

A structured literature synthesis of wrist outcome measures: An evidence-based approach to determine use among common wrist diagnoses

STUDY DESIGN

Structured literature synthesis.

INTRODUCTION

Hand therapists and researchers have numerous options when selecting outcome measures for patients with wrist pathologies. An evidence-based approach to determining which measures are used most often can inform choices.

PURPOSE OF THE STUDY

To describe how frequently outcome measures are used in recent randomized controlled trials of patients with wrist diagnoses. Identifying assessment design and related International Classification of Functioning, Disability and Health (ICF) domains provides additional consideration for selection.

METHODS

Systematic PubMed and Cumulative Index to Nursing and Allied Health Literature searches for the time frame between January 2005 and March 2015 captured measures used in randomized controlled trials researching wrist-specific fractures, ligament injuries, nerve injuries, arthritis/arthroplasty, or stress injuries/wrist pain.

RESULTS

Three most frequent measures used within each diagnostic category are detailed with assessment design described and ICF domain identified. Across diagnoses, grip/pinch strength and Disabilities of Arm, Shoulder and Hand were the most frequently used physical and patient-reported outcome measures, respectively. The Jebsen-Taylor Hand Function Test was the most frequently used performance measure.

DISCUSSION AND CONCLUSIONS

Consideration of the evidence, ICF domains, wrist diagnoses, and assessment design can help hand therapists select the measure most appropriate for use.

LEVEL OF EVIDENCE

2a.

Distal radius fractures in the athlete

PURPOSE OF REVIEW

Distal radius fractures are one of the most common upper extremity fractures. Athletes with distal radius fractures are treated according to the same principles as non-athletes but present several unique considerations. At all levels of sport, injured athletes desire to return to play as rapidly as possible.

RECENT FINDINGS

Earlier operative fixation may allow an athlete to return to play more quickly. Volar locking plates are most commonly used for operative treatment of distal radius fractures due to their stability and low incidence of complications. Although the majority of distal radius fractures in athletes are treated non-operatively, operative intervention is offered when required to restore and maintain acceptable skeletal alignment. Return to sport is individualized guided by fracture stability, athlete age, and wrist-specific demands for competition.

Differences in the Treatment of Distal Radius Fractures by Hand Fellowship Trained Surgeons: A Study of ABOS Candidate Data

PURPOSE

The management of distal radius fractures differs based on the nature of the fracture and the experience of the surgeon. We hypothesized that patients requiring surgical intervention would undergo different procedures when in the care of a surgeon with subspecialty training in hand surgery as compared with surgeons with no subspecialty training in hand surgery.

METHODS

We queried the ABOS database for case log information submitted for part II of the ABOS examination. Queries for all codes involved with distal radius fracture management were combined with associated codes for the management of median nerve neuropathy, triangular fibrocartilage complex tears, ulnar shaft, and styloid fractures. Hand fellowship trained orthopedic surgeons were compared with those completing other fellowships and non-fellowship trained orthopedic surgeons during their board collection period.

RESULTS

During the study period, 2,317 orthopedic surgeons reported treatment of 15,433 distal radius fractures. Of these surgeons, 411 had hand fellowship training. On a per surgeon basis, fellowship trained hand surgeons operatively treated more multifragment intra-articular distal radius fractures than their non-hand fellowship trained counterparts (5.3 vs 1.2). Additional procedures associated with the management of distal radius fractures were also associated with the fellowship training of the treating surgeon.

CONCLUSIONS

Among orthopedic surgeons taking part II of the ABOS certifying examination, differences exist in the type, management, and reporting of distal radius fractures among surgeons with different areas of fellowship training.

CLINICAL RELEVANCE

This study describes the association of hand surgery fellowship training on the choice of intervention for distal radius fractures and associated conditions.

Comparison of effects of seven treatment methods for distal radius fracture on minimizing complex regional pain syndrome

INTRODUCTION

Using network meta-analysis, we evaluated the adverse effects of the seven most common treatment methods, i.e., bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating, by their associated risk of developing complex regional pain syndrome (CRPS) in distal radius fracture (DRF) patients.

MATERIAL AND METHODS

Following an exhaustive search of scientific literature databases for high quality studies, randomized controlled trials (RCTs) related to our study topic were screened and selected based on stringent predefined inclusion and exclusion criteria. Data extracted from the selected studies were used for statistical analyses using Stata 12.0 software.

RESULTS

A total of 17 RCTs, including 1658 DRF patients, were enrolled in this network meta-analysis. Among the 1658 DRF patients, 452 received bridging external fixation, 525 received non-bridging external fixation, 154 received K-wire fixation, 84 received plaster fixation, 132 received dorsal plating, 123 received volar plating, and 188 received dorsal and volar plating. When compared to bridging external fixation patients, there was no marked difference in the CRPS risk in DRF patients receiving different treatments (all p > 0.05). However, the surface under the cumulative ranking curves (SUCRA) for plaster fixation (77.0%) and non-bridging external fixation (71.3%) were significantly higher compared with the other five methods.

CONCLUSIONS

Our findings suggest that compared with bridging external fixation, K-wire fixation, dorsal plating, volar plating, dorsal and volar plating, plaster fixation and non-bridging external fixation might be the better treatment methods to reduce the risk of CRPS in DRF patients.

Comparison of Medial Malleolar Fracture Healing at 8 Weeks After Open Reduction Internal Fixation Versus Percutaneous Fixation: A Retrospective Cohort Study

Unstable medial malleolar fractures are treated with either standard open reduction internal fixation (ORIF) or a percutaneous approach. The percutaneous approach avoids the potentially excessive soft tissue dissection associated with an open approach but can also result in inadequate anatomic reduction. No studies have compared the incidence of radiographic healing of medial malleolar fractures between an open approach and percutaneous fixation. A retrospective comparative study was performed at a single institution across multiple sites. Electronic medical records and digital radiographs were reviewed for 845 patients who had undergone either ORIF or percutaneous screw fixation (PSF) of a medial malleolar fracture. The interval to fracture healing was measured. Logistic regression analysis was used. Of the 490 included patients, 458 (93.44%) underwent standard ORIF and 32 (6.53%) underwent PSF. Patients who underwent ORIF were 5 times more likely to have a healed fracture at 8 weeks than were patients who had undergone PSF (p < .001). Compared with standard ORIF, PSF of medial malleolar fractures leads to an increased risk of an unhealed fracture at 8 weeks. This was likely due to a combination of soft tissue interposition within the fracture site and inadequate fluoroscopic reliability, leading to poor anatomic reduction and inaccurate fixation.

Distal radius fractures: Minimally invasive plate osteosynthesis with dorsal bicolumnar locking plates fixation

BACKGROUND

Controversy still exists regarding the current treatment modalities for unstable distal radius fractures. There are yet few articles investigating the efficacy of bicolumnar dorsal plating technique, which is designed to minimize tissue dissection while providing sufficiently secure fixation. A clinical study was performed to evaluate the feasibility of the minimally invasive plate osteosynthesis (MIPO) technique using a modified dorsal approach for the treatment of distal radius fractures.

MATERIALS AND METHODS

Thirty patients with unilateral distal radius fracture who underwent bicolumnar plate fixation with a minimally invasive dorsal approach between September 2008 and December 2010 were included in this retrospective study. Twenty four patients (8 men and 16 women) with a mean age of 53 years (range 18-85 years) were available for followup of at least 1 year or more were included in final study. Herein, we report the functional radiological outcomes of the study. There were three cases of AO Type A fracture, five cases of AO Type B fracture, and 16 cases of AO Type C fracture.

RESULTS

The union was achieved in all the patients. The functional results at one-year followup, assessed using the modified Gartland and Werley scoring system, were excellent in 14 patients, good in seven patients, and fair in three patients. The average correction of deformity was 4.1 mm for radial height, 7.6° for radial inclination, and 20.7° for volar tilt.

CONCLUSIONS

MIPO with a dorsal approach is a feasible option for the management of displaced distal radius fractures and can result in favorable surgical outcomes.

How well can step-off and gap distances be reduced when treating intra-articular distal radius fractures with fragment specific fixation when using fluoroscopy

INTRODUCTION

Although fragment specific fixation has proved to be an effective treatment regime, it has not been established how successfully this treatment could be performed using fluoroscopy and what the added value of arthroscopy could be. Establish gap and step-off distances after in intra-articular distal radius fractures that have been treated with fragment specific fixation while using fluoroscopy.

MATERIAL

Forty-four patients with an intra-articular distal radius fracture were treated with fragment specific fixation while using fluoroscopy.

METHODS

After the treatment of the intra-articular distal radius fracture with fragment specific fixation and the use of fluoroscopy, but before the completion of the surgical intervention, all gap, and step-off distances were determined by using arthroscopy. In addition, the joint was checked for any other wrist pathologies.

RESULTS

Arthroscopy after the surgical intervention showed that in 37 patients no gap distances could be detected, while in six patients a gap distance of≤2mm was found and in one patient, a gap distance of 3mm. Similarly, arthroscopy revealed no step-off distances in 33 patients, while in 11 patients a step-off distance of≤2mm was found. Although additional wrist pathologies were found in 48% of our population, only one patient needed surgical intervention. Three months after the surgical intervention wrist flexion was 41±10°, wrist extension 51±17°, ulnar deviation 19±10°, radial deviation 32±12° while patients could pronate and supinate their wrist to 85±5° and 74±20°, respectively.

CONCLUSION

Intra-articular distal radius fractures can be treated successfully with fragment specific fixation and the use of fluoroscopy. As almost all gap and step-off distances could be reduced to an acceptable level, the scope for arthroscopy to further improve this treatment regime is limited. The functional outcome scores that were found 3 months after the surgical intervention were similar to what has been reported in other studies using different treatment option. These findings suggest that fragment specific fixation is a good alternative for treating intra-articular distal radius fractures. As in most cases, only fluoroscopy is needed for fragment specific fixation, this treatment technique is a good treatment option for resource-limited hospitals, setting who do not have access to arthroscopy.

LEVEL OF EVIDENCE

III, case-control study.

Volar locking plate fixation for distal radius fractures: Does age affect outcome?

BACKGROUND

The AAOS guidelines are unable to recommend for or against operative treatment of distal radius fractures in older patients.

AIMS

This study compares the outcomes of older patients (≥60 years) against a cohort of younger patients treated with volar locking plate (VLP) fixation.

METHODS

We assessed 78 patients, comparing range of movement (ROM), grip and pinch strength, subjective Visual Analogue Score (VAS) for pain and function and composite outcome scores.

RESULTS

There was no difference in clinical outcomes between the two groups at six months.

CONCLUSION

Open reduction and VLP for distal radius fractures gives comparable outcomes in the older population.

Management of Complex Distal Radius Fractures: Review of Treatment Principles and Select Surgical Techniques

Most distal radius fractures are the result of low-energy mechanisms that can be successfully treated either non-operatively or with a variety of operative techniques if indicated. Complex distal radius fractures occur most commonly in high-energy injuries with extensive comminution or bone loss and associated soft tissue or vascular injuries. These high-energy fractures can present many challenges in reconstructing the distal radius. Effective restoration of the bony architecture requires a thorough knowledge of distal radius anatomy, understanding of the goals of treatment, versatility in surgical approaches, and familiarity with multiple fixation options.

Internal Versus External Fixation for the Treatment of Distal Radial Fractures: A Systematic Review of Overlapping Meta-Analyses

Although a serious of meta-analyses have been published to compare the effects of internal versus external fixation (IF vs EF) for treating distal radial fractures (DRF), no consensus was obtained.B y performing a systematic review of overlapping meta-analyses comparing IF versus EF for the treatment of distal radial fractures, we attempted to evaluate the methodology and reporting quality of these meta-analyses, interpret the source of discordant results, and therefore determine the dominant strategy for the treatment of distal radial fractures based on the best evidence currently. An electronic databases search was conducted in MEDLINE, Embase, and Cochrane library to retrieve meta-analyses comparing IF versus EF for treating DRF. Reference lists of relevant literatures were also screened manually to retrieve additional ones. Two investigators independently assessed the eligibility of retrieved articles using predefined inclusion and exclusion criteria. All characteristics as well as outcome variables including functional outcomes, range of motion, radiological results, and complication rates with relevant heterogeneity information presented in each included study were extracted. Heterogeneity was thought to be significant when I² > 50%. We adopted the Oxford Levels of Evidence and the Assessment of Multiple Systematic Reviews (AMSTAR) Instrument to assess the methodological quality of every included study, and applied the Jadad decision algorithm to select studies with more likely reliable conclusions. A total of 8 studies met the inclusion criteria. The AMSTAR scores ranged from 5 to 9 with a median of 7.75. Following the Jadad algorithm, the meta-analyses with most reliable results can be selected based on the search strategies and application of selection. Finally, 2 meta-analyses with most RCTs and highest AMSTAR scores were selected in this systematic review of overlapping meta-analysis. The best available evidence suggested that compared with EF, IF was significantly associated with lower Disabilities of the Arm, Shoulder and Hand (DASH) scores, better rehabilitation of volar tilt and radial inclination, and lower infection rate at 1-year follow-up. Therefore, we could conclude that internal fixation is superior to external fixations for the treatment of distal radial fractures.

Stabilisation of distal radius fractures: Lessons learned and future directions

Our understanding of the diagnosis and management of distal radius fractures has been a long developed over centuries. There has been a shift in treatment of these very common injuries from closed reduction and casting to internal fixation. The answer to the best method of treatment has yet to be found. Today, we have a multitude of treatment options available with varying degrees of evidence to support their use. This review helps to illustrate the lessons we have learned and future directions for treatment.

Anatomic relationships in distal radius bridge plating: a cadaveric study

BACKGROUND

Two separate approaches have been described for radiocarpal spanning internal fixation for high-energy distal radius fractures with metaphyseal extension. To our knowledge, relevant anatomic relationships and structures at risk for iatrogenic injury have not been identified in the literature.

METHODS

Twelve fresh frozen cadaver arms were randomized to fixation with a dorsal radiocarpal spanning plate using one of two techniques: (1) index finger metacarpal fixation (index group) or (2) middle finger metacarpal fixation (middle group). Cadaveric dissection and relevant anatomic relationships were assessed in relation to the plate.

RESULTS

Superficial branches of the radial sensory nerve were in contact with the index group plate in all specimens, while no contact occurred in the middle group specimens. No extensor digitorum comminus (EDC) middle extensor tendons contacted the plate in the index group; an average of 10 cm of plate contact was seen in the middle group. The extensor pollicis longus (EPL) tendon contacted the plate in both the index and middle groups for an average distance of 12.4 and 25.5 mm, respectively. One complication [EPL and extensor indicis proprius (EIP) entrapment] was observed in the middle finger metacarpal group.

CONCLUSION

Mounting the dorsal bridge plate to the index finger metacarpal places the superficial branches of the radial sensory nerve at risk during dissection, while mounting the plate to the middle finger metacarpal leads to a greater degree of tendon-plate contact.

Comparison of intraoperative flat panel imaging and postoperative plain radiography for the detection of intraarticular screw displacement in volar distal radius plate ostheosynthesis

OBJECTIVES

To investigate if intraoperative 3D flat panel imaging improves the detection of radiocarpal intraarticular screw misplacement (RCSM) in comparison to standard postoperative x-ray.

METHODS

In a study on cadaver specimens, we evaluated the sensitivity and specificity to detect RCSM using X-ray, intraoperative 3D-fluoroscopy as well as the digital volume tomography. The gold standard reference was computed tomography.

RESULTS

Sensitivity for the detection of RCSM for X-ray was 58% and specificity 88%. For DVT, the sensitivity to detect RCSM was 88% and the specificity 53%. For 3D-fluoroscopy, the sensitivity for RCSM was 68% and specificity 95%. When combining the methods, the best performance was found, when combining the two intraoperative imaging methods, with a resulting sensitivity of 88% and a specificity of 73%.

CONCLUSIONS

Intraoperative 3D fluoroscopy and digital volume tomography appear to be at least as sensitive and specific to detect RCSM than the regular postoperative radiography in two planes. However, especially discrete screw misplacements can be missed with either method.

LEVEL OF EVIDENCE

Level IV. Diagnostic device study.

The comparative risk of developing postoperative complications in patients with distal radius fractures following different treatment modalities

In this study, we performed a network meta-analysis to compare the outcomes of seven most common surgical procedures to fix DRF, including bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating. Published studies were retrieved through PubMed, Embase and Cochrane Library databases. The database search terms used were the following keywords and MeSH terms: DRF, bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating. The network meta-analysis was performed to rank the probabilities of postoperative complication risks for the seven surgical modalities in DRF patients. This network meta-analysis included data obtained from a total of 19 RCTs. Our results revealed that compared to DRF patients treated with bridging external fixation, marked differences in pin-track infection (PTI) rate were found in patients treated with plaster fixation, volar plating, and dorsal and volar plating. Cluster analysis showed that plaster fixation is associated with the lowest probability of postoperative complication in DRF patients. Plaster fixation is associated with the lowest risk for postoperative complications in DRF patients, when compared to six other common DRF surgical methods examined.

Management of Severely Comminuted Distal Radius Fractures

Distal radius fractures are among the most common fractures of the upper extremity. Indications for operative and nonsurgical management have evolved over time, as have fixation techniques. Volar locking plates are commonly used in the treatment of selected distal radius fractures such as low-energy or relatively uncomplicated fractures. They have limitations, however, in the management of highly comminuted fracture patterns and in polytrauma patients. In these patients, other methods ranging from spanning fixation to fragment-specific fixation have emerged as useful alternatives in the surgeon's armamentarium for treatment of these challenging fractures.

Is it really necessary to restore radial anatomic parameters after distal radius fractures?

Small variations within normal range of radiographic parameters, except ulnar variance and volar tilt, do not influence the final functional outcome in distal radius fractures.

INTRODUCTION

There are many reports in the literature on the relationship between radiographic variables and their influence on the final outcome of distal radius fractures. Most authors report that a good functional result depends on anatomical restoration of the articular surface and extra-articular alignment. The aim of this study was to verify if it is really necessary to restore anatomic radiographic parameters to obtain satisfactory functional outcome in distal radius fractures treated with volar plate.

MATERIALS AND METHODS

We retrospectively evaluated 51 patients treated with volar locked plate for articular unstable distal radius fractures from December 2006 to March 2009. Each fracture was evaluated according to the AO classification. The average follow-up was 40.5 months. Radiological measurements were performed considering radial height, radial inclination, volar tilt and ulnar variance, both preoperatively and postoperatively, to estimate the correction value. We examined range of motion (ROM), grip strength with a Jamar(®) dynamometer and Disabilities of the Arm, Shoulder and Hand (DASH) score. The τ Student test was performed for statistical analysis.

RESULTS

The persistence of articular step-off was assessed in 35.3% of patients. Normal radial inclination (21-25°) was restored in 74.5% of patients (range 15-27.5°). Normal radial height (10-13 mm) was restored in 66.6% of patients (range 6.8-17.3mm). Normal volar tilt (7-15°) was achieved in 90.2% of patients (range 3-17°). Normal ulnar variance (0.7-1.5mm) was restored in 86.3% of patients (range 0.7-4.1mm). There was a statistically significant difference between the preoperative and postoperative radiographic values (p<0.01). The majority of patients showed complete recovery of ROM, with no statistically significant difference (p>0.05) in extension, flexion, supination and pronation compared with the contralateral hand. Eight patients who had postoperative volar tilt and/or ulnar variance out of range had a statistically significant difference (p<0.05) in ROM compared with the non-operated side. At final follow-up, all patients had a statistically significant difference (p<0.05) in grip strength compared with the contralateral side, even with good strength values. The mean DASH score was 12.2 (range 0-61).

DISCUSSION AND CONCLUSION

Our experience suggests that ulnar variance and volar tilt are the most important radiographic parameters to be restored to obtain good functional outcome in distal radius fracture. Small variations of other radiographic parameters seem to not affect the final outcome at minimum 3 years' follow-up.

External fixation versus open reduction with locked volar plating for geriatric distal radius fractures

The optimal management of displaced dorsal radius fractures (DRFs) in older patients remains an issue of debate. Bridging external fixation is a well-accepted treatment modality for severely comminuted DRFs, while open reduction and internal fixation with locked volar plating has emerged as a promising alternative in recent years. The current body of randomized trials supports the trend toward locked volar plating, as it allows for quicker improvement in subjective and functional outcomes. There is no clear evidence to suggest that one technique carries significantly less complications than the other. Locked volar plating should be considered in patients for whom an accelerated functional recovery would be advantageous. Otherwise, both external fixation and locked volar plating provide good long-term clinical outcomes.

Outcomes and cost of care for patients with distal radius fractures

This study was designed to evaluate treatment patterns in open treatment and percutaneous fixation of distal radius fractures, compare morbidity rates for the 2 types of treatment, and compare costs associated with the procedure and treatment of complications up to 1 year after surgery. From a 5% sample of nationwide Medicare claims records (1997-2009), patients with distal radius fractures were identified with International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM), codes. Patients who underwent percutaneous fixation and open treatment were tracked with appropriate Current Procedural Terminology codes. Complications were identified at 3 and 12 months. Medicare charges and payments associated with the treatment groups were compiled from the claims data. The rate of surgical treatment increased from 44.7 to 82.0 surgeries per 100,000 persons (+83.0%) over the study period. A total of 9343 procedures met the inclusion criteria between 1998 and 2008. The proportion of open treatment procedures increased from 25.5% in 1998 to 73.4% in 2008. Percutaneous fixation was associated with lower adjusted risk of carpal tunnel syndrome and release and mononeuritis at 3 and 12 months. The percutaneous fixation group had lower adjusted risk of malunion/nonunion at 3 months and tendon rupture at 12 months. Average charges were lower in the percutaneous fixation group for the index operation as well as for treatment of morbidities at 3 and 12 months. The operative fixation rate for distal radius fractures in the Medicare population continues to rise, with a significant trend toward open fixation. Charges and payments associated with open treatment are significantly higher than those for percutaneous fixation.

Ultrasound-assisted closed reduction of distal radius fractures

PURPOSE

To assess the accuracy and ability of ultrasound for monitoring closed reduction for distal radius fractures.

METHODS

Consecutive patients undergoing ultrasound-guided closed reduction of acute, displaced distal radius fractures between January 2003 and December 2006 at our department were enrolled. The control group was extracted from patients who underwent a closed reduction for similar fractures under fluoroscopy or without any imaging assistance. To confirm the accuracy of the ultrasonography measurements, displacement distance values were compared with those on radiographic imaging before and after reduction. X-ray parameters for pre- and postreduction, reduction time, total cost, and success rate were compared between the ultrasound-guided and the control groups.

RESULTS

The ultrasound-guided group consisted of 43 patients (mean age, 68 y) and the control group consisted of 57 patients, which included 35 patients (mean age, 74 y) with fluoroscopic reduction and of 22 patients (mean age, 72 y) with reduction unaided by imaging. There were no significant displacement differences between radiographic and ultrasound measurements. In x-ray parameters for pre- and postreduction, there were no significant differences between the 2 groups. Ultrasound-guided reduction took longer than the other 2 methods. The success rate of the ultrasound and the fluoroscopic groups were similar (95% and 94%, respectively).

CONCLUSIONS

Our data suggest that ultrasound assistance can aid reduction of distal radius fractures as well as fluoroscopy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

The association of education level on outcome after distal radius fracture

BACKGROUND

Socioeconomic factors have been found to be predictors of outcome for other ailments. The purpose of this study was to evaluate the association of patient education level on pain and disability after distal radius fracture.

METHODS

A series of patients with distal radius fractures (n = 335) were enrolled into a prospective research registry. Standard demographic information was obtained from patients, including a five-value categorical education variable. After treatment with closed reduction, external fixation, or internal fixation patients were evaluated for pain, function (Disability of the Arm, Shoulder, and Hand score [DASH]), range of motion (ROM), and grip strength at standard intervals until 12 months post-injury. A series of linear mixed effects models were developed to evaluate the relationship between time from injury and education level with each of the outcomes measured.

RESULTS

Complete demographic and 12-month follow-up data were available on 227 patients (75 %). There were neither group differences in mode of injury, severity, nor treatment modality after stratification by education level. Mixed effects model analyses revealed a significant linear association between level of education and measured outcomes at each follow-up point. Overall, each increase in education level demonstrated a doubling of improvement in pain, ROM, grip strength, and DASH score.

CONCLUSIONS

Outcome of distal radius fracture depends on acute care and follow-up rehabilitation; however, patient-related factors indicative of socioeconomic status are becoming increasingly relevant as predictors of outcome and should be considered by the orthopaedist.