A comparison between subjective outcome score and moderate radial shortening following a fractured distal radius in patients of mean age 69 years

Distal Radius Fracture Rehabilitation

Distal radius fracture (DRF) is arguably the most common upper extremity fracture resulting from a fall accident. These clinical practice guidelines (CPG) were developed to guide all aspects of the management of DRF by physical therapists and other rehabilitation practitioners, such as certified hand therapists. This CPG employed a systematic review methodology to locate, appraise, and synthesize contemporary evidence while developing practice recommendations for determining the prognosis of outcomes, examination, and interventions while managing individuals with DRF. The quality of the primary studies found in the literature search was appraised using standardized tools. The strength of the available evidence for a particular practice domain (e.g., prognosis or intervention) was graded as strong, moderate, weak, or conflicting, where such gradings guided the level of obligation for each practice recommendation. Lastly, the CPG also provided the gaps in the evidence pool for the rehabilitation of DRF that future research efforts can address. J Orthop Sports Phys Ther 2024;54(9):CPG1-CPG78. doi:10.2519/jospt.2024.0301.

Distal radius malunion: outcomes following an ulnar shortening osteotomy

PURPOSE

Positive ulnar variance following a distal radius malunion can lead to ulnar-sided wrist pain, loss of grip strength, and distal radioulnar joint impingement. The primary aim of this study is to describe upper limb-specific functional outcomes following ulnar shortening osteotomy (USO) for ulnar-sided wrist pain associated with malunion of the distal radius.

METHODS

We retrospectively identified 40 adult patients from a single centre over a 9-year period that had undergone an USO for symptomatic malunion of the distal radius. The primary outcome was the patient-rated wrist evaluation (PRWE). Secondary outcomes were the QuickDASH, EQ-5D-5L, complications, and net promoter score (NPS).

RESULTS

Outcomes were available for 37 patients (93%). The mean age was 56 years and 25 patients were female (68%). At a mean follow-up of 6 years (range 1-10 years) the median PRWE was 11 (IQR 0-29.5), the median QuickDASH 6.8 (IQR 0-29.5), and the median EQ-5D-5L index was 0.88 (IQR 0.71-1). The NPS was 73. Complications occurred in nine patients (24%) and included non-union (n = 4), early loss of fixation requiring revision surgery (n = 1), superficial wound infection (n = 2), neurological injury (n = 1), and further surgery for symptomatic hardware removal (n = 1).

CONCLUSIONS

For patients with a symptomatic distal radius malunion where the predominant deformity is ulnar positive variance, this study has demonstrated that despite 1 in 4 patients experiencing a complication, USO can result in excellent patient reported outcomes with high levels of satisfaction.

LEVEL OF EVIDENCE

III (Cohort Study).

Are Radiographic Characteristics Associated With Outcome in Surgically Treated Distal Radius Fractures?

PURPOSE

Evidence to date shows that distal radius fracture displacement measured on radiographs does not correlate with patient-reported outcomes. Quantitative 3-dimensional computed tomography (CT) (Q3DCT) potentially captures fracture displacement more accurately. We aimed to assess the independent association between radiographic, CT, and Q3DCT measures of residual displacement and change in disability, quality of life, range of motion (ROM), and grip strength 12 weeks and 1 year after volar plating of intra-articular distal radius fractures.

METHODS

We performed a secondary analysis of data from a prospective multicenter trial. Seventy-one patients underwent volar plating of their AO Foundation/Orthopaedic Trauma Association type B or C distal radius fracture and were available at 12 weeks; 67 (94%) were available at 1 year. We recorded demographics, postoperative periapical radiographs (radial height, ulnarward inclination, ulnar variance, gap, and step off), lateral radiographs (palmar tilt, scapholunate angle, teardrop angle, and anteroposterior distance), postoperative CT scans (gap [coronal, sagittal and axial]) and step off [sagittal and coronal]), and in 3-dimensional models (number of articular fragments, mean fragment articular surface area, 3-dimensional fragment displacement, and gap surface area). Radiographs and CT scans were obtained within 10 working days after fracture fixation. Outcome measures were change in Patient-Rated Wrist Evaluation (PRWE) scores, EuroQol Group 5-Dimension questionnaire (EQ5D) results, grip strength, and composite wrist ROM at 12 weeks and 1 year compared to preinjury level.

RESULTS

At 1 year, greater recovery in PRWE scores was independently associated with older age. Greater recovery in composite ROM at 1 year was associated with injury to the dominant side and less step-off on posteroanterior radiographs.

CONCLUSIONS

Less posteroanterior step-off was associated with a small improvement in composite wrist ROM at 1 year. This should be considered when counseling patients on the risks and benefits of surgical treatment when radiographic and CT measures of displacement fall within the range found in this study, and in older, low-demand patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Clinical and functional analysis of closed reduction-plastering and volar locking plate methods in distal radius fractures in patients over 60 years of age

Aim: Many different methods have been described in the treatment of distal radius fractures (DRF) in the elderly population, and which one is the better method is a matter of debate among orthopedic surgeons. The aim of this study was to compare the results of closed reduction and plastering (CRP) and volar locking plate (VLP), which are used in the treatment of DRF in the elderly population. Materials and Methods: Between January 2019 and December 2020, 36 patients with DRF aged > 60 years were evaluated retrospectively. There were 19 patients in the CRP group and 17 patients in the VLP group. Wrist flexion, extension, pronation, supination, ulnar deviation, and radial deviation degrees and grip strength were measured in the first year of their treatment. The patients were evaluated functionally by patient-rated wrist evaluation (PRWE), modified Green and O'Brien score (MGOS), and resting and stress visual analogue scale (VAS). Results: In both groups, similar ROM values were obtained and no significant difference was observed. While the PRWE score was 17.5 ± 5.5 in the CRP group and 12.5 ± 4.8 in the VLP group, the MGOS score was 83.0 ± 7.4 in the CRP group and 86.8 ± 12.6 in the VLP group, and the scores were not significantly different (p = 0.802, p = 0.315). While there was almost no pain in both groups at rest, more pain was felt in the VKP group under stress. While grip strength was 20.9 ± 6.4 kg in the CRP group, it was 22.2 ± 6.8 kg in the VLP group, and there was no significant difference compared to the contralateral wrist. Conclusion: There is no clinical and functional difference between CRP and VLP in the one-year period after DRF treatment in the patient population aged > 60 years. Treatment should be planned according to the functional capacity of the patient.

Outcome Metrics in the Treatment of Distal Radius Fractures in Patients Aged Above 50 Years: A Systematic Review

BACKGROUND

The inclusion of patient-reported outcome measures (PROMs) serves to better quantify aspects of patient outcomes missed with objective measures, including radiographic indices and physical examination findings. We hypothesize that PROMs are inconsistently and heterogeneously captured in the treatment of distal radius fractures.

METHODS

We performed a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines of all level I and II randomized controlled trials (RCTs) of distal radius fracture treatment of any modality for those older than 50 years of age from January 2008 to January 2018. A total of 23 studies were included in the final analysis. The metrics used by each study to assess outcomes were collected, compared, and described.

RESULTS

Physical examination findings and radiographic measures were reported in 70% and 74% of studies, respectively. Patient-reported outcomes measures were used to assess outcomes in 74% of studies. Only the Disabilities of the Arm, Shoulder, and Hand was used in greater than half of the studies (57%). Pain scores were assessed in 39% of studies and complications in only 26%.

CONCLUSIONS

There is substantial heterogeneity and lack of standardization in the collection of both objective outcome measures and PROMs in level I and II RCTs for the treatment of distal radius fractures. The ability to compare between studies or aggregate data among studies is therefore limited. Radiographic and physical examination findings remain frequently reported despite known limitations of these metrics. The routine collection of PROMs after the treatment of distal radius fractures can ensure care is directed toward improving what is most important to patients.

Effectiveness of surgical versus conservative treatment of distal radius fractures in elderly patients: A systematic review and meta-analysis

BACKGROUND

The aim of this study was to determine whether surgical treatment is more effective than conservative treatment in terms of functional outcomes in elderly patients with distal radius fractures (DRFs).

METHODS

An electronic search of the Medline, Central, Embase, PEDro, Lilacs, CINAHL, SPORTDiscus, and Web of Science databases was performed, from inception until July 2021. The eligibility criteria for selecting studies were randomized clinical trials that compared surgical versus conservative treatment in subjects older than 60 years with DRFs. Two authors independently performed the search, data extraction, and assessed risk of bias (RoB) using the Cochrane RoB tool.

RESULTS

Twelve trials met the eligibility criteria, and nine studies were included in the quantitative synthesis. For volar plate versus cast immobilization at 1-year follow-up, the mean difference (MD) for PRWE was -5.36 points (p=0.02), for DASH was -4.03 points (p=0.02), for grip strength was 8.32% (p=0.0004), for wrist flexion was 4.35 degrees (p=0.10), for wrist extension was -1.52 degrees (p=0.008), for pronation was 2.7 degrees (p=0.009), for supination was 4.88 degrees (p=0.002), and for EQ-VAS was 2.73 points (p=0.0007), with differences in favor of volar plate. For K-wire versus cast immobilization at 12 months, there were no statistically significant differences in wrist range of motion (p>0.05).

CONCLUSIONS

There was low to high evidence according to GRADE ratings, with a statistically significant difference in functional outcomes in favor of volar plate versus conservative treatment at 1-year follow-up. However, these differences are not minimally clinically important, suggesting that both types of management are equally effective in patients older than 60 years with DRFs.

LEVEL OF EVIDENCE

I; Therapeutic (Systematic review and meta-analysis of randomized clinical trials).

Comparison of 24-Month Outcomes After Treatment for Distal Radius Fracture: The WRIST Randomized Clinical Trial

IMPORTANCE

Distal radius fractures (DRFs) are common injuries among older adults and can result in substantial disability. Current evidence regarding long-term outcomes in older adults is scarce.

OBJECTIVE

To compare outcomes across treatment groups at 24 months among adults with DRFs who participated in the WRIST trial.

DESIGN, SETTING, AND PARTICIPANTS

The Wrist and Radius Injury Surgical Trial (WRIST) randomized, international, multicenter trial was conducted from April 1, 2012, through December 31, 2016. Participants were adults aged 60 years or older with isolated, unstable DRFs at 24 health systems in the US, Canada, and Singapore. Data analysis was performed from March 2019 to March 2021.

INTERVENTIONS

Participants were randomized to open reduction and volar locking plate system (VLPS), external fixation with or without supplementary pinning (EFP), and percutaneous pinning (CRPP). The remaining participants chose closed reduction and casting.

MAIN OUTCOMES AND MEASURES

The primary outcome was the 24-month Michigan Hand Outcomes Questionnaire (MHQ) summary score. Secondary outcomes were scores on the MHQ subdomains hand strength and wrist motion.

RESULTS

A total of 304 adults were recruited for the study, and 187 were randomized to undergo surgery, 65 to VLPS, 64 to EFP, and 58 to CRPP; 117 participants opted for closed reduction and casting. Assessments were completed at 24 months for 182 participants (160 women [87.9%]; mean [SD] age, 70.1 [8.5] years). Mean MHQ summary scores at 24 months were 88 (95% CI, 83-92) for VLPS, 83 (95% CI, 78-88) for EFP, 85 (95% CI, 79-90) for CRPP, and 85 (95% CI, 79-90) for casting, with no clinically meaningful difference across groups after adjusting for covariates (χ23 = 1.44; P = .70). Pain scores also did not differ across groups at 24 months (χ23 = 2.64; P = .45). MHQ summary scores changed from 82 (95% CI, 80-85) to 85 (95% CI, 83-88) (P = .12) between 12 and 24 months across groups. The rate of malunion was higher in the casting group (26 participants [59.1%]) than in the other groups (4 participants [8.0%] for VLPS, 8 participants [17.0%] for EFP, and 4 participants [9.8%] for CRPP; χ23 = 43.6; P < .001), but malunion was not associated with the 24-month outcome difference across groups.

CONCLUSIONS AND RELEVANCE

The study did not find clinically meaningful patient-reported outcome differences 24 months after injury across treatment groups, with little change between 12 and 24 months. These findings suggest that long-term outcomes need not necessarily be considered in deciding between treatment options. Patient needs and recovery goals that fit to relative risks and benefits of each treatment type will be more valuable in treatment decision-making.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01589692.

Nonoperative treatment versus volar locking plate fixation for elderly patients with distal radial fracture: a systematic review and meta-analysis

Background

This systematic review and meta-analysis assessed the role of nonoperative treatment and volar locking plate (VLP) fixation in elderly patients with distal radial fracture.

Methods

The systematic literature review identified randomized controlled trials (RCTs) and observational studies using VLP and nonoperative treatment for distal radial fractures in the elderly. Two investigators independently extracted data and evaluated the quality of the studies. A meta-analysis was performed using RevMan version 5.3.

Results

The five RCTs and six observational studies included 585 and 604 patients in the VLP and nonoperation groups, respectively. The quality of these 11 studies was moderate. Compared to nonoperation treatment, VLP did not improve the disabilities of the arm, shoulder and hand (DASH) score (weighted mean difference [WMD] = −1.67; 95% confidence interval [CI], −3.58–−0.24; P = 0.09), decrease complications (odds ratio = 1.05; 95% CI, 0.51–2.19; P = 0.89), or improve range of motion in flexion, extension, pronation, supination, and radial deviation. The VLP group had better grip strength (WMD = 10.52; 95% CI, 6.19–14.86; P < 0.0001) and radiographic assessment than the nonoperation group.

Conclusions

Although insufficient, the study evidence shows that VLP does not improve DASH scores, complications, or range of motion, but it might provide better grip strength and radiographic assessment than nonoperation treatment.

Correlation Between Radiological Parameters and Functional Outcomes in Patients Older Than 60 Years of Age With Distal Radius Fracture

Background: The relationship between radiographic and functional outcomes is controversial in the elderly. The objective of this study is to determine whether there is a correlation between functional outcome and acceptable distal radius fracture (DRF) alignment in patients older than 60 years of age. Methods: This correlation study was carried out at the Central Metropolitan Health Service of Chile. A total of 180 patients diagnosed with extra-articular DRF, according to the AO classification, were prospectively recruited. Radiological parameters, including radial inclination, residual dorsal angulation, ulnar variance, and articular step-off, were evaluated to assess the results of orthopedic reduction. Functional outcome was assessed immediately following cast removal and again at the 6-month follow-up. The Disabilities of the Arm, Shoulder and Hand (DASH) and Patient-Rated Wrist Evaluation (PRWE) questionnaires were administered to assess upper extremity function, and the visual analog scale (VAS) was used to assess pain intensity. Results: Only 68 patients (37.8%) showed acceptable DRF alignment. After cast removal, the correlations between alignment and the functional outcome measures were as follows: DASH 0.071 (P = .546), PRWE 0.03 (P = .823), and VAS 0.12 (P = .631). At the 6-month follow-up, the correlations between alignment and the functional outcome measures were as follows: DASH 0.029 (P = .768), PRWE 0.014 (P = .895), and VAS 0.09 (P = .614). Conclusions: There was no significant correlation between acceptable alignment according to radiological parameters and short- or medium-term functional outcome in patients older than 60 years with extra-articular DRF treated conservatively.

Treatment Trends, Complications, and Effects of Comorbidities on Distal Radius Fractures

Background: Distal radius fractures (DRFs) are the most common upper extremity fractures in adults. This study seeks to elucidate the impact age, fracture type, and patient comorbidities have on the current treatment of DRFs and risk of complications. We hypothesized that comorbidities rather than age would relate to the risk of complications in the treatment of DRFs. Methods: A retrospective review of data was performed for patients treated between 2007 and 2014 using Truven Health MarketScan Research Databases. Patients who sustained a DRF were separated into "closed" versus "open" treatment groups, and the association between patient demographics, treatment type, and comorbidities with complication rates was analyzed, along with the trend of treatment modalities throughout the study time interval. Results: In total, 155 353 DRFs were identified; closed treatment predominated in all age groups with the highest percentage of open treatment occurring in the 50- to 59-year age group. Between 2007 and 2014, there was an increase in the rate of open reduction and internal fixation (ORIF) in all age groups <90 with the largest increase (11%) occurring in the 70- to 79-year age group. Higher complication rates were observed in the open treatment group in all ages <90 years with a trend toward decreasing complication rates as age increased. Comorbidities were more strongly associated with the risk of developing complications than age. Conclusions: Closed treatment of DRFs remains the predominant treatment method among all age groups, but DRFs are increasingly being treated with ORIF. Emphasis on the patients' comorbidities rather than chronological age should be considered in the treatment decision-making process of elderly patients with DRFs.

Assessment of Distal Radius Fracture Complications Among Adults 60 Years or Older: A Secondary Analysis of the WRIST Randomized Clinical Trial

IMPORTANCE

Complications affect treatment outcomes and quality of life in addition to increasing treatment costs.

OBJECTIVES

To evaluate complication rates after the treatment of a distal radius fracture, to determine whether the rate or complication type is associated with treatment method, and to determine predictors of complications.

DESIGN, SETTING, AND PARTICIPANTS

The multicenter Wrist and Radius Injury Surgical Trial (WRIST), a randomized clinical trial, enrolled participants from April 10, 2012, to December 31, 2016. The study included 304 adults 60 years or older with isolated unstable distal radius fractures; 187 were randomized and 117 opted for casting. The study was conducted at 24 health systems in the United States, Canada, and Singapore. Data for this secondary analysis were collected from April 24, 2012, to February 28, 2018.

INTERVENTIONS

Participants opting for surgery were randomized to receive the volar locking plate system (n = 65), percutaneous pinning (n = 58), or bridging external fixation with or without supplemental pinning (n = 64). Patients who chose not to have surgery (n = 117) were not randomized and were enrolled for casting.

MAIN OUTCOMES AND MEASURES

Complication rate.

RESULTS

The WRIST enrolled a total of 304 participants, of whom 8 casting group participants were later found to be ineligible and were excluded from the analysis, leaving 296 participants. Randomized participants' mean (SD) age was 68 (7.2) years, 163 (87%) were female, and 165 (88%) were white. Casting participants' mean (SD) age was 75.6 (9.6) years, 93 (84%) were female, and 85 (85%) were white. The most common type of complications varied by treatment. Twelve of 65 participants (18.5%) in the internal fixation group reported a median nerve compression, while 16 of 26 participants (25.8%) who received external fixation and 13 of 56 participants (23.2%) who received pinning sustained pin site infections. Compared with the internal fixation group, complication rate for any severity complication was higher in participants who initially received casting (adjusted rate ratio, 1.88; 95% CI, 1.22-2.88), whereas the rate for moderate complications was higher in the external fixation group (adjusted rate ratio, 2.52; 95% CI, 1.25-5.09).

CONCLUSIONS AND RELEVANCE

The distal radius fracture treatment decision-making process for older patients should incorporate a complication profile for each treatment type. For example, external fixation and pinning could be used for patients after apprising them of pin site infection risk. Internal fixation can be done in patients with high functional demands who are willing to receive surgery. Internal fixation use should be substantiated owing to the time and cost involved.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01589692.

Corrective Osteotomy with Autogenous Bone Graft with Callus after Malunion of Distal Radius Fracture

Corrective osteotomy with callus filling at fracture site for malunion after distal radius fracture is a rare technique, but it achieved a favorable postoperative outcome. The patient, 66-year-old female, visited our hospital 4 months after distal radius fracture. Corrective osteotomy of the distal radius was planned aiming at improving the wrist joint function, and was performed using a volar locking plate, then the bone defect was filled with callus as autogenous bone grafting. At 12 months after surgery, left wrist joint pain and the range of motion have improved, and the Mayo wrist score was excellent. To our knowledge, there has been no study on the treatment of bone defects by filling with callus. Since favorable bone fusion was achieved with callus, this treatment method may overcome the disadvantages of autogenous bone graft, such as pain at the donor region.

Association Between Radiological and Patient-Reported Outcome in Adults With a Displaced Distal Radius Fracture: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the association between alignment, as determined by plain radiographs, and patient-reported outcome in adults with a displaced distal radius fracture. We also determined which specific radiological parameters are associated with patient-reported outcomes.

METHODS

We performed a systematic literature search to identify studies that evaluated the association between radiological and patient-reported outcome in adults with a displaced distal radius fracture and who had an average follow-up of at least 12 months. Radiological outcome was determined as acceptable or unacceptable reduction, defined by radiological parameters. Patient-reported outcome was assessed with the Disability of the Arm, Shoulder, and Hand, the Quick-Disability of the Arm, Shoulder, and Hand, and the Patient-Rated Wrist Evaluation questionnaires.

RESULTS

Sixteen articles were included, comprising 1,961 patients with a distal radius fracture. A significant mean difference of 4.15 points in patient-reported outcomes (95% confidence interval [CI], 0.26-8.04) was found in favor of an acceptable radiological reduction. Moreover, a significant mean difference of 5.38 points in patient-reported outcomes (95% CI, 1.69-9.07) was found in favor of an acceptable dorsal angulation, and 6.72 points (95% CI, 2.16-11.29) in favor of an acceptable ulnar variance.

CONCLUSIONS

An unacceptable radiological reduction is significantly associated with worse patient-reported outcomes in adults with a displaced distal radius fracture. Dorsal angulation and ulnar variance are the most important radiological parameters. Despite the statistical significance, the mean difference of each association did not meet the threshold of the minimally clinically important difference and therefore were unlikely to be clinically important.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Use of a 5-Item Modified Frailty Index for Risk Stratification in Patients Undergoing Surgical Management of Distal Radius Fractures

PURPOSE

Compared with cast treatment, surgery may expose patients with distal radius fractures to undue risk. Surgical intervention in this cohort may offer less benefit than previously thought and appropriate patient selection is imperative. The modified Frailty Index (mFI) predicts complications after other orthopedic surgeries. We hypothesized that this index would predict, and might ultimately prevent, complications in patients older than 50 years with distal radius fractures.

METHODS

We retrospectively reviewed the American College of Surgeons-National Surgery Quality Improvement Program (ACS-NSQIP) database, including patients older than 50 years who underwent open reduction and internal fixation of a distal radius fracture. A 5-item mFI score was then calculated for each patient. Postoperative complications, readmission and reoperation rates, as well as length of stay (LOS) were recorded. Bivariate and multivariable statistical analysis was then performed.

RESULTS

We identified 6,494 patients (mean age, 65 years). Compared with patients with mFI of 0, patients with mFI of 2 or greater were nearly 2.5 times as likely to incur a postoperative complication (1.7% vs 7.4%). Specifically, the rates of Clavien-Dindo IV, wound, cardiac, and renal complications were increased significantly in patients with mFI of 2 or greater. In addition, as mFI increased from 0 to 2 or greater, 30-day reoperation rate increased from 0.8% to 2.4%, 30-day readmission from 0.8% to 4.6%, and LOS from 0.5 days to 1.44 days. Frailty was associated with increased complications as well as rates of readmission and reoperation even when controlling for demographic data, LOS, and operative time. Age alone was not significantly associated with postoperative complications, readmission, reoperation, or LOS.

CONCLUSIONS

A state of frailty is highly predictive of postoperative complications, readmission, reoperation, and increased LOS following open reduction and internal fixation of distal radius fractures. Our data suggest that a simple frailty evaluation can help inform surgical decision making in patients older than 50 years with distal radius fractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Conservative Treatment of Distal Radius Fractures: A Prospective Descriptive Study

BACKGROUND

Disability of the upper limb is one of the consequences of distal radius fracture (DRF). The outcome of DRF treatment is based on objective clinical variables, as strength or range of movement (ROM); sometimes these variables do not correlate with the functional level of the patient. The principal objective of our study was to assess the repercussion of conservative treatment of DRF on upper limb disability.

METHODS

This is a retrospective review of prospectively collected data. We collected data of 61 nonconsecutive DRFs treated conservatively from July 2007 to August 2008.

RESULTS

Average Disabilities of the Arm, Shoulder and Hand (DASH) score before fracture was 20.8 points; average DASH score after the fracture was 42.6. There was a significant increase in the upper limb disability after 1 year of follow-up in the patients treated conservatively ( P < .001; size effect, 1.06). Average radial inclination, radial tilt, and radial length were 18.18°, 3.35°, and 5.76 mm, respectively. Average ROM for flexion-extension was 100.6° and for pronation-supination 144.0°. ROM for flexion-extension of the unaffected wrist was 128.2° and for pronation-supination 172.4°. We did not find any significant statistical correlation between the increase in disability and the decrease in the ROM ( P > .05). We did not find any significant statistical correlation between the increase in the disability and the worsening in the radiological parameters ( P > .05). Our results confirm the hypothesis that the conservative treatment of DRF produced an increase in the upper limb disability after 1 year of follow-up.

CONCLUSIONS

Our study does not show a correlation between the increase in upper limb disability and the decrease in wrist ROM. Our study did not find a correlation between radiological measures and DASH scores.

Clinical Management of Osteoporotic Fractures

PURPOSE OF REVIEW

This review examines recent literature regarding the clinical management of fragility fractures, provides insight into new practice patterns, and discusses controversies in current management.

RECENT FINDINGS

There are declining rates of osteoporosis management following initial fragility fracture. Management of osteoporotic fractures via a multidisciplinary team reduces secondary fracture incidence and improves overall osteoporotic care. Anabolic agents (abaloparatide and teriparatide) are effective adjuvants to fracture repair, and have shown positive results in cases of re-fracture in spite of medical management (i.e., bisphosphonates). For AO 31-A1 and A2 intertrochanteric hip fractures (non-reverse obliquity), no clinical advantage of intramedullary fixation over the sliding hip screw (SHS) has been proven; SHS is more cost-effective. As fragility fracture incidence continues to rise, orthopedic surgeons must play a more central role in the care of osteoporotic patients. Initiation of pharmacologic intervention is key to preventing subsequent fragility fractures, and may play a supportive role in initial fracture healing. While the media bombards patients with complications of medical therapy (atypical femur fractures, osteonecrosis of jaw, myocardial infarction), providers need to understand and communicate the low incidence of these complications compared with consequences of not initiating medical therapy.

Supervised physical therapy vs home exercise program for patients with distal radius fracture: A single-blind randomized clinical study

STUDY DESIGN

Randomized clinical study.

INTRODUCTION

Supervised physical therapy (PT) and home exercise programs (HEPs) are frequently used in the rehabilitation of patients with distal radius fracture (DRF). However, there is no consensus as to whether unsupervised HEP provides comparable benefits to those achieved by supervised PT.

PURPOSE OF THE STUDY

To compare the improvements in pain and functional status between a supervised PT program and unsupervised HEP in DRF patients older than 60 years.

METHODS

A total of 74 patients were randomized into 2 groups. One group received 12 sessions of supervised PT (n = 37), and the other group followed an exercise program at home (n = 37). Three evaluations were performed, before the initiation of treatment, at 6-week, and 6-month follow-up. The study conducted a statistical power analysis to detect an intergroup difference score of 15 points on the Patient-Rated Wrist Evaluation (PRWE). The t-test or Mann-Whitney test was used, and it was set with a significance level of .05.

RESULTS

The supervised PT group showed clinically significant differences in the total PRWE score at 6 weeks (17.67 points, P = .000) in the PRWE function score (15.2 points, P = .000) and in the PRWE pain score (5.6 points, P = .039). There was also a significant difference in the total PRWE score at 6-month follow-up (17.05 points, P = .000) in the PRWE function score (14.5 points, P = .000) and in the PRWE pain score (2.5 points, P = .35).

CONCLUSIONS

A supervised PT program is more effective for improving function in the short- and medium-term when compared with HEP in patients older than 60 years with DRF extraarticular without immediate complications.

LEVEL OF EVIDENCE

1b.

Outcomes and financial implications of intra-articular distal radius fractures: a comparative study of open reduction internal fixation (ORIF) with volar locking plates versus nonoperative management

Background

To evaluate the functional and radiographic outcomes, as well as the treatment costs, of closed displaced intra-articular distal radius fractures treated with either open reduction internal fixation (ORIF) with volar locking plates or nonoperative treatment with plaster cast immobilisation.

Materials and methods

A total of 60 patients (32 receiving ORIF, 28 receiving nonoperative treatment) with closed intra-articular distal radius fractures were included. The mean age was 52.1 and 57.4, respectively. Functional and radiographic assessments were carried out at 12 months post-injury. Patients’ treatment costs, median salaries and lengths of medical leave were obtained.

Results

DASH and MAYO wrist score in the ORIF group did not differ significantly from those in the nonoperative group. Apart from superior ulnar deviation in the ORIF group (p = 0.0096), differences in the range of motion of the injured wrists were not significant. Similarly, there were no significant differences in grip strength and visual analog scale for pain. Volar tilt (p = 0.0399), radial height (p = 0.0087), radial inclination (p = 0.0051) and articular step-off (p = 0.0002) were all significantly superior in the ORIF group. There was a 37-fold difference in mean treatment costs between ORIF (SGD 7951.23) and nonoperative treatment (SGD 230.52).

Conclusion

Our study shows no difference in overall functional outcomes at 12 months for closed displaced intra-articular distal radius fractures treated with either ORIF with volar locking plates or plaster cast immobilisation, and this is independent of radiographic outcome. A longer follow-up, nevertheless, is needed to determine whether the development of post-traumatic arthritis will have an effect on function. The vast difference in treatment costs should be taken into consideration when deciding on the treatment option.

Level of evidence

Level 3.

Safety and Efficacy of Operative Versus Nonsurgical Management of Distal Radius Fractures in Elderly Patients: A Systematic Review and Meta-analysis

PURPOSE

To assess the safety and efficacy of operative versus nonsurgical treatment of distal radius fractures in elderly patients.

METHODS

We comprehensively searched the PubMed, Web of Science, and Cochrane Library databases for studies that satisfied predetermined inclusion and exclusion criteria. Outcomes of interest included pain level, grip strength, wrist range of motion, wrist functional assessment, radiographic parameters, and complications; we compared these using continuous measurements. We performed a systematic review and meta-analysis to assess operative versus nonsurgical procedures in patients aged 60 years and older.

RESULTS

Two randomized controlled trials and 6 retrospective studies were included. Meta-analysis did not detect statistically significant differences in pooled data for pain level, functional assessment, and wrist range of motion between the operative and nonsurgical groups. Grip strength was significantly greater in the operative group. The incidence of major complications requiring surgery and that of tendon injury were significantly higher in the operative group. Radiographic outcomes including volar tilt, radial inclination, and ulnar variance were significantly better in the operative group. Considerable heterogeneity was present in all studies and adversely affected the precision of the meta-analysis.

CONCLUSIONS

The current literature does not support the theory that operative management can provide better clinical outcomes for elderly patients with distal radius fractures. Although operative management can offer better radiographic outcomes and grip strength than can nonsurgical treatment, the risk of complications requiring surgical treatment is greater. Thus, indications for operative fixation should be considered carefully in the treatment of elderly patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

ADVANCES IN KNOWLEDGE

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

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.

A descriptive study on wrist and hand sensori-motor impairment and function following distal radius fracture intervention

STUDY DESIGN

Descriptive cross-sectional design.

INTRODUCTION

Wrist and hand sensori-motor impairment have been observed after distal radius fracture (DRF) treatment. This impairment and its relationship to function lack research.

PURPOSE OF THE STUDY

The primary aim of this exploratory study was to determine the magnitude of wrist and hand sensori-motor impairment following surgical and non-surgical treatment among older patients following DRF. Secondary aims were to determine the relationship between wrist and hand sensori-motor impairment with function and pain as well as the relationships among wrist and hand sensori-motor impairment and function and age following DRF.

METHODS

Ten Test (TT), active joint position sense (JPS), electromyography (EMG), computerized hand-grip dynamometer (CHD), and the Patient-Rated Wrist Evaluation (PRWE) were used to assess twenty-four female participants 8 weeks following DRF treatment and their 24 matched-control healthy counterparts on wrist and hand sensibility, proprioception, muscle recruitment, grip force, muscle fatigue, and functional status.

RESULTS

Participants following DRF demonstrated significantly (p < .05) greater sensory (i.e., JPS, TT), and motor (i.e., EMG, CHD) deficits than their control counterparts. A significantly higher functional deficit (i.e., PRWE) also existed among participants following DRF than the control group. Participants following surgical and non-surgical DRF treatment were found to be statistically different only on total grip force. Group differences on JPS and total grip force revealed the strongest effect size with the highest correlations to PRWE. EMG and muscle fatigue ratio group differences revealed a weaker effect size with a fair degree of correlation to PRWE. Pain significantly correlated with sensori-motor function. Age did not correlate with any measured variable.

CONCLUSIONS

Significant wrist and hand sensori-motor impairment and functional deficits among older females 8 weeks following DRF surgical and non-surgical interventions were revealed. JPS and total grip force were the most clinically meaningful tests for assessing the sensori-motor status as well as explaining functional disability and pain levels for these patients.

LEVEL OF EVIDENCE

2c.

A simple method for choosing treatment of distal radius fractures

PURPOSE

To design an easy-to-use guide for decision making in distal radius fractures in patients older than 50 years and to retrospectively analyze its ability to predict treatment in 164 patients.

METHODS

The present study consisted of 4 parts. The first part was a review of the literature to identify possible important factors that predict treatment outcome of distal radius fractures in patients 50 years old and older. The second part identified which of these first-tier factors that orthopedic surgeons consider to be important by a questionnaire that was sent to 83 orthopedic surgeons qualified by the Japanese Orthopedic Association with response rate of 61%. The third part further identified which of the subsets of factors best predict outcome in a retrospective study of 41 patients 50 years old or older, yielding a final subset of factors to create a scoring system. The fourth part of the study then evaluated the ability of this scoring system to predict the outcome as evaluated by the modified Mayo wrist score and the Disabilities of the Arm, Shoulder and Hand score in a retrospective study of 164 distal radius fractures in patients 50 years old or older.

RESULTS

The 164 patients were divided into 4 groups by the present scoring system: conservative group, relative conservative group, relative surgical group, and surgical group according to the recommended therapeutic modalities. Clinical outcomes of those that followed the recommendation of the present scoring system resulted in favorable consequences. In contrast, the outcomes of those not following the recommendation were inferior.

CONCLUSIONS

The present scoring system may be used as an easy-to-use decision-making tool when choosing conservative or surgical treatment for distal radius fractures.

Three-dimensional assessment of hand outcome

INTRODUCTION

Patient reported outcome measures are central to National Health Service quality of care assessments. This study investigated the benefit of elective hand surgery by the simultaneous analysis of pain, function and appearance, using a three-dimensional (3D) graphical model for evaluating and presenting outcome.

METHODS

A total of 188 patients scheduled for surgery completed pre- and postoperative questionnaires grading the severity of their pain, dysfunction and deformity of their hand(s). Scores were plotted on a 3D graph to demonstrate the degree of 'normalisation' following surgery.

RESULTS

Surgical groups included: nerve compression (n=53), Dupuytren's disease (n=51), trigger finger (n=20), ganglion (n=17) or other lump (n=21), trapeziometacarpal joint osteoarthritis (n=10), rheumatoid disease (n=5) and other pathology (n=13). A significant improvement towards normality was seen after surgery in each group except for patients with rheumatoid disease.

CONCLUSIONS

This study provides a simple, visual representation of hand surgery outcome by plotting patient scores for pain, function and appearance simultaneously on a 3D graph.

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

BACKGROUND

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

METHOD

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

RESULTS

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

INTERPRETATION

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

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

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

Extra-articular fractures of the distal radius--a European view point

There is no unified consensus view on the management of distal radius fractures within Europe. This is partially because of the failure of clinical studies to demonstrate superiority of one treatment technique over the others. Nonclinical factors, such as cost and operating room availability, also contribute to the decision making regarding treatment, and there remains uncertainty as to the criteria that need to be fulfilled to achieve a good functional result. This article therefore does not describe a unified European viewpoint, but the viewpoint of two Europeans working within the health care system of one European country.

A comparative study of Colles' fractures in patients between fifty and seventy years of age: percutaneous K-wiring versus volar locking plating

PURPOSE

This retrospective study was to compare the clinical outcomes of volar locking plating (VLP) and percutaneous Kirschner wiring (PKW) for the management of displaced Colles type distal radius fractures in patients between 50 and 70 years old.

METHODS

There were 31 elderly patients with displaced Colles' fractures treated by VLP. We compared them to 31 match-paired patients treated by PKW. The patients were matched according to age (within five years) and sex. All patients were followed up retrospectively for at least 12 months. The functional outcomes and radiological results were compared between the two groups.

RESULTS

All fractures healed within three months. There were two complications (6.5%) in the PKW group and one complication (3.2%) in the VLP group. At final follow-up, wrist flexion, extension, and ulnar deviation were significantly better in the VLP group compared with the PKW group (all p values<0.05). According to modified Green and O'Brien criteria, the VLP group showed a trend towards increased rate of satisfactory outcome compared with the PKW group (p = 0.09).

CONCLUSION

For the treatment of displaced Colles' fractures in patients between 50 and 70 years old, both groups had high union rate and low complication rate. However, better functional results can be expected in association with open reduction and volar locking plating.

A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older

BACKGROUND

Despite the recent trend toward the internal fixation of distal radial fractures in older patients, the currently available literature lacks adequate randomized trials examining whether open reduction and internal fixation (ORIF) with a volar locking plate is superior to nonoperative (cast) treatment. The purpose of the present randomized clinical trial was to compare the outcomes of two methods that were used for the treatment of displaced and unstable distal radial fractures in patients sixty-five years of age or older: (1) ORIF with use of a volar locking plate and (2) closed reduction and plaster immobilization (casting).

METHODS

A prospective randomized study was performed. Seventy-three patients with a displaced and unstable distal radial fracture were randomized to ORIF with a volar locking plate (n = 36) or closed reduction and cast immobilization (n = 37). The outcome was measured on the basis of the Patient-Rated Wrist Evaluation (PRWE) score; the Disabilities of the Arm, Shoulder and Hand (DASH) score; the pain level; the range of wrist motion; the rate of complications; and radiographic measurements including dorsal radial tilt, radial inclination, and ulnar variance.

RESULTS

There were no significant differences between the groups in terms of the range of motion or the level of pain during the entire follow-up period (p > 0.05). Patients in the operative treatment group had lower DASH and PRWE scores, indicating better wrist function, in the early postoperative time period (p < 0.05), but there were no significant differences between the groups at six and twelve months. Grip strength was significantly better at all times in the operative treatment group (p < 0.05). Dorsal radial tilt, radial inclination, and radial shortening were significantly better in the operative treatment group than in the nonoperative treatment group at the time of the latest follow-up (p < 0.05). The number of complications was significantly higher in the operative treatment group (thirteen compared with five, p < 0.05).

CONCLUSIONS

At the twelve-month follow-up examination, the range of motion, the level of pain, and the PRWE and DASH scores were not different between the operative and nonoperative treatment groups. Patients in the operative treatment group had better grip strength through the entire time period. Achieving anatomical reconstruction did not convey any improvement in terms of the range of motion or the ability to perform daily living activities in our cohorts.

SURGICAL TREATMENT OF DISTAL RADIUS FRACTURES WITH A VOLAR LOCKED PLATE: CORRELATION OF CLINICAL AND RADIOGRAPHIC RESULTS

Objectives: To analyze and correlate the clinical and radiographic results from patients with distal radius fractures who underwent surgical treatment with a fixed-angle volar locked plate. Methods: Sixty-four patients with distal radius fractures were evaluated. They all underwent surgical treatment with a volar locked plate for the distal radius, with a minimum of six months of postoperative follow-up. They underwent a physical examination that measured range of motion and grip strength, answered the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and underwent radiographic examination. Results: In the physical examination on the patients, all the range-of-motion measurements were reduced. Grip strength measured in kgf was on average 85.8% of the strength on the unaffected side. The mean DASH score was 15.99. A significant relationship was found between lower DASH scores and losses of extension and grip strength. On the radiographs, the mean values in relation to the unfractured side were 84.0% for radial inclination, 85.4% for radial length and 86.8% for volar deviation of the radius. Loss of radial length was correlated with losses of extension and grip strength.

A comparative study of clinical and radiologic outcomes of unstable colles type distal radius fractures in patients older than 70 years: nonoperative treatment versus volar locking plating

OBJECTIVES

To compare final functional and radiographic outcomes of closed reduction and casting (CAST) with open reduction and internal fixation (ORIF) with palmar locking plate for unstable Colles type distal radius fractures (DRFs) in low-demand patients older than 70 years.

DESIGN

Retrospective, clinical study.

SETTING

Level 1 university trauma center.

PATIENTS

Over a mean period of 4 years and 7 months, 130 consecutive patients older than 70 years were treated for an unstable dorsally displaced DRF of which 114 or 87% were followed for 1 year or longer.

INTERVENTION

ORIF (n = 53) using volar locking plate or closed reduction and casting (n = 61).

MAIN OUTCOME MEASUREMENTS

Objective and subjective functional results (active range of motion; grip strength; disabilities of the arm, shoulder and hand (DASH) score; patient-rated wrist evaluation (PRWE) score; visual analog scale; and Green and O'Brien score) and radiographic assessment (dorsal tilt, radial inclination, radial shortening, fracture union, and posttraumatic arthritis) were assessed.

RESULTS

At final follow-up, there was no significant difference between the 2 groups for mean ranges of motion, grip strength, DASH score, PRWE score, and Green and O'Brien score. Pain level was significantly less for the patients in the CAST group. An obvious clinical deformity was present in 77% of cast group and none in the ORIF group. At final follow-up, in the ORIF group, there was a mean loss of dorsal tilt of 1.3 degrees, radial inclination of 0.3 degrees, and radial length of 0.5 mm compared with the postoperative measurements. No primary acceptable reduction was achieved in 44% of the CAST group. At final follow-up, in the CAST group, dorsal tilt, radial inclination, and radial shortening averaged -24.4 +/- 12 degrees, 19.2 +/- 6.5 degrees, and +3.9 +/- 2.7 mm, respectively. Malunion occurred in 89% primarily reduced fractures. Dorsal tilt, radial inclination, and radial shortening were significantly better in the ORIF group.

CONCLUSIONS

Radiographic results (dorsal tilt, radial inclination, and radial shortening) after unstable dorsally displaced DRFs are significantly better in patients treated by ORIF using a volar fixed-angle plate rather than those treated by cast immobilization (P < 0.05). At a mean follow-up time of 4 years and 7 months, the clinical outcomes of active range of motion, the PRWE, DASH, and Green and O'Brien scores do not differ between the 2 methods of treatment. The pain level was significantly less in the CAST group (P < 0.05), and this group experienced no complications. There was no difference between the subjective and functional outcomes for the surgical and the nonsurgical treatments in a cohort of patients older than 70 years. Unsatisfactory radiographic outcome in older patients does not necessarily translate into unsatisfactory functional outcome. Nonoperative treatment may be the preferred method of treatment in this age group.

A revolution in the management of fractures of the distal radius?

The recent development of locking-plate technology has led to a potential revolution in the management of fractures of the distal radius. This review examines the evidence for pursuing anatomical restoration of the distal radius and the possible advantages and pitfalls of using volar locking plates to achieve this goal. The available evidence for adopting volar locking plates is presented and a number of important and, as yet unanswered, questions are highlighted.