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

Risk factors for surgical site infection after surgical treatment of closed distal radial fractures

We assessed operatively treated closed distal radial fractures to identify independent risk factors for surgical site infection after treatment. A retrospective review was carried out of 531 operatively treated closed distal radial fractures over a 5-year period. Multiple logistic regression was performed with infection as the dependent variable, using a stepwise regression procedure to select variables to construct the final model. In total, 19 (3.6%) fractures were complicated by postoperative surgical site infection. Uncontrolled diabetes with HbA1c >7, the presence of external fixation or external Kirschner wires, and tobacco use were significant independent predictors of infection. Age and time in the operating room were also statistically significant predictors but deemed to be not clinically meaningful.Level of evidence: IV.

Evaluation of a 3D-printed hands-on radius fracture model during teaching courses

OBJECTIVE

This study aimed to evaluate the effectiveness of a 3D-printed hands-on radius fracture model for teaching courses. The model was designed to enhance understanding and knowledge of radius fractures among medical students during their clinical training.

METHODS

The 3D models of radius fractures were generated using CT scans and computer-aided design software. The models were then 3D printed using Fused-Filament-Fabrication (FFF) technology. A total of 170 undergraduate medical students participated in the study and were divided into three groups. Each group was assigned one of three learning aids: conventional X-ray, CT data, or a 3D-printed model. After learning about the fractures, students completed a questionnaire to assess their understanding of fracture mechanisms, ability to assign fractures to the AO classification, knowledge of surgical procedures, and perception of the teaching method as well as the influence of such courses on their interest in the specialty of trauma surgery. Additionally, students were tested on their ability to allocate postoperative X-ray images to the correct preoperative image or model and to classify them to the AO classification.

RESULTS

The 3D models were well received by the students, who rated them as at least equal or better than traditional methods such as X-ray and CT scans. Students felt that the 3D models improved their understanding of fracture mechanisms and their ability to explain surgical procedures. The results of the allocation test showed that the combination of the 3D model and X-ray yielded the highest accuracy in classifying fractures according to the AO classification system, although the results were not statistically significant.

CONCLUSION

The 3D-printed hands-on radius fracture model proved to be an effective teaching tool for enhancing students' understanding of fracture anatomy. The combination of 3D models with the traditional imaging methods improved students' ability to classify fractures and allocate postoperative images correctly.

The Pitfalls of Difficult Distal Radius Fractures and Provisional Reduction

Distal radius fractures are some of the most common injuries encountered in orthopedics and require careful consideration when determining the appropriate treatment options. These fractures can be difficult injuries to treat surgically based on a large variability of fracture patterns, bone quality, and anatomy. It is important to understand the potential pitfalls associated with the treatment of difficult distal radius fractures to prevent avoidable complications. Some of these pitfalls include but are not limited to appropriate surgical exposure and soft tissue handling, provisional reduction, fixation type, and augmentation of fracture fixation.

The use of a laminar spreader for the reduction of extra-articular distal radius fractures: A technical trick

Extra-articular distal radius fractures are often accompanied with shortening, loss of radial height, and radial displacement of the articular segment relative to the shaft of the radius, all seen in the coronal plane. Reduction can be somewhat challenging when reliance on traction and ligamentotaxis fails, especially in subacute or osteoporotic fractures. In this technical report, we describe a technique where application of a laminar spreader between the radius and the ulna in the metaphyseal region can easily reduce the fracture and help attain anatomic alignment in the coronal plane. An acute and a subacute fracture are shown for illustration of the technique.

Treatment outcomes of applying external fixator on distal radius fractures: a randomized clinical trial to compare between two directions of force exertion in parallel to radius shaft and perpendicular to the distal radius articular surface

BACKGROUND

External fixation has been one of the conventional managements of unstable distal radius fracture. The main aim of this paper is to compare two methods of applying distractive force along the radius shaft versus perpendicular to the distal radius articular surface.

DESIGN

Sixty patients with unstable distal radius fracture were included in present clinical trial and randomized in two groups, using block randomization method. In group A (first arm), distraction force was exerted parallel to the radius shaft. In group B (second arm), the external fixator was adjusted based on radial and palmar tilt of the mean population healthy wrist so that distraction was exerted perpendicular to the wrist articular surface.

METHODS

Radiological and clinical parameters were evaluated in both groups of patients pre-operatively, immediately after surgery, and 6 weeks post-operatively. We also followed up patients clinically at 12 weeks after surgery. Patient-Rated Wrist Evaluation (PRWE), Mayo wrist score, and Quick Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires were used in order to assess patients' clinical and functional states.

RESULTS

The method used in group B resulted in better improvement of palmar tilt both immediately (P = 0.007) and at 6 weeks follow up (P = 0.013) post-operatively in comparison with patients in group A. Radius height and radial inclination were also better restored when using the proposed modified method (P = 0.001 and < 0.001, respectively). There was no difference in any of clinical results (range of motion, grip strength, PRWE, Mayo, and DASH scores) between two groups of study, 12 weeks after surgery.

CONCLUSION

Applying distractive force perpendicular to the distal radius articular surface seems to improve some radiological outcomes, probably due to better reduction maintenance, when compared with the technique of applying distraction force along distal radius shaft axis.

LEVEL OF EVIDENCE

Level I (clinical trial study).

TRIAL REGISTRATION

This study is registered at Iranian Registry of Clinical Trials (IRCT) with approval code of IRCT20200313046759N1.

Use of Hand Therapy After Distal Radius Fracture: A National Perspective

PURPOSE

To assess whether certain distal radius fracture (DRF) patients, such as opioid users or complex regional pain syndrome (CRPS) patients, receive more hand therapy.

METHODS

Using the IBM MarketScan Research Databases from January 1, 2012, to December 31, 2016, we identified a cohort of DRF patients and created 4 subgroups of interest: frequent follow-up patients, persistent opioid users, prior opioid users, and patients with CRPS. We measured rates and demographic characteristics associated with therapy use in our populations of interest.

RESULTS

In this cohort of 87,313 patients, 21% received hand therapy after primary DRF treatment. Patients with CRPS had a higher rate of therapy than non-CRPS patients (44% vs 21%, respectively). Frequent follow-up patients used more therapy than those with less follow-up (30% vs 17%, respectively). Persistent opioid users demonstrated slightly increased therapy use compared to the remaining population (25% vs 22%, respectively). Prior opioid users underwent less therapy than patients without prior opioid use (19% vs 22%, respectively). Female sex, residing in the Northeast, being on a preferred provider organization plan, and having more intense surgical treatments were associated with increased therapy use.

CONCLUSIONS

This study showed variations in therapy use after DRF in subpopulations of interest. Patients with CRPS, persistent opioid use, and frequent follow-ups had higher rates of therapy. Patients with prior opioid use had lower rates of therapy.

CLINICAL RELEVANCE

Therapy is more common in patients with DRF with CRPS, persistent opioid use, or more follow-up visits.

Clinical Features and Surgical Strategies of Distal Radius Posttraumatic Deformity

Objective

To investigate the clinical features and surgical strategies of distal radius posttraumatic deformity.

Methods

A retrospective analysis was performed on the data of 30 patients with distal radius posttraumatic deformity treated by osteotomy and orthopedic surgery in the department of orthopedics, the First Affiliated Hospital of Nanjing Medical University, from February 2016 to November 2018. All the patients underwent preoperative anterior and lateral X-ray plain scanning of bilateral wrist joints, showing different degrees of radius shortening, inferior ulnar and radial mismatch, palmar angle, and ulnar deviation angle, among which 11 patients had an uneven joint surface. After a full evaluation, osteotomy and orthopedic surgery were performed to restore the original anatomical structure, plaster fixation was performed for two weeks after surgery, and regular outpatient follow-up was conducted. The function of the wrist was evaluated by the MMWS (wrist joint improvement) scoring scale before and after surgery, and the changes in the wrist joint-related treatment parameters were evaluated according to X-ray.

Results

All 30 patients had no neurological symptoms after surgery, and all wounds healed within the first stage. All patients were followed up for 6–12 months, with an average healing time of 3.5 months. There was no reduction loss, internal fixation loosening, or fracture in the regular postoperative review. Postoperative MMWS (wrist joint improvement) score scale data were significantly higher than those before surgery, and there were differences between groups (P < 0.05). Postoperative treatment parameters of wrist joints such as palmar inclination angle, ulnar deviation angle, radius height, and lower ulnar and radial matching were significantly improved, and there were differences between groups (P < 0.05).

Conclusions

The patients with distal radius posttraumatic deformity have the clinical characteristics of shortening of radius, mismatch of lower ulnar and radius, an abnormal inclination of palm, and ulnar declination. For patients with distal radius posttraumatic deformity, osteotomy and orthopedic surgery can effectively improve wrist function and improve patients' quality of life, which is worthy of clinical reference.

Post-arthrolysis rehabilitation in a patient with wrist stiffness secondary to distal radio-ulnar fracture: A case report

BACKGROUND

Arthrolysis is usually performed when stiffness has a disabling effect on quality of life and in cases where physiotherapy has not been effective. This report describes one patient with a chronic stiff wrist who underwent open arthrolysis. The purpose of this case report is to describe the rehabilitation following arthrolysis, in order to illustrate the effects of intensive physiotherapy for this patient.

CASE DESCRIPTION

A 54-year-old woman with chronic wrist stiffness secondary to a radio-ulnar fracture was described. The patient presented severe pain and unsatisfactory wrist range of motion and muscle strength almost 2 years after the traumatic event.

INTERVENTION

Post-arthrolysis rehabilitation was based on edema control, manual therapy, transcutaneous electrical nerve stimulation (TENS), static splinting and strengthening exercises. In addition, graded motor imagery and proprioceptive rehabilitation were included to address impaired motor control. Outcome measures of passive range of motion (PROM), active range of motion (AROM), grip and pinch strength, numeric rating scale (NRS), disability of the arm, shoulder and hand (DASH) and patient-rated wrist/hand evaluation (PRWHE) were recorded.

CONCLUSIONS

The outcomes of this case report suggest that arthrolysis combined with immediate and intensive physiotherapy were a suitable option for the treatment of post-traumatic wrist stiffness in this patient. The passive motion measured intraoperatively was maintained, while pain, functional active motion and strength were improved allowing for social reintegration.

Trends in the Incidence and Treatment of Distal Radius Fractures in the United States in Privately Insured and Medicare Advantage Enrollees

Background: This study aims to determine the trends in the treatment of distal radius fractures (DRFs) in patients aged 18 years and older. Methods: An administrative claims database of more than 100 million patients was used to identify patients aged 18 years and older with a DRF between 2005 and 2014. A total of 137 130 DRFs were identified in 135 128 patients. Results: The proportion and rate of fractures were more predominant in those aged 55 years and older compared with a decreasing incidence in patients younger than 55 years. Age-adjusted rates of surgical treatment have significantly increased in both women and men by 15.9% (absolute change, 4.8%) and 5.0% (absolute change, 1.7%) change over time, respectively. Conversely, age-adjusted rates of nonsurgical treatment have significantly decreased overtime in both women and men by 6.9% and 2.6%, respectively. Conclusions: These data provide better understanding of the epidemiology of DRF, which is important to develop preventive strategies targeting high-risk populations and to develop effective treatment strategies.

In vivo measurement of distal radioulnar translation following distal radius fracture

The incidence of distal radioulnar joint instability following a distal radius fracture is estimated around one in three based upon clinical examination. Using a validated rig, we objectively measured distal radioulnar joint translation in vivo following distal radius fracture. Dorsopalmar translation of the distal radioulnar joint was measured in 50 adults with previous distal radius fractures. Measurements were compared with the uninjured wrist and against a database of previous measurements within healthy and clinically lax populations. Translation at the distal radioulnar joint was greater in injured wrists at 12.2 mm (range 10-15, SD 1.2) than the uninjured wrists at 6.4 (range 4-9, SD 0.8) (p < 0.001) and was always outside the established normal range. There was no statistically significant link between translation and the severity of the injury. Instability appears almost inevitable following a distal radius (wrist) fracture, albeit subclinical in the vast majority.

Periarticular screws: what's in and what's out of the joint?

Periarticular hardware placement can be challenging and a source of angst for orthopaedic surgeons due to fear of penetrating the articular surface and causing undue harm to the joint. In recent years, many surgeons have turned to computed tomography (CT) and other intraoperative or postoperative modalities to determine whether hardware is truly extraarticular in areas of complex anatomy. Yet, these adjuncts are expensive, time consuming, and often unnecessary given the advancement in understanding of intraoperative fluoroscopy. We present a review article with the goal of empowering surgeons to leave the operating room, with fluoroscopy alone, assured that all hardware is beneath the articular surface that is being worked on. By understanding a simple concept, surgeons can extrapolate the information in this article to any joint and bony surface in the body. While targeted at both residents and surgeons who may not have completed a trauma fellowship, this review can benefit all orthopaedic surgeons alike.

Origins of the threshold for surgical intervention in intra-articular distal radius fractures

AIMS

The aim of this study was to identify the origin and development of the threshold for surgical intervention, highlight the consequences of residual displacement, and justify the importance of accurate measurement.

METHODS

A systematic review of three databases was performed to establish the origin and adaptations of the threshold, with papers screened and relevant citations reviewed. This search identified papers investigating functional outcome, including presence of arthritis, following injury. Orthopaedic textbooks were reviewed to ensure no earlier mention of the threshold was present.

RESULTS

Knirk and Jupiter (1986) were the first to quantify a threshold, with all their patients developing arthritis with > 2 mm displacement. Some papers have discussed using 1 mm, although 2 mm is most widely reported. Current guidance from the British Society for Surgery of the Hand and a Delphi panel support 2 mm as an appropriate value. Although this paper is still widely cited, the authors published a re-examination of the data showing methodological flaws which is not as widely reported. They claim their conclusions are still relevant today; however, radiological arthritis does not correlate with the clinical presentation. Function following injury has been shown to be equivalent to an uninjured population, with arthritis progressing slowly or not at all. Joint space narrowing has also been shown to often be benign.

CONCLUSION

Knirk and Jupiter originated the threshold value of 2 mm. The lack of correlation between the radiological and clinical presentations warrants further modern investigation. Measurement often varies between observers, calling a threshold concept into question and showing the need for further development in this area. The principle of treatment remains restoration of normal anatomical position. Cite this article: Bone Joint J 2021;103-B(9):1457-1461.

Distal Radius Fractures: Recognizing and Treating Complex Fracture Patterns

Volar fixed-angle plate fixation is a commonly used treatment modality for distal radius fractures. However, not all fracture patterns are amenable to this type of fixation strategy. In this article, we review pertinent anatomy and radiographic landmarks that together highlight key differences when considering treatment strategies for complex distal radius fractures.

Quality of life after distal radius fractures

Introduction: Distal radius fractures (DRFs) are among the most commonly seen types of fractures worldwide. Numerous studies suggested that surgical treatment of DRFs results in better quality of life. Objectives: The aim of this study was to assess long-term quality of life after operative and nonoperative treatment of distal radius fractures among adults. Material and methods: We retrospectively studied 207 patients with isolated DRF (mean age 64 ±17.9 years, women comprised 150 (72.5%), men 57 (27.5%). There were no significant differences in sex, age, hand dominancy, energy of trauma, AO type fracture and comorbidities between patients treated operatively (n=101) and nonoperatively (n=106). After 3.9 ±1.6 years (mean ±SD) quality of life assessment was conducted using Short Form Health Survey (SF-36) and International Osteoporosis Foundation Quality of Life Questionnaire (IOF QLQ). Functional outcomes were evaluated using Disabilities of the Arm, Shoulder and Hand (DASH) and Patient Rated Wrist Evaluation (PRWE) questionnaires. Results: Quality of life in operatively treated distal radius fracture patients was better than amongst those treated nonsurgically. However, after subdivision of cohorts we observed no such differences regardless of treatment method in patients aged ≥ 50 years. SF-36 and IOF QLQ scores were correlated with DASH and PRWE results. Conclusions: Quality of life questionnaires are useful tools for determining outcomes after distal radius fractures. Operative treatment may not always be superior to nonoperative management especially in patients aged 50 years or above with distal radius fractures.

Myelomeningocele: a new functional classification

PURPOSE

In myelomeningocele, several classifications have been used. The present manuscript proposes a new functional classification to better assess the prognosis and management of these patients.

METHODS

The manual muscle test is what defines the actual group in which the patient should be included. Furthermore, this new classification brings information about the bracing and external supports recommended to each functional level. We also recommend that the patient's Functional Mobility Scale should always be mentioned together with their functional level.

RESULTS

The four levels in this classification are MMFC1, MMFC2, MMFC3 and MMFC4. The MMFC1 group includes patients with significant muscle weakness. They need to use high braces crossing the hip joint with a walker to achieve some ambulation. The MMFC2 group includes patients who have functional hip flexors, knee extensors and knee flexors. However, the hip abductors are quite weak. These patients usually need to use a walker - or crutches - and Ankle-Foot Orthosis (AFOs). The MMFC3 group includes patients with functional hip flexors, knee extensors, knee flexors and hip abductors. However, the ankle plantar flexion function is absent. Most of them are able to walk independently, only using AFOs without any external support. The MMFC4 group includes patients who have preserved function in the entire lower limb musculature. These patients don't need any assistive devices to achieve an adequate ambulation pattern.

CONCLUSIONS

We hope that this new classification is a system that is simple to understand, serves as a gait prognosis guide and facilitates communication among healthcare professionals.

LEVEL OF EVIDENCE

V.

Biodegradable metals for bone fracture repair in animal models: a systematic review

Biodegradable metals hold promises for bone fracture repair. Their clinical translation requires pre-clinical evaluations including animal studies, which demonstrate the safety and performance of such materials prior to clinical trials. This evidence-based study investigates and analyzes the performance of bone fractures repair as well as degradation properties of biodegradable metals in animal models. Data were carefully collected after identification of population, interventions, comparisons, outcomes and study design, as well as inclusion criteria combining biodegradable metals and animal study. Twelve publications on pure Mg, Mg alloys and Zn alloys were finally included and reviewed after extraction from a collected database of 2122 publications. Compared to controls of traditional non-degradable metals or resorbable polymers, biodegradable metals showed mixed or contradictory outcomes of fracture repair and degradation in animal models. Although quantitative meta-analysis cannot be conducted because of the data heterogeneity, this systematic review revealed that the quality of evidence for biodegradable metals to repair bone fractures in animal models is 'very low'. Recommendations to standardize the animal studies of biodegradable metals were proposed. Evidence-based biomaterials research could help to both identify reliable scientific evidence and ensure future clinical translation of biodegradable metals for bone fracture repair.

Radial Plate Fixation of Distal Radius Fracture

Background: A radial incision with radial plate fixation for distal radius fracture has historically been avoided due to its risk to the superficial branch of the radial nerve (SBRN). With careful technique, it is possible to avoid injury to the SBRN, thereby minimizing the soft tissue injury associated with other approaches. We compare subjective and objective functional outcomes of radial plate fixation surgeries that we performed with those of dorsal and volar plate fixation in current literature. Methods: Patients at a single center who underwent radial plate fixation for an AO type A or AO type B distal radius fracture between December 2006 and December 2014 were enrolled in the study. Postoperative grip strength and 3-digit pinch strength were measured systematically in the injured and uninjured wrists. Patients also completed a Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire to assess subjective outcomes. Results: Thirty-six patients met our inclusion criteria and had available medical records. Postoperative grip strength in the injured wrist was significantly lowered-68% compared with the uninjured wrist. After subgroup analysis of dominant and nondominant wrist injuries, there was no significant difference in grip strength between injured and uninjured wrists. There was no significant decrease in postoperative 3-digit pinch strength in the injured wrist-89% compared with the uninjured wrist. The mean QuickDASH score for our study participants was 20.9. Conclusions: Radial plate fixation is an effective approach for distal radius fractures. Objective and subjective outcomes are noninferior to those of a dorsal or volar approach.

Adhering to Radiographic Clinical Practice Guidelines for Distal Radial Fracture Management Is Associated with Improved Outcomes and Lower Costs

BACKGROUND

The American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the Treatment of Distal Radius Fractures has not been evaluated in clinical practice. We hypothesized that adhering to the distal radial fracture radiographic clinical practice guideline (CPG) improves outcomes and reduces costs.

METHODS

We reviewed 266 patients with distal radial fractures treated at 1 institution. Based on CPG radiographic parameters (Recommendation 3), care was rated as "appropriate" or "inappropriate." QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire) scores were collected. The direct costs of distal radial fracture care were determined. Descriptive statistics and nonparametric tests were used to evaluate demographic characteristics and outcomes across groups. QuickDASH scores, grouped by postoperative time interval, were analyzed using linear mixed effect models to predict outcome trends.

RESULTS

In this study, 145 patients in the operative treatment group and 121 patients in the nonoperative treatment group were included. Of the 145 patients in the operative treatment group, 6 underwent an inappropriate surgical procedure, limiting any analyses of that group. Of the 121 patients in the nonoperative treatment group, 68 were treated inappropriately. For the patients in the nonoperative treatment group, appropriate care provided a significant outcome benefit by 1 year; the median QuickDASH score was 10.1 points for the appropriate treatment group and 19.5 points for the inappropriate treatment group (p = 0.05). The total direct costs for inappropriate nonoperative treatment were, on average, 60% higher than appropriate nonoperative treatment. In predictive models, patients with appropriate care in the operative treatment group and the nonoperative treatment group had better outcomes than patients with inappropriate nonoperative treatment at all time points after 29 days.

CONCLUSIONS

When nonoperative distal radial fracture management was aligned with radiographic CPG criteria, patients in our cohort had improved patient-reported outcomes with lower costs.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Management of distal radius fracture: A comparison of actual and theoretical treatments

PURPOSE

The objective of this study was to explore whether there were any differences between the theoretical operative treatment of distal radius fractures according to AAOS guideline on basis of measurement of radiographs and the treatment they actually received in our institution.

METHODS

From April 2015 to February 2018, a total of 693 patients with 697 fresh close adult distal radius fractures were evaluated retrospectively. Fractures were respectively grouped into categories by AAOS criterion and actually treatment. After gleaning demographic information and measuring radiographic items, all results were put into a database. Single factors analysis, Chi-square test and further logistic regression analysis were performed to determine correlations between actual and theoretical treatments.

RESULTS

In all 240 fractures fulfilled at least one AAOS criterion for surgery, only 61 fractures actually received operation. And in the conservative group recommended by AAOS, 52 of 457 fractures actually were proceeded with surgery. There were slight correlation between AAOS guideline and actually operation (Phi = 0.181). From multivariable logistic regression analysis, Only one of three AAOS criterion was proved probable indicator of clinic treatment. Three factors, namely age, intra-articular step-off as well as with other fractures, were proved probable actually surgery indications (P < 0.05).

CONCLUSIONS

AAOS surgery criteria of distal radius fractures were partially instructive, but not so precise predictors for actually operation. In the clinic, the choice of operative treatment correlated with multiple factors.

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.

Restoring Volar Tilt in AO Type C2 Fractures of the Distal Radius With Unilateral External Fixation

PURPOSE

To determine whether unilateral external fixation using a staged multiplanar reduction technique restores anatomic volar tilt in a distal radius fracture model.

METHODS

We used radiographic images to obtain baseline measurements in 20 fresh-frozen cadaveric wrists. Through a standard dorsal approach to the radius, we performed osteotomies to simulate displaced AO/ASIF type C2 fractures. After placement of a unilateral external fixator, a stepwise technique of applying longitudinal traction followed by a volar translational maneuver was performed. Radiographic imaging was obtained after each step of the multiplanar reduction technique.

RESULTS

Standard longitudinal traction did not restore volar tilt angles to their baseline measurements. The addition of a volar translation maneuver had a significant effect on restoring baseline volar tilt. There was a statistically significant difference in volar tilt measurements between straight longitudinal traction and volar translation. Radial inclination, radial height, and ulnar variance did not differ significantly between longitudinal traction and the addition of volar translation.

CONCLUSIONS

A criticism of traditional external fixation is the inability of longitudinal ligamentotaxis to attain sagittal plane (volar tilt) reduction of the articular surface. This study demonstrates that a multiplanar reduction technique using unilateral external fixation devices on cadaveric distal radius fractures can achieve an acceptable reduction.

CLINICAL RELEVANCE

External fixation of distal radius fractures may be favorable in situations where soft tissue loss, wound contamination, and comorbid medical factors preclude the use of internal fixation techniques. A multiplanar reduction technique using a unilateral external fixation device may facilitate fracture reduction in acceptable alignment.

Fixation of intra-articular fractures of the distal radius using intramedullary nailing: a randomized trial versus palmar locking plates

BACKGROUND

Proposed benefits of intramedullary techniques include limited soft tissue dissection while affording sufficient stability to allow early wrist motion. The primary null hypothesis of this randomized trial was that there is no significant difference with respect to functional outcome, pain and disability between patients treated with either 2.4-mm volar locking plate fixation or intramedullary nail fixation of intra-articular fractures of the distal radius.

METHODS

We conducted a single-centre, prospective randomized matched-pairs trial. Patients with intraarticular distal radius fractures with metaphyseal comminution and a sagittal fracture line (AO 23 C2.1) were randomized to receive volar locking plate fixation (n = 14) or intramedullary nailing (n = 14). The outcome was measured on the basis of the Gartland and Werley and Castaing score; the pain level; the range of wrist motion; the rate of complications; and radiographic measurements including volar tilt and ulnar variance. Clinical and radiographic assessment was performed at 8 weeks and 2 years after the operation.

RESULTS

There were no significant differences between groups in terms of range of motion, grip strength or the level of pain at eight weeks. At the final follow up, patients in the nail group had regained more extension than in the plate group (98% of the unaffected side vs. 94%, this however, did not reach significance). Reduction was maintained in both groups; however volar tilt and ulnar variance were significantly better in the plate group. There was no significant difference in the complication rate between groups.

CONCLUSION

The present study suggests that intramedullary nail fixation is a reasonable alternative to volar plate fixation for the treatment of intra-articular distal radius fractures and both techniques can yield reliably good results.

Determinants of Functional Outcome in Distal Radius Fractures in High-Functioning Patients Older Than 55 Years

OBJECTIVES

To determine the influence of treatment and radiographic parameters on patient-reported functional outcomes on a population of non-frail elderly with distal radius fractures.

DESIGN

Prospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Patients older than 55 years presenting with a distal radius fracture and a Canadian Study of Health and Aging Clinical Frailty Scale score of 1 or 2.

INTERVENTION

Closed reduction and casting or open reduction and internal fixation as per the treating surgeons' decision.

MAIN OUTCOME MEASURES

Radiographic scores at baseline, 6 weeks, and 12 weeks, as well as Disabilities of the Arm, Shoulder and Hand, Short Form 36, and Patient-Reported Wrist Evaluation scores up to 1 year after injury. Univariate analysis and linear regression analysis were performed on outcome measures.

RESULTS

No difference exists in outcomes based on treatment choice. Patients with ulnar positivity greater than 2 mm at baseline, after treatment, and at final follow-up had worse patient-reported scores at 1 year. Persistent articular gaps and/or steps greater than 2 mm after treatment were also associated with worse patient-reported outcomes.

CONCLUSION

Even in high-functioning patients older than 55 years, there was no difference in patient-reported outcomes at 1 year in the open reduction group as compared with the closed reduction group. Instead, physicians should pay particular attention to radial shortening and persistent articular gaps following their chosen treatment plan for distal radial fractures.

LEVEL OF EVIDENCE

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

Development and Assessment of a Distal Radial Fracture Model as a Clinical Teaching Tool

BACKGROUND

Simulation-based learning is increasingly prevalent in the curricula of many surgical training programs. Newly developed simulators must undergo rigorous validity testing before they are used to assess and evaluate surgical trainees. We describe the development of a model that simulates a distal radial fracture requiring closed reduction and cast application and demonstrate its validity.

METHODS

We developed a model for simulated treatment of a distal radial fracture with use of a modified Sawbones forearm. Ten junior and ten senior orthopaedic residents were videotaped performing a closed reduction and applying a cast on the model. After each procedure, standard anteroposterior and lateral radiographs of the forearm model were obtained. Two blinded orthopaedic surgeons then rated each resident using a task-specific checklist (Objective Structured Assessment of Technical Skills [OSATS]) and a global rating scale (GRS) as well as radiographic measurements of palmar tilt and three-point index.

RESULTS

Compared with the junior residents, senior residents had significantly higher OSATS (p < 0.001) and GRS scores (p < 0.001). The groups did not differ significantly with respect to radiographic palmar tilt (p = 0.86) and three-point index (p = 0.43). All residents were able to restore anatomical alignment, with a mean palmar tilt of 9.1°. In addition, the mean three-point index of all residents was acceptable (0.76). There was a strong correlation between OSATS and GRS scores (r > 0.87; p < 0.01). The inter-rater reliability was high (≥ 0.79) for the OSATS, GRS, and radiographic measurements.

CONCLUSIONS

We developed an educational model that simulates a distal radial fracture requiring closed reduction and cast application. We demonstrated construct validity, as the GRS and OSATS tools were able to differentiate senior from junior residents. We were unable to differentiate trainees using radiographic assessment, as all residents restored anatomical alignment and had comparable three-point index scores.

Osteosynthesis in Distal Radius Fractures with Conventional Bridging External Fixator; Tips and Tricks for Getting Them Right

BACKGROUND

Distal radius fractures are the commonest fractures occurring in the upper extremity, accounting for 15-20% of patients treated in emergency department. Although distal radial fractures were described 200 years ago, they still remain as unsolved fractures with no clear guidelines. It is often reported that anatomical reduction has a bearing on the functional outcome.

AIM

To study the management of distal end radius fracture by utilizing the principle of ligamentotaxis where in the reduction obtained by closed means is maintained by external fixator till solid bony union occurs.

MATERIALS AND METHODS

A total of 26 cases were selected for study by scrutiny of the inclusion and exclusion criteria. Most of our cases were treated with external fixator within 8 hrs of injury. Small A.O external fixator (bridging ex-fix) with 2 pins each in radius and 2(nd) metacarpal percutaneously was used for all the cases. Selective k wire fixation was done in cases of instability. Fixator was removed after 6 weeks. Guided physiotherapy was ensured in all the cases. Patients were followed up for an average of 9 months.

RESULTS

Modified Gartland and Werley scoring system was used to evaluate the overall functional results. Excellent to good results were achieved in 88.45% of our cases while fair result was in 11.54 %. One case had pin loosening and two other cases had malunion.

CONCLUSION

External fixator used for ligamentotaxis is an effective method of treating unstable extraarticular and complex intraarticular fractures of distal radius. Improved anatomical restoration with early rehabilitation has produced favourable functional outcome in our series. The complications like pin tract infection is rare due to the availability of superior antibiotics and sterile surgical technique. complications like wrist and finger stiffness has improved with physiotherapy.

Treatment of unstable distal radius fractures: non-invasive dynamic external fixator versus volar locking plate - functional and radiological outcome in a prospective case-controlled series

Introduction: Distal radius fracture (DRF) is a common injury and various treatment modalities including open reduction and internal fixation (ORIF) with volar locking plate are available. More recently, a non-invasive external fixator has been used.

Aims: To prospectively compare the use of a non-invasive external fixator with early dynamisation for DRF against ORIF with volar locking plate control group.

Methods: Consecutive patients with closed DRF were included in a prospective case-controlled study. Patients were assigned to non-invasive external fixator or ORIF. Minimum follow-up was two years. Follow-up was at weeks 2, 4, 6, 8, 12, 26 and at one and two-year post-operatively. The outcome measures included demographic details, injury mechanism, AO fracture type, risk factors, body mass index (BMI), ulnar styloid fracture and dorsal comminution, radiographs, grip strength and DASH score.

Results: Consecutive 50 patients were treated either with non-invasive external fixator (25/50) or with ORIF (25/50) and the mean age of the two groups was 53 years (SD 17.1) and 49 years (SD 19.5), respectively. Demographics were matched in two groups. In the non-invasive external fixator group, there were 10 AO Type-A, 5 Type-B and 10 Type-C fractures. The ORIF group included 8 Type-A, 6 Type-B and 11 Type-C fractures. The mean DASH score at three-months and one-year post-injury in non-invasive fixator group was 12.2 (SD 3.1) and 3.5 (SD 0.7), respectively, significantly greater than those of ORIF group 14.5 (SD 5.6) and 11.2 (SD 4.4), respectively (p < 0.05).

Conclusion: DRF treated with non-invasive external fixator can give functional results superior to ORIF at three-months and the trend is maintained at one and two-year post-operatively.

A Brachioradialis Splitting Approach Sparing the Pronator Quadratus for Volar Plating of the Distal Radius

Fractures of the distal radius account for up to 15% of all extremity fractures. Volar plating has become more popular, as it allows locking plate technology to be applied. Traditionally, access to the volar radius has been achieved through the approach of Henry using the interval between flexor carpi radialis and the radial artery, involving incising the radial border of the pronator quadratus (PQ). With this approach, PQ repair is difficult, and when attempted is often incomplete or tenuous, as it is a direct muscle-to-muscle repair. Theoretical advantages of repairing the PQ include the provision of plate coverage, a protective gliding layer, a well-vascularized coverage of the fracture fragments, and a protective barrier against deep infection in the case of superficial infection. Techniques have been developed to try and improve on the Henry approach. We have developed a surgical approach to volar plating that utilizes the anatomic relationship between brachioradialis and PQ in a way that allows simple and stable reattachment of the PQ muscle. We have termed the technique the "Brachioradialis splitting" approach. We present it here.

Management of complications of distal radius fractures

Treating a fracture of the distal radius may require the surgeon to make a difficult decision between surgical treatment and nonsurgical management. The use of surgical fixation has recently increased because of complications associated with conservative treatment. However, conservative action may be necessary depending on certain patient factors. The treating surgeon must be aware of the possible complications associated with distal radius fracture treatments to prevent their occurrence. Prevention can be achieved with a proper understanding of the mechanism of these complications. This article discusses the most recent evidence on how to manage and prevent complications following a fracture of the distal radius.

Radiographs Versus Radiographic Measurements in Distal Radius Fractures

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

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level II. Therapeutic study.

The IDEAL classification system: a new method for classifying fractures of the distal extremity of the radius - description and reproducibility

CONTEXT AND OBJECTIVE There is no consensus concerning which classification for distal radius fractures is best and the existing methods present poor reproducibility. This study aimed to describe and assess the reproducibility of the new IDEAL classification, and to compare it with widely used systems. DESIGN AND SETTING Reproducibility study, Hand Surgery Section, Universidade Federal de São Paulo. METHODS The IDEAL classification and its evidence-based rationale are presented. Sixty radiographs (posteroanterior and lateral) from patients with distal radius fractures were classified by six examiners: a hand surgery specialist, a hand surgery resident, an orthopedic generalist, an orthopedic resident and two medical students. Each of them independently assessed the radiographs at three different times. We compared the intra and interobserver concordance of the IDEAL, AO, Frykman and Fernandez classifications using Cohen's kappa (κ) (for two observers) and Fleiss's κ (for more than two observers). RESULTS The concordance was high for the IDEAL classification (κ = 0.771) and moderate for Frykman (κ = 0.556), Fernandez (κ = 0.671) and AO (κ = 0.650). The interobserver agreement was moderate for the IDEAL classification (κ = 0.595), but unsatisfactory for Frykman (κ = 0.344), Fernandez (κ = 0.496) and AO (κ = 0.343). CONCLUSION The reproducibility of the IDEAL classification was better than that of the other systems analyzed, thus making the IDEAL system suitable for application. Complementary studies will confirm whether this classification system makes adequate predictions for therapy and prognosis.

Articular cartilage skiving: the concept defined

'Skiving' is commonly used to refer to the condition when the subchondral plate is disrupted and the overlying cartilage physically displaced without the screw tip entering the joint. In this study we sought to define radiographic parameters of skiving and compare radiographs with computed tomography (CT) for accuracy in determining joint skiving. Cadaveric specimens of the distal radius were implanted with a volar plate and screws. Arthrotomies were performed to definitively assess the positions of the screws. Standard and anatomic tilt radiographs as well as CT were performed. Orthopaedic surgeons and radiologists evaluated the images and reported whether screw penetration or skiving had occurred. For screws which penetrated or skived, measurements were made to record the distances from the screw tips to the subchondral plate. Sensitivity, specificity and percent correct interpretations were 53%, 83%, 60% respectively for radiographs; and 100%, 72%, 69% for CT. Screws penetrating the articular surface protruded an average 2.3 mm (range 2-2.6 mm) from the subchondral plate and those skiving protruded 1.4 mm (range 1-1.8 mm). This study shows that articular skiving can occur with penetration of the subchondral plate of up to 1.8 mm. CT has a greater sensitivity and lower specificity in determining skiving compared to radiographs.

Who is lost to followup?: a study of patients with distal radius fractures

Distal radius fractures are the most common upper extremity fracture, representing one-sixth of all fractures treated in emergency departments nationwide. Beyond the initial reduction and immobilization of these fractures, providing proper followup to ensure maintenance of the reduction and identify complications is necessary for optimal recovery of forearm and wrist functions. We sought to identify the clinical and demographic factors that characterize patients with distal radius fractures who do not return for followup and to assess the underlying causes for their poor followup rates. Compared with patients who were compliant with followup, those lost to followup had lower Physical and Mental Health scores on the SF-36 forms, more often were treated nonoperatively, and more likely had not surpassed secondary education. However, we found no difference between these two groups based on age, gender, mechanism of injury, marital status, or hand dominance. Early identification of patients who potentially are noncompliant can result in additional measures being taken to ensure the patient's return to the treating hospital and physicians. This in turn will prevent complications attributable to lack of followup and allow more accurate assessment of results, thereby improving patient outcomes.