Non-operative treatment of displaced distal radius fractures leads to acceptable functional outcomes, however at the expense of 40% subsequent surgeries

Delayed fixation of distal radial fractures beyond three weeks after initial failed closed reduction increases the odds of reoperation

Aims

We aimed to compare reoperations following distal radial fractures (DRFs) managed with early fixation versus delayed fixation following initial closed reduction (CR).

Methods

We used administrative databases in Ontario, Canada, to identify DRF patients aged 18 years or older from 2003 to 2016. We used procedural and fee codes within 30 days to determine which patients underwent early fixation (≤ seven days) or delayed fixation following CR. We grouped patients in the delayed group by their time to definitive fixation (eight to 14 days, 15 to 21 days, and 22 to 30 days). We used intervention and diagnostic codes to identify reoperations within two years. We used multivariable regression to compare the association between early versus delayed fixation and reoperation for all patients and stratified by age (18 to 60 years and > 60 years).

Results

We identified 14,960 DRF patients, 8,339 (55.7%) of whom underwent early surgical fixation (mean 2.9 days (SD 1.8)). In contrast, 4,042 patients (27.0%) underwent delayed fixation between eight and 14 days (mean 10.2 days (SD 2.2)), 1,892 (12.7%) between 14 and 21 days (mean 17.5 days (SD 1.9)) and 687 (4.6%) > 21 days (mean 24.8 days (SD 2.4)) post-fracture. Patients who underwent delayed fixation > 21 days post-fracture had a higher odds of reoperation (odds ratio (OR) 1.33 (95% CI 1.11 to 1.79) vs early fixation). This worsened for patients aged > 60 years (OR 1.69 (95% CI 1.11 to 2.79)). We found no difference in the odds of reoperation for patients who underwent delayed fixation within eight to 14 or 15 to 21 days post-fracture (vs early fixation).

Conclusion

These data suggest that DRF patients with fractures with unacceptable reduction following CR should be managed within three weeks to avoid detrimental outcomes. Prospective studies are required to confirm these findings.

Evaluating the physico-chemical properties of water-based and 2% lidocaine hydrochloride-based aluminum-free glass polyalkenoate cements for distal radius fixation

Lidocaine hydrochloride is used as an anesthetic for clinical applications. This study considers the effects of the substitution of 2% lidocaine hydrochloride for deionized (DI) water on the rheological, mechanical, ion release, pH and injectable properties of two formulations of aluminum-free glass polyalkenoate cements (GPCs) using two distinct poly(acrylic) acids (PAA), E9 and E11, which have different molecular weights (Mw). The substitution of 2% lidocaine hydrochloride demonstrated increased injectability, but did not affect mechanical properties. The mechanical properties increased with time, as expected, and, in general, E9-based GPCs displayed significantly higher strengths over E11-based GPCs. With respect to ion release, which includes calcium (Ca), strontium (Sr), zinc (Zn) and silicon (Si); all ions displayed a steady and consistent increased release over time. Ca and Sr showed similar ion release patterns, whereby the GPC made with E11 PAA and lidocaine hydrochloride released significantly more ions than all other compositions likely due to similar chemical kinetics. However, Zn is also divalent in nature, but displayed only one significant difference across the GPC series at all time points, which was attributed to its higher electronegativity allowing for increased participation in the setting reaction. Finally, an analysis of the pH confirmed an increase in pH with time, suggesting that H+ ions were attacking the glass structure to allow for ion release. After 1 and 7 days, water-based GPCs environments achieved a higher pH than lidocaine hydrochloride-based GPCs, indicating that the lidocaine hydrochloride may be releasing additional protons upon bond formation with PAA.

Percutaneous treatment of type C distal radius fractures using dual-external fixator

BACKGROUND

This study aimed to introduce a potential alternative percutaneous treatment for AO types C1, C2, and C3 distal radius fractures using dual-external fixator (a no-bridging cemented-pin frame and a conventional wrist-bridging external fixator).

MATERIALS AND METHODS

From January 2018 to January 2021, 52 patients (52 distal radius fractures) were treated with dual-external fixator. For comparison, 61 patients (61 distal radius fractures) were treated with a plate and screw system. Wrist function was assessed using the Mayo Wrist Score. Patient satisfaction was assessed using the Short Assessment of Patient Satisfaction. A P < 0.05 was considered statistically significant.

RESULTS

Fracture healing was achieved in all patients. At the final follow-up of 29 months (range, 24-34 months) vs 36 months (range, 26-39 months) (P > 0.05), the patients treated with dual-external fixator and a plate and screw system achieved mean ulnar deviations of 31° vs 29° (P < 0.05), mean Mayo Wrist Scores of 91.12 ± 5.98 vs 88.12 ± 7.54 (P < 0.05), and mean patient satisfaction scores of 23.42 ± 2.47 vs 23.04 ± 2.32 (P > 0.05).

CONCLUSIONS

AO types C1, C2, and C3 distal radius fractures can be treated successfully using dual-external fixator. The technique is a potential alternative in addition to the conventional treatments.

LEVEL OF EVIDENCE

Level IIa.

Variations in Treatment and Costs for Distal Radius Fractures in Patients Over 55 Years of Age: A Population-Based Study

Objective  To evaluate the rate of surgery for symptomatic malunion after nonoperatively treated distal radius fractures in patients aged 55 and above, and to secondarily report differences in demographics, geographical variation, and utilization costs of patients requiring subsequent malunion correction. Methods  We identified patients aged 55 and above who underwent nonoperative treatment for a distal radius fracture between 2007 and 2016 using the IBM MarketScan database. In the nonoperative cohort, we identified patients who underwent malunion correction between 3 months and 1 year after distal radius fracture. The primary outcome was rate of malunion correction. Multivariable logistic regression controlling for sex, region, and Elixhauser Comorbidity Index (ECI) was used. We also report patient demographics, geographical variation, and utilization cost. Results  The rate of subsequent malunion surgery after nonoperative treatment was 0.58%. The cohort undergoing malunion surgery was younger and had a lower ECI. For every 1-year increase in age, there was a 6.4% decrease in odds of undergoing surgery for malunion, controlling for sex, region, and ECI (odds ratio = 0.94 [0.93-0.95]; p  < 0.01). The southern United States had the highest percentage of patients initially managed operatively (30.7%), the Northeast had the lowest (22.0%). Patients who required a malunion procedure incurred higher costs compared with patients who did not ($7,272 ± 8,090 vs. $2,209 ± 5,940; p  < 0.01). Conclusion  The rate of surgery for symptomatic malunion after initial nonoperative treatment for distal radius fractures in patients aged 55 and above is low. As younger and healthier patients are more likely to undergo malunion correction with higher associated costs, surgeons may consider offering this cohort surgical treatment initially.

The hematoma block is not enough as method of anesthesia in reduction of displaced distal radius fractures

BACKGROUND

Two out of three wrist fractures seen in the emergency are displaced but most can be treated conservatively after closed reduction. Patient-reported pain during closed reduction of distal radius fractures varies widely and the best method to decrease the perceived pain has not been well established. The purpose of this study was to assess the pain during closed reduction of distal radius fractures after using the hematoma block as method of anaesthesia.

PATIENTS AND METHODS

Cross-sectional clinical study including all patients who presented an acute fracture of the distal radius requiring closed reduction and immobilization during a six-month period in two University Hospitals. Demographic data, fracture classification, perceived pain using a visual analog scale at different times of reduction and complications were registered.

RESULTS

Ninety-four consecutive patients were included. Mean age was 61 years. Mean pain score at initial assessment was 6 points. After the hematoma block, the perceived pain during the reduction manoeuvre improved to 5.1 points at the wrist, but increased to 7.3 points at the fingers. Pain decreased to 4.9 points during cast placement and reached 1.4 point after sling placement. The reported pain was higher in women at all times. There were no significant differences according to the according to the type of fracture. No neurological or skin complications were observed.

CONCLUSIONS

The hematoma block is only a mild effective method to reduce the wrist pain during closed reduction of distal radius fractures. This technique decreases slightly the perceived pain in the wrist and does not reduce the pain in the fingers. Other reduction methods or other analgesic techniques may be more effective options.

LEVEL OF EVIDENCE

Therapeutic study. Cross-sectional study - Level IV.

[Translated article] The haematoma block is not enough as method of anaesthesia in reduction of displaced distal radius fractures

BACKGROUND

Two out of three wrist fractures seen in an emergency department are displaced but most can be treated conservatively after closed reduction. Patient-reported pain during closed reduction of distal radius fractures varies widely and the best method to decrease the perceived pain has not been well established. The purpose of this study was to assess pain during closed reduction of distal radius fractures after using haematoma block as method of anaesthesia.

PATIENTS AND METHODS

Cross-sectional clinical study including all patients who presented an acute fracture of the distal radius requiring closed reduction and immobilisation during a six-month period in two University Hospitals. Demographic data, fracture classification, perceived pain using a visual analogue scale at different times of reduction and complications were registered.

RESULTS

Ninety-four consecutive patients were included. Mean age was 61 years. Mean pain score at initial assessment was 6 points. After the haematoma block, the perceived pain during the reduction manoeuvre improved to 5.1 points at the wrist, but increased to 7.3 points at the fingers. Pain decreased to 4.9 points during cast placement and reached 1.4 point after sling placement. The reported pain was higher in women at all times. There were no significant differences according to the according to the type of fracture. No neurological or skin complications were observed.

CONCLUSIONS

Haematoma block is only a mildly effective method to reduce wrist pain during closed reduction of distal radius fractures. This technique slightly decreases the perceived pain in the wrist and does not reduce the pain in the fingers. Other reduction methods or other analgesic techniques may be more effective options.

LEVEL OF EVIDENCE

Therapeutic study. Cross-sectional study - Level IV.

If at first you don't succeed, should you try again? The efficacy of repeated closed reductions of distal radius fractures

INTRODUCTION

A repeated closed reduction ("re-reduction") of a displaced distal radius fracture is a common procedure performed to obtain satisfactory alignment and avoid surgery when the initial reduction is deemed unsatisfactory. However, the efficacy of re-reduction is unclear. Compared to a single closed reduction, does a re-reduction of a displaced distal radius fracture: (1) improve radiographic alignment at the time of fracture union and, (2) decrease the rate of operative intervention?

MATERIALS AND METHODS

Retrospective cohort analysis of 99 adults aged 20-99 years with extra-articular or minimally displaced intra-articular, dorsally angulated, displaced distal radius fracture with or without an associated ulnar styloid fracture who underwent a re-reduction, compared against 99 adults matched for age and sex who were managed with a single reduction. Exclusion criteria were skeletal immaturity, fracture-dislocation and articular displacement greater than 2 mm. Outcome measures included radiographic alignment at fracture union and rate of surgical intervention.

RESULTS

At 6-8 weeks follow-up, the single reduction group had greater radial height (p = 0.045, CI 0.04 to 3.57), and less ulnar variance (p < 0.001, CI - 3.08 to - 1.00) compared to the re-reduction group. Immediately following re-reduction, 49.5% of patients met radiographic non-operative criteria, but by 6-8 weeks follow-up, only 17.5% of patients continued to meet these criteria. Patients in the re-reduction group were treated with surgery 34.3% of the time, compared to 14.1% of the time for patients in the single reduction group (p = 0.001). In patients aged under 65 years, 49.0% of those who underwent a re-reduction were managed with surgery, compared to 21.0% of those who had a single reduction (p = 0.004).

CONCLUSION

A re-reduction performed to improve radiographic alignment and avoid surgical management in this subset of distal radius fractures had minimal value. Alternative treatment options should be considered before attempting a re-reduction.

The Relation between the Radial Collapse and the Number of Metaphyseal Screws for Distal Radius Fractures

Introduction

The purpose of this study is the evaluation of radial collapse, based on the number of screws used in the metaphyseal region and by distal dorsal distance (DDD) and lunate facet distance (LFD) measurement.

Materials and methods

Between 2015 and 2019, 60 patients who were being treated with volar locking plates due to isolated distal radius fracture were evaluated. Control radiographs were taken on the first day and at 3rd-, 6th- and 12th-month follow-ups. Distal dorsal cortex distance and lunate facet distance were measured in the lateral radiographs. The number of screws used in the metaphyseal region was also evaluated. According to the number of screws, the amount of collapse was analysed based on both the LFD and the DDD.

Results

The mean age of patients was 43.5±12.7 years. Thirty-three of the patients included in the study were male and 27 were female, and the minimum follow-up period was one year. According to the mean number of screws, groups were defined as up to 6 screws or 7 screws and above. There was a statistically significant difference between the groups in terms of DDD collapse at the 6th-month and 12th-month follow-ups (p<0.005). It was observed that the radial collapse and decrease in DDD and LFD were lower in plates with seven screws and above.

Conclusion

Decreases in either DDD or LFD, or radial collapse were observed less in patients who had seven or more metaphyseal screws inserted. These findings might be useful for surgeons treating distal radius fractures to reduce radial collapse.

Nonsurgical Management of Distal Radius Fractures in the Elderly: Approaches, Risks and Limitations

The elderly have conventionally been defined as individuals over the age of 65 and are projected to represent about 21% of the United States (US) population by the year 2030. Distal radius fractures (DRF) in particular are one of the most common fractures among elderly patients and their incidence continues to rise in part due to increased activity levels among the elderly, increased life expectancy, rising rates of obesity, changes to dietary habits, and the prevalence of osteoporosis. Although various treatment options exist for these injuries, nonsurgical treatment of distal radius fractures remains a mainstay among elderly patients with mounting evidence of its non-inferiority to surgical fixation in the literature. Here, we summarize the overall approach to nonsurgical treatment of distal radius fractures in the elderly population while examining its supporting data and highlighting potential risks and limitations to it.

Does circumferential casting prevent fracture redisplacement in reduced distal radius fractures? A retrospective multicentre study

Background

This study evaluates whether a circumferential cast compared to a plaster splint leads to less fracture redisplacement in reduced extra-articular distal radius fractures (DRFs).

Methods

This retrospective multicentre study was performed in four hospitals (two teaching hospitals and two academic hospitals). Adult patients with a displaced extra-articular DRF, treated with closed reduction, were included. Patients were included from a 5-year period (January 2012–January 2017). According to the hospital protocol, fractures were immobilized with a below elbow circumferential cast (CC) or a plaster splint (PS). The primary outcome concerned the difference in the occurrence of fracture redisplacement at one-week follow-up.

Results

A total of 500 patients were included in this study (PS n = 184, CC n = 316). At one-week follow-up, fracture redisplacement occurred in 52 patients (17%) treated with a CC compared to 53 patients (29%) treated with a PS. This difference was statistically significant (p = 0.001).

Conclusion

This study suggests that treatment of reduced DRFs with a circumferential cast might cause less fracture redisplacement at 1-week follow-up compared to treatment with a plaster splint.

Level of Evidence Level III, Retrospective study.

Risk Factors for Distal Radius Osteotomy Nonunion

BACKGROUND

Osteotomy-site nonunion after distal radius corrective osteotomy is a detrimental complication. This retrospective study aims to identify patient and surgical factors associated with nonunion risk to help mitigate this. The authors hypothesize that patient factors and potentially modifiable surgical factors are contributory.

METHODS

Thirty-three patients who underwent corrective osteotomy of the distal radius for prior fracture malunion were identified. Radiographs and patient records were reviewed for demographics, comorbidities, nutritional status, plate position, angle and length of osteotomy correction, and graft used. The primary study outcome was osteotomy nonunion. Descriptive and bivariate statistics were used to identify covariates relevant to nonunion. Backward, stepwise logistic regression was applied to investigate the multivariate effects on outcome, and regression analysis was adjusted for confounders.

RESULTS

Seven patients (21 percent) experienced nonunion after initial corrective osteotomy. Risk factors associated with nonunion included correction length of osteotomy of 5 mm or greater and prior treatment with open reduction and internal fixation. Autograft use was protective against nonunion. History of osteoporosis showed a trend toward increased risk. Angle of osteotomy correction, nutritional deficit, age, diabetes, smoking status, and obesity were not identified as risk factors by the multivariate model.

CONCLUSIONS

Distraction length at the osteotomy site, graft selection, and prior internal fixation were significant risk factors for distal radius osteotomy nonunion, but other factors traditionally associated with nonunion did not appear to impact risk. The authors recommend using autograft bone augmentation, particularly when distracting the osteotomy beyond 5 mm or after prior internal fixation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Assessing the Relationship Between Bone Density and Loss of Reduction in Nonsurgical Distal Radius Fracture Treatment

PURPOSE

Whether low bone mineral density affects loss of reduction for distal radius fractures (DRFs) managed without surgery is unknown. Our purpose was to understand how bone mineral density, based on second metacarpal cortical percentage (2MCP) measurement, affects DRF healing after nonsurgical treatment.

METHODS

We retrospectively reviewed 304 patients from 2 health systems with DRFs treated without surgery. The AO classification, 2MCP (<50% indicating osteoporosis), and fracture stability based on Lafontaine criteria were determined from prereduction radiographs. Radial inclination, radial height, volar tilt, ulnar variance, and intra-articular stepoff were measured on initial and 6-week final follow-up radiographs and compared. Bivariate analysis was used to evaluate the association between Lafontaine criteria or 2MCP and changes in radiographic parameters. Radiographic parameters with significant associations in bivariate analysis were evaluated in multivariable models adjusted for age, sex, initial radiographic parameters, reduction status, and AO fracture type.

RESULTS

Across all patients, after 6 weeks of nonsurgical treatment, ulnar variance (shortening of the radius) increased by an average of 1.4 mm. Bivariate analysis showed that lower 2MCP and unstable fractures per Lafontaine criteria were each significantly associated with an increase in ulnar variance (P < .05). In adjusted multivariable models, having both 2MCP less than 50% and an unstable fracture together was associated with an additional 1.2-mm increase in ulnar variance (P < .05).

CONCLUSIONS

A 2MCP in the osteoporosis range and unstable fractures by Lafontaine criteria were each associated with a significant increase in ulnar variance after nonsurgical treatment for DRFs. Patients with unstable fractures and 2MCP less than 50% are likely to have an additional increase of greater than 1 mm in ulnar variance at the end of nonsurgical fracture treatment than patients with similar injuries, but without these features. Using initial radiographs to identify patients with low bone mineral density that may be at risk for more substantial loss of reduction can assist with decision making for managing DRFs.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Differences in patient and injury characteristics between sports- and non-sports related distal radius fractures

INTRODUCTION

The incidence of distal radius fractures (DRFs) is increasing as the number of people in recreational or sporting activities rises, due to a combination of increased leisure time and greater public awareness of the health-related benefits of sports. Despite the increases in sports-related distal radius fractures (SR-DRFs), there are limited studies regarding the characteristics of treatment and recovery.

HYPOTHESIS

There are characteristics specific to SR-DRF treated with conservative or operative management.

MATERIAL AND METHODS

Retrospective review was carried out between January 2010 and December 2017. Overall, 1706 patients were included in the study analysis. Among them, 317 patients were injured during sports activity (18.6%) and 1389 were injured during non-sports activity (81.4%). Demographic data were compared between the two groups. The type of sports was investigated in SR-DRF. Also, we compared surgically treated DRF patients to describe differences in patient characteristics, fracture characteristics, and postoperative complications.

RESULTS

The mean age of patients with SR-DRFs was significantly younger (28 vs. 52 years). The proportion of men was also significantly higher in SR-DRF group compared to NSR-DRF group (62.8 vs. 33.8%). We identified 27 kinds of sports associated with DRFs and the 5 sports topping the list associated were soccer (22.7%), cycling (17.7%), snowboarding (11.0%), ice-skating (9.1%), and mountain hiking (9.1%). There was no difference in terms of the treatment method. However, SR-DRF group had higher proportion of AO/OTA type A fracture (32.6 vs. 13.7%), and NSR-DRF group had higher proportion of type C fracture (79.5 vs. 64.2%). Postoperative complications showed no significant differences, except higher implant removal rate in SR-DRF.

DISCUSSION

Patients with SR-DRF were significantly younger and had higher proportion of men. Proportion of AO/OTA type A was higher in SR-DRF group and proportion of AO/OTA type C was higher in NSR-DRF group. Proportion of surgical treatment was similar in two groups. Given the growing population participating in sports activity worldwide, SR-DRFs are predicted to increase and further study is required.

LEVEL OF EVIDENCE

III; retrospective, epidemiological study.

Artificial intelligence in orthopaedics: false hope or not? A narrative review along the line of Gartner's hype cycle

Artificial Intelligence (AI) in general, and Machine Learning (ML)-based applications in particular, have the potential to change the scope of healthcare, including orthopaedic surgery.

The greatest benefit of ML is in its ability to learn from real-world clinical use and experience, and thereby its capability to improve its own performance.

Many successful applications are known in orthopaedics, but have yet to be adopted and evaluated for accuracy and efficacy in patients’ care and doctors’ workflows.

The recent hype around AI triggered hope for development of better risk stratification tools to personalize orthopaedics in all subsequent steps of care, from diagnosis to treatment.

Computer vision applications for fracture recognition show promising results to support decision-making, overcome bias, process high-volume workloads without fatigue, and hold the promise of even outperforming doctors in certain tasks.

In the near future, AI-derived applications are very likely to assist orthopaedic surgeons rather than replace us. ‘If the computer takes over the simple stuff, doctors will have more time again to practice the art of medicine’.⁷⁶

Cite this article: EFORT Open Rev 2020;5:593-603. DOI: 10.1302/2058-5241.5.190092

Colles’ type distal radial fractures undergoing manipulation in the ED: a multicentre observational cohort study

Background

Colles’ type fractures of the distal radius are one of the most commonly manipulated fractures in the ED. Local audit data suggest that a high proportion of these injuries undergo subsequent surgical fixation. If widespread, this could represent a potential burden on patients and the NHS worthy of further research. The aims of this study were to estimate the rate of surgical fixation of Colles’ type distal radial fractures after ED fracture manipulation and explore variations in their management in UK EDs.

Methods

We conducted a multicentre observational study in 16 EDs in the UK from 4 February 2019 to 31 March 2019. All adult patients with a Colles’ fracture who underwent fracture manipulation in the ED were included. Patients who could not be followed up and those with volar displaced fractures were excluded. We measured the rate of wrist fracture surgery at 6 weeks, patient demographics and variations in anaesthetic technique used.

Results

During the study period, 328 adult patients attended the participating EDs with a distal radial fracture. Of these, 83 patients underwent fracture manipulation in the ED and were eligible for the study. Their mean age (SD) was 65.3 (17.0) years, 84.3% were female and the most common method of anaesthesia used was haematoma block (38.6%). 34 (41.0%, 95 % CI 30.3 to 52.3) patients had subsequent surgical fixation of their fracture. Younger age was associated with higher rates of surgical fixation but ED anaesthetic technique did not affect the subsequent need for surgery in this sample.

Conclusion

Subsequent surgical fixation was carried out in 41% of patients who underwent manipulation of Colles’ type wrist fractures in this cohort. This merits further research and represents a potential target to rationalise repeat procedures.

Long-term follow-up of distal radius fractures, an evaluation of the current guideline: the relation between malunion, osteoarthritis and functional outcome

BACKGROUND

Last decades there is an increased tendency of performing surgery on displaced distal radius fractures. However, it is unclear whether this affects the development of osteoarthritis. This study aims to determine the relation between anatomical position, radiological osteoarthritis and functional outcome of the elderly wrist, 10-15 years after a distal radius fracture.

PATIENTS AND METHODS

173 patients between the age of 50 and 70 at time of trauma were included in this retrospective cohort study with a 10-15-year follow-up. Based on the reassessed initial X-rays, the patients were placed into 4 groups (1: anatomical, 2a: acceptable, 2b: current operative indication but treated conservative, 2c: operative indication and operated). Functional outcome was measured, questionnaires were answered, and new bilateral X-rays of the wrist were obtained. Factors influencing osteoarthritis, the difference in osteoarthritis between the groups and the difference between the fractured and non-fractured wrists were studied.

RESULTS

Group 2b showed a significantly higher degree of osteoarthritis in comparison with the contralateral wrist. In the other groups, this difference was not observed. We found no significant difference in OA and functional outcomes between the groups. The degree of osteoarthritis of the non-fractured wrist appeared to be highly associated with osteoarthritis of the fractured wrist.

CONCLUSION

The results of this study showed that the degree of radiocarpal osteoarthritis is higher in conservatively treated patients that should have been operated on according to current guidelines in comparison with patients without an indication for surgery. This might suggest that our current guidelines can be effective in prevention of posttraumatic osteoarthritis. However, the effect on the functional outcome is very limited. Since the degree of radiocarpal osteoarthritis of the non-fractured wrist appeared to be highly associated with the degree of osteoarthritis of the fractured wrist, future studies should always assess osteoarthritis of both wrists in order to study the real posttraumatic effect of a fracture.

Volar plate for intra-articular distal radius fracture. A prospective comparative study between elderly and young patients

INTRODUCTION

Treatment of the distal radius fracture in elderly remains controversial. The objective was to assess the outcomes of volar locking plate for displaced complete intra-articular distal radius fractures in elderly as compared to younger patients.

HYPOTHESIS

The outcomes in elderly patients would be comparable with those in younger patients with a low rate of complications.

MATERIAL AND METHODS

Non-randomised prospective comparative study between 70 patients older than 65 years and 46 younger patients with AO type-C fractures. The main outcome was Disabilities Arm, Shoulder and Hand (DASH) score. Secondary variables were Patient-Rated Wrist Evaluation (PRWE) score, range of motion, Visual Analogue Scale (VAS) for pain, and grip strength. Radiological measurements were also performed.

RESULTS

The mean follow-up was 30.9 (range, 24-53) months. There were no significant differences in mean DASH, PRWE, VAS-pain, wrist motion or radiological parameters at final follow-up. Multivariate analysis showed that the functional outcomes were significantly influenced by baseline ulnar positivity greater than 3mm at baseline but not by age.

DISCUSSION

The study hypothesis was confirmed. Surgical treatment with volar locking plate for displaced complete intra-articular fractures of the distal radius in elderly patients represents a safe and effective treatment alternative with similar early complication rate than in younger.

LEVEL OF EVIDENCE

III, cohort study.

Volar Plate Fixation in Adults with a Displaced Extra-Articular Distal Radial Fracture Is Cost-Effective

BACKGROUND

To our knowledge, a health economic evaluation of volar plate fixation compared with plaster immobilization in patients with a displaced extra-articular distal radial fracture has not been previously conducted.

METHODS

A cost-effectiveness analysis of a multicenter randomized controlled trial was performed. Ninety patients were randomly assigned to volar plate fixation or plaster immobilization. The use of resources per patient was documented prospectively for up to 12 months after randomization and included direct medical, direct non-medical, and indirect non-medical costs due to the distal radial fracture and the received treatment.

RESULTS

The mean quality-adjusted life-years (QALYs) at 12 months were higher in patients treated with volar plate fixation (mean QALY difference, 0.16 [bias-corrected and accelerated 95% confidence interval (CI), 0.07 to 0.27]). (The 95% CIs throughout are bias-corrected and accelerated.) In addition, the mean total costs per patient were lower in patients treated with volar plate fixation (mean difference, -$299 [95% CI, -$1,880 to $1,024]). The difference in costs per QALY was -$1,838 (95% CI, -$12,604 to $9,787), in favor of volar plate fixation. In a subgroup analysis of patients who had paid employment, the difference in costs per QALY favored volar plate fixation by -$7,459 (95% CI, -$23,919 to $3,233).

CONCLUSIONS

In adults with a displaced extra-articular distal radial fracture, volar plate fixation is a cost-effective intervention, especially in patients who had paid employment. Besides its better functional results, volar plate fixation is less expensive and provides a better quality of life than plaster immobilization.

LEVEL OF EVIDENCE

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

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.

Functional outcome and management pathways for adult patients presenting to an Australian health service with distal radius fracture

OBJECTIVE

Primarily to determine mid-term functional outcome for patients with distal radius fracture (DRF) and to compare this between operative and conservatively managed patients. Secondarily to examine for differences in age, gender and number of instability factors between management groups.

METHODS

Eligible patients (age 18 years or more, closed DRF managed to completion of care within Monash Health), presenting between 1 January and 31 December 2016. Completion of the patient-rated wrist evaluation (PRWE) questionnaire was sought at 6-12 months post-injury. Management was noted (operative or conservative). Age, sex and number of defined instability factors present (dorsal angulation >20°, intra-articular fracture, associated ulna fracture, dorsal comminution, radial shortening >2 mm) are reported and compared between management groups.

RESULTS

Of 369 eligible patients, 199 (54%) completed a PRWE. Median age was 60 years (interquartile range [IQR] 45-71), 150 (75%) were women, median number of instability factors present was 2 (IQR 1-4) and 45 (23%) underwent operative management. Difference in PRWE scores between operative and conservatively managed patients was not significant (20 [IQR 7-36] vs 16 [IQR 5-35]). Differences in age and gender between management groups were not significant. Significantly more in the operative group had presence of four or more instability factors (44% [95% confidence interval 30-60] vs 20% [14-27]).

CONCLUSION

The mid-term median PRWE score was 18 (IQR 5-36). This was not significantly different between operative and conservatively managed patients. Operation was more likely when four or more instability factors were present.

Comparison between Surgical and Conservative Treatment for Distal Radius Fractures in Patients over 65 Years

BACKGROUND

Fractures of the distal radius (DRF) are the most common orthopedic injuries, representing one of the typical fractures indicating underlying osteoporosis. The aim of the study was to compare conservative and surgical treatment, analyzing quality of life and clinical outcome in an over 65 years old population.

METHODS

Ninety one patients were divided into two groups: the ORIF group (39 patients) underwent surgery, and the conservative group (52 patients) was treated conservatively. The clinical and functional outcomes of all patients were evaluated using Short Form 36 (SF36), Modified Mayo Wrist Score (MMWS), Disability of the Arm Shoulder Hand (DASH), and Visual Analogue Scale (VAS). Range of motion at the joint was measured and compared with the contralateral healthy wrist.

RESULTS

No significant difference was found between the overall SF36 score, DASH score, MMWS, and VAS results. Role limitation was significantly better in the surgical group (p < 0.05), and complication incidence was significantly higher (p < 0.05) in the conservative group.

CONCLUSION

The results of this study conform to recent literature, suggesting that a surgical reconstruction of the radius articular surface in an elderly population provides no clear clinical advantage. Treatment decisions must arise from careful diagnoses of the fracture and communication with the patient.

Volar Plate Fixation Versus Plaster Immobilization in Acceptably Reduced Extra-Articular Distal Radial Fractures: A Multicenter Randomized Controlled Trial

BACKGROUND

There is no consensus as to whether displaced extra-articular distal radial fractures should be treated operatively or nonoperatively. We compared the outcomes of open reduction and volar plate fixation with closed reduction and plaster immobilization in adults with an acceptably reduced extra-articular distal radial fracture.

METHODS

In this multicenter randomized controlled trial, patients 18 to 75 years old with an acceptably reduced extra-articular distal radial fracture were randomly assigned to open reduction and volar plate fixation or plaster immobilization. The primary outcome was function as measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire after 12 months. Follow-up was conducted at 1, 3, and 6 weeks and at 3, 6, and 12 months. Analyses were performed according to the intention-to-treat principle.

RESULTS

Ninety-two patients were randomized, 48 to open reduction and volar plate fixation and 44 to plaster immobilization; 1 patient in each group was excluded for withdrawing informed consent. At all follow-up time points, operatively treated patients had significantly better functional outcomes, as indicated by significantly lower DASH scores, than patients treated nonoperatively (all p values < 0.05). Twelve nonoperatively managed patients (28%) had fracture redisplacement within 6 weeks and underwent subsequent open reduction and internal fixation, and 6 patients (14%) had a symptomatic malunion treated with corrective osteotomy.

CONCLUSIONS

Patients with an acceptably reduced extra-articular distal radial fracture treated with open reduction and volar plate fixation have better functional outcomes after 12 months compared with nonoperatively managed patients. Additionally, 42% of nonoperatively managed patients had a subsequent surgical procedure. Open reduction and volar plate fixation should be considered for patients who experience this common injury.

LEVEL OF EVIDENCE

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

Repeated closed reduction attempts of distal radius fractures in the emergency department

INTRODUCTION

Repeated attempts of closed reduction of distal radius fractures (DRF) are performed in the emergency department setting to optimize fracture alignment and avoid surgery. The additional manipulation of the fracture may, however, increase dorsal comminution and lead to loss of reduction in the cast. This retrospective cohort study has investigated the effect of second reduction attempt on fracture alignment and comminution.

MATERIALS AND METHODS

Six-hundred-eighteen patients with DRF were treated in the medical center in 2007-2010. Seventy-six (12.3%) DRF who underwent two reductions were included in the study. Radiographs taken after the first and second reduction attempts were reviewed for changes in fracture alignment parameters (radial height, radial inclination, volar tilt) and dorsal comminution length. Patients were also followed retrospectively to determine the rates of secondary displacement in a cast.

RESULTS

A second closed reduction attempt improved mean radial height by 1.43 mm, mean radial inclination by 1.62° and mean volar tilt by 8.75°. Mean dorsal comminution length increased by 1.6 mm. Of the 19 (25%) patients with acceptable alignments after two reduction attempts, follow-up radiographs were available for 12, which showed successful reduction in four cases (33.3 or 5.2% of total 76 patients).

CONCLUSIONS

A second closed reduction attempt improved immediate fracture alignment, but also worsened dorsal comminution. Only 5.2% of patients who underwent two reduction attempts had an acceptable final alignment and did not require surgery. Increased dorsal comminution may further compromise fracture stability, complicate surgery and have negative effect on the postoperative course.