Low BMD is a risk factor for low-energy Colles' fractures in women before and after menopause

Analysis of Postoperative Distal Radius Fracture Outcomes in the Setting of Osteopenia and Osteoporosis for Patients with Comorbid Conditions

Purpose

Distal radius fractures (DRFs) are among the most common orthopedic injuries, especially in the elderly. A wide variety of approaches have been advocated as successful treatment modalities; yet, there remains variability in practice patterns of DRF in patients with osteoporosis and osteopenia. Using large data set analysis, we sought to determine the risk profile of operative fixation of DRF in patients with low bone mineral density.

Methods

A commercially available health care database, PearlDiver, was queried for all patients who underwent open reduction internal fixation of DRFs between 2010 and 2020. The study population was divided into groups based on the presence or absence of osteopenia or osteoporosis and was further classified by patients who were receiving bisphosphonate therapy. Complication rates were calculated, including rates of malunion, surgical site infection, osteomyelitis, hardware failure, and hardware removal. Five-year future fragility fractures were defined in hip, vertebrae, humerus, and wrist fractures. Chi-square analysis and logistic regression were performed to determine an association between these comorbidities and various postoperative complications.

Results

A total of 152,926 patients underwent open reduction internal fixation of a DRF during the study period. Chi-square analysis of major complications at 3 months showed a statistically significant increase in malunion in patients with osteopenia (P = .05) and patients with osteoporosis (P = .05) who underwent open reduction internal fixation. Logistic regression analysis at 12 months after surgery demonstrated that osteopenia was associated with an increased risk of hardware failure (P < .0001), hardware removal (P < .0001), surgical site infection (P < .0001), and malunion (P = .004). Osteoporosis was associated with a significantly increased risk of hardware failure (P = .01), surgical site infection (P < .0001), and malunion (P < .0001).

Conclusions

We demonstrated, using large data set analysis, that DRF patients with osteopenia and osteoporosis are predicted to be at increased risk of multiple postoperative complications, and thus, bone density should be strongly considered in treatment planning for these patients.

Type of study/level of evidence

Prognostic III.

Glucocorticoid-induced osteoporosis in premenopausal women: management for the rheumatologist

PURPOSE OF REVIEW

This review seeks to summarize the literature relevant to the treatment of glucocorticoid-induced osteoporosis in premenopausal women; an issue commonly encountered by rheumatologists and yet lacking good clinical practice guidelines.

RECENT FINDINGS

Although most of the relevant literature on osteoporosis includes postmenopausal women only, data from both randomized controlled trials and case reports suggest bisphosphonates can be an effective and well tolerated treatment for premenopausal patients. Data for other medications to treat premenopausal osteoporosis is less robust.

SUMMARY

The use of bisphosphonates in young women may be safer than initially thought and should likely be used for the treatment of glucocorticoid-induced osteoporosis in rheumatology clinics. Further research is needed to continue to understand long-term risk.

Relationship Between Carpal Bone Morphology and Distal Radius Fracture Pattern

Abstract Background: In this study, we examined whether carpal bones (lunate, hamate, capitate) morphologies and fourth metecarp-capitate articulation have an effect on the distal radius fracture pattern. Methods: 206 patients who applied to the emergency department with distal radius fracture between 2016-2020 were included in the study. Preoperative and pre-reduction x-ray films of the patients were examined. Lunate, hamate, capitate morphologies and 4.metacarp articulation analyzed and classified. Distal radius fracture types were classified according to AO and Fernandez. The relationship between carpal bone morphology and distal radius fracture type was analyzed. Results: This study consisted of 101 men and 103 women. AO fracture types and carpal bone morphologies (lunate joint type according to Viegas, lunate type according to Zapico, capitate morphology, hamate morphology and capitate-4 metacarpal joint morphology) did not differ significantly (p > 0.05). Fernandez fracture types and carpal bone morphologies (lunate joint type according to Viegas, lunate type according to Zapico, capitate morphology, hamatum morphology and capitate-4.metacarp joint morphology) were compared, there was no significant difference (p > 0.05). Conclusion: As a result, no clear relationship could be demonstrated between carpal bone morphology and distal radius fracture pattern.

Premenopausal osteoporosis

In premenopausal women, bone mineral density measurement by dual-energy X-ray absorptiometry should not be used as the sole guide for diagnosis or treatment of osteoporosis, universal screening with bone mineral density is not advised and the World Health Organization classification of bone status should not be applied. A diagnosis of premenopausal osteoporosis is reserved for those with evidence of fragility and may also be considered in women with low bone mass and an ongoing secondary cause of osteoporosis. Idiopathic osteoporosis in young women is rare. A thorough evaluation of secondary causes is indicated in all patients, with glucocorticoid treatment a common secondary cause of low bone mass and osteoporosis. Hypoestrogenism may be the primary cause of low bone mass and contribute to excessive bone loss in many conditions associated with premenopausal osteoporosis, and should be treated unless contra-indicated. The mainstay of treatment in premenopausal females with low bone mass includes risk factor reduction, advocating a healthy, active lifestyle and optimal treatment of secondary causes of bone loss. The safety of bone-specific therapy, especially long term and during pregnancy, remains uncertain. Bisphosphonates, teriparatide, denosumab and estrogen treatment increase bone density in premenopausal women with osteoporosis, but there are no study data confirming short-term fracture prevention with use of these agents.

Global and Spatial Compartmental Interrelationships of Bone Density, Microstructure, Geometry and Biomechanics in the Distal Radius in a Colles' Fracture Study Using HR-pQCT

BACKGROUND

Bone parameters derived from HR-pQCT have been investigated on a parameter-by-parameter basis for different clinical conditions. However, little is known regarding the interrelationships of bone parameters and the spatial distribution of these interrelationships. In this work: 1) we investigate compartmental interrelationships of bone parameters; 2) assess the spatial distribution of interrelationships of bone parameters; and 3) compare interrelationships of bone parameters between postmenopausal women with and without a recent Colles' fracture.

METHODS

Images from the unaffected radius in fracture cases (n=84), and from the non-dominant radius of controls (n=98) were obtained using HR-pQCT. Trabecular voxel-based maps of local bone volume fraction (L.Tb.BV/TV), homogenized volumetric bone mineral density (H.Tb.BMD), homogenized μFEA-derived strain energy density (H.Tb.SED), and homogenized inter-trabecular distances (H.Tb.1/N) were generated; as well as surface-based maps of apparent cortical bone thickness (Surf.app.Ct.Th), porosity-weighted cortical bone thickness (Surf.Ct.SIT), mean cortical BMD (Surf.Ct.BMD), and mean cortical SED (Surf.Ct.SED). Anatomical correspondences across the parametric maps in the study were established via spatial normalization to a common template. Mean values of the parametric maps before spatial normalization were used to assess compartmental Spearman's rank partial correlations of bone parameters (e.g., between H.Tb.BMD and L.Tb.BV/TV or between Surf.Ct.BMD and Surf.app.Ct.Th). Spearman's rank partial correlations were also assessed for each voxel and vertex of the spatially normalized parametric maps, thus generating maps of Spearman's rank partial correlation coefficients. Correlations were performed independently within each group, and compared between groups using the Fisher's Z transformation.

RESULTS

All within-group global trabecular and cortical Spearman's rank partial correlations were significant; and the correlations of H.Tb.BMD-L.Tb.BV/TV, H.Tb.BMD-H.Tb.1/N, L.Tb.BV/TV-H.Tb.1/N, Surf.Ct.BMD-Surf.Ct.SED and Surf.Ct.SIT-Surf.Ct.SED were significantly different between controls and fracture cases. The spatial analyses revealed significant heterogeneous voxel- and surface-based correlation coefficient maps across the distal radius for both groups; and the correlation maps of H.Tb.BMD-L.Tb.BV/TV, H.Tb.BMD-H.Tb.1/N, L.Tb.BV/TV-H.Tb.1/N, H.Tb.1/N-H.Tb.SED and Surf.app.Ct.Th - Surf.Ct.SIT yielded small clusters of significant correlation differences between groups.

DISCUSSION

The heterogeneous spatial distribution of interrelationships of bone parameters assessing density, microstructure, geometry and biomechanics, along with their global and local differences between controls and fracture cases, may help us further understand different bone mechanisms of bone fracture.

Low Bone Mineral Density of the Forearm and Femur among Postmenopausal Women with Metaphyseal Comminuted Fracture of the Distal Radius

Osteoporosis is characterized by bone loss and skeletal fragility and is likely to occur in postmenopausal women. Distal radius fracture is a type of fragility fractures associated with osteoporosis. Bone mineral density (BMD) refers to the amount of mineral in bone tissue and is an indicator of osteoporosis. This study aimed to investigate the relationship between the severity of distal radius comminution and the BMD of the healthy contralateral forearm and femur in postmenopausal women. Of 165 women who sustained low-energy trauma from falls on flat ground, forearm and femoral neck BMDs were measured in 155 and 163 participants, respectively. Evaluation of distal radius comminution was performed by computed tomography, and the severity is classified based on the degree of articular surface comminution and on the presence of metaphyseal comminution. We thus evaluated 165 cases of articular surface comminution (extra-articular, 43 cases; intra-articular simple, 91 cases; and intra-articular multifragment, 31 cases) and metaphysis comminution (metaphyseal simple, 58 cases; metaphyseal monocortical comminution on either the palmar or dorsal side, 82 cases; and metaphyseal bicortical comminution on the palmar and dorsal sides, 25 cases). There was no significant association between intra-articular comminution and BMD of the forearm and femur. By contrast, the participants with metaphyseal bicortical comminution showed lower BMD of the forearm and femur compared with other types of metaphysis comminution (p < 0.05). In conclusion, postmenopausal women who developed bicortical comminuted fractures of the distal radius tend to have lower femoral BMD, which may predispose them to future hip fractures.

Evidence-Based Review of Distal Radius Fractures

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

Whole bone testing in small animals: systematic characterization of the mechanical properties of different rodent bones available for rat fracture models

Objectives

Rat fracture models are extensively used to characterize normal and pathological bone healing. Despite, systematic research on inter- and intra-individual differences of common rat bones examined is surprisingly not available. Thus, we studied the biomechanical behaviour and radiological characteristics of the humerus, the tibia and the femur of the male Wistar rat—all of which are potentially available in the experimental situation—to identify useful or detrimental biomechanical properties of each bone and to facilitate sample size calculations.

Methods

40 paired femura, tibiae and humeri of male Wistar rats (10–38 weeks, weight between 240 and 720 g) were analysed by DXA, pQCT scan and three-point-bending. Bearing and loading bars of the biomechanical setup were adapted percentually to the bone’s length. Subgroups of light (skeletal immature) rats under 400 g (N = 11, 22 specimens of each bone) and heavy (mature) rats over 400 g (N = 9, 18 specimens of each bone) were formed and evaluated separately.

Results

Radiologically, neither significant differences between left and right bones, nor a specific side preference was evident. Mean side differences of the BMC were relatively small (1–3% measured by DXA and 2.5–5% by pQCT). Over all, bone mineral content (BMC) assessed by DXA and pQCT (TOT CNT, CORT CNT) showed high correlations between each other (BMC vs. TOT and CORT CNT: R² = 0.94–0.99). The load–displacement diagram showed a typical, reproducible curve for each type of bone. Tibiae were the longest bones (mean 41.8 ± 4.12 mm) followed by femurs (mean 38.9 ± 4.12 mm) and humeri (mean 29.88 ± 3.33 mm). Failure loads and stiffness ranged from 175.4 ± 45.23 N / 315.6 ± 63.00 N/mm for the femurs, 124.6 ± 41.13 N / 260.5 ± 59.97 N/mm for the humeri to 117.1 ± 33.94 N / 143.8 ± 36.99 N/mm for the tibiae. Smallest interindividual differences were observed in failure loads of the femurs (CV% 8.6) and tibiae (CV% 10.7) of heavy animals, light animals showed good consistency in failure loads of the humeri (CV% 7.7). Most consistent results of both sides (left vs. right) in failure loads were provided by the femurs of light animals (mean difference 4.0 ± 2.8%); concerning stiffness, humeri of heavy animals were most consistent (mean difference of 6.2 ± 5%). In general, the failure loads showed strong correlations to the BMC (R² = 0.85–0.88) whereas stiffness correlated only moderate, except for the humerus (BMC vs. stiffness: R² = 0.79).

Discussion

Altogether, the rat’s femur of mature specimens showed the most accurate and consistent radiological and biomechanical results. In synopsis with the common experimental use enabling comparison among different studies, this bone offers ideal biomechanical conditions for three point bending experiments. This can be explained by the combination of a superior aspect ratio and a round and long, straight morphology, which satisfies the beam criteria more than other bones tested.

Electronic supplementary material

The online version of this article (10.1186/s40001-018-0307-z) contains supplementary material, which is available to authorized users.

Osteoporosis in premenopausal women

PURPOSE OF REVIEW

The scope of this review was to review the newest developments in the context of the existing knowledge on premenopausal bone fragility. Fragility fractures are common in postmenopausal women and men and diagnostic criteria for osteoporosis have been agreed and multiple pharmacological treatments have been developed over the last 25 years. In premenopausal women, fragility fractures and very low bone mass are uncommon and osteoporosis in premenopausal women has therefore attracted much less interest.

RECENT FINDINGS

Recent studies have highlighted that lifestyle and dietary habits affect premenopausal bone mass. Bone mass may be improved by sufficient intake of calcium and vitamin D together with increased physical activity in premenopausal women with idiopathic osteoporosis. If pharmacological treatment is needed, teriparatide has been demonstrated to efficiently increase bone mass; however, no fracture studies and no comparative studies against antiresorptive therapies have been conducted. Pregnancy affects bone turnover and mass significantly, but pregnancy-associated osteoporosis is a rare and heterogeneous condition.

SUMMARY

The diagnosis of osteoporosis should only be considered in premenopausal women with existing fragility fractures, diseases or treatments known to cause bone loss or fractures. Secondary causes of osteoporosis should be corrected or treated if possible. The women should be recommended sufficient intake of calcium and vitamin and physical activity. In women with recurrent fractures or secondary causes that cannot be eliminated, for example glucocorticoid or cancer treatment, pharmacological intervention with bisphosphonates or teriparatide (not in the case of cancer) may be considered.

Premenopausal Osteoporosis

Most premenopausal women with low trauma fracture(s) or low bone mineral density have a secondary cause of osteoporosis or bone loss. Where possible, treatment of the underlying cause should be the focus of management. Premenopausal women with an ongoing cause of bone loss and those who have had, or continue to have, low trauma fractures may require pharmacologic intervention. Clinical trials provide evidence of benefits of bisphosphonates and teriparatide for bone mineral density in several types of premenopausal osteoporosis, but studies are small and do not provide evidence regarding fracture risk reduction.

Are radiographic measurements of the displacement of a distal radial fracture reliable and reproducible?

AIMS

The degree of displacement of a fracture of the distal radius is an important factor which can be assessed using simple radiographic measurements. Our aim was to investigate the reliability and reproducibility of these measurements and to determine if they should be used clinically.

PATIENTS AND METHODS

A 10% sample was randomly generated from 3670 consecutive adult patients who had presented to University Hospitals of Leicester NHS Trust between 2007 and 2010 with a fracture of the distal radius. Radiographs of the 367 patients were assessed by two independent reviewers. Four measurements of displacement of the fracture were recorded and the inter-observer correlation assessed using the intra-class correlation coefficient.

RESULTS

Inter-observer correlation was high (> 0.8) for three of the four measurements. Repeat measurements of a further randomly generated 10% sample (37) were made four weeks later to assess intra-observer agreement, which was again high (> 0.8) for the same three parameters (radial height, radial inclination and dorsal/palmar tilt). Correlation was poor for articular step and gap.

CONCLUSION

Radiographic assessment of radial angle, radial inclination and dorsal/palmar tilt is a reliable method of determining the degree of displacement of a fracture of the distal radius. Cite this article: Bone Joint J 2016;98-B:1069-73.

Relationship Between Ulnar Variance, Cortical Bone Density, and Load to Failure in the Distal Radius at the Typical Site of Fracture Initiation

PURPOSE

Increased ulnar variance has been shown to lead to diminished load borne by the distal radius. The purpose of this study was to determine the correlations among ulnar variance, bone mineral density, and load to failure at the distal radius.

METHODS

Posteroanterior radiographs and computed tomographic scans were taken of 12 cadaveric forearms in neutral rotation. Ulnar variance was measured for each wrist by the method of perpendiculars. Measurements of cortical, trabecular, and combined bone density were made at the distal radius. We performed linear regression analysis and correlation analysis to determine the relationship between bone densities and ulnar variance measurements. Next, we loaded the 12 cadaveric radii to failure under axial compression. Linear regression analysis and correlation analysis were then performed to determine the relationship between load to failure and both ulnar variance and cortical density.

RESULTS

Increased ulnar variance was significantly correlated with decreased cortical bone density at the distal radius and both were correlated with decreased load to failure. We found no correlation between ulnar variance and trabecular density or combined trabecular and cortical bone density at the distal radius.

CONCLUSIONS

Our study found that increased ulnar variance and decreased cortical bone mineral density correlates with decreased load to failure under axial compression.

CLINICAL RELEVANCE

Ulnar variance is linked to both bone quality and load to failure at the distal radius.

Z-score discordance and contributing factors in healthy premenopausal women with low bone mineral density: the Korean National Health and Nutrition Examination Survey 2008-9

The premenopausal period is important for bone health and prevention of future fractures, but measuring bone mineral density (BMD) at only one site may not be sufficient to determine therapeutic strategies for low BMD in premenopausal women due to the presence of Z-score discordance. In this study, we investigated Z-score discordance in addition to contributing factors of idiopathic low BMD in healthy premenopausal Korean women. We studied 3003 premenopausal women aged 18-50 years, without secondary causes for low BMD and history of fragility fracture, who had participated in the Fourth Korean National Health and Nutrition Examination Surveys (2008-2009). Low body mass index (BMI), low vitamin D level, and low body muscle mass were associated with low BMD even in premenopausal women. Risk factors differed depending on the anatomic site. Low BMI and low vitamin D level were risk factors for low femoral neck BMD (FN-BMD), but not for low lumbar spine BMD (LS-BMD). Only total muscle mass had a slight effect on low LS-BMD. Z-score discordance was much higher than expected, in 75 and 73.8 % of the low LS-BMD and low FN-BMD groups, respectively. Our findings suggest the need to consider BMD discordance in premenopausal women and also to provide information on correctable factors affecting low BMD in younger populations. Long-term follow-up is needed to evaluate the possible effect of Z-score discordance on the prognosis of osteoporosis and subsequent fracture risk.

Osteoporotic Fracture Risk Assessment Using Bone Mineral Density in Korean: A Community-based Cohort Study

Background

Fracture-risk assessment tool (FRAX) using just clinical risk factors of osteoporosis has been developed to estimate individual risk of osteoporotic fractures. We developed prediction model of fracture risk using bone mineral density (BMD) as well as clinical risk factors in Korean, and assessed the validity of the final model.

Methods

To develop and validate an osteoporotic FRAX, a total of 768 Korean men and women aged 50 to 90 years were followed for 7 years in a community-based cohort study. BMD as well as clinical risk factors for osteoporotic fracture including age, sex, body mass index, history of fragility fracture, family history of fracture, smoking status, alcohol intake, use of oral glucocorticoid, rheumatoid arthritis, and other causes of secondary osteoporosis were assessed biannually.

Results

During the follow-up period, 86 osteoporotic fractures identified (36 in men and 50 in women). The developed prediction models showed high discriminatory power and had goodness of fit.

Conclusions

The developed a Korean specific prediction model for osteoporotic fractures can be easily used as a screening tool to identify individual with high risk of osteoporotic fracture. Further studies for validation are required to confirm the clinical feasibility in general Korean population.

The Effect of Osteoporosis on Healing of Distal Radius Fragility Fractures

Although the decision for operative versus nonoperative treatment of distal radius fractures remains subjective and is performed on a case-by-case basis, evaluation and treatment of patients with concomitant osteoporosis requires understanding of the behavior of this injury as a distinct subset of distal radius fractures. Age, infirmity, and osteoporosis affect every aspect of the fracture. Understanding what makes these fractures unique assists surgeons in more effective and efficient treatment. The authors present the current understanding of osteoporotic fragility fractures of the distal radius, focusing on epidemiology, biomechanics of bone healing, and its implication on strategies for management.

Cortical thinning and progressive cortical porosity in female patients with systemic lupus erythematosus on long-term glucocorticoids: a 2-year case-control study

In this study, we characterized longitudinal changes of volumetric bone mineral density and cortical and trabecular microstructure at the distal radius using HR-pQCT in female systemic lupus erythematosus (SLE) patients on long-term glucocorticoids. Cortical thinning and increased cortical porosity are the major features of longitudinal microstructural deterioration in SLE patients.

INTRODUCTION

The study aims to characterize longitudinal changes of volumetric bone mineral density (vBMD) and bone microstructure at distal radius in female systemic lupus erythematosus (SLE) patients on long-term glucocorticoids.

METHODS

This 2-year case-control study consisted of 166 premenopausal subjects (75 SLE patients and 91 controls) and 79 postmenopausal subjects (44 SLE patients and 35 controls). We obtained areal BMD (aBMD) by dual-energy X-ray absorptiometry at multiple skeletal sites and indices of vBMD and microstructure at distal radius by high-resolution peripheral quantitative computed tomography (HR-pQCT) at baseline, 12 and 24 months.

RESULTS

In either premenopausal or postmenopausal subjects, changes in aBMD did not differ between patients and controls except that decrease in aBMD at total hip at 24 months in premenopausal patients was significantly higher. In premenopausal subjects, decrease in cortical area (-0.51 vs. -0.06 %, p = 0.039) and thickness (-0.63 vs. 0.02 %, p = 0.031) and increase in cortical porosity (21.7 vs. 7.16 %, p = 0.030) over study period were significantly larger in patients after adjustment of age and body mass index. Decreased in trabecular vBMD was significantly less (-0.63 vs. -2.32 %, p = 0.001) with trabecular microstructure better maintained in patients. In postmenopausal subjects, decrease in cortical vBMD (-2.66 vs. -1.56 %, p = 0.039) and increase in cortical porosity (41.6 vs. 16.3 %, p = 0.021) were significantly higher in patients, and there was no group-wise difference in change of trabecular microstructure.

CONCLUSION

Longitudinal microstructural deterioration in SLE is characterized by cortical thinning and increased cortical porosity. Cortical bone is an important source of bone loss in SLE patients on glucocorticoids.

The effect of local bone mineral density on the rate of mechanical failure after surgical treatment of distal radius fractures: a prospective multicentre cohort study including 249 patients

INTRODUCTION

The aim of this prospective, multicentre study was to evaluate the influence of local bone mineral density (BMD) on the rate of mechanical failure after locking plate fixation of closed distal radius fractures.

MATERIALS AND METHODS

Between June 2007 and April 2010, 230 women and 19 men with a mean age of 67 years were enrolled. Dual energy X-ray absorptiometry measurements for BMD of the contralateral distal radius were made at 6 weeks post-surgery. Follow-up evaluations at 6 weeks, 3 months and 1 year included wrist mobility and strength as well as standard radiographs. Any local bone/fracture or implant/surgery-related complications were documented. The Disability of the Arm, Shoulder, and Hand (DASH), Patient Rated Wrist Evaluation (PRWE), and EuroQol-5D scores were also recorded at the nominated time points.

RESULTS

Nine patients were reported with mechanical failure at an estimated risk of 3.6 %. The BMD measurements were generally low for the study population with no difference between patients with (0.561 g/cm(2)) and without (0.626 g/cm(2)) mechanical failure (p = 0.148). None of the patients achieved their pre-injury functional level and quality of life status after 1 year. 1-year DASH and PRWE scores as well as the difference in maximum grip strength of the affected wrist relative to the contralateral side were significantly higher for patients with mechanical failure (p ≤ 0.036).

CONCLUSIONS

Our study could not identify a clear association between bone mineral density status and the risk of mechanical failure. Although the risk for mechanical failure after treatment of distal radius fractures with palmar locking plates is low, these complications must be avoided to prevent negative impact on long-term patient functional and quality of life outcome.

Relationship of bone mineral density of spine and femoral neck to distal radius fracture stability in patients over 65

PURPOSE

We hypothesized that an increasing degree of osteopenia in the femoral neck and lumbar spine would be associated with loss of reduction after closed manipulation and splinting of distal radius fractures in patients over 65 years of age.

METHODS

We performed a retrospective review, evaluating 78 patients with displaced distal radius fractures managed with closed reduction and splinting. T-scores from the lumbar spine and femoral neck were recorded from dual-energy x-ray absorptiometry scans performed either within 1 year before or after injury. Volar tilt, radial height, radial inclination, and ulnar variance were evaluated from the initial fracture, postreduction, and final follow-up radiographs. We calculated the percentage of reduction maintained regarding reduction variable. We correlated T-scores of the lumbar spine and femoral neck with the percentage of retained reduction.

RESULTS

We found no correlation between T-scores of the lumbar spine or femoral neck and the amount of reduction lost throughout the healing process of distal radius fractures with respect to volar tilt, radial height, radial inclination, or ulnar variance. Reduction was of no anatomical benefit in 53% to radial height, 44% to radial inclination, and 54% to ulnar variance.

CONCLUSIONS

There appears to be no relationship between bone mineral density, based on T-scores of the lumbar spine and femoral neck, and the ability to maintain reduction after closed manipulation and splinting of displaced distal radius fractures in patients over 65 years of age.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

Evaluation and management of the premenopausal woman with low BMD

Interpretation of bone mineral density (BMD) results in premenopausal women is particularly challenging, since the relationship between BMD and fracture risk is not the same as for postmenopausal women. In most cases, Z scores rather than T scores should be used to define "low BMD" in premenopausal women. The finding of low BMD in a premenopausal woman should prompt thorough evaluation for secondary causes of bone loss. If a secondary cause is found, management should focus on treatment of this condition. In a few cases where the secondary cause cannot be eliminated, treatment with a bone active agent to prevent bone loss should be considered. In women with no fractures and no known secondary cause, low BMD is associated with microarchitectural defects similar to young women with fractures; however, no longitudinal data are available to allow use of BMD to predict fracture risk. BMD is likely to be stable in these women with isolated low BMD, and pharmacologic therapy is rarely necessary. Assessment of markers of bone turnover and follow-up bone density measurements can help to identify those with an ongoing process of bone loss that may indicate a higher risk for fracture, and possible need for pharmacologic intervention.

More radial shortening after low-energy Colles' fractures is associated with type 2 diabetes mellitus among postmenopausal women, irrespective of bone mineral density

BACKGROUND

Recent meta-analysis data reveal that patients with type 2 diabetes mellitus (DM) have a higher risk of fracture, despite higher bone mineral density (BMD), than patients without type 2 DM. The purpose of this study was to compare BMD and distal radial shortening after low-energy Colles' fractures among Japanese postmenopausal women aged ≥50 years with type 2 DM with those in women without it (non-DM).

METHODS

One-hundred and ten postmenopausal women aged ≥50 years with distal radius fractures resulting from a fall were enrolled in this study. Twelve patients had DM. BMD, type I collagen cross-linked N-telopeptide (NTX), undercarboxylated osteocalcin (ucOC), estimated glomerular filtration rate (eGFR), grip strength of the unfractured hand, unipedal standing time, and the degree of radial shortening were measured.

RESULTS

There were no significant differences in age and body height between the two groups. The DM group had significantly greater body weight and body mass index than the non-DM group. BMDs of the lumbar spine and proximal hip were significantly higher in the DM group than in the non-DM group. NTX, ucOC, grip strength, and the percentage of women with unipedal standing time <15 s did not differ between the two groups. Stepwise regression analysis identified DM and shorter unipedal standing time as significant factors associated with more radial shortening, and identified more radial shortening and lower eGFR as significant factors associated with DM.

CONCLUSIONS

More radial shortening after low-energy Colles' fractures was significantly associated with type 2 DM among postmenopausal women aged ≥50 years, irrespective of BMD.

Fracture history of healthy premenopausal women is associated with a reduction of cortical microstructural components at the distal radius

OBJECTIVES

The objective of this study is to determine in healthy premenopausal women with a history of fracture which bone structural components of the distal radius are the most closely associated with a risk of fracture.

METHODS AND PARTICIPANTS

The method was as follows: measurement of radial areal bone mineral density (aBMD) by DXA, microstructural components by high-resolution quantitative peripheral computerized tomography (HR-pQCT) and strength variables by micro Finite Element Analysis (μFEA) in 196 healthy premenopausal women aged 45.9 ± 3.7 (± SD) years with (FX, n = 96) and without (NO-FX, n = 100) a history of fracture. We evaluated differences in T-scores between FX and NO-FX and risk of fracture by Odds ratios (OR with 95% confidence intervals, CI) per one SD decrease, using logistic regression analysis after adjustment for age, height, weight, menarcheal age, calcium and protein intakes, and physical activity.

RESULTS

In the whole group the mean radial metaphysis aBMD T-score was not significantly different from zero. In the FX as compared to the NO-FX group, the differences in T-scores were as follows: for radial metaphysis: aBMD, -0.24 (P = 0.005); for distal radius microstructure components: cortical volumetric BMD, -0.38 (P = 0.0009); cortical thickness, -0.37 (P = 0.0001); cross-sectional area (CSA), +0.24 (P=0.034); and endosteal perimeter, +0.28 (P = 0.032); and for strength estimates: stiffness, -0.15 (P = 0.030); failure load, -0.14 (P = 0.044); and apparent modulus, -0.28 (P = 0.006). T-scores of trabecular volumetric BMD and thickness did not significantly differ between the FX and the NO-FX group. Accordingly, the risk of fracture (OR, 95% CI) for 1 SD decrease in radius bone parameters was as follows: radial metaphysis aBMD: 1.70 (1.18-2.44), P = 0.004; cortical volumetric BMD: 1.86 (1.28-2.71), P = 0.001; and cortical thickness: 2.36 (1.53-3.63), P = 0.0001. The corresponding fracture risk for the strength estimates was as follows: stiffness: 1.66 (1.06-2.61), P = 0.028; failure load: 1.59 (1.02-2.47), P = 0.041; and apparent modulus: 1.76 (1.17-2.64), P = 0.006.

CONCLUSIONS

In healthy premenopausal women, a history of fracture is associated with reduced T-scores in the distal radius, with the cortical components showing the greatest deficit. A reduction of one SD in cortical thickness is associated with a nearly three-fold increased risk of fracture. This finding strengthens the notion that, in healthy women, a certain degree of bone structural fragility contributes to fractures before the menopause and therefore should be taken into consideration in the individual prevention strategy of postmenopausal osteoporosis.

Study of bone mass in young daughters of women with fracture of the distal end of the radius

The main aim was to assess whether young and healthy daughters of women with fractures of the distal end of the radius (DER) had less bone mass than the control group. In an observational study of cases and controls (1:1), the daughters of women with fractures of DER (96) were selected at the age of reaching the peak of bone mass and compared with a control group (91). All women underwent medical history, analytical determinations, and densitometry. In the case group, we found lower bone mass values at the spine and femoral neck than the control group. We also found a lower bone mass at the hips of daughters of women with 1 or more osteoporotic fractures associated with DER and at the lumbar spine in those whose mothers had densitometric osteoporosis. In conclusion, young daughters of women with fractures of DER had lower levels of bone mass density, with a possible "location-specific" occurrence based on the presence of 1 or more osteoporotic fractures associated with DER or on the presence of maternal densitometric osteoporosis.

The effect of osteoporosis on outcomes of operatively treated distal radius fractures

PURPOSE

We hypothesized that postmenopausal osteoporotic women with distal radius fractures treated with open reduction internal fixation had worse functional outcomes than women without osteoporosis sustaining similar injuries.

METHODS

We retrospectively reviewed prospectively collected data for 64 postmenopausal women treated with open reduction internal fixation for distal radius fractures between 2006 and 2010 with known bone mineral density measured by dual-energy x-ray absorptiometry at the time of injury (osteopenia, n = 44; osteoporosis, n = 20). Data collected included age, mechanism of injury, fracture severity, and associated comorbidities. Outcomes included range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and radiographic parameters of fracture reduction. We calculated patients' Charlson Comorbidity Index and tabulated complications. The primary outcome was DASH score at 12 months after injury. We applied multiple linear regression to determine whether bone mineral density status was predictive of functional outcomes 12 months after injury. We used logistic regression analysis to identify factors independently associated with poor outcomes and applied likelihood estimation to determine predictors of a high DASH score at 12 months.

RESULTS

At 1 year postoperatively, women with osteoporosis had average DASH scores 15 points higher than those with osteopenia. Both osteoporosis and the Charlson Comorbidity Index were strong positive independent predictors of higher DASH scores (ie, poorer functional outcomes). There were no significant differences in range of motion or radiographic data between groups. Patients with osteoporosis had a higher rate of major complications.

CONCLUSIONS

Osteoporosis had a negative impact on functional outcomes for women with distal radius fractures treated with open reduction internal fixation. Surgeons should identify high-risk patients, ensure close monitoring, and initiate appropriate preventative measures in this patient population.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Distal radius fracture risk reduction with a comprehensive osteoporosis management program

PURPOSE

To study risk factors associated with osteoporotic distal radius fractures and evaluate the effectiveness of the screening and treatment components of a comprehensive osteoporosis program.

METHODS

We retrospectively identified a cohort of patients aged 60 years or older from a large health maintenance organization. For the period 2002 to 2008, information on age, race, sex, diabetes status, osteoporosis diagnosis, osteoporosis screening activity, medications dispensed, and fracture events, including distal radius, proximal humerus, and hip fractures were recorded. We compared demographic and clinical characteristics for patients with and without distal radius fractures. We estimated multivariable estimates of the associations between pharmacologic treatment, and osteoporosis screening and distal radius fracture risk using Cox proportional hazards methods, and adjusted them for age, sex, race, diabetes status, and prior history of hip or proximal humerus fractures.

RESULTS

Overall, 1.7% of the cohort (n = 8,658) of the study population (N = 524,612) sustained a new distal radius fracture during 2002 to 2008. In the multivariable model, we found that patients who received pharmacological intervention were 48% less likely to sustain a distal radius fracture. Similarly, patients who were screened for osteoporosis were 83% less likely to sustain a distal radius fracture. Patients with osteoporosis were 8.9 times more likely to have a distal radius fracture than patients without osteoporosis. White subjects had a 1.6 times higher risk of distal radius fracture than non-whites, and women had a 3.8 times higher risk than men.

CONCLUSIONS

White race, female sex, and a diagnosis of osteoporosis are high risks for distal radius fracture. Screening for and pharmacologic management of osteoporosis using a multidisciplinary team approach in a comprehensive osteoporosis management program resulted in a statistically significant decrease in the risk of distal radius fracture.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Distraction plating for the treatment of highly comminuted distal radius fractures in elderly patients

PURPOSE

To evaluate internal distraction plating for the management of comminuted, intra-articular distal radius fractures in patients greater than 60 years of age at two level 1 trauma centers. We specifically desired to determine whether patients would have acceptable results from the clinical standpoint of range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and the radiographic measurements of ulnar variance, radial inclination, and palmar tilt. Our hypothesis was that distraction plating of comminuted distal radius fractures in the elderly would result in acceptable outcomes regarding range of motion, DASH score, and radiographic parameters and would, thereby, provide the upper extremity surgeon with another option for the treatment of these fractures.

METHODS

A retrospective review was performed on 33 patients over 60 years of age with comminuted distal radius fractures treated with internal distraction plating at two level 1 trauma centers. Patients were treated with internal distraction plating across the radiocarpal joint. At the time of final follow-up, radiographs were evaluated for ulnar variance, radial inclination, and palmar tilt. Range of motion, complications, and DASH scores were also obtained.

RESULTS

We treated 33 patients (mean age, 70 y) with distraction plating for comminuted distal radius fractures. At final follow-up, all fractures had healed, and radiographs demonstrated mean palmar tilt of 5° and mean positive ulnar variance of 0.6 mm. Mean radial inclination was 20°. Mean values for wrist flexion and extension were 46° and 50°, respectively. Mean pronation and supination were 79° and 77°, respectively. At final follow-up, the mean DASH score was 32.

CONCLUSIONS

In the elderly, distraction plating is an effective method of treatment for comminuted, osteoporotic distal radius fractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A functional outcomes survey of elderly patients who sustained distal radius fractures

PURPOSE

This study aims to examine the subjective functional outcomes of patients 70 years or older who sustained distal radius fractures through the use of the Disability of the Arm, Shoulder, and Hand (DASH) and Short Form-8 Health (SF-8) surveys.

METHODS

Patients at least 70 years old with a distal radius fracture between 2000 and 2004 were identified and their charts reviewed. They were contacted to answer the DASH and SF-8 surveys. The radiographic injury parameters examined were articular stepoff greater than 2 mm, dorsal tilt on the lateral radiograph, ulnar variance, and presence of an ulnar styloid fracture.

RESULTS

Fifty-eight patients answered the DASH and SF-8 surveys. The mean age at the time of injury in the survey group was 78 years old (range 70-94 years). Mean follow-up period was 33 months (range 13-65 months). Average DASH and SF-8 scores were 22.3 (SD 22.4) and 31.5 (SD 6.9), respectively. DASH scores were inversely correlated with SF-8 scores (R = -0.65, p < 0.01). Patients who sustained an associated ulnar styloid fracture demonstrated worse DASH scores than those without an ulnar styloid fracture (presence of ulnar styloid fracture: mean DASH 26.2, no ulnar styloid fracture: mean DASH 12.9, p = 0.04). There were no significant differences in functional outcome for any other radiographic parameters assessed. Males had statistically better DASH scores than the females (males: mean DASH 6.9, females: mean DASH 24.4, p = 0.003). No difference was found in functional outcome scores among different treatment groups.

CONCLUSION

In elderly patients with distal radius fractures, the only radiographic parameter we found that affects functional outcome is an associated ulnar styloid fracture. Additionally, females had worse functional outcomes than males.

Statistical analysis of bone mineral density using voxel-based morphometry-an application on proximal sesamoid bones in racehorses

Voxel-based morphometry (VBM) is a computational technique that has been used to analyze statistical differences between groups of MR brain images. This study outlines a new VBM pipeline, designed for determining statistical variation in bone mineral density (BMD). CT images of proximal sesamoid bone (PSB) specimens from the right forelimb of six racehorses that had suffered PSB fractures were compared with six age-matched control specimens. Following segmentation, masked gray-scale images were co-aligned to a statistical template generated with all 12 CT datasets iteratively. Student t-tests were performed voxel-by-voxel on spatially aligned 3D images to reveal significant differences in the spatial variation of bone density between the fracture and control groups. Overall density and densities from the axial and abaxial areas of PSBs were compared between groups. The BMD in abaxial regions of the medial and lateral PSBs of the fracture group were 12.7% (p = 0.044) and 13.5% (p = 0.047) higher, respectively, than controls. The overall mean density of paired PSB and the medial and lateral PSBs separately were higher in the fracture group. The VBM pipeline facilitates detailed comparison of density variation between bone groups at the voxel level.

What are the radiological predictors of functional outcome following fractures of the distal radius?

The fracture most commonly treated by orthopaedic surgeons is that of the distal radius. However, as yet there is no consensus on what constitutes an 'acceptable' radiological position before or after treatment. This should be defined as the position that will predict good function in the majority of cases. In this paper we review the radiological indices that can be measured in fractures of the distal radius and try to identify potential predictors of functional outcome. In patients likely to have high functional demands, we recommend that the articular reconstruction be achieved with less than 2 mm of gap or step-off, the radius be restored to within 2 mm of its normal length, and that carpal alignment be restored. The ultimate aim of treatment is a pain-free, mobile wrist joint without functional limitation.

Shorter unipedal standing time and lower bone mineral density in women with distal radius fractures

Unipedal standing time was shorter and bone mineral density was lower in Japanese women aged 50 years and over with low-energy distal radius fractures resulting from falls than those in age-matched community-dwelling Japanese women without distal radius fractures.

INTRODUCTION

The aim of this study was to compare unipedal standing time and bone mineral density (BMD) of women >or=50 years of age with distal radius fractures with those of age-matched women without fractures.

METHODS

Fracture group was 54 Japanese women with low-energy distal radius fractures resulting from fall. Non-fracture group was 52 community-dwelling Japanese women without fractures. Unipedal standing time and BMD were measured.

RESULTS

There were no significant differences in age and body mass index between the two groups. The percentage of women with unipedal standing time <15 s was 44.4% in the fracture group and 13.5% in the non-fracture group, while the respective frequencies for >120 s were 20.4% and 50.0%. The T-score of BMD was significantly lower in the fracture than non-fracture group. Logistic regression analysis identified unipedal standing time <15 s and T-score <70% as significant factors associated with distal radius fractures. Notably, T-score <70% was significant in subjects <65 years, and unipedal standing time <15 s was significant in those >or=65 years.

CONCLUSION

Unipedal standing time was shorter and BMD was lower in women >or=50 years of age with distal radius fractures than those in age-matched women without fractures.

Distal radius fractures: nonoperative and percutaneous pinning treatment options

Nonoperative treatment of distal radial fractures by reduction and immobilization remains the most common treatment, based on the incidence of appropriate fracture types, as seen in many epidemiological studies in the literature. In this article, the indications, technique, predictors of failure, outcomes, and complications are reviewed. A variety of treatment options have been proposed for distal radial fractures that are predicted, or subsequently identified, to be too unstable for nonoperative management. Percutaneous pinning is an effective option for select fractures. The authors also review the indications, described techniques, complications and outcomes associated with this treatment option.

Proximal half angle of the screw thread is a critical design variable affecting the pull-out strength of cancellous bone screws

BACKGROUND

Screws with strong pull-out strength have been sought for the treatment of cancellous bone. We hypothesized that an obliquely angled screw thread has advantages over conventional vertical thread with a minimal proximal half angle.

METHODS

Metal and bone screws were made of stainless steel and porcine cortical bone. Their proximal half angle was set at 0 degrees , 30 degrees , or 60 degrees . The screws were inserted into porcine cancellous bone. At 0 degrees , the thread faced the recipient bone vertically. Pullout tests at a rate of 30 mm/min (n=40, each screw type) and microcomputed tomography (n=6) were conducted.

FINDINGS

The pull-out strength of the screws was maximal at 30 degrees ; 348.8 (SD, 44.1)N with metal and 326.6 (39.4)N with bone. It was intermediate at 0 degrees ; 301.9 (35.9)N with metal and 278.2 (30.6)N with bone. It was minimal at 60 degrees; 126.5 (39.0)N with metal and 174.8 (29.7)N with bone. Cancellous bone was damaged between the threads at 30 degrees , while intact cancellous bone was preserved between the threads at 0 degrees.

INTERPRETATION

A proximal half angle of around 30 degrees is appropriate because the pullout force is applied to the recipient bone evenly. Commercial cancellous screws can be improved by changing the thread shape to minimize the damage to recipient bone.

Clinical characteristics and medication use among premenopausal women with osteoporosis and low BMD: the experience of an osteoporosis referral center

AIMS

Osteoporosis is uncommon in premenopausal women, and most cases have a secondary cause. Women with osteoporosis and no known secondary cause are said to have idiopathic osteoporosis (IOP). We aimed to estimate the proportion of premenopausal women seen in our referral center with IOP as opposed to secondary osteoporosis, to describe their clinical characteristics, to compare women with a low-trauma fracture history with those with low bone mineral density (BMD) alone, and to estimate the frequency of bisphosphonate use.

METHODS

We reviewed medical records from all premenopausal women evaluated for osteoporosis or low BMD in our center during 2005. We included premenopausal women diagnosed on the basis of low-trauma fracture, low BMD or both (Z score < or= -2.0 or T score < or = -2.5), or both.

RESULTS

Among these patients (n = 61; mean age 37 +/- 8), 57 (93%) were Caucasian, 34 (57%) had a family history of osteoporosis, and 26 (43%) had used bisphosphonates. The most common secondary causes were amenorrhea (34%, n = 21), anorexia nervosa (16%, n = 10), and glucocorticoid exposure (13%, n = 8). After exclusion of secondary causes, 39% (24 of 61) of the entire group and 48% (14 of 29) of the fracture group were thought to have IOP. Women with a known secondary cause had lower BMD Z scores at the spine and hip than those with IOP. Women with low BMD and no fractures had shorter stature and weighed less than those with fractures, but overall differences between the groups were not statistically significant. Bisphosphonates had been prescribed for 38% (11 of 29) of women with a fracture history and 47% (15 of 32) of women with low BMD and no fractures.

CONCLUSIONS

Our findings suggest that IOP is common among premenopausal women with osteoporosis or low BMD evaluated at a referral center. The smaller stature of women diagnosed only on the basis of BMD criteria raises the question of whether their areal BMD measurements are spuriously low because of smaller bone size. The high proportion of premenopausal women who had been prescribed oral bisphosphonates for low BMD measurements is of concern, as such women are likely to be at low short-term risk of fracture, and a more conservative approach to therapy is preferable in this group.

Association of bone mineral density with deformity of the distal radius in low-energy Colles' fractures in Japanese women above 50 years of age

PURPOSE

To investigate whether the degree of radiographically observed pretreatment radius deformity of low-energy Colles' type distal radius fractures resulting from falls is associated with the degree of bone fragility as measured by bone mineral density (BMD) of the lumbar spine in Japanese women above 50 years of age.

METHODS

The study subjects were 125 consecutive Japanese women older than 50 years of age with Colles' type (AO type A and C) dorsally angulated distal radius fractures caused by falls. Fractures due to high-energy injuries such as traffic accidents were excluded. Radius deformity was assessed on anteroposterior and lateral radiographs by measuring ulnar variance, radial inclination, and dorsal angulation at initial examination before manual repositioning of the bone. Bone mineral density of the lumbar spine was also measured by dual energy x-ray absorptiometry at the follow-up visit.

RESULTS

There were significant differences in the respective values of ulnar variance, radial inclination, and dorsal angulation between patients with BMD values < 70% of the mean value of young adults and those with BMD values > or = 70%. Radius deformity was significantly greater for all parameters in the former group relative to the latter. The respective values of increased ulnar variance, decreased radial inclination, and increased dorsal angulation significantly correlated with lower BMD. Stepwise regression analysis of data of all subjects identified that ulnar variance was significantly associated with dorsal angulation, BMD, and radial inclination. The addition of body height, body weight, body mass index, and urinary type I collagen cross-linked N-telopeptides (bone resorption marker) to the regression analysis of data of a subset of patients confirmed that ulnar variance was significantly associated with BMD and radial inclination.

CONCLUSIONS

There is a significant association between BMD of the lumbar spine and radiographic radius deformity seen in low-energy Colles' type distal radius fractures resulting from falls in Japanese women above 50 years of age.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

Treatment of premenopausal women with low bone mineral density

Interpretation of bone mineral density (BMD) results in premenopausal women is particularly challenging, because the relationship between BMD and fracture risk is not the same as for postmenopausal women. Z scores rather than T scores should be used to define "low BMD" in premenopausal women. The finding of low BMD in a premenopausal woman should prompt an evaluation for secondary causes of bone loss. If a secondary cause is found, management should focus on treatment of this condition. In some cases in which the secondary cause cannot be addressed, such as glucocorticoid therapy or cancer chemotherapy, treatment with a bone-active agent to prevent bone loss should be considered. In women with no fractures and no known secondary cause, low BMD may not signify compromised bone strength. BMD is likely to remain stable in these women, and pharmacologic therapy is rarely justified. Assessment of markers of bone turnover and follow-up bone density measurements can help to identify those with an ongoing process of bone loss that may indicate a higher risk for fracture, and possible need for pharmacologic intervention.

Distal radius fracture management in elderly patients: a literature review

Distal radius fracture management in elderly patients remains without consensus regarding the appropriate treatment or anticipated outcome. Forty-one studies that included at least 10 patients with a minimum mean age of 65 years and that were indexed in Medline or Embase were reviewed. Treatment methods included pins and plaster, external fixation, K-wires, bone cement, and open reduction and internal fixation with plates. The methodological quality of each study was evaluated through use of a grading scale. Despite study heterogeneity, higher rates of infection were noted with external fixation and K-wire stabilization. Stratifying patients into low-demand and high-demand groups may improve the management of distal radius fractures in elderly patients. In sedentary patients with low demands, functional outcomes are good despite the presence of deformity. Patients with higher demands may benefit from fracture stabilization with locking volar plates. Volar plating with fixed-angle screws may be particularly suitable for elderly patients who may take longer to heal a fracture, be more susceptible to pin-track infection, and demonstrate earlier tendon irritation leading to rupture.

A comparative study of clinical and radiological outcomes of dorsally angulated, unstable distal radius fractures in elderly patients: intrafocal pinning versus volar locking plating

PURPOSE

To compare the clinical and radiological outcomes of intrafocal pinning (IFP) and volar locking plating (VLP) of dorsally angulated, unstable distal radius fractures in elderly patients.

METHODS

The subjects were 62 consecutive patients over 60 years of age with dorsally angulated, unstable distal radius fractures treated with IFP or VLP. Bone mineral density (BMD) of the lumbar spine was measured by dual-energy x-ray absorptiometry at first examination. The range of motion and grip strength were measured at follow-up examinations, and ulnar variance (UV) was measured on radiographs at baseline and follow-up postoperative examinations.

RESULTS

There were no notable differences in gender, age, follow-up period, baseline UV, BMD, and AO classification between IFP and VLP groups. There was no difference between the UV in VLP immediately after surgery and at the final follow-up examination; however, IFP showed a significant loss of reduction as measured by UV. In patients with UV more than 5 mm or BMD less than 70% of young adult mean (YAM) at first examination, UV increased again at the final follow-up examination in IFP, while surgically corrected UV was maintained in VLP, independent of the degree of baseline UV and BMD. VLP resulted in earlier recovery of postoperative range of motion and grip strength compared with IFP. The range of flexion and the grip strength value were significantly larger in VLP at final examination.

CONCLUSIONS

VLP, but not IFP, can maintain surgically corrected UV in distal radius fractures, independent of the degrees of initial UV and BMD. VLP enhances earlier recovery in range of motion and grip strength than IFP.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

High-Frequency Whole-Body Vibration Improves Balancing Ability in Elderly Women

OBJECTIVE

To investigate the efficacy of high-frequency whole-body vibration (WBV) on balancing ability in elderly women.

DESIGN

Randomized controlled trial. Subjects were randomized to either the WBV intervention or the no-treatment control group.

SETTING

Community-living elderly women.

PARTICIPANTS

Sixty-nine elderly women aged 60 or above without habitual exercise.

INTERVENTION

Side alternating WBV at 20Hz with 3 minutes a day and 3 days a week for 3 months in the WBV intervention group. Those in control group remained sedentary with normal daily life for the whole study period.

MAIN OUTCOME MEASURES

Limits of stability in terms of reaction time, movement velocity, directional control, endpoint excursion, maximum excursion, and the functional reach test were performed at baseline and endpoint.

RESULTS

Significant enhancement of stability was detected in movement velocity (P<.01), maximum point excursion (P<.01), in directional control (P<.05).

CONCLUSIONS

WBV was effective in improving the balancing ability in elderly women. This also provides evidence to support our user-friendly WBV treatment protocol of 3 minutes a day for the elderly to maintain their balancing ability and reduce risks of fall.

Alendronate increases BMD at appendicular and axial skeletons in patients with established osteoporosis

BACKGROUND

To identify high-risk patients and provide pharmacological treatment is one of the effective approaches in prevention of osteoporotic fractures. This study investigated the effect of 12-month Alendronate treatment on bone mineral density (BMD) and bone turnover biochemical markers in postmenopausal women with one or more non-traumatic fractures, i.e. patients with established osteoporosis.

METHODS

A total of 118 Hong Kong postmenopausal Chinese women aged 50 to 75 with low-energy fracture at distal radius (Colles' fracture) were recruited for BMD measurement at lumbar spine and non-dominant hip using Dual-Energy X-ray Absorptiometry (DXA). 47 women with BMD T-score below -2 SD at either side were identified as patients with established osteoporosis and then randomized into Alendronate group (n = 22) and placebo control group (n = 25) for BMD measurement at spine and hip using DXA and distal radius of the non-fracture side by peripheral quantitative computed tomography (pQCT), and bone turnover markers, including bone forming alkaline phosphatase (BALP) and bone resorbing urinary Deoxypyridinoline (DPD). All measurements were repeated at 6 and 12 months.

RESULTS

Alendronate treatment significantly increased BMD, more in weight-bearing skeletons (5.1% at spine and 2.5% at hip) than in non-weight bearing skeleton (0.9% at distal radius) after 12 months treatment. Spine T-score was significant improved in Alendronate group (p < 0.01) (from -2.2 to -1.9) but not in control placebo group. The Alendronate treatment effect was explained by significant suppression of bone turnover.

CONCLUSION

12 months Alendronate treatment was effective to increase BMD at both axial and appendicular skeletons in postmenopausal women with established osteoporosis.

Distal radius fractures: nonoperative and percutaneous pinning treatment options

Nonoperative treatment of distal radial fractures by reduction and immobilization remains the most common treatment, based on the incidence of appropriate fracture types, as seen in many epidemiological studies in the literature. In this article, the indications, technique, predictors of failure, outcomes, and complications are reviewed. A variety of treatment options have been proposed for distal radial fractures that are predicted, or subsequently identified, to be too unstable for nonoperative management. Percutaneous pinning is an effective option for select fractures. The authors also review the indications, described techniques, complications and outcomes associated with this treatment option.