A randomized, controlled trial of distal radius fractures with metaphyseal displacement but without joint incongruity: closed reduction and casting versus closed reduction, spanning external fixation, and optional percutaneous K-wires

Hospital teaching status is an independent predictor of surgical intervention of distal radius fractures

Background

Distal radius fractures are among the most common orthopaedic injuries and are managed both surgically and non-surgically. To date, no study has examined the role hospital teaching status plays in the rates of surgical intervention.

Methods

The Nationwide Inpatient Sample (NIS) was queried for years 2003-2014. Patients with a distal radius fracture were identified using International Classification for Disease, Ninth Revision (ICD-9) disease codes. Surgical intervention was determined using ICD-9 procedure codes. Exclusion criteria were patients younger than age 18, polytrauma, open fractures, records with missing data, and records where the primary procedure was something other than open reduction of a radius or ulna fracture, closed reduction of a radius or ulna fracture, or blank. Chi-squared tests were run for demographic and socioeconomic data to identify significant variables. Significant variables were then included alongside hospital teaching status in a binomial logistic regression model. Significance was defined as P < 0.05.

Results

A weighted total of 98,831 patients were included in the study. Of those, 45,234 (45.8 %) were treated at teaching hospitals. Patients in teaching hospitals were more likely to be younger, male, non-white, and non-Medicare insured than non-teaching hospitals. Injuries were treated surgically in 64.6 % of total cases. Surgical intervention was more common in teaching hospitals than non-teaching hospitals (69.1 % vs. 60.8 %, P < 0.01). After controlling for demographic and socioeconomic factors, patients at teaching hospitals were 31 % more likely to undergo surgical treatment than those at non-teaching hospitals. Other factors that were independently predictive of surgical treatment were age, race, and insurance type.

Conclusion

In the setting of distal radius fractures, teaching hospitals have higher rates of surgical intervention than non-teaching hospitals. These results suggest that the involvement of medical trainees may play a role in the surgical decision-making process.

Surgical treatment of distal radius fractures: impact on forearm rotation in non-elderly patients

Forearm rotation restriction (FRR) is common after surgery for distal radius fractures (DRFs). The aim of the current study was to investigate the effect of DRFs on forearm rotation. This retrospective study reviewed patients with DRFs who underwent surgical treatment from January 2019 to December 2021. The patients' basic data and radiographic parameters were analyzed. Forearm rotation, including pronation and supination, was assessed using a standard goniometer. The Patient-Rated Wrist Evaluation (PRWE) score was evaluated, and the incidence of FRR at the 6-month follow-up was recorded. Univariate and multivariate logistic regression analyses were performed to identify risk factors correlated with FRR. A total of 127 patients with DRFs were included in this study. After surgery, 46 cases were considered to have FRR, with a rate of 36.2%, while the remaining 81 cases (63.8%) did not have FRR. The PRWE scores were 22.8 ± 5.2 and 17.9 ± 4.2 in the FRR group and non-FRR group, respectively, and the difference was statistically significant (P < 0.05). Multivariate analysis showed that the involvement of the sigmoid notch (OR, 2.88; 95% CI 1.49-5.56), post-operative volar tilt < 0° (OR, 2.16; 95% CI 1.34-3.50), and post-operative ulnar variance > 0 mm (OR, 1.37; 95% CI 1.06-1.78) were independently associated with the incidence of FRR. The FRR is associated with an increased PRWE score and may have had some impact on the patient's daily life. Fractures involving the sigmoid notch, dorsal angulation, and radial shortening deformity were found to be correlated with the incidence of FRR. Preoperative risk notification and intraoperative preventive measures are necessary for these patients.

Long-term subjective results and radiologic prognosis of a distal radius fracture in working-aged patients - a prognostic cohort study of 201 patients

OBJECTIVE

To investigate long-term outcomes associated with distal radius fracture (DRF) in working-aged patients. The authors hypothesized that the majority of patients experience no permanent loss of function when measured with patient-rated wrist evaluation (PRWE).

METHODS

This was a retrospective cohort study of patients with a DRF aged between 18 and 65 years. The primary outcome measure was PRWE score at a minimum of 4 years after DRF. Secondary outcome measures were pain catastrophizing scale (PCS) and radiographic measurements.

RESULTS

Of 201 patients included, 179 were primarily treated non-operatively with a 5-week cast treatment and 22 were primarily operated. The mean follow-up duration was 5 years. The mean PRWE score was 10.9 (95% confidence interval 8.4, 13.4) and median PRWE was 3.5 (interquartile range, 0.0-13.0). There was minor correlation between PCS and PRWE score (correlation coefficient [CC] 0.3), and between PRWE score and dorsal angulation of the fracture measured after closed reduction (CC 0.2) and in one-week follow-up radiographs (CC 0.2).

CONCLUSIONS

Working-aged patients seem to gain nearly normal wrist function after DRF in longer follow-up. Pain catastrophizing appears to correlate with long-term treatment outcome.

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

Introduction:

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

Materials and Methods:

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

Results:

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

Discussion/Conclusions:

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

Level of evidence:

Prognostic Level III

Surgical Plating vs Closed Reduction for Fractures in the Distal Radius in Older Patients: A Randomized Clinical Trial

Importance

The burden of injury and costs of wrist fractures are substantial. Surgical treatment became popular without strong supporting evidence.

Objective

To assess whether current surgical treatment for displaced distal radius fractures provided better patient-reported wrist pain and function than nonsurgical treatment in patients 60 years and older.

Design, Setting, and Participants

In this multicenter randomized clinical trial and parallel observational study, 300 eligible patients were screened from 19 centers in Australia and New Zealand from December 1, 2016, until December 31, 2018. A total of 166 participants were randomized to surgical or nonsurgical treatment and followed up at 3 and 12 months by blinded assessors. Those 134 individuals who declined randomization were included in a parallel observational cohort with the same treatment options and follow-up. The primary analysis was intention to treat; sensitivity analyses included as-treated and per-protocol analyses.

Intervention

Surgical treatment was open reduction and internal fixation using a volar-locking plate (VLP). Nonsurgical treatment was closed reduction and cast immobilization (CR).

Main Outcomes and Measures

The primary outcome was the Patient-Rated Wrist Evaluation score at 12 months. Secondary outcomes were Disabilities of Arm, Shoulder, and Hand questionnaire score, health-related quality of life, pain, major complications, patient-reported treatment success, bother with appearance, and therapy use.

Results

In the 300 study participants (mean [SD] age, 71.2 [7.5] years; 269 [90%] female; 166 [81 VLP and 85 CR] in the randomized clinical trial sample and 134 [32 VLP and 102 CR] in the observational sample), no clinically important between-group difference in 12-month Patient-Rated Wrist Evaluation scores (mean [SD] score of 19.8 [21.1] for VLP and 21.5 [24.3] for CR; mean difference, 1.7 points; 95% CI -5.4 to 8.8) was observed. No clinically important differences were found in quality of life, wrist pain, or bother at 3 and 12 months. No significant difference was found in total complications between groups (12 of 84 [14%] for the CR group vs 6 of 80 [8%] for the VLP group; risk ratio [RR], 0.53; 95% CI, 0.21-1.33). Patient-reported treatment success favored the VLP group at 12 months (very successful or successful: 70 [89%] vs 57 [70%]; RR, 1.26; 95% CI, 1.07-1.48; P = .005). There was greater use of postoperative physical therapy in the VLP group (56 [72%] vs 44 [54%]; RR, 1.32; 95% CI, 1.04-1.69; P = 0.02).

Conclusions and Relevance

This randomized clinical trial found no between-group differences in improvement in wrist pain or function at 12 months from VLP fixation over CR for displaced distal radius fractures in older people.

Trial Registration

http://anzctr.org.au identifier: ACTRN12616000969460.

Surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms

BACKGROUND

A comprehensive overview of treatments of common fractures is missing, although it would be important for shared decision-making in clinical practice. The aim was to determine benefits and harms of surgical compared to non-surgical treatments for traumatic skeletal fractures.

METHODS

We searched Medline, Embase, CINAHL, Web of Science, and CENTRAL until November 2018, for randomized trials of surgical treatment in comparison with or in addition to non-surgical treatment of fractures in adults. For harms, only trials with patient enrollment in 2000 or later were included, while no time restriction was applied to benefits. Two reviewers independently assessed studies for inclusion, extracted data from full-text trials, and performed risk of bias assessment. Outcomes were self-reported pain, function, and quality of life, and serious adverse events (SAEs). Random effects model (Hedges' g) was used.

RESULTS

Out of 28375 records screened, we included 61 trials and performed meta-analysis on 12 fracture types in 11 sites: calcaneus, clavicula, femur, humerus, malleolus, metacarpus, metatarsus, radius, rib, scaphoideum, and thoraco-lumbar spine. Seven other fracture types only had one trial available. For distal radius fractures, the standardized mean difference (SMD) was 0.31 (95% CI 0.10 to 0.53, n = 378 participants) for function, favoring surgery, however, with greater risk of SAEs (RR = 3.10 (1.42 to 6.77), n = 436). For displaced intra-articular calcaneus fractures, SMD was 0.64 (0.13 to 1.16) for function (n = 244) and 0.19 (0.01 to 0.36) for quality of life (n = 506) favoring surgery. Surgery was associated with a smaller risk of SAE than non-surgical treatment for displaced midshaft clavicular fractures (RR = 0.62 (0.42 to 0.92), n = 1394). None of the other comparisons showed statistical significance differences and insufficient data existed for most of the common fracture types.

CONCLUSIONS

Of 12 fracture types with more than one trial, only two demonstrated a difference in favor of surgery (distal radius fractures and displaced intra-articular calcaneus fractures), one of which demonstrated a greater risk of harms in the surgical group (distal radius fractures). Our results highlight the current paucity of high-quality randomized trials for common fracture types and a considerable heterogeneity and risk of bias in several of the available trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015020805.

A Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly (CROSSFIRE): a statistical analyses plan

Background

We are performing a combined randomised and observational study comparing internal fixation to non-surgical management for common wrist fractures in older patients. This paper describes the statistical analysis plan.

Methods/design

A Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly (CROSSFIRE) is a randomised controlled trial comparing two types of usual care for treating wrist fractures in older patients, surgical fixation using volar locking plates and non-surgical treatment using closed reduction and plaster immobilisation. The primary aim of this comparative-effectiveness study is to determine whether surgery is superior to non-surgical treatment with respect to patient-reported wrist function at 12 months post treatment. The secondary outcomes include radiographic outcomes, complication rates and patient-reported outcomes including quality of life, pain, treatment success and cosmesis. Primary analysis will use a two-sample t test and an intention-to-treat analysis using the randomised arm of the study. Statistical analyses will be two-tailed and significance will be determined by p < 0.05. Sensitivity analyses will be conducted to assess for differences in intention-to-treat, per-protocol and as-treated analyses. Sensitivity analyses will also be conducted to assess selection bias by evaluating differences in participants between the randomised and observational study arms, and for bias relating to any missing data. An economic analysis will be conducted separately if surgery is shown to provide superior outcomes to a level of clinical significance.

Discussion

This statistical analysis plan describes the analysis of the CROSSFIRE study which aims to provide evidence to aid clinical decision-making in the treatment of distal radius fractures in older patients.

Trial registration

CROSSFIRE was approved by The Hunter New England Human Research Ethics Committee (HNEHREC Reference No: 16/02/17/3.04). Registered on 22 July 2016 with The Australian and New Zealand Clinical Trials Registry (ANZCTR Number; ACTRN12616000969460).

This manuscript is based on v.11 of the statistical analysis plan. A copy of v.11, signed by the chief investigator and the senior statistician is kept at the administering institution.

Distal radius fractures in the elderly population

We found no clear evidence of the clinical superiority of distal radius fracture surgery among older adults at one year.

Surgical treatment, however, may yield a faster recovery to previous level of activity in elderly patients.

With operative treatment, hardware-based problems may warrant secondary operations and implant removal, whereas in non-operative treatment, symptomatic loss of alignment and malunion can occur.

In elderly patients, non-operative treatment can be considered to be the gold standard.

Cite this article: EFORT Open Rev 2020;5:361-370. DOI: 10.1302/2058-5241.5.190060

Dorsal Bridge Plating versus External Fixation for Distal Radius Fractures

Background  External fixation and dorsal bridge plating are wrist spanning fixation options for distal radius fractures; however, their comparative effectiveness is not well understood. A meta-analysis was conducted to compare the clinical outcomes between these two techniques. Materials and Methods  A PubMed database query of all distal radius fracture cases managed with spanning external fixation or dorsal bridge plating was performed. A total of 28 articles met inclusion criteria, yielding 895 patients for data extraction and comparative analysis. Results  Dorsal bridge plating demonstrated lower rates of infection (2 vs. 10%, p  = 0.05) and complex regional pain syndrome (1 vs. 4%, p  = 0.04) but higher rates of hardware failure (4 vs. 1%, p  = 0.026). Bridge plating also demonstrated higher rates of excellent/good ratings under the Gartland and Werley outcome score (91 vs. 83%, p  = 0.016). There was no significant difference in DASH (Disability of the Arm, Shoulder, and Wrist) scores, radiographic parameters, or unplanned reoperations between the two spanning fixation options. Conclusion  Bridge plating and external fixation both appear to be comparable for spanning fixation constructs for distal radius fractures, but with bridge plating having a potentially lower complication profile.

The Declining Use of Wrist-Spanning External Fixators

Background: External fixation has been traditionally used to treat comminuted or open distal radius fractures that are not amenable to open reduction internal fixation. This procedure is associated with a relatively high complication rate and has been used with decreasing frequency in recent years. However, trends in external fixation utilization for the treatment of distal radius fractures have not been described. Methods: Using the Nationwide Inpatient Sample, patients with a distal radius fracture treated with external fixation from 2003 to 2014 were identified. The annual incidence was reported, and hospital and demographic variables associated with external fixation use were determined. Results: During the study period, 593 929 patients with a distal radius fracture were identified, of which 51 766 (8.7%) were treated with a wrist-spanning external fixator. Wrist external fixation for the treatment of distal radius fractures declined steadily from 2003 to 2014. In 2003, external fixation use was highest, accounting for 17.4% of distal radius fractures. By 2014, only 4.9% of distal radius fracture were treated with external fixation. During this period, the incidence of distal radius fractures declined by 6.9% while external fixator utilization decreased by 73.7%. Patients receiving an external fixator were more likely to be male, low-income, and treated in a rural, nonteaching, privately owned hospital. Conclusions: External fixator use for the treatment of distal radius fractures steadily declined during the study period. Males and those with lower incomes treated in rural, nonteaching, and privately owned hospitals are more likely to receive external fixation.

Review of Internal Radiocarpal Distraction Plating for Distal Radius Fracture Fixation

Internal radiocarpal distraction plating is a versatile tool in the treatment of distal radius fractures that are not amenable to nonoperative treatment or operative fixation with standard volar or dorsal implants. Internal distraction plates may also be indicated in the setting of polytrauma or osteopenic bone. The plate functions as an internal fixator, using ligamentotaxis to restore length and alignment while providing relative stability for bony healing. The plate can be fixed to either the second or the third metacarpal, and anatomic and biomechanical studies have assessed the strengths and weaknesses of each strategy. This operative fixation technique leads to acceptable radiographic results and functional outcomes. Following fracture union, the plate is removed, and wrist range of motion is resumed.

POWIFF- Prospective study of wrist internal fixation of fracture: A protocol for a single centre, superiority, randomised controlled trial to study the efficacy of the VRP (2.0) distal radius plate (Austofix) versus the VA-LCP (Depuy-Synthes) for distal radius fractures

Background

Distal radial fractures are one of the most common orthopaedic cases that present to the A&E department. Surgical intervention is warranted in displaced intraarticular fractures and fractures with more than the recommended angulation or shortening, and is most commonly treated with volarly placed fixed angle locking plates. The aim of this study is to determine and compare the efficacy of two different plates for surgical treatment of distal radius fractures. The VRP 2.0 is a new plate produced by the Austofix company and this system will be compared against the VA-LP (Variable angle-locking plate) produced by Depuy-Synthes which has been used as the standard treatment device.

Methods and Design

Patients between the ages of 18 and 80 presenting to the Royal Adelaide Hospital with isolated closed distal radial fractures will be invited to participate in this study. A total of 200 patients are required to provide 90% statistical power at a 5% alpha level to detect a difference of 11.5 points on the PRWE (Patient rated Wrist evaluation) score. The primary outcome measure will be the PRWE score while the secondary outcome measures will include the DASH score, EQ5D score, clinical range of movements, grip strength as well as patient perceived return of function at the wrist and time to resumption to work. These will be measured at 6 weeks, 3 months and 12 months. Radiographic indices including the radial tilt, length, volar inclination and plate prominence will also be measured. Complications will be recorded up to 12 months. Post hoc comparisons will be done using paired t tests. An intention to treat and a per protocol analysis will be done to compare the 2 groups.

Discussion

Distal radial fractures are increasingly being treated by internal fixation using volar locking plates. However, there is no prospective study to date comparing one plate against another in terms of outcome and complications. This study could provide more information about the best way to treat these injuries surgically.

Trial registration

The trial is registered with the Australia New Zealand Clinical Trials Registry (ANZCTR). Trial registration date-17/11/2016. Trial registration number-ACTRN12616001590459.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2052-4) contains supplementary material, which is available to authorized users.

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

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

LEVEL OF EVIDENCE

II.

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

STUDY DESIGN

Structured literature synthesis.

INTRODUCTION

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

PURPOSE OF THE STUDY

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

METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSIONS

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

LEVEL OF EVIDENCE

2a.

Ten Years' Follow-Up on Combined Palmar and Dorsal Internal Fixation of Complex Distal Radius Fractures

Complex distal intra-articular radial fractures (AO Type C3) are rare, but are life-changing injuries. They are usually related to high-velocity trauma mechanisms in a working male population.We surveyed a cohort of these fractures treated in our institution to assess the functional long-term outcome.Twelve consecutive patients with comminuted intra-articular distal radial fractures were treated at our institution. Osteosynthesis was performed by a single senior surgeon with volar and dorsal extended approaches. The intermediate and final control included conventional X-ray, range of motion (ROM), grip strength, and the Disabilities of the Arm, Shoulder, and Hand index (DASH), as well as the Patient-rated Wrist Evaluation (PRWE) score for functional outcome at 1 and 10 years' of follow-up.At 10 years' follow-up, anatomic reconstruction with a step or gap of <1 mm was achieved in 10 of the 12 above-mentioned patients, whereas 2 patients were lost to follow-up. ROM was good to excellent in 8 patients. Median grip strength was 107% of the contralateral side. Median DASH-Index and PRWE were 2.3 and 6 respectively, at 10 years. Eight patients returned to premorbid heavy labor. One patient was retired at the time of injury.Combined volar and dorsal approaches allow achieving anatomical reconstruction in comminuted intra-articular distal radius fractures and reveal good functional outcomes at intermediate and long-time follow-up.

Volar locking plate osteosynthesis for distal radial fractures

PURPOSE

To review the one-year outcome after volar locking plate fixation for distal radial fractures.

METHODS

Records of 22 men and 40 women aged 17 to 86 (mean, 52.5) years who underwent volar locking plate fixation for distal radial fractures were reviewed. According to the Fernandez classification, the distal radial fractures were classified as type 1 (n=20), type 2 (n=24), type 3 (n=6), type 4 (n=6), or type 5 (n=6). Three types of plate were used: Stryker Variax (n=33), Synthes LCP (n=20), and Smith & Nephew Peri-Loc (n=9). Wrist function was assessed at one year using the validated patient-rated wrist evaluation (PRWE) questionnaire.

RESULTS

14 (23%) of the 62 patients had 24 complications: stiffness (n=13), median nerve symptoms (n=4), malunion (n=2), implant removal for persistent pain and stiffness but no improvement shown (n=2), complex regional pain syndrome (n=2), and carpal arthritis (n=1). The complication rates for types 1, 2, 3, 4, and 5 fractures were 20%, 17%, 67%, 0%, and 33%, respectively (p=0.052). The complication rates for low-risk (types 1 and 2) and high-risk (types 3, 4, and 5) fractures were 18% and 33%, respectively (p=0.315). The complication rates for Stryker Variax, Synthes LCP, and Smith & Nephew Peri-Loc were 26%, 20%, and 14%, respectively (p=0.75). At one year, the mean PRWE score was comparable in patients with low-risk or high-risk fractures (14 vs. 19, p=0.5). 79%, 13%, and 8% of the patients recovered >50%, 20-50%, and <20% of range of movement of the contralateral side, respectively.

CONCLUSION

Volar locking plate fixation followed by early rehabilitation for distal radial fractures achieved good outcome, with a low rate of implant-related complications.

Outcomes and cost of care for patients with distal radius fractures

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

Radiological criteria for acceptable reduction of extra-articular distal radial fractures are not predictive for patient-reported functional outcome

The purpose of this study was to assess the association between arm-specific disability measured with the QuickDASH questionaire and radiological criteria in patients with extra-articular distal radial fractures. A consecutive series of 385 patients were initially treated non-operatively for an extra-articular distal radial fracture and 257 (69 %) patients were included in the study. In 203 of these patients (78%) the quality of radiographic reduction was judged to be adequate by radiological parameters, which included dorsal tilt, radial inclination, and radial shortening. In 54 patients (22%) the quality of radiographic alignment was judged to be inadequate. We observed no effect of radiographic parameters on the functional outcome. Female sex and longer duration of follow-up (>35 months) were the only independent prognostic factors significantly associated with a worse QuickDASH score.

Factors affecting late displacement following volar locking plate fixation for distal radial fractures in elderly female patients

The purpose of this study was to evaluate the risk of late displacement after the treatment of distal radial fractures with a locking volar plate, and to investigate the clinical and radiological factors that might correlate with re-displacement. From March 2007 to October 2009, 120 of an original cohort of 132 female patients with unstable fractures of the distal radius were treated with a volar locking plate, and were studied over a follow-up period of six months. In the immediate post-operative and final follow-up radiographs, late displacement was evaluated as judged by ulnar variance, radial inclination, and dorsal angulation. We also analysed the correlation of a variety of clinical and radiological factors with re-displacement. Ulnar variance was significantly overcorrected (p < 0.001) while radial inclination and dorsal angulation were undercorrected when compared statistically (p < 0.001) with the unaffected side in the immediate post-operative stage. During follow-up, radial shortening and dorsal angulation progressed statistically, but none had a value beyond the acceptable range. Bone mineral density measured at the proximal femur and the position of the screws in the subchondral region, correlated with slight progressive radial shortening, which was not clinically relevant. Volar locking plating of distal radial fractures is a reliable form of treatment without substantial late displacement.

Management of distal radius fractures from the North American perspective

In North America, the rate of nonoperative management of displaced distal radius fractures has declined as the rate of internal fixation has increased. Volar locking plate fixation has increased in popularity despite a lack of supportive level 1 evidence. Issues of cost-effectiveness are relevant because there is no best-practice treatment at this stage. Clinicians should be aware of the goals of treatment and challenges, particularly in managing elderly patients with distal radius fractures. Large, randomized controlled trials or meta-analyses may provide answers about when operative intervention is favored over nonoperative management and which operative intervention provides the best outcomes.

Displaced distal forearm fractures in children with an indication for reduction under general anesthesia should be percutaneously fixated

PURPOSE: Worldwide, many displaced distal forearm fractures in children are treated by closed reduction under local anesthesia and cast immobilization. If mal-alignment of the fracture persists after initial reduction attempt, final fracture reduction will be performed under general anesthesia, followed by cast immobilization. The purpose of this study was to analyze the results of minimally invasive fixation with K-Wire or ESIN after fracture reduction in children under general anesthesia, compared with the results of closed reduction and plaster immobilization. We hypothesize that primary percutaneous fixation prevents secondary redisplacement and reduces the number of secondary interventions. METHODS: All skeletally immature children who sustained a distal forearm fracture, and treated under general anesthesia in the operation room (OR), were included. The patients were analyzed according to three treatment groups and fracture type. The primary outcome measure was the number of patients who required a second procedure of fracture reduction after initial treatment. RESULTS: A considerable amount of children with displaced distal forearm fractures treated by closed reduction and cast immobilization show loss of reduction and require secondary reduction (43.7%). After closed reduction with primary internal fixation, with minimally invasive techniques such as K-wires or ESIN, secondary loss of reduction did not occur. CONCLUSIONS: Additional internal fixation after reduction of a forearm fracture minimizes the secondary displacement risk and the subsequent risk of a re-intervention. Therefore, primary minimal invasive fixation of displaced distal forearm fractures after closed reduction under general anesthesia seems preferable to closed reduction only and is strongly recommended as the preferred treatment strategy.

The surgical treatment of unstable distal radius fractures by angle stable implants: a multicenter prospective study

OBJECTIVES

The goal of this study is to document the 2-year outcome after surgical treatment of distal radius fractures using an angle stable implant.

DESIGN

Prospective case-series.

SETTING

Multicenter study in nine trauma units with recruitment between December 2001 and May 2003.

PATIENTS

One hundred eight patients with the same number of distal radius fractures.

INTERVENTION

Open reduction and internal fixation with the LCP DR 3.5 mm (Synthes GmbH, Oberdorf, Switzerland).

MAIN OUTCOME MEASUREMENTS

Disabilities of the Arm, Shoulder and Hand, Gartland and Werley, SF-36 scores, radiologic assessment, and return to work status at 2 years.

RESULTS

At 2 years, the mean range of motion (relative to the contralateral wrist) was 83% for palmar flexion, 91% for extension, 94% for radial deviation, 92% for ulnar deviation, and 98%/94% for pronation/supination angles. Grip strength was 90% of the mean uninjured side. The average radiographic measurements were 23.6° for radial inclination angle, 6.1° for palmar (volar) tilt angle, and 0 mm for ulnar variance. The proportion of fractures for which the Gartland and Werley score was categorized as either good or excellent was 89%. Minor complications occurred in 14 patients, although none of these events were considered to be directly related to the implant.

CONCLUSION

After a 2-year follow-up period, the use of an angle stable implant for unstable distal radius fractures provides adequate fixation with minimal loss of reduction. This device is associated with good functional and radiologic outcome for the patient and is indicated for distal radius fractures classified as Orthopaedic Trauma Association (OTA) Type 23-A2/A3, OTA Type 23-B2/B3, and OTA Type 23-C.

Distal radial fractures in the elderly: operative compared with nonoperative treatment

BACKGROUND

There is much debate regarding the optimal treatment of displaced, unstable distal radial fractures in the elderly. The purpose of this retrospective review was to compare outcomes for elderly patients with a displaced distal radial fracture who were treated with or without surgical intervention.

METHODS

This case-control study examined ninety patients over the age of sixty-five who were treated with or without surgery for a displaced distal radial fracture. All fractures were initially treated with closed reduction and splinting. Patients who failed an acceptable closed reduction were offered surgical intervention. Patients who did not undergo surgery were treated until healing with cast immobilization. Patients who underwent surgery were treated with either plate-and-screw fixation or external fixation. Baseline radiographs and functional scores were obtained prior to treatment. Follow-up was conducted at two, six, twelve, twenty-four, and fifty-two weeks. Clinical and radiographic follow-up was completed at each visit, while functional scores were obtained at the twelve, twenty-four, and fifty-two-week follow-up evaluations. Outcomes at fixed time points were compared between groups with standard statistical methods.

RESULTS

Forty-six patients with a mean age of seventy-six years were treated nonoperatively, and forty-four patients with a mean age of seventy-three years were treated operatively. Other than age, there was no difference with respect to baseline demographics between the cohorts. At twenty-four weeks, patients who underwent surgery had better wrist extension (p = 0.04) than those who had not had surgery. At one year, this difference was not seen. No difference in functional status based on the Disabilities of the Arm, Shoulder and Hand scores and pain scores at any of the follow-up points was seen between the groups. Grip strength at one year was significantly better in the operative group. Radiographic outcome was superior for the patients in the operative group at each follow-up interval. There was no difference between the groups with regard to complications.

CONCLUSIONS

Our findings suggest that minor limitations in the range of wrist motion and diminished grip strength, as seen with nonoperative care, do not seem to limit functional recovery at one year.

LEVEL OF EVIDENCE

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

The efficacy of closed reduction in displaced distal radius fractures

INTRODUCTION

Closed reduction (CR) to restore fracture alignment and subsequent cast fixation is a common practice in the treatment of distal radius fractures. No clear consensus exists about the appropriate indication for CR. This study aims to compare radiological and functional results in patients with moderately to severely displaced distal radius fractures that were immobilised by cast fixation with or without prior CR.

PATIENTS AND METHODS

A total of 206 patients with distal radius fractures from one UK hospital were prospectively documented between 2001 and 2002. Patients with moderately to severely displaced fractures that were treated conservatively with or without CR were eligible for this analysis. Fracture displacement was assessed by measurements on injury radiographs and latent class analysis. The radiological and functional results as assessed by range of motion; and the Disabilities of the Arm, Shoulder and Hand (DASH); Gartland and Werley; and SF-36 scores were compared after 6 weeks, 6 months and 1 year.

RESULTS

As many as 83 patients (seven males) with a mean age of 62.2 years were included; 62 patients were treated with CR, the remaining 21 did not receive CR. During the follow-up period, no differences were found in the measurements of range of motion, DASH and SF-36 scores between the treatment groups. Fractures that were treated with CR lost anatomical restoration. However, after 1 year, palmar tilt and radial angles had significantly improved compared with the baseline measurements. Although no significant difference of radiological parameters between the treatment groups was found, the Gartland and Werley score resulted in a significantly better outcome for those patients without CR after 1 year.

CONCLUSIONS

Although all patients - independent of their treatment - reached a successful level of activities in their daily life, there was no benefit of CR for patients with moderately to severely displaced fractures. The decision to treat with CR should be made carefully, especially in patients with high wrist-function demands.

Comparison between external fixation and cast treatment in the management of distal radius fractures in patients aged 65 years and older

PURPOSE

The aim of this study was to compare the functional and radiographic outcomes of dorsally displaced distal radius fractures treated by closed reduction plaster cast fixation (CRPCF) and external fixation (EF) in patients 65 years and older.

METHODS

This retrospective and nonrandomized study comprised 46 consecutive patients older than 65 years who had distal radial fractures. Patients were divided into 2 groups according to treatment: a CRPCF group and an EF group. All the fractures were dorsally displaced and AO/ASIF type A or C, without articular stepoff or gap. Cases were evaluated based on the criteria of Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score, wrist range of motion, and radiologic results.

RESULTS

The mean follow-up period was 25.1 months. Union was achieved in all cases. Although it was not a statistically significant difference, posttreatment complications were more common in the CRPCF group (10 patients) than in the EF group (7 patients). In the CRPCF group, most complications were discomfort from the cast, whereas in the EF group, most were pin site infections. The average wrist extension and ulnar deviation (clinically) and palmar tilt and radial height (radiologically) were statistically better in the EF group at the final follow-up. The mean DASH scores were 20.3 in the CRPCF group and 21.9 in the EF group. There was no statistically significant difference in the DASH scores; in wrist flexion, radial deviation, pronation, supination, grip strength, or pinch strength (clinically); or in ulnar variance or radial inclination (radiologically). There was no correlation between the DASH scores and palmar tilt and ulnar variance.

CONCLUSIONS

We concluded that both CRPCF and EF are useful methods for distal radius fractures in elderly patients. The results showed significant differences in wrist extension and ulnar deviation.

External fixation of distal radius fractures

Fractures of the distal radius are the most common fractures that occur in patients between ages 15 and 75 years. Many methods for treating displaced distal radius fractures are available. All forms of treatment involve obtaining fracture reduction, which may then be maintained by casting, functional bracing, external fixation, percutaneous pinning, internal fixation, or a combination of these methods. This article discusses the indications and technique of fracture treatment with external fixation and, when required, adjuvant percutaneous pins.

Locked volar plating for unstable distal radial fractures: clinical and radiological outcomes

We studied 40 patients treated with locked volar plates for unstable distal radial fractures. Outcome was assessed at a mean of 59 weeks, both radiologically and functionally using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire, range of motion and grip strength. The complication rate in our series was 48%. In 11 cases, screw penetration into the radiocarpal joint occurred as a consequence of postoperative collapse. Of these, 25% had malunited and 12.5% ruptured their extensor pollicus longus (EPL) tendon. Functionally, when compared with the contralateral side, 74% of extension, 67% of flexion, 91% of pronation and supination and 81% of grip strength were regained. The mean DASH score was 23. Although locked volar plates can achieve good results in the management of unstable distal radial fractures, there remains a high major complication rate. They should be used with caution particularly in fractures with significant metaphyseal comminution.

The role of locking technology in the upper extremity

The technique of locked plating has been a major advance in Orthopaedic fracture surgery and has had an equal impact on the management of upper extremity fractures. The recognition of the role of vascularity and soft tissues in fracture healing was central to the research and development of newer plate designs that left minimal footprints on the surface of the bone. Subsequently, innovative locking technology has improved our ability to manage cases with extensive communition, inadequate bone stock, and peri-articular fractures. This paper will review the role of locking technology in the management of fractures of the upper extremity.

Validity and responsiveness of the Jebsen-Taylor Hand Function Test

PURPOSE

The aim of this study was to demonstrate the validity and responsiveness of the Jebsen-Taylor Hand Function Test (JTT) in measuring hand function in patients undergoing hand surgery, compared with the Michigan Hand Outcomes Questionnaire (MHQ).

METHODS

A prospective cohort of patients with rheumatoid arthritis (n = 37), osteoarthritis (n= 10), carpal tunnel syndrome (n = 18), and distal radius fracture (n = 46) were evaluated preoperatively and at 9 to 12 months of follow-up. We administered the JTT and MHQ. We performed correlation and receiver operating characteristic analyses to evaluate the validity of the JTT as a measure of disability. Effect size and standardized response means were calculated to determine responsiveness.

RESULTS

Correlation studies revealed poor correlation of the JTT with MHQ total scores and subsets that relate to hand function. Patients with high MHQ scores generally perform well on the JTT; however, patients with good JTT scores do not necessarily have high MHQ scores. Receiver operating characteristic curves for each condition showed that the change in JTT total score had poor ability to discriminate between high and low MHQ score subjects, with an area under the curve result of 0.52 to 0.66 for each condition. Effect size and standardized response means for all states showed greater responsiveness with the MHQ for each condition compared with the JTT.

CONCLUSIONS

We found poor correlation between the change in JTT and absolute JTT scores after surgery compared with change in MHQ and absolute MHQ scores. In addition, the JTT had poor discriminant validity based on the MHQ as a reference. This study showed that the time to complete activities does not correlate well with patient-reported outcomes. We conclude that the JTT should not be used as a measure of disability or clinical change after surgical intervention.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Distal radial fracture treatment: what you get may depend on your age and address

BACKGROUND

Distal radial fractures are common and confer a considerable financial burden on the health-care system; however, controversy surrounds the optimal treatment of these injuries. This study was performed to determine (1) the rate of distal radial fractures in the U.S. Medicare population stratified by hospital referral region and (2) whether the type of fracture treatment is affected by patient age, race, sex, comorbidity, or hospital referral region.

METHODS

A 20% sample of Medicare Part-B claims from the years 1998 through 2004 was analyzed. Procedural codes for nonoperative treatment, percutaneous fixation, and open reduction and internal fixation of distal radial fractures were identified. These codes were then used to determine the overall rate of distal radial fracture. The rates of distal radial fracture were then evaluated according to hospital referral region and patient age, sex, comorbidity, and race. The types of treatment were determined and were also analyzed on the basis of hospital referral region and patient age, sex, comorbidity, and race. Regression analysis was performed with use of the above variables.

RESULTS

We identified 107,190 patients. The rate of distal radial fracture was 125 per 10,000 Medicare beneficiaries. The rate of the fracture in white individuals (136 per 10,000) was more than twice that in non-white individuals (fifty-nine per 10,000), and the rate in women (189 per 10,000) was 4.8 times higher than that in men (thirty-nine per 10,000). The overall fracture rate varied widely across the United States, from forty-seven per 10,000 beneficiaries in New Orleans, Louisiana, to 220 per 10,000 in Spartanburg, South Carolina. Treatment rates were similar across race, with the rate of nonoperative treatment being 84% for white beneficiaries compared with 83% for non-white beneficiaries, the rate of percutaneous fixation being 11% for white beneficiaries compared with 10% for non-white beneficiaries, and the rate of open treatment being 6% for white beneficiaries compared with 7% for non-white beneficiaries. There was variation across the country, with the rate of nonoperative treatment ranging from 60% in San Luis Obispo, California, to 96% in Covington, Kentucky; the rate of percutaneous fixation ranging from 2% in Boulder, Colorado, to 39% in San Luis Obispo, California; and the rate of open treatment ranging from 0.4% in Wilkes-Barre, Pennsylvania, to 25% in Great Falls, Montana. While the rates of percutaneous fixation and nonoperative treatment remained relatively stable, the overall rate of operative fixation nearly doubled from 5% in 1998 to 8% in 2004.

CONCLUSIONS

There is wide variation in the rate of distal radial fractures across sex, age, race, and geographic region in the United States. There is also significant variation in the treatment of these fractures, driven mainly by age and region. Between 1998 and 2004, a strong trend toward more frequent operative fixation was apparent. While white individuals had more than twice as many fractures as did non-white individuals, there did not appear to be significant racial variation in the treatment of this injury.

Distal radius fractures in older patients: is anatomic reduction necessary?

The relationship between radiographic and functional outcomes in older patients with distal radius fractures is controversial. We explored this relationship by assessing the influence of radiographic displacement and fracture comminution on the functional outcomes of these fractures. We also asked whether operative intervention and demographic factors (age, gender, duration of followup) influenced outcome. We examined 53 patients older than 55 years with distal radius fractures with various functional assessments: range of motion (ROM) and strength measurements, three subjective surveys (Disabilities of the Arm, Shoulder, and Hand; Patient-rated Wrist Evaluation; Modernized Activity Subjective Survey of 2007), a Gartland and Werley score, and an objective, standardized hand performance test (Jebsen-Taylor). We measured angulation, articular gap/stepoff, and radial shortening on final radiographs and fracture comminution of preoperative radiographs. We observed no effect of radiographic displacement on subjective or objective outcome assessments, including standardized hand performance timed testing. Surgically treated fractures were less likely to display residual dorsal angulation and radial shortening, but surgical intervention did not independently predict functional outcome. Fracture comminution, patient gender, and months of followup similarly had no effect on outcome. We found no relationship between anatomic reduction as evidenced by radiographic outcomes and subjective or objective functional outcomes in this older patient cohort.

LEVEL OF EVIDENCE

Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

What counts: outcome assessment after distal radius fractures in aged patients

OBJECTIVES

Outcome of surgical interventions at the distal radius does not only depend on the type of intervention used, it also depends on the way the outcome is measured. Substantial differences in outcome assessment between different measurement tools and poor correlation among them result in the question about the best instrument for the evaluation of treatment after distal radius fractures. The aim of the review is to discuss pros and cons of the parameters that are available to assess the outcome after distal radius fractures. The review should help to choose the appropriate instruments for a given research question in aged patients with distal radius fractures.

DATA SOURCES AND SYNTHESIS

Objective and subjective measures were reviewed with respect to their suitability in outcome assessment. Radiological parameters like inclination, palmar slope, and length of the radius are most common and used to determine especially surgical success. Grip strength and range of motion are considered objective and used as study endpoints in many studies. Functional tests like the Jebsen test provide a realistic feedback about disability but require special skills and resources of the testing personnel. Patient self-assessment adds perceived patient benefit. The patient-rated wrist evaluation (PRWE) provides a reliable and valid instrument for subjective outcome assessment.

CONCLUSIONS

A combination of objective and subjective parameters should be used to assess the outcome of different treatment strategies due to the known discrepancies. Objective parameters like shortening, radial shift, or others should be clearly defined in the study methodology.

Variability in the assessment of fracture-healing in orthopaedic trauma studies

BACKGROUND

There is a lack of consensus among orthopaedic surgeons in the assessment of fracture-healing. We conducted a systematic review of recent clinical studies of long-bone fracture care that were published in three major orthopaedic journals to identify current definitions of fracture-healing.

METHODS

MEDLINE and the computerized databases for The Journal of Bone and Joint Surgery (American Volume), The Journal of Bone and Joint Surgery (British Volume), and the Journal of Orthopaedic Trauma were searched from January 1996 through December 2006 with use of title, abstract, keyword, and medical subject headings. Therapeutic clinical studies of long-bone fractures of the appendicular skeleton in adults in which fracture-healing was assessed were selected. Two reviewers independently identified articles and extracted data. Any disagreement was resolved by consensus. We qualitatively and quantitatively summarized the definition of fracture union and the reliability of the assessment of radiographic fracture-healing.

RESULTS

One hundred and twenty-three studies proved to be eligible. Union was defined on the basis of a combination of clinical and radiographic criteria in 62% of the studies, on the basis of radiographic criteria only in 37%, and on the basis of clinical criteria only in 1%. Twelve different criteria were used to define fracture union clinically, and the most common criterion was the absence of pain or tenderness at the fracture site during weight-bearing. In studies involving the use of plain radiographs, eleven different criteria were used to define fracture union, and the most common criterion was bridging of the fracture site. A quantitative measure of the reliability of the radiographic assessment of fracture union was reported in two studies.

CONCLUSIONS

We found a lack of consensus with regard to the definition of fracture-healing in the current orthopaedic literature. Without valid and reliable clinical or radiographic measures of union, the interpretation of fracture care studies remains difficult.

Do We need to include osteoporosis in today's classification of distal radius fractures?

Although the correlation between decreased bone mineral density and increased incidence of distal radius fractures is widely acknowledged, the effect of osteoporosis on specific fracture types is seldom addressed. No classification system has been established for clinical use that has been validated for osteoporotic fractures or that includes parameters of the bone density or bone quality. So far, only one experimental study could report a clear correlation between bone properties and fracture patterns, and an additional clinical study assesses bone density in relation to displacement in Colles fractures. Further studies are needed to analyze the intra- and interobserver reproducibility of more simplified but nonetheless comprehensive classification systems that recognize the impact of osteoporosis on distal radius fracture and that specifically incorporate bone mineral density.

Biology versus mechanics in the treatment of distal radial fractures

This manuscript aims to address the biologic and mechanical principles underlying the treatment of displaced distal radial fractures. A literature review was performed using Ovid Medline 1950-2007 and all evidence-based medicine reviews. A recent Cochrane review and a meta-analysis were reference searched. All randomized trials comparing internal and external fixation and all articles related to volar locked plates were searched for. Based on current literature, there is no evidence to support internal fixation with plates over minimally invasive fixation with external fixation. Recent results using volar locked plate fixation are promising, but comparative studies with either conventional plating or external fixation are lacking.

Biomechanical comparison of different volar fracture fixation plates for distal radius fractures

The purpose of this study was to compare the biomechanical properties of four volar fixed-angle fracture fixation plate designs in a novel sawbones model as well as in cadavers. Four volar fixed angle plating systems (Hand Innovations DVR-A, Avanta SCS/V, Wright Medical Lo-Con VLS, and Synthes stainless volar locking) were tested on sawbones models using an osteotomy gap model to simulate a distal radius fracture. Based on a power analysis, six plates from each system were tested to failure in axial compression. To simulate loads with physiologic wrist motion, six plates of each type were then tested to failure following 10,000 cycles applying 100N of compression. To compare plate failure behavior, two plates of each type were implanted in cadaver wrists and similar testing applied. All plate constructs were loaded to failure. All failed with in apex volar angulation. The Hand Innovations DVR-A plate demonstrated significantly more strength in peak load to failure and failure after fatigue cycling (p value < 0.001 for single load and fatigue failure). However, there was no significant difference in stiffness among the four plates in synthetic bone. The cadaveric model demonstrated the same mode of failure as the sawbones. None of the volar plates demonstrated screw breakage or pullout, except the tine plate (Avanta SCS/V) with 1 mm of pullout in 2 of 12 plates. This study demonstrates the utility of sawbones in biomechanical testing and indicates that volar fixation of unstable distal radius fractures with a fixed angle device is a reliable means of stabilization.

Can the displacement of a conservatively treated distal radius fracture be predicted at the beginning of treatment?

The aim of this study was to investigate whether the final displacement of conservatively treated distal radius fractures can be predicted after primary reduction. We analysed the radiographic documents of 311 patients with a conservatively treated distal radius fracture at the time of injury, after reduction and after bony consolidation. We measured the dorsal angulation (DA), the radial angle (RA) and the radial shortening (RS) at each time point. The parameters were analysed separately for metaphyseally "stable" (A2, C1) and "unstable" (A3, C2, C3) fractures, according to the AO classification system. Spearman's rank correlations and regression functions were determined for the analysis. The highest correlations were found for the DA between the time points 'reduction' and 'complete healing' (r = 0.75) and for the RA between the time points 'reduction' and 'complete healing' (r = 0.80). The DA and the RA after complete healing can be predicted from the regression functions.

Current utilization, interpretation, and recommendations: the musculoskeletal function assessments (MFA/SMFA)

The development of patient-oriented health status measurements has resulted in the emergence of several generic condition-specific and anatomic-specific instruments. These instruments are generally designed to measure the function of the individual as a whole from the individual's own point of view. They are not intended to replace traditional physician-oriented clinical outcome measures, such as complication rates, ranges of motion, or time to fracture union; instead, they are an attempt to measure the results of a treatment or condition from the patient's perspective. Over the past decade, the Musculoskeletal Function Assessment (MFA) instrument has been developed and used as one of the primary generic musculoskeletal functional assessment tools, in part because of its validity, reliability, and responsiveness. Despite the numerous publications reporting the MFA/SMFA, we are unaware of any publications that have used those results to subsequently affect patient care. We hope that this special interest article highlights the current underutilization of the available data and encourages the orthopedic community to maximize the clinical and research potential of the MFA/SMFA (Short Musculoskeletal Function Assessment).

External fixation versus conservative treatment for distal radial fractures in adults

BACKGROUND

Fracture of the distal radius ('broken wrist') is a common clinical problem. It can be treated conservatively, usually involving wrist immobilisation in a plaster cast, or surgically. A key method of surgical fixation is external fixation.

OBJECTIVES

To evaluate the evidence from randomised controlled trials comparing external fixation with conservative treatment for fractures of the distal radius in adults.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2006), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, conference proceedings and reference lists of articles. No language restrictions were applied.

SELECTION CRITERIA

Randomised or quasi-randomised controlled clinical trials involving adults with a fracture of the distal radius, which compared external fixation with conservative treatment.

DATA COLLECTION AND ANALYSIS

After independent study selection by all review authors, two authors independently assessed the included trials. Independent data extraction of new trials was performed by two authors. Pooling of data was undertaken where appropriate.

MAIN RESULTS

Fifteen heterogeneous trials, involving 1022 adults with dorsally displaced and potentially or evidently unstable distal radial fractures, were included. While all trials compared external fixation versus plaster cast immobilisation, there was considerable variation especially in terms of patient characteristics and interventions. Methodological weaknesses among these trials included lack of allocation concealment and inadequate outcome assessment. External fixation maintained reduced fracture positions (redisplacement requiring secondary treatment: 7/356 versus 51/338 (data from 9 trials); relative risk 0.17, 95% confidence interval 0.09 to 0.32) and prevented late collapse and malunion compared with plaster cast immobilisation. There was insufficient evidence to confirm a superior overall functional or clinical result for the external fixation group. External fixation was associated with a high number of complications, such as pin-track infection, but many of these were minor. Probably, some complications could have been avoided using a different surgical technique for pin insertion. There was insufficient evidence to establish a difference between the two groups in serious complications such as reflex sympathetic dystropy: 25/384 versus 17/347 (data from 11 trials); relative risk 1.31, 95% confidence interval 0.74 to 2.32.

AUTHORS' CONCLUSIONS

There is some evidence to support the use of external fixation for dorsally displaced fractures of the distal radius in adults. Though there is insufficient evidence to confirm a better functional outcome, external fixation reduces redisplacement, gives improved anatomical results and most of the excess surgically-related complications are minor.

External fixation of distal radius fractures

Fractures of the distal radius are the most common fractures that occur in patients between ages 15 and 75 years. Many methods for treating displaced distal radius fractures are available. All forms of treatment involve obtaining fracture reduction, which may then be maintained by casting, functional bracing, external fixation, percutaneous pinning, internal fixation, or a combination of these methods. This article discusses the indications and technique of fracture treatment with external fixation and, when required, adjuvant percutaneous pins.