The Epidemiology of Upper Extremity Fractures in the United States, 2009

CT-like images based on T1-weighted gradient echo MRI sequences for the assessment of fractures of the hand and wrist compared to CT

OBJECTIVE

To evaluate the performance of a 3D T1-weighted gradient-echo (3D T1GRE) computed tomography (CT)-like magnetic resonance imaging (MRI) sequence for detecting and assessing wrist and hand fractures compared to conventional CT.

METHODS

Subjects with acute wrist or hand fracture in CT underwent additional 3 T MRI including a CT-like 3D T1GRE sequence and were compared to patients without fractures. Two radiologists assessed fracture morphology on both modalities according to the Arbeitsgemeinschaft Osteosynthese (AO) and graded image quality and diagnostic confidence on a 5-point Likert scale. Besides diagnostic test evaluation, differences in image quality and diagnostic confidence between CT-like MRI and CT were calculated using the Wilcoxon test. Agreement of AO classification between modalities and readers was assessed using Cohen's Kappa.

RESULTS

Twenty-eight patients with 43 fractures and 43 controls were included. Image quality (3D T1GRE 1.19 ± 0.37 vs. CT 1.22 ± 0.42; p = 0.65) and diagnostic confidence (3D T1GRE 1.28 ± 0.53 vs. CT 1.28 ± 0.55; p = 1.00) were rated excellent for both modalities. Regarding the AO classification, intra- (rater 1 and rater 2, κ = 0.89; 95% CI 0.80-0.97) and interrater agreement were excellent (3D T1GRE, κ = 0.82; 95% CI, 0.70-0.93; CT, κ = 0.85; 95% CI, 0.75-0.94). CT-like MRI showed excellent sensitivity, specificity and accuracy for fracture detection (reader 1: 1.00, 0.92, 0.96; reader 2: 0.98, 0.94, 0.96).

CONCLUSION

CT-like MRI is a comparable alternative to CT for assessing hand and wrist fractures, offering the advantage of avoiding radiation exposure.

Trends in inpatient versus outpatient upper extremity fracture surgery from 2008 to 2021 and their implications for equitable access: a retrospective cohort study

PURPOSE

The aim of this study is to describe trends in inpatient and outpatient upper extremity fracture surgery between 2008 and 2021, along with identifying patient factors (age, sex, race, socioeconomic status) associated with outpatient surgery.

METHODS

Retrospectively, 12,593 adult patients who underwent upper extremity fracture repair from 2008 to 2021 at one of five urban hospitals in the Northeastern USA were identified. Using Distressed Communities Index (DCI), patients were divided into five quintiles based on their level of socioeconomic distress. Multivariable logistic regression was performed on patients from 2008 to 2019 to identify independent factors associated with outpatient management.

RESULTS

From 2008 to 2019, outpatient procedures saw an average increase of 31%. The largest increases in the outpatient management were seen in humerus (132%) and forearm fractures (127%). Carpal and hand surgeries had the lowest percent increase of 8.1%. Clavicle and wrist fractures were independently associated with outpatient management. Older age, male sex, higher Elixhauser comorbidity index, DCI scores in the 4th or 5th quintile, and fractures of the scapula, humerus, elbow, and forearm were associated with inpatient management. During the onset of the COVID-19 pandemic, there was a decrease in outpatient procedures.

CONCLUSION

There is a shift toward outpatient surgical management of upper extremity fractures from 2008 to 2021. Application of our findings can serve as an institutional guide to allocate patients to appropriate surgical settings. Moreover, physicians and institutions should be aware of the potential socioeconomic disparities and implement plans to allow for equal access to care.

Supplementary Fixation Improves Stability of Intra-Articular Distal Radius Fractures Managed With a Spanning Plate

PURPOSE

Previous studies evaluating weight bearing of distal radius fractures treated through dorsal spanning bridge plates used extra-articular fracture models, and have not evaluated the role of supplementary fixation. We hypothesized that supplementary fixation with a spanning dorsal bridge plate for an intra-articular wrist fracture would decrease the displacement of individual articular pieces with cyclic axial loading and allow for walker or crutch weight bearing.

METHODS

Thirty cadaveric forearms were matched into 3 cohorts, controlling for age, sex, and bone mineral density. An intra-articular fracture model was fixed with the following 3 techniques: (1) cohort A with a dorsal bridge plate, (2) cohort B with a dorsal bridge plate and two 1.6-mm k-wires, and (3) cohort C with a dorsal bridge plate and a radial pin plate. Specimens were axially loaded cyclically with escalating weights consistent with walker and crutch weight-bearing with failure defined as 2-mm displacement.

RESULTS

No specimens failed at 2- or 5-kg weights, but cohort A had significantly more displacement at these weights compared with cohort B. Cohort A had significantly more failure than cohort C. Both cohort A and cohort B had significantly more displacement at crutch weight bearing compared with cohort C. The supplementary fixation group had significantly lower displacement at crutch weight-bearing compared with cohort A in all gaps. Survival curves demonstrated the fixation cohort to survive higher loads than the nonfixation group.

CONCLUSION

There was significantly less displacement and less failure of intra-articular distal radius fractures treated with a spanning dorsal bridge plate and supplementary fixation. Our model showed that either type of fixation was superior to the nonfixation group.

CLINICAL SIGNIFICANCE

When considering early weight-bearing for intra-articular distal radius fractures treated with a spanning dorsal bridge plate, supplementary fixation may be considered as an augmentation to prevent fracture displacement.

Determination of the internal loads experienced by proximal phalanx fracture fixations during rehabilitation exercises

Phalangeal fractures are common, particularly in younger patients, leading to a large economic burden due to higher incident rates among patients of working age. In traumatic cases where the fracture may be unstable, plate fixation has grown in popularity due to its greater construct rigidity. However, these metal plates have increased reoperation rates due to inflammation of the surrounding soft tissue. To overcome these challenges, a novel osteosynthesis platform, AdhFix, has been developed. This method uses a light-curable polymer that can be shaped in situ around traditional metal screws to create a plate-like structure that has been shown to not induce soft tissue adhesions. However, to effectively evaluate any novel osteosynthesis device, the biomechanical environment must first be understood. In this study, the internal loads in a phalangeal plate osteosynthesis were measured under simulated rehabilitation exercises. In a human hand cadaver study, a plastic plate with known biomechanical properties was used to fix a 3 mm osteotomy and each finger was fully flexed to mimic traditional rehabilitation exercises. The displacements of the bone fragments were tracked with a stereographic camera system and coupled with specimen specific finite element (FE) models to calculate the internal loads in the osteosynthesis. Following this, AdhFix patches were created and monotonically tested under similar conditions to determine survival of the novel technique. The internal bending moment in the osteosynthesis was 6.78 ± 1.62 Nmm and none of the AdhFix patches failed under the monotonic rehabilitation exercises. This study demonstrates a method to calculate the internal loads on an osteosynthesis device during non-load bearing exercises and that the novel AdhFix solution did not fail under traditional rehabilitation protocols in this controlled setting. Further studies are required prior to clinical application.

Is the Repair of Acute Scapholunate Injuries Associated With Distal Radius Fractures Necessary at the Time of Osteosynthesis? A Systematic Review and Meta-Analysis

BACKGROUND

Acute scapholunate ligament injuries (SLIs) can occur in distal radial fractures (DRFs). This systematic review compares patient-reported outcomes and range of motion (ROM) between operative and nonoperative treatment of acute SLIs in association with surgical fixation of DRFs. We hypothesize that there is no clinical difference.

METHODS

A meta-analysis was used to evaluate the effectiveness of SLI repair versus no repair occurring with DRF with Disabilities of the Arm, Shoulder, and Hand (DASH) scores. We identified 154 articles of which 14 were eligible for review. Only 7 studies reported sufficient radiographic or clinical outcomes data and were included: 3 for meta-analysis and 4 underwent narrative analysis due to lack of homogeneity. We analyzed the patients in 2 groups: operative SLI (O-SLI) versus nonoperative SLI (NO-SLI). The primary outcomes were ROM and DASH scores with 1-year follow-up, where a pooled effect size was generated to determine a difference between groups.

RESULTS

A total of 128 patients were included (71 O-SLI and 57 NO-SLI), with a mean follow-up of 70.2 months (SD: 23.5). The overall effect size for ROM for flexion was 1.74 (95% confidence interval [CI], -3.48 to 6.95; P = .51) and for extension was 0.79 (95% CI, -3.41 to 4.99; P = .71), while the overall effect size for DASH scores was -0.28 (95% CI, -0.66 to 0.10; P = .14). Although NO-SLI led to better ROM and O-SLI led to lower DASH scores, these were not significantly different.

CONCLUSION

The acute surgical intervention of a scapholunate interosseous ligament injury is no different from conservative management in the setting of acute DRFs undergoing osteosynthesis. But the sample size for pooed analyses was small, hence the evidence to date is low to recommend either way.

Distal Radius Fracture Rehabilitation

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

The Association Between Social Determinants of Health and Distal Radius Fracture Outcomes

PURPOSE

The purpose of this study was to determine if adverse social determinants of health (SDOH) are associated with differential complication rates following surgical fixation of distal radius fractures and assess which SDOH domain (economic, educational, social, health care, or environmental) is most associated with postoperative complications.

METHODS

Using a national administrative claims database, we conducted a retrospective cohort analysis of patients undergoing open treatment for an isolated distal radius fracture between 2010 and 2020. Patients were stratified based on the presence/absence of at least one SDOH code and propensity score matched to create two cohorts balanced by age, sex (male or female), insurance type, and comorbidities. Social determinants of health examined included economic, educational, social, health care, and environmental factors. Multivariable logistic regression analyses were performed to assess the isolated effect of SDOH on 90-day and 1-year complication rates.

RESULTS

After propensity matching, 57,025 patients in the adverse SDOH cohort and 57,025 patients in the control cohort were included. Patients facing an adverse SDOH were significantly more likely to experience 90-day complications, including emergency department visits (Odds ratio (OR): 3.18 [95% confidence interval (CI): 3.07-3.29]), infection (OR: 2.37 [95% CI: 2.12-2.66]), wound dehiscence (OR: 2.06 [95% CI: 1.72-2.49]), and 1-year complications, including complex regional pain syndrome (OR: 1.35 [95% CI: 1.15-1.58]), malunion/nonunion (OR: 1.18 [95% CI: 1.08-1.29]), and hardware removal (OR: 1.13 [95% CI: 1.07-1.20]). Additionally, patients facing an adverse SDOH had a significantly increased risk of 90-day complications, regardless of fracture severity, and patients with economic and social challenges had the highest odds of both 90-day and 1-year postoperative complications.

CONCLUSIONS

Social determinants of health are associated with increased complications following distal radius fracture fixation, even when controlling for demographic and clinical factors. We recommend routine screening for adverse SDOH and inclusion of SDOH data into health records to not only inform quality improvement initiatives and risk adjustment for outcome-based quality measurements but also to allow providers to begin to discuss and address such barriers during the perioperative period.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognosis II.

Psychometric properties of patient-reported outcome measures assessing recovery from hand fractures: a systematic review

PURPOSE

To extensively review Patient Reported Outcome Measures (PROMs) used to assess outcomes in persons with hand fractures in terms of their psychometric properties.

METHODS

A COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodological review was conducted. Six electronic databases were searched (Medline, Embase, Scopus, Web of Science, PsycINFO, CINAHL) for studies evaluating the psychometric properties of PROMs assessing recovery from hand fracture. Titles and abstracts, full text review, quality assessment and data extraction were performed by two reviewers. Any disagreements were resolved after review by a third, expert reviewer. Quality assessment of included studies was performed using the COSMIN checklist.

RESULTS

This COSMIN review found that there were only 4 studies that fulfilled the inclusion criteria in terms of assessing measurement properties of PROMs in hand fractures. Only the construct validity of the Disabilities of the Arm, Shoulder, and Hand (DASH), the Quick DASH (QDASH) and the Duruoz Hand Index (DHI), and the responsiveness of the DASH, the Patient Specific Functional Scale (PSFS), the Patient-Rated Wrist and Hand Evaluation (PRWHE) and the Michigan Hand Outcomes Questionnaire (MHQ) were assessed in these studies. The overall rating of the studies was assessed as insufficient or indeterminate and quality of evidence was assessed as moderate, low, or very low by our team.

CONCLUSIONS

This study identified that there is a lack of evidence in the medical literature with regards to the measurement properties of PROMs in patients with hand fractures. The 4 included studies do not provide good quality data to support the use of these PROMS in patients with hand fractures. There is a need for more studies for more PROMs. This has important consequences for how outcomes will be measured in clinical studies in hand research and in clinical practice.

Locked Stem Reverse Total Shoulder Arthroplasty for Complex Proximal Humerus Fracture in the Elderly: Clinical and Radiological Short-Term Results

Purpose

To evaluate both the short-term clinical and radiological results of reverse shoulder arthroplasty (RSA) with uncemented locked stem in the management of a proximal humerus fracture (PHFs) in the elderly.

Methods

Retrospective study including 40 consecutive 3-4 part proximal humerus fractures treated with reverse shoulder arthroplasty with a minimum of 24 months follow-up. In all the cases, the greater tuberosity (GT) was reattached with a standardized suture technique and a local horseshoe bone graft. All the patients were assessed at the 24-month follow-up with Constant-Murley Score (CMS) and Visual Analog Score (VAS). Radiographic healing of the greater tuberosity was noted in addition to stem locking screws radiographic changes. Complications and revision rates were reported.

Results

Mean final CMS for this cohort was 80 points. The greater tuberosity healed in the anatomic position in 90% of the cases (N = 36), obtaining an average CMS of 80 in these patients. Healing of the greater tuberosity did not occur in 10% of the cases (N = 4), obtaining an average CMS of 60. All patients scored above 100° in forward elevation with a mean of 140°. Mean active external rotation was 30°. Low-grade scapular notching was reported in <1% of the cases. Major complications were reported in one patient with an acromial fracture. No complications or loosening of stem locking screws were noted. There were no reoperations.

Conclusion

In the elderly population, reverse shoulder arthroplasty utilizing a fracture-specific locking stem, low-profile metaphysis, suture-friendly groove, meticulous suture technique, and local bone grafting allows adequate fixation, variable prosthesis height adjustment, and enhances greater tuberosity healing. This approach yields positive short-term clinical outcomes without complications related to the stem's locking screws.

Level of Evidence

Level IV Retrospective Case Series.

The Volar Midline Longitudinal Groove of the Middle Phalanx: An Anatomic Study and Clinical Implications

PURPOSE

To investigate the volar anatomy of the middle phalanges of the hand; in particular, to define the presence and depth of a volar midline longitudinal groove.

METHODS

Measurements were performed at 5 equidistant points along the shafts of 60 skeletonized middle phalanges from 15 cadaveric hands. The thickness at the midline of each phalanx was subtracted from the maximal dorsovolar thickness to indicate the presence or absence of a groove at each point. The phalanges were also evaluated by computed tomography to confirm the presence of a volar groove and to rule out morphological abnormalities.

RESULTS

A volar groove was confirmed in all 60 phalanges. The groove had an average depth of 0.4 mm and was found to be deepest at the mid-phalangeal shaft. The groove reached a depth of greater than 1 mm in 23% of the phalanges. The middle phalanges of the middle and ring digits consistently revealed deeper grooves than those found in the index and little fingers. Computed tomography confirmed the presence of a volar groove and showed no morphological abnormalities.

CONCLUSIONS

A midline volar longitudinal groove is present in the middle phalanges, is most pronounced in the mid-phalangeal shaft, and is the deepest in the middle and ring fingers.

CLINICAL RELEVANCE

Surgeons should be cognizant of the volar longitudinal groove when inserting screws from dorsal to volar during the fixation of middle phalangeal fractures. Lateral intraoperative fluoroscopy may not reveal excessive screw penetration because of the presence of ridges on either side of the groove. Particular care should be taken at the mid-phalangeal level of the middle phalanges of the middle and ring fingers.

Presentations and management of hospitalized patients with upper extremity fractures at a level 1 trauma center: a 5-year observational study

BACKGROUND

Upper extremity injuries (UEIs) are common in the emergency departments, yet they are under-reported in developing countries. This study examined the frequency, injury characteristics, and treatment approaches of upper extremity fractures (UEFs) among hospitalized trauma patients in a nationally representative population.

METHODS

We conducted a retrospective, observational study including all the hospitalized patients with UEFs in the only level 1 trauma center in Qatar between July 2015 and August 2020. Comparative analyses were performed according to injury mechanisms, severity, and management approach.

RESULTS

A total of 2,023 patients sustained UEIs with an average age of 34.4 ± 12.9 years, and 92% were males. Motor vehicle crashes (MVCs; 42.3%) were the primary cause of shoulder girdle injuries in 48.3% of cases. Fractures of the radius, ulna, and hands occurred in 30.8, 16.5 and 14.5%, respectively. Young adults were more involved in MVCs and motorcycle crashes (MCCs), while pedestrians who were typically older had a higher rate of humerus fractures. Patients with MCCs had a higher rate of clavicle and ulna fractures. Pedestrians were at risk of serious injuries, with a higher mean injury severity score and lower Glasgow Coma Scale.

CONCLUSION

Most UEFs patients were young males and mainly affected by MVCs. Shoulder girdle, particularly clavicle and scapula/glenoid fractures, emerged as common injury sites. The study highlighted the potential risk of pedestrian injuries, as reflected in higher injury severity, concomitant injuries, and higher mortality. Future studies are needed to optimize preventive measures by incorporating insights into specific injury mechanisms and patterns of UEIs.

Intramedullary versus locking plate fixation for proximal humerus fractures: indications and technical considerations

Background

The incidence of proximal humerus fractures (PHFs) continues to increase with an aging population, and intramedullary nailing (IMN) and locking plate fixation are two commonly employed techniques for the surgical management of PHF. However, the optimal fixation method can be a source of ongoing controversy. Some influencing factors include the extent of humeral head involvement, fracture complexity, patient age, and surgeon preference. There are many studies that provide a mix of data either when comparing the two techniques or analyzing them in isolation. The aim of this review is to further elucidate the indications and technical considerations involved specifically in IMN vs. locking plate fixation for PHF to further aid orthopedic surgeons when choosing surgical management.

Methods

A narrative approach was chosen for this review allowing for a comprehensive review of literature, including recent findings pertaining to the comparison of management options for PHF. A comprehensive literature search was conducted using the PubMed, Embase, and Cochrane Library databases. The inclusion criteria involved studies that discussed "proximal humerus fracture" and either "intramedullary nail" or "locking plate fixation."

Results

Complications such as avascular necrosis, hardware failure, additional surgical interventions, infection, fracture redisplacement, rotator cuff rupture, and nonunion did not show significant differences between the two groups. Newer generation humeral nails have minimized early complications. As both techniques undergo further refinement and utilization when specifically indicated, functional outcomes, potential complications, and postoperative pain continue to be improved.

Conclusion

The available evidence suggests that both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures, with unclear superiority of either method. The choice of technique should be tailored to patient factors such as fracture type, age, bone quality, and functional expectations. Surgeon experience also plays a role. While certain presentations may exhibit trends that favor one fixation, no specific technique can be universally recommended. Both IMN and LP have shown comparable and satisfactory outcomes, and the final fixation method chosen should take into account the unique characteristics of each patient.

Clinical and radiographic results of locking plate with medial support screw in Proximal Humerus fracture - the more, the better?

BACKGROUND

The calcar of the proximal humerus is a fundamental structure for medial humeral column support. This study aimed to assess the outcome of osteosynthesis across cases of unstable proximal humerus fractures (PHFs) with medial calcar comminution, following treatment with a PHILOS locking plate and medial support screw (MSS).

METHODS

Between January 2010 and December 2018, we retrospectively analyzed the outcomes of 121 cases of osteosynthesis for PHFs with medial column disruption. For the medial support, at least one oblique screw was inserted within 5 mm of the subchondral bone in the inferomedial quadrant of the humeral head. All patients were categorized into two groups: 26 patients in the single MSS group, and 95 in the multiple MSS group. Follow-up after at least an year involved clinical and radiographic outcome evaluations, and correspondingly measuring the Constant-Murley score, University of California, Los Angeles (UCLA) shoulder scale, pain visual analogue scale (VAS), major complications, neck-shaft angle (NSA), humeral head height (HHH), and the eventual time to bone union. Risk factors for the major complications were assessed by multivariate logistic regression analyses.

RESULTS

The cohort's mean age was 64.4 ± 15.4 years, and the mean follow-up duration was 19.5 ± 7.6 months. At the final follow-up, between the single MSS and multiple MSS groups, no significant differences in the Constant-Murley score (p = 0.367), UCLA score (p = 0.558), VAS (p = 0.571), time to bone union (p = 0.621), NSA loss (p = 0.424), and HHH loss (p = 0.364) were observed. The incidence of complications (p = 0.446) based on the number of MSS were not significantly different. The initial insufficient reduction after surgery (of NSA < 125°) was found to be a significant risk factor for post-surgical complications.

CONCLUSIONS

To treat unstable PHFs, the use of at least one MSS along with a locking plate system is sufficient to achieve satisfactory outcomes. Successful operative treatment using a locking plate for PHF treatment is inherent in anatomical fracture reduction, coupled with medial column support.

Multicenter, Prospective, Observational Study of Nonoperative Versus Operative Treatment for High-Energy Midshaft Clavicle Fractures

OBJECTIVES

Evaluate if nonoperative or operative treatment of displaced clavicle fractures delivers reduced rates of nonunion and improved Disability of the Arm, Shoulder, and Hand (DASH) scores.

METHODS

DESIGN

Multicenter, prospective, observational.

SETTING

Seven Level 1 Trauma Centers in the United States.

PATIENT SELECTION CRITERIA

Adults with closed, displaced (100% displacement/shortened >1.5 cm) midshaft clavicle fractures (Orthopaedic Trauma Association 15.2) were treated nonoperatively, with plates and screw fixation, or with intramedullary fixation from 2003 to 2018.

OUTCOME MEASURES AND COMPARISONS

DASH scores (2, 6 weeks, 3, 6, 12, and 24 months), reoperation, and nonunion were compared between the nonoperative, plate fixation, and intramedullary fixation groups.

RESULTS

Four hundred twelve patients were enrolled, with 203 undergoing plate fixation, 26 receiving intramedullary fixation, and 183 treated nonoperatively. The average age of the nonoperative group was 40.1 (range 18-79) years versus 35.8 (range 18-74) in the plate group and 39.3 (range 19-56) in the intramedullary fixation group (P = 0.06). One hundred forty (76.5%) patients in the nonoperative group were male compared with 154 (75.9%) in the plate group and 18 (69.2%) in the intramedullary fixation group (P = 0.69). All groups showed similar DASH scores at 2 weeks, 12 months, and 24 months (P > 0.05). Plate fixation demonstrated better DASH scores (median = 20.8) than nonoperative (median = 28.3) at 6 weeks (P = 0.04). Intramedullary fixation had poorer DASH scores at 6 weeks, 3 months, and 6 months than plate fixation and worse DASH scores than nonoperative at 6 months (P < 0.05). The nonunion rate for nonoperative treatment (14.6%) was significantly higher than the plate group (0%) (P < 0.001).

CONCLUSIONS

Operative treatment of displaced clavicle fractures provided lower rates of nonunion than nonoperative treatment. Except at 6 weeks, no difference was observed in DASH scores between plate fixation and nonoperative treatment. Intramedullary fixation resulted in worse DASH scores than plate fixation at 6 weeks, 3 months, and 6 months and worse DASH scores than nonoperative at 6 months. Implant removal was the leading reason for reoperation in the plate and intramedullary fixation groups, whereas surgery for nonunion was the primary reason for surgery in the nonoperative group.

LEVEL OF EVIDENCE

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

Surgical Considerations for Osteoporosis, Osteopenia, and Vitamin D Deficiency in Upper Extremity Surgery

Fragility fractures as a result of osteoporosis, osteopenia, or vitamin D deficiency are some of the most common injuries encountered in orthopedics and require careful consideration when determining the appropriate management and treatment options. A thorough perioperative evaluation can identify causes of low bone mineral density allowing for initiation of appropriate therapy. Surgical treatment of these fractures can be difficult, and techniques should be employed to ensure stable fixation. It is important to understand the potential pitfalls associated with treatment of fragility fractures to prevent avoidable complications. Postoperative management is key to preventing future injuries in this unique patient population.

The Role of External Fixation in the Treatment of Distal Radius Fractures

There are numerous internal fixation (IF) options available for distal radius fractures (DRFs). The choice of fixation method depends on factors such as fracture morphology, soft tissue integrity, the patient's clinical status, and the surgeon's training. While volar plate fixation has become the primary approach for addressing these fractures, alternative IF methods like K-wire fixation, fragment-specific fixation, and dorsal bridge plating continue to be effective. Despite the versatility of IF, there are certain clinical situations where prompt and conclusive management through open reduction and internal fixation (ORIF) is not suitable. These instances include the treatment of polytraumatized patients, individuals with compromised soft tissues, or those medically unstable to tolerate lengthy anesthesia. In such cases, proficiency in closed reduction and external fixation (EF) proves invaluable. Being able to identify these clinical scenarios and comprehend the efficacy and safety of EF in addressing DRFs is valuable for any surgeon handling such injuries.

Rehabilitation protocols in proximal humerus fracture management: A systematic review

Background

Proximal humerus fractures (PHFs) are relatively common, although optimal rehabilitation is unknown. This review aims to characterize the published rehabilitation regimens utilized for PHFs.

Methods

A systematic review was performed per PRISMA guidelines, utilizing PubMed/MEDLINE, Embase, and Cochrane. All studies reporting PHF rehabilitation protocols after nonoperative management, open reduction internal fixation with a plate, or intramedullary nailing were included.

Results

Forty articles comprising 3507 patients (66% female, weighted mean age 63.5 years) were included. Substantial variability was present regardless of management. Rehabilitation modalities reported were: sling use in 34 cohorts, most commonly for three weeks; pendulum exercises in 21 cohorts, most commonly starting at post-intervention day 1; post-intervention passive range of motion (ROM) for 30 cohorts, most commonly starting at two days; active-ROM in eight cohorts, most commonly starting at three weeks; active-assisted ROM for 21 cohorts, most commonly starting at three weeks; unlimited ROM for 20 cohorts, most commonly at 4 or 6 weeks; non-weight-bearing for six cohorts, most commonly for six weeks; strengthening for 16 cohorts, most commonly at six weeks; removal of all restrictions for nine cohorts, most commonly starting at six weeks.

Conclusions

Published rehabilitation protocols for PHFs vary considerably regardless of management. Future studies comparing methods of management need to consider the influence of postoperative rehabilitation protocol heterogeneity when aggregating data from multiple sites.

Level of Evidence

IV.

Intramedullary Threaded Nail Fixation of Distal Ulnar Fractures: The Surgical Technique and Case Series

BACKGROUND

 To describe the surgical technique of non-compressive intramedullary threaded nail (IMTN) fixation of distal ulnar neck fractures and present the clinical and radiographic outcomes of four patients treated with this novel technique.

METHODS

At a single Level 1 Trauma Center, a retrospective review was conducted for patients with distal ulnar neck fractures treated with retrograde IMTN between 2022 and 2024. Exclusion criteria included inadequate follow-up. A single surgeon performed all procedures using percutaneous retrograde IMTN fixation through the central disc of the triangular fibrocartilage complex (TFCC). Patients initiated a range of motion (ROM) protocol two weeks post-operatively. Post-operative radiographic images were used to calculate the ratio of IMTN diameter to the distal ulnar medullary isthmus diameter proximal to the fracture site. Radiographic changes in displacement, angulation, and ulnar variance were calculated between the first and last follow-up radiographs. Functional outcomes including grip strength and ROM were collected.

RESULTS

Four patients with distal ulnar neck fractures were treated with retrograde IMTN between 2022 and 2024. They were followed for a minimum of three months post-operatively. All were female with an average age of 65 years. All distal ulna fractures were associated with operatively treated intraarticular distal radius fractures. All patients were treated with 75 mm length and 4.5 mm diameter IMTNs. IMTN-to-Isthmus ratio was greater than 60% in all cases. Average radiographic displacement and angulation were unchanged at the final follow-up. The average ulnar variance increased by 1.2 mm. At the final follow-up, there were no post-operative complications. No cases demonstrated ulnar-sided wrist pain, nonunion, or required revision surgery.

CONCLUSIONS

Retrograde IMTN fixation is a novel surgical technique for the treatment of distal ulnar neck fractures. We found limited but promising post-operative radiographic and functional outcomes in our patients without reported ulnar-sided wrist pain, nonunion, or need for hardware removal.

A Comparison of the Rates of Postoperative Infection Following Distal Radius Fixation Between Pediatric and Young Adult Populations: An Analysis of 32 368 Patients

BACKGROUND

Infection following surgical fixation of a distal radius fracture can markedly compromise a patient's functional outcome. This study aimed to compare infection rates in pediatric (5-14 years) and adolescent (15-17 years) patients undergoing fixation of a distal radius fracture to a cohort of young adult (18-30 years) patients.

METHODS

A matched retrospective study was performed using PearlDiver to determine the rates of postoperative infection following distal radius fixation. χ2 and logistic regression were used to assess differences in rates, while linear regression was used to analyze rates of infection over time.

RESULTS

In 32 368 patients, young adults experienced postoperative infection at a significantly increased rate (odds ratio [OR] = 1.81; 95% confidence interval [CI], 1.45-2.27). This trend was consistent among the male (OR = 1.96; 1.49-2.57) and female (OR = 2.11, 1.37-3.27) cohorts. In the multivariate model, the adult cohort remained at increased risk (OR = 1.40; 95% CI, 1.04-1.89), with open fracture (OR = 4.99; 3.55-6.87), smoking (OR = 1.76; 1.22-2.48), hypertension (OR = 1.69; 1.20-2.33), and obesity (OR = 1.37; 1.02, 1.80) identified as other significant risk factors. There was no significant change in the rate of postoperative infections over the 11-year study period.

CONCLUSION

This study demonstrated that although surgical site infections following distal radius fixation are low in patients aged 30 years or younger (0.97%), young adults develop infections at a significantly increased rate. This is important for surgeons to recognize when counseling patients on the risks of surgical fixation.

Risk Factors for 30-Day Complications and Unplanned Reoperation Following Surgical Treatment of Distal Radius Fractures

BACKGROUND

The purpose of this study was to identify demographic data, medical comorbidities, and perioperative factors that are associated with increased risk of overall surgical complications, wound complications, and reoperation within 30 days of open reduction and internal fixation (ORIF) of distal radius fractures.

METHODS

All adult patients undergoing ORIF of distal radius fractures in the National Surgical Quality Improvement Program database between 2005 and 2020 were identified. Patients were excluded for secondary procedures, open/infected injuries, or inpatient surgical setting. Demographic data, medical comorbidities, and perioperative data were examined for each patient, and patients were grouped by the presence or absence of any surgical complication. Univariate analysis and multivariate logistic regression were used to identify risk factors.

RESULTS

A total of 20 301 patients from between 2005 and 2020 met the inclusion criteria, of which 219 complications (1.1% of cases) were identified. Following multivariate analysis, independent risk factors found to be associated with surgical complications included male sex, smoking, heart failure, longer operative time, and American Society of Anesthesiologists (ASA) classification of 3 or higher.

CONCLUSION

Male sex, smoking, heart failure, prolonged operative time, and ASA status of 3 or higher are associated with an increased risk of surgical complications following ORIF of distal radius fractures. These complications, with the exception of heart failure, were also associated with an increased risk of wound complications. Finally, male sex, nonwhite race, smoking, dialysis, prolonged operative time, and 3 or higher ASA class were associated with reoperations. Understanding these risk factors allows surgeons to better predict and prevent complications in high-risk populations.

Buried or exposed Kirschner wire for the management of hand and forearm fractures: A systematic review, meta-analysis, and meta-regression

BACKGROUND

The recommendation on whether to bury or expose the Kirschner wire (K-wire) for the management of fractures has still been controversial with inconsistent results in the published studies due to the potential issue associated with exposed K-wire is the heightened risk of infection, as it comes into direct contact with the external environment and air. This study aims to summarize the specific outcomes between buried and exposed K-wire for the management of hand and forearm fractures.

METHODS

We conducted relevant literature searches on Europe PMC, Medline, Scopus, and Cochrane Library databases using specific keywords. This investigation focuses on individuals of any age diagnosed with hand or forearm fractures who underwent surgery involving Kirschner wire (K-wire) fixation. It examines the comparison between buried and exposed K-wire fixation, emphasizing primary outcome pin infection, along with secondary outcomes such as early pin removal, days to pin removal, and surgical duration. The study includes observational studies (cohort/case-control) or randomized clinical trials (RCTs). The results of continuous variables were pooled into the standardized mean difference (SMD), while dichotomous variables were pooled into odds ratio (OR) along with 95% confidence intervals using random-effect models. The quality of included studies was assessed with Cochrane Collaborations, Risk of Bias version 2 (RoB v2).

RESULTS

A total of 11 studies were included. Our pooled analysis revealed that buried K-wire was associated with a lower risk of pin site infection [RR 0.49 (95% CI 0.36-0.67), p < 0.00001, I2 = 0%] and 33.85 days longer duration until pin removal [MD 33.85 days (95% CI 18.68-49.02), p < 0.0001, I2 = 99%] when compared with exposed K-wire. However, the duration of surgery was 9.98 minutes significantly longer in the buried K-wire [MD 6.98 minutes (95% CI 2.19-11.76), p = 0.004, I2 = 42%] with no significant difference in the early pin removal rate [RR 0.73 (95% CI 0.36-1.45), p = 0.37, I2 = 0%]. Further regression analysis revealed that sample size, age, sex, and duration of follow-up did not affect those relationships.

CONCLUSION

Buried K-wire may offer benefits in reducing the infection rate with a longer duration until pin removal. However, further RCTs with larger sample sizes are still needed to confirm the results of our study.

Redefining Surgical Materials: Applications of Silk Fibroin in Osteofixation and Fracture Repair

Silk and silk derivatives have emerged as a possible alternative in surgical device development, offering mechanical strength, biocompatibility, and environmental sustainability. Through a systematic review following PRISMA guidelines, this study evaluated silk fibroin's application across pre-clinical and clinical settings, focusing on its role as screws and plates for osteofixation. A comprehensive search yielded 245 studies, with 33 subjected to full-text review and 15 ultimately included for qualitative analysis. The findings underscore silk fibroin's superior properties, including its tunable degradation rates and ability to be functionalized with therapeutic agents. In vivo and in vitro studies demonstrated its efficacy in enhancing bone healing, offering improved outcomes in osteofixation, particularly for craniofacial defects. Silk fibroin's remarkable attributes in biodegradation and drug release capabilities underscore its potential to enhance patient care. Ultimately, silk fibroin's integration into surgical practices promises a revolution in patient outcomes and environmental sustainability. Its versatility, coupled with the continuous progress in fabrication techniques, signals a promising horizon for its widespread acceptance in the medical field, potentially establishing a new benchmark in surgical treatment. Further research is expected to solidify the transition of silk products from basic science to patient care, paving the way for widespread use in various surgical applications.

Conservative treatment of 3- and 4-part proximal humeral fractures: Can poor outcomes be predicted?

PURPOSE

3- and 4-part proximal humeral fractures are frequently treated conservatively. This study aims to combine radiographic, and patient reported outcome data to identify factors leading to poor outcomes following conservative treatment.

METHODS

A retrospective local database analysis identified 3- and 4-part fractures. Radiographic and functional outcomes including Oxford Shoulder Score (OSS), QuickDash (QD), Subjective Shoulder Score (SSV) and VAS pain scores were collected.

RESULTS

104 patients were included at mean follow-up of 55 months. Analysis highlighted significant OSS differences in 3- versus 4-part (p = 0.027), dominant arm injury (p = 0.046), age > 65 (p = 0.006), varus coronal neck-shaft angle < 115 versus 115-155 degrees (p = 0.008), posterior head tilt > 155 degrees (p = 0.005), greater tuberosity (GT) displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.032). According to QD scores; age > 65 (p = 0.012), varus neck-shaft angle (p = 0.01), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.006). SSV varied significantly with 3- versus 4-part fractures (p = 0.005), age > 65 (p = 0.04), varus neck-shaft angle (p = 0.001), posterior head tilt (p = 0.005), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.003), and medial calcar hinge displacement > 2 mm (p = 0.001).

CONCLUSION

We highlight risk factors for unfavourable outcomes following conservative management, aiding surgeons in shared decision-making and patient expectation management.

Outcomes Following Surgical Fixation of Upper Extremity Fractures in Patients with Chronic Kidney Disease

Purpose

Moderate to severe (stage III-IV) chronic kidney disease (CKD) and end stage renal disease (ESRD) have been shown to be independent risk factors for sustaining a fragility fracture. High rates of complications and mortality are associated with fracture fixation in patients with CKD, but existing literature is limited. It is unknown how CKD stage III-IV or ESRD affects outcomes in upper-extremity fractures. We hypothesize that patients with CKD stage III-IV or ESRD will have high complication rates after surgical fixation of upper extremity fractures.

Methods

We identified all patients between 2008 and 2018 who underwent operative fixation of an upper extremity fracture proximal to the distal radius with a diagnosis of CKD stage III-IV or ESRD at the time of injury. Those with an acute kidney injury at the time of injury or a history of a kidney transplant were excluded. Demographics, medical complications, and surgical complications were collected retrospectively. Data on readmissions within 90 days and mortality within 1 year were also collected.

Results

Thirty-five patients were identified. Three patients had ESRD. Fractures included two clavicle, twelve proximal humerus, one humeral shaft, ten distal humerus, five olecranon, two ulnar shaft, one radial shaft, and two both-bone forearm fractures. In total, 91.4% of fractures were closed injuries. Surgical complications occurred in 40% of patients. The reoperation rate was 11.4%, and all cases of reoperation involved hardware removal. The all-cause 90-day readmission rate was 34.3%. The 1-year mortality rate was 8.6%.

Conclusions

Surgical complications occurred in 40% of patients with CKD stage III-IV or ESRD who underwent fixation for an upper extremity fracture. It is important to counsel these patients regarding their high risk for complications. Further research is needed to investigate and identify how to mitigate risk.

Type of study/level of evidence

Prognostic IV.

Outcomes Following Surgical Fixation of Distal Radius Fractures in Patients With Chronic Kidney Disease

Purpose

Moderate-to-severe chronic kidney disease (CKD, stages III-IV) and end-stage renal disease (ESRD or CKD stage V) are known to be independent risk factors for fragility fracture. Altered bone and mineral metabolism contributes to greater complications and mortality rates in the setting of fractures, although most existing literature is limited to hip fractures. We hypothesized that patients with moderate-to-severe CKD or ESRD would have greater complication rates after surgical treatment of distal radius fractures compared with those without CKD.

Methods

We retrospectively identified all patients at a level 1 trauma center between 2008 and 2018 who had a diagnosis of stage III-IV CKD or ESRD at the time of operative fixation of a distal radius fracture. We recorded demographic data, comorbidities, and surgical complications. Data for readmissions within 90 days and 1-year mortality were collected. A 2:1 sex-matched control group without CKD who underwent distal radius fixation was selected for comparison, with age-adjusted analysis.

Results

A total of 32 patients with CKD (78.1% CKD stage III/IV, 21.9% ESRD) and 62 without CKD were identified. The mean age was 67 ± 12 years in the CKD group and 55 ± 15 years in the control group. The CKD group had a higher Charlson Comorbidity Index (5.7 vs 2.0). Surgical complication rate in the CKD group was 12.5% (12.0% CKD III/IV; 14.3% ESRD). Neither early nor late surgical complication rates were statistically different from those in patients without CKD. Reoperation rate as well as 30- and 90-day readmission rates were similar between groups. Overall, 1-year mortality was greater in the CKD group (9.4% vs 0%).

Conclusions

Surgical complications and readmission rates are similar in patients with and without CKD after distal radius fracture fixation. However, 1-year mortality rate is significantly higher after distal radius fixation in patients with moderate-to-severe CKD or ESRD.

Type of study/level of evidence

Prognostic IIIa.

Impact of Socioeconomic Factors on Time to Surgery for Distal Radius Fractures

Background

Delay in care secondary to socioeconomic status (SES) and demographic factors represents an area for potential improvement. Reducing time to surgery in distal radius fracture (DRF) fixation may improve outcomes while reducing cost. The purpose of this study is to investigate the effect of SES on time to surgery in our study population.

Methods

Patients undergoing outpatient DRF surgery within an academic healthcare system during a 4-year period were reviewed. Time to surgery and demographic factors were analyzed. The US Census Bureau was used to determine median household income (MHI) for a patient's ZIP code; patients were stratified into three groups based on MHI.

Results

A total of 413 patients met inclusion criteria. SES (14.7 d in the low-SES group, 14.0 d in the mid-SES group, and 11.1 d in the high-SES group, P = 0.00063), insurance (11.7 d for insured versus 16.3 d for Medicaid/uninsured, P < 0.0001), race (non-White group: 15.2 d versus White group: 10.9 d, P < 0.0001), and treatment facility (16.2 d at county hospital versus 10.9 d at university hospital, P < 0.0001) were associated with time to surgery in univariate analysis. Multivariate analysis found that only treatment facility was associated with time to surgery.

Conclusions

Non-White, uninsured/Medicaid individuals residing in low-SES areas may be more likely to receive care at a safety-net facility and are at greatest risk for delay in time to surgery. Measures aimed to reduce barriers to care, increase healthcare coverage, and improve patient education should be initiated to mitigate these disparities.

Negative Ulnar Variance Lessens DRUJ Instability After DRUJ Disruption: A Biomechanical Analysis

BACKGROUND

The purpose of this study was to perform a biomechanical investigation on the effect of ulnar variance (UV) on the stability of the distal radioulnar joint (DRUJ) prior to and after DRUJ sectioning.

METHODS

Ten cadaveric forearm specimens were included in the study and baseline UV was assessed radiographically. Radial motion relative to the ulna was evaluated using Intel real sense cameras and a custom developed program. The forearms were dissected, and a radial osteotomy was performed. Using a custom-made plate, radial stability was assessed with an UV of + 4, 0, and -4 mm by measuring the maximum and minimum radial position relative to the ulna during a simulated Shuck test. The volar radioulnar ligaments and triangular fibrocartilage complex (TFCC) were then sectioned, and testing was repeated at each UV state.

RESULTS

Sectioning significantly increased radial translation at neutral (P = .008), +4 mm UV (P = .008), and -4 mm UV (P = .018). There were no significant differences in translation between the 3 UV groups with the DRUJ intact (P = .124). The ulnar negative (-4 mm) state had significantly lower translation compared to the positive (+4 mm) (P < .001) and the neutral (0 mm) (P = .026) UV states. There were no significant differences between the positive and neutral UV groups with the DRUJ sectioned.

CONCLUSIONS

Fixating the radius in -4 mm of ulnar negativity significantly decreased radial translation after sectioning the volar radioulnar ligament and TFCC. Ulnar variance had no effect on stability with an intact DRUJ.

STUDY TYPE

Biomechanical Study.

How Preoperative Closed Reduction and Time to Surgery Impact Postoperative Palmar Inclination in Distal Radius Fractures

Background: The anatomical reconstruction of the wrist is the aim when treating distal radius fractures. Current literature on the importance of preoperative reduction in fractures that are treated operatively is limited. Methods: This study investigated the effect of the preoperative closed reduction of distal radius fractures on the day of trauma and the time to surgery on postoperative palmar inclination. A total of eighty patients (48 females and 32 males, mean age 55.6 years) were studied retrospectively. All patients were treated with an open reduction and internal fixation. The palmar inclination angle was measured using X-rays by two investigators, and the interobservers and pre- and post-reduction parameters were compared. Results: When the surgical management of closed distal radius fractures is required, neither initial repositioning nor a delay of up to 14 days to the surgical treatment influences postoperative palmar inclination. Conclusions: The significance of preoperative reduction of distal radius fractures without neurovascular or extensive soft tissue damage is limited and is not leading to improved outcomes. When surgery is about to be performed, surgeons should carefully consider if reduction is really vital preoperatively. Level of evidence: III.

Measurement of Radiological Parameters of Distal Radius Fracture Using the Ulnar Axis Compared with the Radial Axis

Background: The long axis of the radius is a standard reference for measuring radiological parameters in distal radius fractures. However, in patients with severe comminution and anatomical variation with distal radius bowing, it is challenging to assess using the long axis of the radius. The long axis of the ulna can be used as an alternative reference. The aim of this study is to assess the reliability and level of agreement using the long axis of the ulna as an alternative reference in comparison to the long axis of the radius. Methods: Posteroanterior (PA) radiography of the wrist in patients with acute distal radius fractures was evaluated in two rounds by four observers. Radial height, radial inclination and ulnar variance were measured using radial and ulnar long axis as references. The intraobserver and interobserver reliability of the measurements with two reference axes was assessed using intraclass correlation coefficient (ICC). The level of agreement was determined using the Bland-Altman plot. Results: In total, 59 patients who underwent PA radiography of the wrist were included in this study. All parameters exhibited good agreement between the two methods, with a mean difference of nearly zero (radial height = -0.03 mm, radial inclination = -0.14° and ulnar variance = 0.03 mm). The limits of agreement in radial height (-2.87, 2.82 mm) and ulnar variance (-0.81, 0.87 mm) were narrow. However, for the radial inclination, it was wider (-6.21, 5.94°). Intraobserver reliability between the long axis of radius and ulna (ICC = 0.85-0.99 and 0.84-0.98, respectively) was good to excellent. The interobserver reliability of each parameter was excellent (ICC = 0.94-0.97). Conclusions: The ulnar long axis can be used as an alternative reference for measuring radial height, radial inclination and ulnar variance in PA radiography of the wrist in acute distal radius fracture, particularly if the radial long axis is distorted. Level of Evidence: Level III (Diagnostic).

Choosing the proper implant for extra-articular fractures of proximal phalanges: A study on 75 cases

INTRODUCTION

Phalangeal fractures are the most common fractures of the hand and in particular the proximal phalanx of the long fingers is the most involved. These fractures can ben conservatively managed but, when the fracture pattern is considered unstable, surgical treatment is recommended. However, there is no consensus in literature about the proper surgical option for extra-articular proximal phalanx fractures.

MATERIAL AND METHODS

We compared clinical and radiographical results after treatment of 75 cases of extra-articular proximal phalanx fractures using three different surgical techniques: closed reduction and internal fixation (CRIF) with Kirschner wires (G1 group), open reduction internal fixation (ORIF) with plates and screws or lag screws (G2 group), and closed reduction and intramedullary screw fixation (CRIMEF)(G3 group).

RESULTS

We found no significant differences in term of union rate and time to fracture healing between the three groups. However, we found a significant reduction in time to return at work and in TAM at the final follow-up examination in G3 group (treated with CRIMEF) when compared with both G1 and G2. No differences in complications rate were found between three groups.

DISCUSSION

The surgical variability in the management of extra-articular phalanx fractures create lacks on standard guide for treatment.

CONCLUSIONS

In conclusion, our results showed good clinical and radiographical results with all the three surgical options. However, the closed reduction and internal fixation with intramedullary screws (CRIMEF) seems to be better in terms of time to return to work and TAM at the final follow-up, probably due to good primary stability and little risk of soft tissue adherence development.

Understanding Variations in the Management of Displaced Distal Radius Fractures With Satisfactory Reduction

BACKGROUND

The American Academy of Orthopaedic Surgeons has set forth Clinical Practice Guidelines (CPGs) to help guide management of closed, displaced distal radius fractures (DRFs). There still exists variation in practice regarding operative vs nonoperative decision-making. This study aims to identify which factors influence the decision to treat DRFs not indicated for surgery by the CPGs after initial closed reduction.

METHODS

Fifteen sets of DRFs and clinical vignettes were distributed via email to over 75 orthopedic residency programs, Orthopaedic Trauma Association, and New York Society for Surgery of the Hand membership. A Qualtrics survey collected respondent demographics, choice of treatment, and rationale.

RESULTS

Responses were received from 106 surgeons and resident trainees. The odds of selecting operative management for fractures with 5 or more radiographic instability signs versus 3 or 4 was 3.11 (P < .05). Age over 65, higher patient activity level, and dominant-hand injury were associated with greater odds of operative management (3.4, 30.28, and 2.54, respectively). In addition, surgeons with more years in practice and high-volume surgeons had greater odds of selecting operative management (2.43 and 2.11, respectively).

CONCLUSIONS

Assessment of instability at the time of injury, patient age and activity level, as well as surgeon volume and time in practice independently affect the decision to manage well-reduced DRF with surgical or nonsurgical treatment. The source of heterogeneity in the treatment of these fractures is borne at least in part from a lack of formal direction on the importance of prereduction instability from the CPGs.

Comparison of Low-Dose Computed Tomography Versus Conventional-Dose Computed Tomography in the Evaluation of Distal Radius Fractures

BACKGROUND

Distal radius fractures (DRFs) are common upper extremity fractures and often require surgical fixation when they are intraarticular. Preoperative computed tomography (CT) has emerged as a surgical planning tool to evaluate intraarticular DRFs. Although CT affords additional details, patients receive higher radiation doses than standard radiographs. We aim to develop a low-dose CT (LDCT) protocol, relative to the institutional standard-dose CT wrist for intraarticular DRFs although providing adequate detail for surgical decision-making.

METHODS

A single-institution prospective study was conducted on patients with intraarticular DRFs who underwent closed reduction and below-elbow splinting who otherwise would undergo wrist CT. Observations were defined as total measurements taken, with each view undergoing 44 measurements. Patients underwent 2 scans with a standard dose and a 10× dose reduction. Articular step and gap measurements were recorded in the sagittal and coronal images.

RESULTS

A total of 11 patients were enrolled (7 women and 4 men). The mean age was 55 years (SD = 20.1). There were a total of 4 reviewers: 1 attending surgeon, 2 resident physicians, and 1 student. When comparing LDCT and conventional-dose CT (CDCT), there were no significant differences in step and gap measurements across all reviewers.

CONCLUSION

This study demonstrated that LDCT provides comparable imaging quality for surgical planning as a CDCT without significant diagnostic decay in the setting of DRFs. This comes with the added benefit of a 10-fold reduction in radiation exposure. These results suggest that LDCT is an opportunity to reduce effective radiation in patients although providing beneficial preoperative imaging.

Phalangeal Fractures Requiring Vascular Reconstruction: Epidemiology and Factors Predictive of Reoperation

BACKGROUND

Demographic information related to phalangeal fractures that undergo simultaneous vascular repair, as well as their complication and reoperation profiles, remain incompletely understood. This study aimed to examine the patient and fracture characteristics influencing the outcomes after these injuries in a large Unites States adult patient cohort and to identify risk factors associated with unplanned reoperation of these fractures.

METHODS

A retrospective study was performed, identifying 54 phalangeal fractures in 48 patients; all fractures were also associated with vascular injuries requiring repair. Patients with digital amputations were excluded. A manual chart review was performed to collect epidemiologic, radiographic, and surgical outcome information.

RESULTS

The incidence of phalangeal fractures undergoing vascular repair was higher in the non-dominant hand, middle finger, proximal phalanx, and phalangeal shaft. Most (52.9%) fractures were due to occupational injury, with the most common mechanism being sharp injuries. More than half of the fractures had a nerve injury, and 13% required a vein graft for vascular repair. More than half of the fractures required at least one reoperation, most commonly due to "stiffness/tendon adhesion" (50%) and "nonunion or delayed union" (21.4%). In multivariable analysis, thumb (odds ratio [OR]: 35.1, P = .043) and index (OR: 14.0, P = .048) fingers' fractures were found to be independently associated with unplanned reoperation.

CONCLUSIONS

Phalangeal fractures requiring vascular repair occurred most often in the occupational setting and more than 50% required at least one unplanned reoperation. Injuries sustained in the thumb and index finger were more likely to undergo unplanned reoperation, which may guide initial treatment decision-making and postoperative follow-up.

Geriatric proximal humerus fracture operative management: a Truven Health Analytics database study (2015-2020)

BACKGROUND

The purpose of this study is to assess the trends in operative management of geriatric (≥65 years) proximal humerus fractures during a 6-year period (2015-2020) within an insurance claims database.

METHODS

This retrospective database cohort study used data gathered from the 2015-2020 IBM Truven MarketScan Commercial and IBM Truven MarketScan Medicare Supplemental databases. The International Statistical Classification of Disease and Related Health Problems, Tenth Revision, data was correlated to the Current Procedural Terminology code for shoulder arthroplasty (proximal humeral prosthetic replacement: 23616, shoulder hemiarthroplasty [HA]: 23470, reverse total shoulder arthroplasty [rTSA]: 23472) or open reduction internal fixation (ORIF; open treatment of proximal humerus fracture with internal fixation: 23615, open treatment of proximal humerus fracture-dislocation with internal fixation: 23680). We investigated the number of proximal humerus fracture operative cases per year, percentage arthroplasty used per year, rTSA and HA per year, hospital cost information, as well as percentage arthroplasty per US geographic region.

RESULTS

A total of 8057 operative proximal humerus fractures cases were identified in 7697 patients aged >65 years, with 0.45% (360 of 8057) being bilateral. There was a 40.8% decrease in the rate of operative management of proximal humerus fractures between the first half (2015-2017, 1687.3 ± 146.6) and the second half of the study period (2018-2020, 998.3 ± 258.7). Arthroplasty accounted for 78.7% of all surgeries, 91% of those being rTSA. The total number of cases of rTSA and ORIF performed decreased per year (P = .01). The downward trend of percentage ORIF per year approached significance (P = .054). Arthroplasty was a more expensive option of payment for total case by almost $850.00 (P = .001). There was a larger percentage of arthroplasty performed in the Northeast and North Central US geographic regions.

CONCLUSION

Despite the rise of both the elderly population and related geriatric proximal humerus fractures, they were less operatively represented in this insurance claims database across the 6-year period. There may be a trend to use less ORIF when addressing these fractures. Although it incurred a higher in-hospital cost, arthroplasty was being performed at a higher percentage in the Northeast and North Central regions of the United States.

Efficiency of a virtual fracture care protocol in non-operative treatment of adult patients with a distal radial fracture

This study aimed to determine the effects of virtual fracture care (VFC) on secondary healthcare utilization in non-operative treatment of adult patients with a distal radial fracture. A retrospective cohort study was performed, including those who received non-operative treatment without VFC (pre-VFC) and with VFC (VFC). Outcomes included secondary healthcare utilization, calculated treatment costs, emergency department (ED) reattendances and complication rates. In total, 88 pre-VFC and 99 VFC patients were included. Pre-VFC patients had more follow-up appointments, with a median of 4 (IQR: 3) versus a median of 4 (IQR: 1) in VFC patients. In addition, 3% of follow-up appointments for pre-VFC patients were performed remotely compared to 18% for VFC patients. Complications and ED reattendances were comparable between groups. In this study, non-operative treatment of adult patients with a distal radial fracture through VFC reduced secondary healthcare utilization, with similar reported complication and ED reattendance rates compared with treatment without VFC.Level of evidence: III.

Comorbidities Associated With Increased Likelihood of Postoperative Surgical Site Infection in Patients Treated for Hand or Finger Fracture and/or Dislocations

BACKGROUND

We aimed to determine the relationship between common preoperative comorbidities and subsequent incidence of postoperative surgical site infections (SSIs) in hand and finger fractures and/or dislocations.

METHODS

We queried the American College of Surgeons National Safety and Quality Improvement Program from January 1, 2015 to December 31, 2019. Patients were included in our study if they were treated by open or percutaneous fixation for any hand or finger fracture and/or dislocation. Predictor variables were smoking status, diabetes mellitus status, and obesity (body mass index > 30) status. Primary outcome was incidence of postoperative SSI.

RESULTS

There were a total of 9245 patients included in our study, and 148 patients (1.6%) experienced postoperative SSI. Of these, 59 patients (39.9%) were only smokers, 7 patients (4.7%) only had diabetes mellitus, and 55 patients (37.2%) were only obese. Overall, patients experienced greater odds of sustaining a postoperative SSI if they were a smoker or diabetic compared to non-smokers and non-diabetics, respectively. Considering only open fixation modality, patients with comorbidities were not at significantly increased odds of sustaining postoperative SSI. Considering only percutaneous fixation modality, patients experienced significantly greater odds of sustaining postoperative SSI if they were a smoker compared to non-smoker.

CONCLUSIONS

Common preoperative comorbidities, including smoking status and diabetes mellitus, increase the likelihood of postoperative complication in patients with hand and finger fractures and/or dislocations undergoing surgical treatment. Further investigation into the different relationship of these comorbidities between open and closed fractures with larger sample sizes will be valuable.

The Impact of Social Determinants of Health on the Treatment of Distal Radius Fracture

BACKGROUND

Disparities in social determinants of health (SDH) have been shown to play an increasingly important role in the equitable delivery of health care. Distal radius fractures (DRFs) are among the most common upper-extremity injuries encountered. This study aims to examine the influence of economic, educational, social, environmental, and healthcare disparities on management of these injuries.

METHODS

PearlDiver Mariner insurance claims database was analyzed for treatment patterns of DRF in patients aged 18 to 65 years based on the presence or absence of social determinants of health disparities (SDHDs). Outcome variables included the primary mode of management of DRF, including operative versus non-operative, as well as concomitant procedures. Multivariate logistic regression was used to compare fracture management modality in patients with and without SDHDs.

RESULTS

Of 161 704 patients identified with DRF, 38.3% had at least 1 reported SDHD. The majority of SDHDs were economic. Patients identified with 1 or more SDHDs had a higher medical comorbidity index. Patients with environmental SDHD were more likely to receive non-operative management. Within any SDHD and economic subgroups, odds of operative management were higher. No relationship was identified between SDHD and concomitant procedures.

CONCLUSIONS

The presence of environmental disparities in SDH may predispose patients disproportionately to non-operative management. The presence of SDHDs may influence medical decision-making in favor of open reduction and internal fixation in patients with DRF treated operatively. In treating at-risk populations, providers should be aware of the potential for implicit bias associated with SDHDs and prioritize shared decision-making between patients and physicians.

Fracture related infection (FRI) of the upper extremity correlates with poor bone and soft tissue healing

PURPOSE

The purpose of this study was to evaluate the specific course and complication profile following the development of FRI in the upper extremity.

METHODS

An IRB-approved retrospective review was conducted on a consecutive series of operatively managed patients within an academic medical center between 1/2010 and 6/2022. Included patients met the following criteria: (1) upper extremity fracture definitively treated with internal fixation (2) development of criteria for suggestive or confirmatory FRI (as per the FRI Consensus Group) and (3) age ≥ 18 years. Baseline demographics, medical history, injury information, infection characteristics, hospital quality measures, and outcomes were recorded. A 3:1 propensity-matched control cohort of patients without FRI was obtained using the same dataset. Univariable analysis was performed to compare the outcomes (rate of nonunion, time to bone healing, need for soft tissue coverage, patient reported joint stiffness at final follow-up) of the FRI vs Non-FRI cohorts.

RESULTS

Of 2827 patients treated operatively for an upper extremity fracture, 43 (1.53%) met criteria for suggestive of confirmatory FRI. The successful propensity match (43 FRI, 129 Non-FRI) revealed no differences in demographics, baseline health status, or fracture location. FRI patients underwent more reoperations (p < 0.001), experienced an increased rate of removal of hardware (p < 0.001), and were admitted more frequently following index operation (p < 0.001). The FRI cohort had higher rates of fracture nonunion (p = 0.003), and a prolonged mean time to bone healing in months (8.37 ± 7.29 FRI vs. 4.14 ± 5.75 Non-FRI, p < 0.001). Additionally, the FRI cohort had a greater need for soft tissue coverage throughout their post-operative fracture treatment (p = 0.014). While there was no difference in eventual bone healing (p = 0.250), FRI patients experienced a higher incidence of affected joint stiffness at final follow-up (p < 0.001).

CONCLUSION

Patients who develop an FRI of the upper extremity undergo more procedures and experience increased complications throughout their treatment, specifically increased joint stiffness. Despite this, ultimate outcome profiles are similar between patients who experience FRI and those who do not following operative repair of an upper extremity fracture.

LEVEL OF EVIDENCE

III.

Adjuvant Arthroscopy Does Not Improve the Functional Outcome of Volar Locking Plate for Distal Radius Fractures: A Randomized Clinical Trial

PURPOSE

To evaluate the outcomes of adding arthroscopy to osteosynthesis of distal radius fractures (DRF) with volar locking plate (VLP), by Patient-Rated Wrist Evaluation (PRWE) 1 year after surgery.

METHODS

In total, 186 functionally independent adult patients who met the inclusion criteria (DRF and a clinical decision for surgery with a VLP) were randomized to arthroscopic assistance or not. Primary outcome was PRWE questionnaire results 1 year after surgery. For the main variable, PRWE, we obtained the minimal clinically important difference based on a distribution-based method. Secondary outcomes included Disabilities of the Arm, Shoulder and Hand and 12-Item Short Form Health Survey questionnaires, range of motion, strength, radiographic measures, and presence of joint step-offs by computed tomography. Data were collected preoperatively and at +1 and +4 weeks, +3 and +6 months, and +1 year after surgery. Complications were recorded throughout the study.

RESULTS

In total, 180 patients (mean age: 59.0 ± 14.9 years; 76% women) were analyzed by modified intention to treat. A total of 82% of the fractures were intra-articular (AO type C). No significant difference between arthroscopic (AG) and control (CG) groups in median PRWE was found at +1 year (median AG: 5.0, median CG: 7.5, difference in medians 2.5; 95% confidence interval [CI] -2.0, 7.0, P = .328). The proportion of patients who exceeded the minimal clinically important difference of 12.81 points in the AG and CG was 86.4% vs 85.1%, P = .819, respectively. Percentage of associated injuries and step-offs reduction maneuvers was greater with arthroscopy (mean differences: 17.1 95% CI -0.1, 26.1, P < .001) and 17.4 (95% CI 5.0, 29.7, P = .007). The difference in percentage of residual joint step-offs at the postsurgical computed tomography in radioulnar, radioscaphoid, and radiolunate joints was not significant (P = .990, P = .538, and P = .063). Complications were similar between groups (16.9% vs 20.9%, P = .842).

CONCLUSIONS

Adjuvant arthroscopy did not significantly improve PRWE score +1 year after surgery for DRF with VLP, although the statistical power of the study is below the initially estimated to detect the expected difference.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Arthroscopic Assistance in Surgical Management of Distal Radius Fractures: A Systematic Review and Meta-analysis

Background  Wrist arthroscopy has become a commonly used tool for the management of adults with distal radius fractures (DRFs), although its implementation requires technical competence. This systematic review and meta-analysis appraised the available evidence concerning the contribution of wrist arthroscopy to the functional and radiological outcomes of patients with DRFs operated with arthroscopic assistance. Methods  Randomized control trials were identified through five principal electronic databases on May 31, 2022: Web of Science, Scopus, EBSCO, Embase, and PubMed. Two authors independently performed the search and data extraction and assessed risk of bias (RoB) using the Cochrane RoB tool. Results  A total of 1,780 relevant abstracts and citations were extracted in the preliminary search, which yielded 6 trials that met the eligibility criteria, and 3 studies were included in the quantitative synthesis. The overall pooled mean difference (MD) estimate showed no significant difference in the Disabilities of the Arm, Shoulder, and Hand scores between surgical groups with and without arthroscopic assistance (MD = 0.77 points, 95% confidence interval = -6.58 to 5.03, p  = 0.79), with substantial heterogeneity (I 2  = 85%). Conclusion  There was low-quality evidence that wrist arthroscopy conveyed not clinically or statistically significant difference to functional outcomes of patients with DRFs. However, our findings are limited by the numbers of studies included and lack of long-term follow-up, although they do provide a good starting point for future quality research.

Incidence of Infection in Operatively Treated Distal Radius Fractures After Conversion From External to Internal Fixation

PURPOSE

The purpose of this study was to report the incidence of infection after conversion from external fixation (EF) to internal fixation (IF) of distal radius fractures and to evaluate the relationship between infection and secondary variables, including time to conversion from EF to IF, internal hardware overlapping EF pin sites, and definitive fixation with a dorsal-spanning bridge plate.

METHODS

A retrospective review was performed at 2 level 1 trauma centers including all patients aged ≥18 years from 2006 to 2019 with a distal radius fracture treated initially with EF followed by subsequent IF. The patients were excluded from analysis if they had <10 weeks of clinical follow-up, a history of prior distal radius surgery, or evidence of infection before EF to IF conversion. Patient demographic data, mechanism of injury, presence of hardware overlapping pin sites, and timing to definitive fixation were obtained from the medical records. Infection was defined as positive intraoperative cultures or documented return to the operating room for debridement after IF.

RESULTS

A total of 64 fractures in 61 patients with a median age of 50 years (range, 18-75 years) were included. Infections developed in 6 patients (6 of 64 fractures). The incidence of infection was higher in patients with a time to conversion from EF to IF of >14 days (infection in 2 of 5 patients vs 4 of 59 patients). The incidence of infection was similar in patients with and without hardware overlapping EF pin sites (3 of 27 vs 3 of 37, respectively).

CONCLUSIONS

Infections occurred in 6 of 64 distal radius fractures following conversion from EF to IF, and delay in conversion of >14 days was associated with an increased infection risk.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Complications of operatively treated distal radial fractures

Distal radial fractures represent the most common fractures of the upper extremity. Operative treatment is performed for approximately one-third of distal radial fractures in the adult population. Complications following operative treatment of distal radial fractures vary depending on the treatment modality and can be stratified into preoperative and postoperative complications. Complications can occur in the near, intermediate and long term. The most common complications seen are tendon irritation and rupture, chronic regional pain syndrome (CRPS), carpal tunnel syndrome, ulnar or radial neuropathy, compartment syndrome, malunion, inadequate fixation or loss of fixation, symptomatic hardware, post-traumatic arthritis, stiffness and infection. Careful planning, treatment and patient selection can help to mitigate these complications.Level of evidence: V.

Study of the position of six volar locking plates for distal radius fracture relative to the watershed line

INTRODUCTION

Volar plate malpositioning in the treatment of distal radial fracture can lead to tendinitis or even tendon tear, especially when the plate position is very distal. We studied the impact of design on plate position in the distal radius. The primary aim was to compare the position of six volar wrist plates relative to the watershed line using the Soong classification. The secondary objectives were to assess the epidemiology of volar locking plate fixation within the administrative Département of Finistère (northwestern France) and to study whether the type of fracture played a role in plate position.

HYPOTHESIS

The plate design itself influences positioning relative to the watershed line on the Soong classification.

MATERIALS AND METHODS

A total of 2723 volar locking plate fixation cases were analyzed and categorized according to the Soong classification. Plates used were divided into six groups based on design: Zimmer Biomet®, Newclip Technics®, Stryker®, Synthes®, Medartis® and Medartis® Footprint. The number of Soong 0 + 1 plates (i.e., plates graded 0 and 1 taken together) was determined for each design, then compared using the Marascuilo procedure with a significance level of α = 0.05.

RESULTS

On the Marascuilo procedure, we found significant differences in the number of Soong grade 0 + 1 plates. The Zimmer Biomet and Newclip Technics® plates were significantly more often proximal to the watershed line than the Synthes and Medartis Footprint plates. Plate position with the Medartis® design was significantly more proximal to the watershed line than for its companion design, the Medartis® Footprint plate. The rate of volar locking plate fixation of distal radial fractures over the past 10 years increased in Finistère. Also, the type of fracture affected the choice of plate when different designs were available within a hospital center (Medartis® Footprint plate used in 2R3A fractures).

CONCLUSION

Our study highlights a significant difference in volar locking plate position relative to the watershed line between the various models available. Plate design is a deciding factor when treating distal radial fracture, to avoid impingement when implant removal is not routinely planned.

LEVEL OF EVIDENCE: 3

[Effectiveness of a tablet telerehabilitation application in patients with distal radius fracture]

INTRODUCTION

To assess whether, in patients with distal radius fracture feedback-guided exercises performed on a tablet touchscreen reduce healthcare usage and improve clinical recovery, more than the conventional home exercise program prescribed on paper.

MATERIAL AND METHODS

A multicentre, parallel, two-group, pragmatic, controlled trial with assessor blinding and intention-to-treat analysis. Forty-six patients with distal radius fracture were recruited in Andalusian Public Health System. Participants in the experimental and control groups received the same in-patient physiotherapy sessions. Experimental group received a home exercise program using the ReHand tablet application and control group received an evidence-based home exercise program on paper. The primary outcome was the number of physiotherapy sessions tallied from hospitals data management system. Secondary outcomes included: the face-to-face rehabilitation consultations with a physiatrist, and clinical outcomes such as functional ability, grip strength, dexterity, pain intensity and range of motion.

RESULTS

The experimental group required fewer physiotherapy sessions (MD: -16.94; 95%CI: -32.5 to -1.38) and rehabilitation consultations (MD: -1.7; 95%CI: -3.39 to -0.02) compared to the control group.

CONCLUSIONS

In patients with distal radius fracture, prescribing feedback-guided exercises performed on a tablet touchscreen provided by ReHand reduced number of physiotherapy sessions and rehabilitation consultations.

Outcomes Following Fully Threaded Intramedullary Nailing of Metacarpal Fractures

Purpose

Intramedullary screw fixation has emerged as a popular approach for the treatment of displaced metacarpal fractures. The purpose of this study was to investigate the functional and radiographic outcomes of a newly designed, headless noncompressive fully threaded intramedullary nail (TIMN) for the treatment of metacarpal fractures.

Methods

A retrospective chart review was performed on patients who were treated with the INnate TIMN (ExsoMed) at a single academic institution with a minimum of 1-year follow-up. Patient-reported functional outcomes included Quick Disabilities for the Arm, Shoulder, and Hand (QuickDASH) questionnaires, return to work and physical activity time, and overall satisfaction. Radiographs were retrospectively reviewed to determine radiographic union, change in angulation, and metacarpal shortening.

Results

A total of 49 patients (58 fractures) with a mean age of 36 years (range: 17-75 years) were included. The mean follow-up time was 2.7 years (range: 1.4-4.3 years). Overall, the mean patient satisfaction rating was 4.9 of 5 (range: 3-5). The mean return to work time was 7.2 weeks (range: 0.14-28 weeks), and the mean return to sport or activity was 8.3 weeks (range: 1-28 weeks). Average QuickDASH scores across all patients were 4 (range: 0-56.9). The median radiographic healing time was 6.1 weeks (range: 4.7-15.4 weeks). Mean postoperative shortening in the fifth metacarpal fracture was 3 mm (range: -4.2 to 8 mm) at the initial postoperative visit and 3.6 mm (range: -3.3 to 7.9 mm) at the final radiographic follow-up. Subgroup analysis showed that postoperative shortening was similar, regardless of the fracture pattern. The following four complications were reported: one case of persistent pain and stiffness, one case of carpal tunnel syndrome, one nonunion, and one fractured intramedullary nail.

Conclusions

Our findings suggest that the TIMN allows for a reliable return to work and physical activity, high patient satisfaction, low complication rate, and minimal shortening at the final radiographic follow-up.

Type of study/level of evidence

Therapeutic IV.

Cluster analysis to identify the profiles of individuals with compromised bone health versus unfortunate wrist fractures within the Canadian Longitudinal Study of Aging (CLSA) database

We used cluster analysis to determine the profiles of individuals who sustained wrist fractures. We found two groups: (1) young and active and (2) older and less active. This information may be used to identify individuals who require further bone health interventions to optimize healthy aging.

INTRODUCTION

Distal radial fractures (DRF) are the most common of all fractures, with 6% of males and 33% of females having one at some point in their lifetime. We hypothesize that DRF consists of two subpopulations: one with compromised bone health that is early in the osteoporosis (OP) trajectory and another which are active and healthy and suffer a misfortune fracture due to their high activity levels or risk-taking behaviors. The latter is likely to recover with a minimal disability, while the former may signal a negative health trajectory of disability and early mortality.

OBJECTIVE

To determine the profiles of individuals who sustained wrist fractures using cluster analysis within the Comprehensive Cohort of the Canadian Longitudinal Study on Aging (CLSA) database considering factors that reflect bone health and activity levels.

METHODS

We included all the individuals who had a wrist fracture within the CLSA comprehensive cohort of the database (n = 968). The baseline data was used for this analysis. A 2-step cluster analysis was used to identify profiles that were both statistically and clinically meaningful. Variables that were used in the cluster analysis include demographic variables, physical activity status indicators, general health indicators, mobility indicators, bone health indicators, comorbid conditions, and lifestyle factors.

RESULTS

We were able to identify two distinct profiles that were statistically and clinically meaningful confirming our hypothesis. One cluster included a predominantly younger cohort, who are physically active, with less comorbid conditions, better bone health, and better general health, while the opposite was true of the first cohort.

CONCLUSION

We were able to identify two clusters-a healthy profile and a bone health compromised profile. This information may be used to identify the subgroup of people who should be targeted in the future for more intensive preventive health services to optimize healthy aging.

CT-Based Micromotion Analysis After Locking Plate Fixation of AO Type C Distal Radius Fractures

Background

Volar locking plate fixation (VLPF) is the most common method for operative fixation of distal radius fractures (DRF). The dorsal ulnar corner (DUC) can be difficult to stabilize as the fragment is small and not exposed when using the volar approach. The purpose of this study was to study fracture fragment migration after VLPF of AO type C DRF, using a volume registration technique of paired CT scans with special focus on the DUC fragment.

Materials and Methods

This pilot study included ten patients with AO type C DRF, all operated with VLPF. The primary outcome was radiographic outcome. Postoperative and 1-year scans were compared and analyzed. Fragment migration was assessed with CT-based micromotion analysis (CTMA), a software technique used for volume registration of paired CT scans.

Results

All plates were stable over time. Two patients showed signs of screw movement (0.2-0.35 mm and 0.35- > 1 mm respectively). Postoperative reduction was maintained, and there was no fragment migration at the 1-year follow-up except for one case with increased dorsal tilt. The DUC fragment was found in 8/10 cases, fixated in 7/8 cases, and not dislocated in any case at the 1-year follow-up.

Conclusion

The CTMA results indicate that variable-angle VLPF after AO type C DRF can yield and maintain a highly stable reduction of the fracture fragments. The DUC fragment remained stable regardless of the number of screws through the fragment. CT volume registration can be a valuable tool in the detailed assessment of fracture fragment migration following volar plate fixation of DRFs.

How do surgeons decide when to treat proximal humerus fractures with operative versus nonoperative management?

PURPOSE

The objective of this study was to determine the underlying factors that drive the decision for surgeons to pursue operative versus nonoperative management for proximal humerus fractures (PHF) and if fellowship training had an impact on these decisions.

METHODS

An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons Society to assess differences in patient selection for operative versus nonoperative management of PHF. Descriptive statistics were reported for all respondents.

RESULTS

A total of 250 fellowship trained Orthopaedic Surgeons responded to the online survey. A greater proportion of trauma surgeons preferred nonoperative management for displaced PHF fractures in patients over the age of 70. Operative management was preferred for older patients with fracture dislocations (98%), limited humeral head bone subchondral bone (78%), and intraarticular head split (79%). Similar proportions of trauma surgeons and shoulder surgeons cited that acquiring a CT was crucial to distinguish between operative and nonoperative management.

CONCLUSION

We found that surgeons base their decisions on when to operate primarily on patient's comorbidities, age, and the amount of fracture displacement when treating younger patients. Further, we found a greater proportion of trauma surgeons elected to proceed with nonoperative management in patients older than the age of 70 years old as compared to shoulder surgeons.

Medicare Eligibility and Racial and Ethnic Disparities in Operative Fixation for Distal Radius Fracture

Importance

Medicare provides near-universal health insurance to US residents aged 65 years or older. How eligibility for Medicare coverage affects racial and ethnic disparities in operative management after orthopedic trauma is poorly understood.

Objective

To assess the association of Medicare eligibility with racial and ethnic disparities in open reduction and internal fixation (ORIF) after distal radius fracture (DRF).

Design, Setting, and Participants

This retrospective cohort study with a regression discontinuity design obtained data from the Healthcare Cost and Utilization Project all-payer statewide databases for Florida, Maryland, and New York. These databases contain encounter-level data and unique patient identifiers for longitudinal follow-up across emergency departments, outpatient surgical centers, and hospitals. The cohort included patients aged 57 to 72 years who sustained DRFs between January 1, 2016, and November 30, 2019. Data analysis was performed between March 1 and October 15, 2023.

Exposure

Eligibility for Medicare coverage at age 65 years.

Main Outcomes and Measures

Type of management for DRF (closed treatment, external fixation, percutaneous pinning, and ORIF). Time to surgery was ascertained in patients undergoing ORIF. Multivariable logistic regression and regression discontinuity design were used to compare racial and ethnic disparities in patients who underwent ORIF before or after age 65 years.

Results

A total of 26 874 patients with DRF were included (mean [SD] age, 64.6 [4.6] years; 22 359 were females [83.2%]). Of these patients, 2805 were Hispanic or Latino (10.4%; hereafter, Hispanic), 1492 were non-Hispanic Black (5.6%; hereafter, Black), and 20 548 were non-Hispanic White (76.5%; hereafter, White) and 2029 (7.6%) were individuals of other races and ethnicities (including Asian or Pacific Islander, Native American, and other races). Overall, 32.6% of patients received ORIF but significantly lower use was observed in Black (20.2% vs 35.4%; P < .001) and Hispanic (25.8% vs 35.4%; P < .001) patients compared with White individuals. After adjusting for potential confounders, multivariable logistic regression analysis confirmed the disparity in ORIF use in Black (odds ratio [OR], 0.60; 95% CI, 0.50-0.72) and Hispanic patients (OR, 0.82; 95% CI, 0.72-0.94) compared with White patients. No significant difference in ORIF use was found among racial and ethnic groups at age 65 years. The expected disparity in ORIF use between White and Black patients at age 65 years without Medicare coverage was 12.6 percentage points; however, the actual disparity was 22.0 percentage points, 9.4 percentage points (95% CI, 0.3-18.4 percentage points) greater than expected, a 75% increase (P = .04). In the absence of Medicare coverage, the expected disparity in ORIF use between White and Hispanic patients was 8.3 percentage points, and this result persisted without significant change in the presence of Medicare coverage.

Conclusions and Relevance

Results of this study showed that surgical management for DRF was popular in adults aged 57 to 72 years, but there was lower ORIF use in racial or ethnic minority patients. Medicare eligibility at age 65 years did not attenuate race and ethnicity-based disparities in surgical management of DRFs.

Intramedullary K-wires versus Alternate Techniques for Metacarpal Shaft and Neck Fractures: A Systematic Review and Meta-analysis

Intramedullary K-wire (IMKW) fixation is one of the mainstays for surgically treating metacarpal shaft and neck fractures. However, there remains a lack of literature comparing outcomes of the various available surgical repair techniques in all indicated metacarpals. Therefore, we conducted a systematic review and meta-analysis to investigate the clinical advantages and drawbacks of IMKW compared with alternate fracture repair techniques. A comprehensive systematic literature review was performed to identify studies that compared clinical outcomes of IMKW to alternate metacarpal fixation modalities. Outcomes included Disabilities of the Arm, Shoulder, and Hand (DASH/ quick DASH) scores, grip strength, union rate, visual analog scale pain, operative time, and complications. A random-effects model was used to compare IMKW to the pooled effect of other fixation techniques. A total of 10 studies were included in our analysis, comprising 497 metacarpal fractures (220 shafts and 277 necks). IMKW fixation was identified as the control group in all studies. The pooled experimental group included plates, transverse K-wires (TKWs), interfragmentary screws (IFSs), and K-wire cross-pinning (CP). In treating metacarpal shaft fractures, IMKW showed significantly shorter operative time ( p  = 0.04; mean difference = - 13; 95% confidence interval = -26 to -0.64). No significant differences were observed in treating metacarpal neck fractures for disability, grip strength, healing rate, pain, operative time, or complication rate. This systematic review and meta-analysis found no difference in clinical outcomes among various surgical techniques for treating metacarpal shaft and neck fractures. Further high evidence studies are required that investigate the efficacy and safety of IFS, CP, TKW, and intramedullary screws versus IMKW for treating closed, unstable metacarpal fractures.