Distal radius fractures in the elderly population

A meta-analysis comparing volar locking plates and cast immobilization for distal radius fractures in the elderly

BACKGROUND

The long-term outcomes (≥ 2 years of follow-up) of volar locked plate (VLP) fixation versus closed reduction and casting (CRC) for the treatment of displaced distal radial fractures (DRFs) remain unclear. This study aimed to conduct a meta-analysis comparing the long-term clinical outcomes of VLP and CRC in elderly patients (aged ≥ 60 years).

METHODS

A comprehensive search of PubMed, Web of Science, and Cochrane Library was performed to identify studies comparing the long-term outcomes of VLP and CRC for DRFs. Only randomized controlled trials (RCTs) with a mean follow-up duration of at least 2 years and participants aged 60 years or older were included. The risk of bias in the included studies was assessed. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE). Secondary outcomes included the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, EuroQol 5 Dimension 5-level score (EQ-5D-5 L), grip strength, and incidence of reoperation.

RESULTS

Four RCTs, comprising 423 patients, were included. The meta-analysis revealed that VLP fixation was associated with significantly improved outcomes compared to CRC in terms of PRWE score (pooled mean difference: -6.21; 95% CI: -10.28 to -2.15; p = 0.003), DASH score (pooled mean difference: -8.18; 95% CI: -13.35 to -3.01; p = 0.002), and grip strength (pooled mean difference: -6.63; 95% CI: 0.25 to 13.01; p = 0.04). There were no significant differences in EQ-5D-5 L score (95% CI: -0.08 to 0.05; p = 0.74) or incidence of reoperation (RR = 0.56; 95% CI: 0.22 to 1.42; p = 0.22).

CONCLUSIONS

A two-year follow-up of displaced DRFs in elderly patients showed no significant long-term clinical advantage of VLP fixation over CRC.

[Osteoporosis-Definition, risk assessment, diagnosis, prevention and treatment (update 2024) : Guidelines of the Austrian Society for Bone and Mineral Research]

BACKGROUND

Austria is among the countries with the highest incidence and prevalence of osteoporotic fractures worldwide. Guidelines for the prevention and management of osteoporosis were first published in 2010 under the auspices of the then Federation of Austrian Social Security Institutions and updated in 2017. The present comprehensively updated guidelines of the Austrian Society for Bone and Mineral Research are aimed at physicians of all specialties as well as decision makers and institutions in the Austrian healthcare system. The aim of these guidelines is to strengthen and improve the quality of medical care of patients with osteoporosis and osteoporotic fractures in Austria.

METHODS

These evidence-based recommendations were compiled taking randomized controlled trials, systematic reviews and meta-analyses as well as European and international reference guidelines published before 1 June 2023 into consideration. The grading of recommendations used ("conditional" and "strong") are based on the strength of the evidence. The evidence levels used mutual conversions of SIGN (1++ to 3) to NOGG criteria (Ia to IV).

RESULTS

The guidelines include all aspects associated with osteoporosis and osteoporotic fractures, such as secondary causes, prevention, diagnosis, estimation of the 10-year fracture risk using FRAX®, determination of Austria-specific FRAX®-based intervention thresholds, drug-based and non-drug-based treatment options and treatment monitoring. Recommendations for the office-based setting and decision makers and institutions in the Austrian healthcare system consider structured care models and options for osteoporosis-specific screening.

CONCLUSION

The guidelines present comprehensive, evidence-based information and instructions for the treatment of osteoporosis. It is expected that the quality of medical care for patients with this clinical picture will be substantially improved at all levels of the Austrian healthcare system.

Impact of Vitamin D Status and Nutrition on the Occurrence of Long Bone Fractures Due to Falls in Elderly Subjects in the Vojvodina Region of Serbia

Bone fractures are a significant public health issue among elderly subjects. This study examines the impact of diet and vitamin D status on the risk of long bone fractures due to falls in elderly subjects in Vojvodina, Serbia. Conducted at the University Clinical Center of Vojvodina in autumn/winter 2022-2023, the study included 210 subjects >65 years: 105 (F: 80/M: 15) with long bone fractures due to falls and 105 (F: 80/M: 15) controls. Groups were similar regarding age and BMI. Dietary intakes (by two 24-h recalls) and serum vitamin D levels were analyzed. The fracture group had a significantly lower median daily vitamin D intake (1.4 μg/day vs. 5.8 μg/day), intake of calcium, energy, proteins, fats, fibers, dairy products, eggs, fish, edible fats/oils, and a higher intake of sweets (p < 0.001 for all). Serum vitamin D levels were significantly lower in the fracture group (40.0 nmol/L vs. 76.0 nmol/L, p < 0.001). Logistic regression identified serum vitamin D as the most important protective factor against fractures, and ROC curve analysis indicated that serum vitamin D levels > 50.5 nmol/L decreased fracture risk. Nutritional improvements (increased intake of vitamin D and protein sources such as fish, eggs, and dairy), increased sun exposure, and routine vitamin D supplementation during winter are advised.

A Unique "Galeazzi-Like" Fracture through a Vacated External-Fixator Pin Track: A Case Report

Introduction

Galeazzi fractures are fractures of the radial shaft accompanied by distal radioulnar joint (DRUJ) instability. They usually occur due to a mechanical fall or direct trauma to the wrist or forearm. Management of this serious injury varies from non-operative treatment with closed reduction and splinting to operative fixation using an external fixator (ex-fix) or open reduction internal fixation with plate and screws.

Case Report

We present a 76-year-old female who presented with a right distal radius fracture after a ground-level fall. Due to fracture displacement after initial conservative management, she was placed in an external fixator for stabilization. After removal of the ex-fix, she sustained a midshaft radius fracture with DRUJ malalignment, consistent with a "Galeazzi-like" fracture.

Conclusion

"Galeazzi-like" fractures with associated DRUJ malalignment can occur from previous external fixator pin sites and are adequately treated with standard operative fixation.

Assessing the Radiological and Functional Outcomes of Colles' Cast Versus Functional Position Cast Immobilization in the Conservative Treatment of Distal End of Radius Fractures

INTRODUCTION

The distal end radius fracture represents a prevalent orthopedic condition that affects individuals across various age groups, commonly resulting from falls onto outstretched hands. Ongoing research endeavors have delved into diverse methodologies for addressing this condition, encompassing conservative and operative modalities, yielding variable outcomes. While the literature extensively delineates numerous mobilization approaches, such as the functional position cast and Colle's cast, scant comparative studies evaluate these immobilization forms. Consequently, our study sought to holistically appraise and compare the radiological and functional outcomes associated with Colles' cast and functional position cast immobilization in managing distal end radius fractures.

METHOD

This retrospective study was conducted at a tertiary trauma center over two years, from October 2018 to September 2020. Data was collected from medical records with prior approval from the institutional ethics committee. The study included 64 patients, all above the age of 40, who suffered from distal end radius fractures and received conservative management. Patients with bilateral distal end radius fractures, associated ipsilateral limb injury, open or comminuted fractures, or inadequate medical records were excluded. The patients were divided into two groups based on the type of cast immobilization: group I comprised 30 patients managed with Colles' cast immobilization (volar-flexion and ulnar deviation position). In contrast, group II consisted of 34 patients with functional position cast immobilization (immobilization with dorsiflexion). The clinical (including pain, thumb swelling, finger swelling, finger stiffness, shoulder stiffness, and tenderness), radiological (including radial deviation, radial height, and volar tilt), and functional (range of motion (ROM), and disability of arm, shoulder, and hand (DASH)) outcomes were evaluated at 6, 12, and 24 weeks. The data analysis was conducted using the IBM SPSS Statistics for Windows, Version 25 (Released 2017; IBM Corp., Armonk, New York, United States). The chi-square test, independent samples t-test, and paired t-test were employed to analyze and compare radiological and functional outcomes between the two groups. A p-value of less than 0.05 indicated a statistically significant association.

RESULTS

The radiological parameters, including volar tilt, radial inclination, and radial shortening, were derived from the medical records at various points: pre-reduction, post-reduction, 6-week follow-up, 12-week follow-up, and 24-week follow-up. Upon assessing these parameters, no statistically significant variance was observed between the two groups at specified time points. Comparison of the ROM between the two groups unveiled noteworthy results, indicating superior outcomes in the functional cast group at 6 and 12 weeks as opposed to the Colles' cast group. Grip strength assessment at the 24-week follow-up demonstrated statistically significant differences, with the functional cast group displaying enhanced grip strength.

CONCLUSION

 Our study revealed comparable radiological parameters between the two cohorts, yet it demonstrated a notable enhancement in both the ROM and functional outcomes in those subjected to functional cast positioning. These findings underscore the potential advantages of functional immobilization in bolstering patient rehabilitation.

Patients Aged 80 or More With Distal Radius Fractures Have a Lower One-Year Mortality Rate Than Age- and Gender-Matched Controls: A Register-Based Study

Introduction

With a rapidly ageing population, the number of distal radius fractures (DRFs) in the elderly will increase dramatically. The aim of this retrospective register study was to examine the 1- and 5-year mortality in DRF patients aged 80 years or more and correlate the overall survival to factors not related to the fracture itself.

Material and Methods

Patients aged ≥80 diagnosed with DRFs in Lund University Hospital in Sweden in the period 2010-2012 were extracted from the prospective Lund Distal Radius Fracture register. One- and 5-year standardised mortality rates (SMRs) were calculated using the Swedish standard population as a reference. Medical records were searched for non-fracture-related factors including comorbidity, medications, cognitive impairment and type of living. Cox proportional hazard regression models were used to identify prognostic factors for all-cause mortality.

Results

The study cohort included 240 patients, with a mean age of 86. The overall 1-year mortality was 5% (n = 11/240) and the 5-year mortality was 44% (n = 105/240). The 1-year SMR was .44 (CI .18-.69, P < .01) when indirectly adjusted for age and gender and compared to the Swedish standard population. The 5-year SMR was .96 (CI .78-1.14). The patients' ability to live independently in their own home had the highest impact on survival.

Discussion

The 1-year mortality rate among the super-elderly DRF patients was only 44% of that expected. Possibly, a DRF at this age could be a sign of a healthier and more active patient.

Conclusions

The DRF patients aged 80 or more had a substantially lower mortality rate 1 year after fracture compared to the age- and gender-matched standard population. Patients living independently in their own homes had the longest life expectancy. Treatment should not be limited solely because of old age, but individualised according to the patient's ability and activity level.

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.

A proposed paradigm shift in the management of distal radius fractures

Background and objective

Distal radius fractures represent a remarkable orthopaedic entity. Most distal radius fractures can be treated conservatively with closed reduction and immobilisation with satisfactory results, while open reduction and internal fixation is reserved for displaced fractures. Our objective was to propose a paradigm shift in the management of distal radius fractures.

Methods

A literature search of management of distal radius fractures was conducted. PubMed and Cochrane databases were used for the search. English articles with open access or institutional subscription availability were included.

Key content and finding

Current literature supports operative management for younger active patients with defined radiographic inclusion parameters, but among the elderly there is little evidence of benefit. Most orthopaedic literature defines "elderly" as patients above 65 years of age. Non-surgical treatment for fractures of the distal radius tends to yield satisfactory functional results, and these favourable outcomes do not necessarily align with normal radiological parameters. For the minority of patients that have symptomatic malunion, corrective osteotomy is a good option to improve the function provided the symptoms can be clearly attributed to the malalignment.

Conclusion

The vast majority of distal radius fractures can be managed conservatively. Further studies are recommended to explore the feasibility of advocating for universal conservative treatment for patients with less functional demands while still having the option of staged surgery in the form of corrective osteotomy where there is symptomatic malunion amenable to anatomical correction. Future research should also aim to identify patients who would benefit most from surgical intervention by considering the type of functional recovery needed, rather than relying predominantly on the patient's chronological age as the determining factor in the decision-making process.

Epidemiology of distal radius fractures: Elucidating mechanisms, comorbidities, and fracture classification using the national trauma data bank

BACKGROUND

An update on the epidemiology of distal radius fractures in the United States is necessary, particularly as the elderly population grows. Additionally, age and frailty have been associated with complications following surgical fixation of DRFs. Herein, we utilize the National Trauma Data Bank, a robust nationwide resource, to investigate the relationship between demographics, comorbidities, injury and fracture characteristics, and admission details.

METHODS

Patients with isolated distal radius fractures were identified from the National Trauma Data Bank (2016-2019) according to ICD-10 codes. Univariate and multivariate regressions were conducted to determine independent risk factors for bilateral fractures, displaced fractures, open fractures, as well as length of hospital stay and adverse discharge disposition for patients undergoing inpatient surgical fixation.

RESULTS

The incidence of DRFs was 3.6/1,000 trauma-related emergency department visits and 10.8/1,000 upper extremity traumas. Trauma mechanism was significantly associated with displaced and open fractures. Age (OR 1.01, 95% CI 1.01-1.01), BMI (OR 1.02, 95% CI 1.01-1.02), smoking (OR 1.34, 95% CI 1.15-1.57), and alcohol level (trace: OR 2.18, 95% CI 1.41-3.29; intoxicated: OR 2.20, 95% CI 1.63-2.95) were significantly associated with open fractures. Machinery (β=2.04, 95% CI 1.00-3.08) and MVT (β=0.39, 95% CI 0.08-0.69) mechanisms were independent risk factors for longer length of stay. mFI-5 was an independent risk factor, in a stepwise fashion, for both length of stay and adverse discharge disposition.

CONCLUSIONS

High-energy mechanisms and risk factors for poor skin quality were significantly associated with open fractures. mFI-5 was an independent risk factor for longer length of stay and non-routine discharges in patients of all ages, despite controlling for other comorbidities, unrelated complications, and mechanism of injury. Trauma mechanism was an independent risk factor for prolonged length of stay only, particularly in patients younger than 65 years of age.

Trends and projection of forearm fractures including elbow fractures of the Olecranon in Sweden: an analysis of 363 968 fractures using public aggregated data

BACKGROUND

Forearm and olecranon fractures are a common orthopaedic injury. This study aimed to analyse whether the incidence of forearm injury is changing and identifying trends in the number of forearm and olecranon fractures using public aggregated data in Sweden.

METHODS

The number of forearm and olecranon fractures as defined by the number of registered diagnoses with the ICD-10 code of S52 were collected and normalized per 100,000 inhabitants and stratified per sex, age, and month. Age-adjusted incidence for forearm and olecranon fractures were calculated using the direct method. Poisson regression was used to analyse monthly, seasonal and yearly change in forearm and olecranon fracture incidence. Logistical regression was used to predict future trends of forearm and olecranon fractures.

RESULTS

The findings revealed a slight decreasing trend in forearm and olecranon fractures. The average incidence rate during the study period was 333 with women having a higher incidence rate than men. More fractures occurred in the winter months. Fluctuations in the number of forearm and olecranon fractures were observed during 2020 which may be influenced by the COVID-19 pandemic. Based on current data, forearm and olecranon fractures are expected to decrease in Sweden by 2035.

CONCLUSION

This study describes the trend of forearm and olecranon fractures among individuals according to sex and age in Sweden using easily obtainable data. Trends in forearm and olecranon fractures are dependent on sex and age but generally show a decreasing trend. More precise studies are needed in order to properly quantify the specific incidence of various subtypes of forearm and olecranon fractures and associated risk factors.

Current Management and Volar Locking Plate Fixation with Bone Cement Augmentation for Elderly Distal Radius Fractures-An Updated Narrative Review

Distal radius fractures (DRFs) are the most common among all kinds of fractures with an increase in incidence due to the rapidly expanded size of the elderly population in the past decades. Both non-surgical and surgical treatments can be applied for this common injury. Nowadays, more and more elderly patients with DRFs undergo surgical treatments to restore pre-injury activity levels faster. However, optimal treatment for geriatric DRFs is still debated, and careful evaluation and selection of patients are warranted considering clinical and functional outcomes, and complications following surgical treatments. Furthermore, osteoporosis is a predominant factor in elderly DRFs mostly deriving from a low-energy trauma, so many treatment modalities are developed to enhance better bone healing. Among various options for bone augmentation, bone cement is one of the most widely used measures. Bone cement such as calcium phosphate theoretically improves fracture stability and healing, but whether the elderly patients with DRFs can significantly benefit from surgical fixation with bone cement augmentation (BCA) remains controversial. Hence, in the present review, the latest literature regarding current concepts of management and evidence about volar locking plate fixation (VLPF) with BCA for elderly DRFs was searched in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science; out of >1000 articles, full texts of 48 and 6 articles were then examined and analyzed separately for management and VLPF with BCA for elderly DRFs. We aim to provide the readers with updates concerning the above issues.

Surgical options for distal radius fractures of type C in elderly patients over 65 years old: a comparison of external fixation with Kirschner wires and volar locking plate

BACKGROUND

ue to the lack of consensus on the optimal surgical treatment for distal radius fractures (DRF) in elderly patients over 65 years old, the purpose of this study was to compare the efficacy of external fixation (EF) with Kirschner wires and volar locking plate (VLP) in the treatment of DRF through a retrospective cohort study. We hypothesized that there would be no significant difference in overall complications and functional recovery between the two methods.

METHODS

We retrospectively analyzed 62 patients over 65 years old who underwent surgical treatment for C-type DRF between 2019 and 2022. Based on the different treatment methods, they were divided into the EF group and the VLP group. General data, inpatient data, and postoperative complications during follow-up were recorded. The X-ray images before surgery, after surgery, and at the last follow-up were analyzed, and the results of wrist motion range, Gartland-Werley wrist joint score, and DASH score were evaluated 6 months after surgery for both groups.

RESULT

Thirty patients underwent closed reduction and external fixation combined with Kirschner wire fixation, while 32 underwent open reduction and VLP fixation. The EF group had significantly shorter operation time, intraoperative blood loss, injury-to-surgery time, and hospital stay compared to the VLP group (all p < 0.001). At the last follow-up, the radiographic parameters (ulnar variance and radial inclination) and wrist joint function (wrist dorsiflexion and forearm supination) were better in the VLP group than in the EF group (p = 0.04, p = 0.01, p = 0.001, p = 0.02, respectively). However, there was no significant difference in overall Gartland-Werley wrist joint score, DASH score, and incidence of postoperative complications between the two groups (p = 0.31, p = 0.25, p = 0.47, respectively).

CONCLUSION

For patients aged 65 and above with distal radius fractures (DRF) of type C, VLP and external fixation with Kirschner wires yield comparable functional outcome and complications rate at the short term. However, VLP allowed restoration of better radiological parameters.

Is Capitate Shift Reliable as a Single Indicator for Failure of Non-operative Management in Distal Radius Fractures?

Background Distal radius fractures (DRFs) are the most commonly treated fracture; however, their treatment remains controversial. There is significant variation in the rate of surgical intervention related to a lack of consensus regarding the displacement threshold for surgery. Although studies have advocated that carpal malalignment is the most important radiographic parameter for surgical correction, it is rarely considered in general clinical practice and remains poorly studied. Recently, capitate shift was identified as the most useful measure of carpal malalignment, and a capitate shift threshold of -5.98 mm was proposed to indicate surgical intervention. This study aimed to investigate if this threshold is associated with the failure of non-operatively managed DRFs and should be used as a threshold for primary surgical intervention. Methodology A retrospective analysis was performed of all adult patients who underwent closed manipulation and cast immobilisation for DRFs in a UK district general hospital between September 2021 and February 2022. Capitate shift was measured on initial post-casting radiographs using the validated capitate-to-axis-of-radius distance (CARD) by a junior surgeon. The outcome measure was the failure of conservative management, which was defined as the need for repeat intervention (i.e., cast reapplication or surgical fixation) following closed reduction and cast immobilisation. Results A total of 64 patients with 65 DRFs (16 (25%) male, 49 (75%) female) were included in the study. The mean age was 66.6 years (SD = 17.9, 95% CI = 62.2 to 70.9). The mean capitate shift was -1.51 mm (SD = 5.05, 95% CI = -0.28 to -2.73) in all cases (n = 65). The failure rate of DRFs with an 'unacceptable' capitate shift (i.e., equal or less than -5.98 mm) compared to those with an 'acceptable' capitate shift (i.e., greater than -5.98 mm) was 16.7% versus 3.8% (p = 0.09). Conclusions The study concluded that there was no significant association between a capitate shift threshold of -5.98 mm and failure of non-operatively managed DRFs. Given the ease of use and reliability of capitate shift, we advocate for multicentre large cohort studies to identify a threshold for surgical intervention and establish its association with functional outcomes.

Association of Open Reduction and Internal Fixation With Volar Locking Plate for Distal Radius Fractures With Patient-Reported Outcomes in Older Adults: A Network Meta-analysis

Importance

Randomized clinical trials (RCTs) and meta-analyses have reported inconsistent conclusions regarding optimal distal radius fracture (DRF) treatment in older adults and are limited due to the inclusion of cohort studies with small sample sizes. A network meta-analysis (NMA) addresses these limitations by only synthesizing direct and indirect evidence from RCTs and may clarify optimal DRF treatment in older adults.

Objective

To examine DRF treatment results in optimal short-term and intermediate-term patient-reported outcomes.

Data Sources

Searches of MEDLINE, Embase, Scopus, and Cochrane Central Register of Controlled Trials were conducted for RCTs that investigated DRF treatment outcomes in older adults between January 1, 2000, and January 1, 2022.

Study Selection

Randomized clinical trials including patients with a mean age of 50 years or older that compared the following DRF treatments were eligible for inclusion: casting, open reduction and internal fixation with volar lock plating (ORIF), external fixation, percutaneous pinning, and nail fixation.

Data Extraction and Synthesis

Two reviewers independently completed all data extraction. An NMA aggregated all direct and indirect evidence among DRF treatments. Treatments were ranked by surface under the cumulative ranking curve score. Data are reported as standard mean differences (SMDs) and 95% CIs.

Main Outcomes and Measures

The primary outcome was short-term (≤3 months) and intermediate-term (>3 months to 1 year) Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores. Secondary outcomes included Patient-Rated Wrist Evaluation (PRWE) scores and 1-year complication rates.

Results

In this NMA, 23 RCTs consisting of 3054 participants (2495 women [81.7%]) with a mean (SD) age of 66 (7.8) years were included. At 3 months, DASH scores were significantly lower for nail fixation (SMD, -18.28; 95% CI, -29.93 to -6.63) and ORIF (SMD, -9.28; 95% CI, -13.90 to -4.66) compared with casting. The PRWE scores were also significantly lower for ORIF (SMD, -9.55; 95% CI, -15.31 to -3.79) at 3 months. In the intermediate term, ORIF was associated with lowered DASH (SMD, -3.35; 95% CI, -5.90 to -0.80) and PRWE (SMD, -2.90; 95% CI, -4.86 to -0.94) scores. One-year complication rates were comparable among all treatments.

Conclusions and Relevance

The findings of this NMA suggest that ORIF may be associated with clinically significant improvements in short-term recovery compared with casting for multiple patient-reported outcomes measures with no increase in 1-year complication rates. Shared decision-making with patients may be useful to identify patient preferences regarding recovery to determine optimal treatment.

Does Radiographic Alignment Correlate With Patient-Reported Functional Outcomes and Posttreatment Complications in Older Patients Treated for Wrist Fractures?

PURPOSE

Surgical treatment of distal radius fractures provides better fracture alignment than closed reduction; however, surgical treatment does not lead to better patient-reported function at 12 months. The aims of this study were to report the radiographic outcomes from the Combined Randomized and Observational Study of Surgery for Fractures In the distal Radius in the Elderly trial, investigate the association between radiographic outcomes and patient-reported function, and explore whether this association was affected by posttreatment complications and direction of malalignment.

METHODS

This study used the outcomes of the Combined Randomized and Observational Study of Surgery for Fractures In the distal Radius in the Elderly trial, which is a combined randomized and observational trial that compared volar-locking plate fixation with closed reduction and cast immobilization, to treat distal radius fractures in patients aged ≥60 years. Four radiographic outcomes (dorsal angulation, radial inclination, ulnar variance, and articular step) were reported at the following three time frames: (1) baseline, (2) after treatment, and (3) ≥6 weeks by treatment group. Secondary analysis was correlation of 12-month patient-reported function scores with 6-week radiographic measures for each of four radiographic parameters, and a subgroup analysis was conducted to investigate if this was affected by posttreatment complications. Tertiary analysis investigated if direction of malalignment affected the secondary analysis.

RESULTS

We recruited 300 participants (166 randomized and 134 observational); 113 had volar-locking plate fixation, and 187 had closed reduction. There were no between-group differences for each of the four pretreatment radiographic parameters, but there were between-treatment group differences for all four radiographic parameters apart from articular step. We found no association between patient-reported function at 12 months and each of the four radiographic parameters at 6 weeks. This lack of association was unaffected by posttreatment complications and the direction of malalignment.

CONCLUSIONS

For patients with wrist fractures aged ≥60 years, final radiographic alignment did not correlate with patient-reported function at 12 months. These findings were not affected by treatment type, and there was no association between radiographic alignment and posttreatment complications.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Closed reduction of dorsally displaced distal radius fractures in the elderly provided improved final radiographic results

BACKGROUND

Recent guidelines recommend non-operative treatment as primary treatment in elderly patients with displaced distal radius fractures. Most of these fractures are closely reduced. We aimed to evaluate the radiological results of closed reduction and casting of dorsally displaced distal radius fractures in patients 65 years or older.

METHODS

A total of 290 patients treated during the years 2015, 2018 and 2019 in an urban outpatient fracture clinic with complete follow-up at least 5 weeks post-reduction were available for analysis. Closed fracture reduction was performed by manual traction under hematoma block. A circular plaster of Paris cast was used. Radiographs pre- and post-reduction and at final follow-up were analyzed.

RESULTS

Mean age was 77 years (SD 8) and 258 (89%) were women. Dorsal tilt improved from mean 111° (range 83-139) to 89° (71-116) post-reduction and fell back to mean 98° (range 64-131) at final follow-up. Ulnar variance was 2 mm ((-1)-12) pre-reduction, 0 mm ((-3)-5) post-reduction and ended at mean 2 mm (0-8). Radial inclination went from 17° ((-6)-30) to 23° (SD 7-33), and then back to 18° (0-32) at final follow-up. 41 (14%) patients had worse alignment at final follow-up compared to pre-reduction. 48 (17%) obtained a position similar to the starting point, while 201 (69%) improved. Fractures with the volar cortex aligned after reduction retained 0.4 mm (95% Confidence Interval (CI) 0.1 to 0.7; p = 0,022) more radius length during immobilization. In a regression analysis, less ulnar variance in initial radiographs (OR 1.8 (95% CI 1.4 to 2.3) per mm, p < 0.001) and lower age (OR 1.06 (95% CI 1.02 to 1.09) per year, p < 0.003) protected against loss of reduction.

CONCLUSION

Subsequent loss of reduction after initial closed reduction was seen in most distal radius fractures. Reduction improved overall alignment in 2/3 of the patients at final follow-up. An aligned volar cortex seemed to protect partially against loss of radial length.

Distal Radius Extra-Articular Fractures: The Impact of Anatomical Alignment on Patient’s Perceived Outcome (A Single Center Experience)

Purpose: The effects of the anatomical alignment of distal radial extra-articular fractures on the patient's perceived outcome have been drawing much attention recently, and much controversy exists in the literature. The primary purpose of this study was to explore the relationship between the radiological parameters of reduction (radial inclination, radial length, and radial tilt) and the patient's perceived functional outcome, which was quantified using the DASH questionnaire.

Methods: The study included one hundred twenty-four patients with distal radial extra-articular fractures managed by closed reduction and casting. Their radiological (anatomical) outcome was determined by measuring the radial inclination, tilt, and length. Subjective functional outcome was quantified using the DASH score, calculated from the Arabic-translated DASH questionnaire at three months and six months after cast removal.

Results: the mean DASH score was 31.56 SD± 9.1 at three months and 29 SD± 3.89 at six months, and the acceptable radiological results for radial tilt, radial inclination, and radial length (according to McDermid's criteria for acceptable reduction) were 77.4%, 88.7% and 74.4%, respectively. There was a significant linear correlation between two radiological parameters (radial tilt and radial length) and the DASH score at three-month follow-up, which was more profound among patients under 70 years old and with diabetes mellitus. At the six-month follow-up, there was no significant relationship between the radiological parameters and the DASH score.

Conclusion: This study confirmed that radiological outcome affects the early patient-perceived outcome, with a more significant effect among patients under 70 and diabetics. Nonetheless, over time, there will be no significant relationship between the quality of reduction and patients' perceived outcomes. And this phenomenon requires further investigation.

Effectiveness and Safety of Different Treatment Modalities for Patients Older Than 60 Years with Distal Radius Fracture: A Network Meta-Analysis of Clinical Trials

The aim of this study was to compare the clinical effectiveness and complications of different treatment modalities for elderly patients with distal radius fracture (DRF).

METHODS

We performed a network meta-analysis (NMA) of randomized clinical trials (RCTs). Eight databases were searched. The eligibility criteria for selecting studies were RCTs that compared different treatment modalities (surgical or nonoperative) in patients older than 60 years with displaced or unstable intra-articular and/or extra-articular DRFs.

RESULTS

Twenty-three RCTs met the eligibility criteria (2020 patients). For indirect comparisons, the main findings of the NMA were in volar locking plate (VLP) versus cast immobilization, with the mean differences for the patient-rated wrist evaluation (PRWE) questionnaire at -4.45 points (p < 0.05) and grip strength at 6.11% (p < 0.05). Additionally, VLP showed a lower risk ratio (RR) of minor complications than dorsal plate fixation (RR: 0.02) and bridging external fixation (RR: 0.25). Conversely, VLP and dorsal plate fixation showed higher rates of major complications.

CONCLUSIONS

Compared with other treatment modalities, VLP showed statistically significant differences for some functional outcomes; however, most differences were not clinically relevant. For complications, although most differences were not statistically significant, VLP was the treatment modality that reported the lowest rate of minor and overall complications but also showed one of the highest rates of major complications in these patients. PROSPERO Registration: CRD42022315562.

Anterior locking plate versus non-operative treatment in different age groups with distal radial fractures: a systematic review and meta-analysis

This meta-analysis compared anterior locking plate and non-operative treatment for distal radial fractures and assessed if the age of the patients is associated with the treatment effect. We searched the MEDLINE, Embase and CENTRAL databases and included 12 studies with 1366 patients. Compared with non-operative care, anterior locking plate treatment does not seem to provide clinically important benefits in mean DASH score, mean pain or their mean quality of life at 12 to 24 months if the patients' ages are not considered (moderate to low certainty evidence). However, the younger the patients, the larger the benefit for surgery. Meta-regression with the DASH score suggested that while people over 70 likely experience no clinically relevant benefit from surgery, the mean effects cannot be generalized to people under 60. The evidence regarding the risk of adverse events is too uncertain to make firm conclusions.

Perioperative Morbidities in Distal Radius Fractures Treated Using Locking Plates in the Super-Elderly Population: A Retrospective Study

Purpose

Currently, there is no consensus on the treatment of distal radius fractures in the super-elderly population. The aim of this study was to evaluate the perioperative morbidities and the need for rehabilitation care after a distal radius fracture treated with locking plates among patients aged 85 years or older.

Methods

A retrospective study was conducted in all patients aged 85 years or older who underwent open surgical treatment using a locking plate for an isolated distal radius fracture from January 2013 to December 2018 at a level 1 trauma center. The occurrence of minor complications (tendinopathy, neuropathy, carpal tunnel syndrome, and infection), major complications (complex regional pain syndrome, nonunion, loss of reduction, intra-articular screw, and hardware failure), and the need for revision surgery were recorded. The need and timing of rehabilitation were also documented. A nested case-control study was performed to evaluate predictive factors associated with the need for inpatient rehabilitation.

Results

The majority of fractures were AO type A, numbering 88 (55.7%), followed by 64 type C (40.5%), and then 6 type B (3.8%). The overall complication rate among the 158 included patients was 17% (n = 26), with 12 (7.6%) having minor complications and 14 (8.9%) having major complications. Inpatient rehabilitation was required for one-third of the patients (n = 59), and 11 (7%) were definitively discharged to a nursing home. The place of residence before the fracture, American Society of Anesthesiologist score, and the type of anesthesia were associated with a need for inpatient rehabilitation.

Conclusions

Overall, this study suggests that perioperative morbidity of distal radius fractures treated using a locking plate is acceptable even in the super-elderly population. Nevertheless, given the frequent requirement for rehabilitation, the impact of age cannot be ignored.

Type of Study/level of evidence

Therapeutic IV.

Forearm bone mineral density as a predictor of reduction loss in distal radius fractures treated with cast immobilization

Objective

Many potential predictors have been identified and proposed for predicting late reduction loss in distal radius fractures. However, no report exists on whether the bone mineral density (BMD) of the forearm correlates with the loss of reduction in distal radius fractures. This study aimed to investigate whether forearm BMD can be used as a predictor of reduction loss in distal radius fractures treated with cast immobilization.

Methods

Ninety patients with distal radius fractures were divided into two groups according to the maintenance or loss of reduction evaluated from radiographs taken at least 6 weeks after their injury. Lumbar and forearm BMD (total and metaphysis) T-scores were measured and compared between the maintenance of reduction (MOR) group and the loss of reduction (LOR) group. Additionally, serologic markers (C-terminal telopeptide, osteocalcin, vitamin D) and radiologic risk factors (intra-articular fracture, ulnar fracture, dorsal comminuted fracture, volar hook) were evaluated and a logistic multiple regression analysis was performed to know the main risk factors of reduction loss.

Results

Reduction loss was observed in 38 patients (42.2%). The total and metaphyseal BMD of the forearm was less in the LOR group than in the MOR group. However, the difference was not statistically significant [−2.9 vs. −2.5 for total (p = 0.18), −2.3 vs. −2.0 for metaphysis (p = 0.17)]. Multiple logistic regression analysis showed initial dorsal comminution (p = 0.008) and ulnar variance (p = 0.01) were the main risk factors for reduction loss.

Conclusions

Forearm BMD was not a valuable prognostic factor for reduction loss in distal radius fractures. Initial dorsal comminution and ulnar variance rather than forearm BMD should be considered preferentially when predicting which patients are at high risk of reduction loss in distal radius fractures.

VOLCON: a randomized controlled trial investigating complications and functional outcome of volar plating vs casting of unstable distal radius fractures in patients older than 65 years

BACKGROUND

Primary aim: to compare complications of operative vs non-operative treatment of unstable distal radius fractures (DRF) fulfilling national clinical guidelines for operative treatment. Secondary aim: to compare the functional outcomes.

MATERIALS AND METHODS

A single-centre randomized controlled trial of unstable DRF. 50 patients: volar locking plate, 2 weeks casting + 3 weeks orthosis. 50 patients: 5 weeks casting.

PRIMARY OUTCOME

complications assessed after 2 and 5 weeks and 6 and 12 months.

SECONDARY OUTCOMES

Quick-DASH, PRWHE, range of motion, grip strength, EQ-5D-3L.

RESULTS

148 patients were screened from November 2019 to March 2021. 48 patients did not want to participate or were unable to participate in the follow-up. 100 patients were randomized and 85 patients were available for full analysis due to there being 4 deaths, 6 withdrawals, 1 wrong inclusion, 1 emigration, 1 refracture, 1 patient with compartment syndrome, and 1 who was advised to undergo surgery after being randomized to non-operative treatment. Median age was 74 years (range 65-92), 81 women/19 men, 42 right/58 left side, 87 retired, 11 smokers, 86 ASA class 1 or 2. Complication rates did not statistical significantly vary between the operative and non-operative group: 20.9% (9/43) vs 16.6% (7/42), p = 0.78 (Fisher's exact test). Complications were driven by sensory disturbances. Four reoperations were performed: two in the non-operative group: carpal tunnel syndrome; two in the operative group: one carpal tunnel syndrome, one protruding screw causing extensor tendon irritation. Mean difference in Quick-DASH varied from 2.3 (95% CI - 3 to 8) pre-injury to 4.2 (- 4 to 12) at 12 months. Quick-DASH and PRWHE were neither statistically nor clinically-relevant different between groups.

CONCLUSIONS

Complication rates after operative and non-operative treatment of DRF were similar. Volar plating did not improve the functional outcome after 5 weeks, 6 months, and 12 months. These findings are in line with recent RCTs and mandate a revision of guidelines towards more conservative treatment.

TAKE HOME MESSAGES

(1) consider non-operative treatment in elderly patients sustaining unstable DRFs; (2) choosing operative treatment in patients older than 65 years should not be the gold standard; (3) however, non-operative treatment still carries a risk for complications.

LEVEL OF EVIDENCE

II. Trial registration Clinicaltrials.gov NCT03716661, registered 23rd Oct 2018; Published protocol PMC6599306.

The Relationship Between Colles’ Fractures and Leukocytosis in the Emergency Department

In Taiwan, emergency physicians often perform wrist joint reduction and cast immobilization before orthopedic surgeons arrange for surgical management. Prophylactic antibiotics can decrease the risk of wound infection and have been routinely employed in orthopedic surgery. In Taiwan, emergency physicians also regularly perform blood investigations and administer prophylactic antibiotics to prevent infection if the patient exhibits leukocytosis. However, pain and pressure also cause leukocytosis, making it difficult to discern if the cause is infection or injury. Therefore, we explored the relationship between Colles’ fractures and leukocytosis to determine if antibiotic treatment is necessary for this type of injury.

Treatment of Distal Radius Fractures with Bridging External Fixator with Optional Percutaneous K-Wires: What Are the Right Indications for Patient Age, Gender, Dominant Limb and Injury Pattern?

The aim of this retrospective study was to evaluate the medium-term clinical and functional outcomes of patients with closed, displaced, and unstable, simple or complex, intra- and extra-articular distal radius fractures (DRFs) treated with a bridging external fixator (BEF) and optional K-wires (KWs). AO classification was used to differentiate the injuries radiographically. Clinical-functional outcomes were evaluated using the Patient-Rated Wrist and Hand Evaluation Score (PRWHE Score) and the Quick Disabilities of the Arm Shoulder and Hand Score (QuickDASH). A total of 269 dorsally displaced fractures of 202 female (75%) and 67 male subjects (25%) were included, with a mean follow-up of 58.0 months. Seventy-five patients (28%) were treated by additional KWs. No differences were found comparing the two groups of patients (BEF vs. BEF + KWs) regarding age, sex, and fracture side (dominant vs. non-dominant). PRWHE and QuickDASH scores were lower in the BEF + KWs group compared to the BEF group (p < 0.0001 and p = 0.0007, respectively). Thus, patients treated with KWs had a better clinical outcome. Beta multivariate regression analysis confirmed that patients of the BEF + KWs group exhibited a better PRWHE score but not a better QuickDASH score. Patients treated by the BEF + KWs with the fracture on the dominant site were characterised by better clinical outcomes. Older patients had a better PRWHE score independently from the treatment. Our findings suggest that the use of BEF for DRFs with optional KWs can be indicated in both young and elderly patients of any gender, independent of limb side and fracture pattern. As the best functional results were achieved in the elderly when KWs were added, the combination of BEF and KWs seems to be mainly indicated for the treatment of DRF, also complex, in the elderly population.

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

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

Patterns of injury and treatment for distal radius fractures at a major trauma centre

Aims

Fractures of the distal radius are common, and form a considerable proportion of the trauma workload. We conducted a study to examine the patterns of injury and treatment for adult patients presenting with distal radius fractures to a major trauma centre serving an urban population.

Methods

We undertook a retrospective cohort study to identify all patients treated at our major trauma centre for a distal radius fracture between 1 June 2018 and 1 May 2021. We reviewed the medical records and imaging for each patient to examine patterns of injury and treatment. We undertook a binomial logistic regression to produce a predictive model for operative fixation or inpatient admission.

Results

Overall, 571 fractures of the distal radius were treated at our centre during the study period. A total of 146 (26%) patients required an inpatient admission, and 385 surgical procedures for fractures of the distal radius were recorded between June 2018 and May 2021. The most common mechanism of injury was a fall from a height of one metre or less. Of the total fractures, 59% (n = 337) were treated nonoperatively, and of those patients treated with surgery, locked anterior-plate fixation was the preferred technique (79%; n = 180).

Conclusion

The epidemiology of distal radius fractures treated at our major trauma centre replicated the classical bimodal distribution described in the literature. Patient age, open fractures, and fracture classification were factors correlated with the decision to treat the fracture operatively. While most fractures were treated nonoperatively, locked anterior-plate fixation remains the predominant method of fixation for fractures of the distal radius; this is despite questions and continued debate about the best method of surgical fixation for these injuries.

Cite this article: Bone Jt Open 2022;3(8):623–627.

Acupuncture combined with TCM bonesetting in the treatment of distal radius fractures: A protocol for systematic review and meta-analysis

BACKGROUND

Acupuncture combined with traditional Chinese medicine (TCM) bonesetting is an effective and more acceptable treatment method for distal radius fractures; this study aims to evaluate the clinical efficacy and other relevant factors of it compared with western medicine therapy such as operation.

METHODS

Databases CNKI, Wanfang, VIP, SinoMed, and PubMed were searched for the current study. The retrieval time was from the establishment to November 14, 2021. Literature quality was evaluated according to the bias risk assessment criteria of Cochrane Collaboration network. RevMan 5.3 and Stata 12.0 were used to perform this research.

RESULTS

This study will appraise the effectiveness and advantages of acupuncture combined with TCM bonesetting for distal radius fractures in terms of excellent and good rate, length of stay, hospitalization expenses, complication, and other factors.

CONCLUSION

This study provides reliable evidence-based support for the clinical efficacy and advantages of acupuncture combined with TCM bonesetting for distal radius fractures.

OSF REGISTRATION DOI

10.17605/OSF.IO/BUPE8.

Surgical treatment is not cost-effective compared to nonoperative treatment for displaced distal radius fractures in patients 65 years and over

Aims

The purpose was to compare operative treatment with a volar plate and nonoperative treatment of displaced distal radius fractures in patients aged 65 years and over in a cost-effectiveness analysis.

Methods

A cost-utility analysis was performed alongside a randomized controlled trial. A total of 50 patients were randomized to each group. We prospectively collected data on resource use during the first year post-fracture, and estimated costs of initial treatment, further operations, physiotherapy, home nursing, and production loss. Health-related quality of life was based on the Euro-QoL five-dimension, five-level (EQ-5D-5L) utility index, and quality-adjusted life-years (QALYs) were calculated.

Results

The mean QALYs were 0.05 higher in the operative group during the first 12 months (p = 0.260). The healthcare provider costs were €1,533 higher per patient in the operative group: €3,589 in the operative group and 2,056 in the nonoperative group. With a suggested willingness to pay of €27,500 per QALY there was a 45% chance for operative treatment to be cost-effective. For both groups, the main costs were related to the primary treatment. The primary surgery was the main driver of the difference between the groups. The costs related to loss of production were high in both groups, despite high rates of retirement. Retirement rate was unevenly distributed between the groups and was not included in the analysis.

Conclusion

Surgical treatment was not cost-effective in patients aged 65 years and older compared to nonoperative treatment of displaced distal radius fractures in a healthcare perspective. Costs related to loss of production might change this in the future if the retirement age increases.

Level of evidence: II

Cite this article: Bone Jt Open 2021;2(12):1027–1034.

Use of Ultrasound-Guided Selective Sensory Nerve Blocks to Provide Satisfactory Postoperative Analgesia Without Motor Paralysis in Bilateral Distal Radius Fracture Fixation: A Case Report

Peripheral nerve blocks for postoperative pain management in distal radius fracture fixation with volar locking plates can cause undesirable motor paralysis. We performed bilateral ultrasound-guided selective sensory nerve blocks to the lateral cutaneous nerve of the forearm, superficial branch of the radial nerve, and anterior interosseous nerve for a patient undergoing bilateral distal radius fracture fixation with volar locking plates. This case report describes the first successful use of this ultrasound-guided selective sensory nerve block, which provided satisfactory postoperative analgesia and preserved the patient's motor function following distal radius fracture fixation with volar locking plates.

Impact of the COVID-19 pandemic on orthopedic fracture characteristics in three hospitals in Turkey: A multi-center epidemiological study

Objectives

In this study, we present the use of case specific three- dimensional (3D) printed plastic models and custom-made acetabular implants in orthopedic surgery.

Materials and methods

Between March 2018 and September 2020, surgeries were simulated using plastic models manufactured by 3D printers on the two patients with pilon fractures. Also, custom-made acetabular implants were used on two patients with an acetabular bone defect for the revision of total hip arthroplasty (THA).

Results

More comfortable surgeries were experienced in pilon fractures using preoperative plastic models. Similarly, during the follow-up period, the patients that applied custom-made acetabular implants showed a fixed and well-positioning in radiographic examination. These patients did not experience any surgical complications and achieved an excellent recovery.

Conclusion

Preoperative surgical simulation with 3D printed models can increase the comfort of fracture surgeries. Also, custom-made 3D printed acetabular implants can perform an important task in patients treated with revision THA surgery due to severe acetabular defects.

Impact of the COVID-19 pandemic on orthopedic fracture characteristics in three hospitals in Turkey: A multi-center epidemiological study

Objectives

The aim of this study was to evaluate the impact of novel coronavirus-2019 (COVID-19) on the epidemiological characteristics of orthopedic fractures.

Patients and methods

A total of 2,960 patients (1,755 males, 1,205 females; mean age: 39.6 years; range, 1 to 98 years) with orthopedic fractures were included in the study: 552 patients during the pandemic period (March 10th and July 1st, 2020) and 1,158 control patients in the same period 2019 and 1,250 control patients in 2018. Epidemiological characteristics, injury mechanisms, fracture locations and treatment details of the patients were analyzed and compared between 2018, 2019 and 2020 for adult and pediatric populations.

Results

Of a total of 552 patients, 485 were adults and 67 were pediatric patients. In the control groups, of 1,158 patients (2019), 770 were adults and 378 were pediatric patients and, of 1,250 patients (2018), 857 were adults and 393 were pediatric patients. The proportion of proximal femur and hand fractures significantly increased during the pandemic period (p=0.025 and p=0.038, respectively). The most frequent surgical indication in the pandemic period was proximal femoral fracture. The proportion of home accidents as an injury mechanism significantly increased in the pandemic period compared to 2018 and 2019 (48.5% vs. 18.6% and 20.6%, respectively; p=0.000). The proportion of female pediatric patients significantly increased during the pandemic period compared to 2018 and 2019 (44.8% vs. 25.4% and 27.2%, respectively, p=0.004). The proportion of forearm fractures (p=0.001) also increased, and the proportion of tibia-fibula fractures (p=0.03) decreased. The most frequent surgical indication in pediatric patients was distal humeral fracture in both groups.

Conclusion

During the pandemic period, proximal femoral fractures in the elderly remained a concern. In-home preventative strategies may be beneficial to reduce the incidence of hip fractures in the elderly.

No benefit for elbow blocking on conservative treatment of distal radius fractures: A 6-month randomized controlled trial

Purpose

For displaced distal radius fracture, this trial aimed to compare an above-elbow (AE) and below-elbow (BE) cast at the end of a 24-week follow-up using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire as a primary outcome.

Methods

This is a clinical trial with parallel groups (1:1) and a blinded evaluator. There are two non-surgical interventions: AE and BE. A total of 128 adult patients with acute (up to 7 days) displaced distal radius fracture of type A2-3, C1-3 by the AO classification were included. The follow-up was 24 weeks. The primary outcome was the DASH questionnaire at 24 weeks. Secondary outcomes were the maintenance of reduction by the evaluation of radiographic parameters, pain measured by VAS, PRWE, objective functional evaluation and rate of adverse effects.

Results

The difference between the two groups in the DASH score at 24 weeks was not significant, with the mean (95% CI) DASH score being AE: 9.44 (2.70 to 16.17) vs. BE: 9.88 (3.19 to 16.57) (p = 0.895). The above-elbow group had a significantly greater worsening of the mean DASH score from baseline to 2 weeks (p < 0.001). No statistically significant differences were found between the 2 groups in any of the other follow-up assessments. Objective functional evaluation, PRWE, radiographical measures and rates of reduction loss were similar between groups. Above-elbow casting resulted in more adverse effects (mostly shoulder pain; 19 events vs. 9 events); RR = 0.39 (0.19–0.94); p = 0.033 at the end of six-month follow-up.

Conclusions

This study did not demonstrate a difference between above-elbow and below-elbow cast in terms of DASH outcome at 6 months in non-surgical treatment of deviated distal radius fractures. However, below-elbow casting is less debilitating during the treatment period, has comparable performance in maintaining the reduction, and is related to fewer minor adverse effects than above-elbow casting.

A scoping review of high-fidelity bench models for teaching closed reduction of distal radial fractures

This article was migrated. The article was marked as recommended.

INTRODUCTION

Simulation training can be beneficial for developing clinical skills without risks to patients. This review considers the literature on simulation models used for teaching closed reduction (manipulation) procedures for distal radius (wrist) fractures, particularly high-fidelity models, and the evidence supporting the use of such models.

METHODS

A scoping review of Medline and Embase was performed.

RESULTS

Five articles described low-fidelity models, predominantly focussing on low costs and teaching basic principles. Three articles and two commentary pieces discussing high-fidelity models were identified.

DISCUSSION

Attitudes towards a high-fidelity simulator were assessed by Egan et al. (2013), who found the majority of participants to be in favour of the model's use as a teaching tool, although participant selection may have been subject to bias. Mayne et al. (2016) subsequently used a high-fidelity model including radio-opaque markers and more objective measurements tools to assess orthopaedic trainees' closed reduction technique and adequacy of the achieved fracture position and casting. Seniority correlated with higher scores on objective structured assessment of technical skills (OSATS) and global rating scores (GRS) but not radiological measures of fracture position or cast quality, and over 90% of all participants achieved an adequate reduction. Seeley et al. (2017) used radiological measurements and time to task completion with another high-fidelity reduction model. The two most experienced participant groups could not be differentiated on any radiological measures of fracture reduction or on the time taken for reduction, although these groups were significantly better than the most junior participants.

CONCLUSION

The discussed models appear helpful to teach inexperienced participants the basic principles and steps in a procedures but a plateau effect appears to limit the potential benefit to more experienced learners. The constraints of educators' time and financial costs may influence the usage of such models in this type of training.

Manual passive rehabilitation program for geriatric distal radius fractures

Limitation of wrist range of motion (ROM) is a common complication of distal radius fractures (DRFs) in geriatric patients. The present study aimed to evaluate the effectiveness of rehabilitation in the restoration of wrist ROM after geriatric DRF. Eighty-eight geriatric patients with DRF, 59 women and 29 men aged 71.69 ± 6.232 years participated in the study. The time from wrist immobilization to rehabilitation was 12.89 ± 5.318 weeks. Daily rehabilitation was performed 30 minutes a day for 8 weeks. Active wrist ROM was measured before and at 2, 4, and 8 weeks after rehabilitation. Data were analyzed by the repeated measures multivariate analysis of variance (MANOVA), one-way MANOVA, and analysis of variance (ANOVA). Repeated measures MANOVA suggested a significant time effect for ROM (Wilks Lambda = 0.002, F = 7500.795, P < .001). Compared with before rehabilitation, each wrist ROM was significantly improved at 2, 4, and 8 weeks after rehabilitation. The one-way MANOVA demonstrated that changes in ROM were significantly different between groups (Wilks Lambda = 0.007, F = 559.525, partial eta square = 0.993, P < .001), indicating that patients in the short-term stiffness group (≤3 months) had a significantly greater increase in ROM than patients in the long-term stiffness group (>3 months). The results of this study suggest an 8-week daily rehabilitation program for geriatric patients with limited ROM <3 months after DRF.