Incidence of Colles' fracture in a North American community

Hemiarthroplasty for irreparable distal radius fractures in the elderly: A comprehensive review

BACKGROUND

Elderly patients maintaining functional independence can now be candidates for primary wrist hemiarthroplasty to manage acute irreparable distal radius fractures (DRFs). However, further investigation with long-term follow-up is required to validate these initial findings.

AIM

To review the literature on the outcomes of distal radius hemiarthroplasty with available implants to assess its viability as a treatment option.

METHODS

A comprehensive review of the literature was conducted using electronic databases, including PubMed, Medline, and Scopus. The search terms employed were "distal radius fracture" , "hemiarthroplasty" , "wrist arthroplasty" , and related terminology. The search was restricted to articles published in English from 1980 until June 2023. Inclusion criteria encompassed cases or case series of DRF treated with hemiarthroplasty, providing clinical or radiographic outcomes, and published in peer-reviewed journals.

RESULTS

A total of 2508 articles from PubMed and 883 from Scopus were identified initially. Following screening and removal of duplicates, 13 articles met the inclusion criteria. These articles, predominantly clinical retrospective studies, provided insights into hemiarthroplasty outcomes, including functional improvements and complications. Hemiarthroplasty was a treatment option for complex DRF, particularly those cases with severe comminution, intraarticular involvement, or severe osteoporosis. Functional outcomes demonstrated improvements in pain relief, wrist mobility, and grip strength, with variability across studies. Complications included implant loosening, infection, nerve injury, and stiffness, with varying incidence rates influenced by surgical techniques and implant choice. Long-term outcomes were inadequately documented, warranting further research.

CONCLUSION

Hemiarthroplasty is a promising treatment for irreparable DRF in the elderly. Long-term outcomes and complications require further study.

Opportunistic hand radiographs to screen for low forearm bone mineral density: a prospective and retrospective cohort study

BACKGROUND

Low bone mineral density affects 53% of women over age 65 in the US, yet many are unaware and remain untreated. Underdiagnosis of forearm osteoporosis and related fragility fractures represent missed warning signs of more deadly, future fractures. This study aimed to determine if hand radiographs could serve as early, simple screening tools for predicting low forearm bone mineral density (BMD).

METHODS

We evaluated posterior-anterior (PA) hand radiographs (x-rays) and Dual-energy X-ray absorptiometry (DXA) scans of 43 participants. The ratio of the intramedullary cavity to total cortical diameter of the second metacarpal (second metacarpal cortical percentage (2MCP)) was used as a potential diagnostic marker. Mixed-effects linear regression was performed to determine correlation of 2MCP with BMD from various anatomic regions. Repeated measures ANOVAs were used to compare BMD across sites. An optimal 2MCP cutoff for predicting forearm osteopenia and osteoporosis was found using Receiver Operating Curves.

RESULTS

2MCP is directly correlated with BMD in the forearm. The optimal 2MCP of 48.3% had 80% sensitivity for detecting osteoporosis of the 1/3 distal forearm. An 2MCP cutoff of 50.8% had 84% sensitivity to detect osteoporosis of the most distal forearm. Both 2MCP cutoffs were more sensitive at predicting forearm osteoporosis than femoral neck T-scores.

CONCLUSIONS

These findings support the expansion of osteoporosis screening to include low-cost hand x-rays, aiming to increase diagnosis and treatment of low forearm BMD and fractures. Proposed next steps include confirming the optimal 2MCP cutoff at scale and integrating automatic 2MCP measurements into PAC systems.

The past, present and future of the conservative treatment of distal radius fractures

The distal radius fracture is a common fracture with a prevalence of 17% on the emergency departments. The conservative treatment of distal radius fractures usually consists of three to six weeks of plaster immobilization. Several studies show that one week of plaster immobilization is safe for non- or minimally displaced distal radius fractures that do not need reduction. A shorter period of immobilization may lead to a better functional outcome, faster reintegration and participation in daily activities. Due to upcoming innovations such as three-dimensional printed splints for distal radius fractures, a patient specific splint can be produced which may offer more comfort. Furthermore, these three-dimensional printed splints are expected to be more environmental friendly in comparison with traditional plaster casts.

Outcome Analysis of Distal End Radius Fractures Managed With Antegrade Intramedullary K-wire Fixation

Background The most frequent upper limb fractures are distal end radius fractures, accounting for around 17% of all fractures in clinical practice. Falling on an outstretched hand is the most common mechanism of injury, and it can also occur in high-energy trauma in young individuals. A minimally invasive technique of percutaneous pinning was introduced to sustain the fracture's reduction after manipulation and avoid the re-displacement of fractured fragments. Antegrade intramedullary K-wire fixation is a cost-efficient procedure that can be done in rural settings. Methodology A total of 30 patients with fractures of the distal end radius managed with antegrade intramedullary K-wire fixation were included in the study. Operated patients were followed up at one month, three months, and six months for functional assessment. An X-ray was taken on every follow-up to assess the union and implant positioning. Results In our study, the mean age was 45.6 years. Out of the 30 patients, 12 were males and 18 were females. All 30 patients at the final follow-up showed good functional improvement, with statistically significant improvements in palmar flexion, adduction and abduction, and pain scale scores. Conclusions Antegrade K-wire fixation is an effective technique for fractures of the distal end radius that can be performed in rural settings with effective results.

Volar locking plate vs cast immobilization for distal radius fractures: a systematic review and meta-analysis

Introduction

Materials and methods

Results

Conclusions

General versus Brachial Plexus Block Anesthesia in Pain Management after Internal Fixation in Patients with Distal Radius Fracture: A Randomized Controlled Trial

Distal radius fractures (DRFs) are very common injuries associated with aging, and the number of fractures is increasing with the increase in the elderly population. General anesthesia or brachial plexus block (BPB) is required for fracture fixation, and acute postoperative pain control is necessary after operation. Early pain control can improve patient satisfaction and functional outcomes. In this study, we report the clinical differences in postoperative pain, according to the method of anesthesia (general anesthesia versus brachial plexus block). Volar plating was used to treat 72 patients older than 60 years who had comminuted DRF. Patients were randomized to either group A (36 patients), who underwent general anesthesia, or group B (36 patients), who underwent BPB. We compared these two groups prospectively for acute postoperative pain using a visual analog scale (VAS) at 2, 4, 6, 12, and 24 h after surgery. The VAS scores of each group were: 6.8 ± 2.5 in general anesthesia and 0.5 ± 2.3 in BPB at 2 h, postoperatively; 6.5 ± 2.4 in general anesthesia and 0.5 ± 2.4 in BPB anesthesia at 4 h, postoperatively; 5.2 ± 2.4 in general anesthesia and 1.5 ± 2.4 in BPB anesthesia at 6 h, postoperatively; 4.5 ± 2.5 in general anesthesia and 3.4 ± 2.7 in BPB anesthesia at 12 h, postoperatively; and 3.5 ± 2.5 in general anesthesia and 3.2 ± 2.7 in BPB anesthesia at 24 h, postoperatively. DRF patients with BPB anesthesia showed a lower VAS score than those subjected to general anesthesia in early postoperative period. As a result, the effect of BPB anesthesia on acute pain management after surgery was excellent, which resulted in a lower pain score compared with general anesthesia in DRF patients undergoing volar plating.

Evaluation of the Coronal Malposition of the Volar Locking Plate in the Treatment of Distal Radius Fractures

Background and objectives: Literature does not show any studies regarding plate placement problems in the coronal plane of patients with volar plating due to distal radius fracture diagnosis. We aimed to investigate the functional and laboratory results of the coronal malposition of the volar locking plate in patients with distal radius fracture treated with internal fixation.

Methods: In this retrospective study, we included patients who had volar plate fixation, were aged between 18 and 80, had no pathological fracture, had a minimum of six months of follow-up, and had the same rehabilitation protocol. We consider the angle subtended on the coronal axis between the distal radius long axis and the distal radius locking plate as coronal malposition. We named the coronal malposition angle the "AYE Angle." Patients with an AYE angle of over 1 degree were evaluated under group 1. Patients with an AYE angle of 0-1 degrees were evaluated under group 2. Radiological parameters were taken from AP-Lateral X-ray views. Superficial University System of Georgia (USG) examinations were applied to detect tendon problems. The DASH and QUICK-DASH scoring systems were used for clinical evaluation. Grip strength was measured with a dynamometer in all patients. All results were compared between the two groups.

Results: Thirteen patients were female and 27 patients were male. Nineteen patients who had coronal malposition were added to group 1, while 21 patients who had no coronal malposition were added to group 2. Fifteen patients had normal USG results in group 2, while 18 patients had edema around the flexor pollicis longus (FPL) tendon as a result of USG in group 1. Statistically, a significant difference was detected between the two groups in terms of the amount of tenosynovitis around FPL (p=0.01).

A statistically significant relationship was found between USG grading and malposition grading. The study revealed that a higher rate of USG grade 2 was found in patients with malposition grade 2 (90.9%), while a higher rate of USG grade 1 (50%) was observed in patients with malposition grade 1 (p=0.01).

A statistically significant difference was not found between Soong grading and USG in terms of the level of tenosynovitis around the FPL tendon. The amount of tenosynovitis detected around the FPL tendon was 62.5% for Soong and grade 0 level, 60.7% for grade 1 level, and 50% for grade 2 level. There was no statistically significant difference between the two groups in the DASH and QUICK-DASH scoring systems (p=0.96). There was no statistically significant difference between the two groups in the grip strength (p=0.52).

Conclusion: Coronal plate position in the treatment of the distal radius fracture is important to avoid potential flexor tendon problems. The volar plate position should be adjusted properly both in the coronal and sagittal axes.

IS VOLAR PLATING IN DISTAL RADIUS FRACTURES SAFE REGARDING PRONATOR QUADRATUS?

ABSTRACT Objective: This study aimed to investigate whether isokinetic strength decrease significantly after using volar plating for distal radius fractures and evaluate the pronator quadratus muscle regarding atrophy. Methods: This study took place between 2011 and 2015 and included 18 distal radius fracture patients (group 1) who were treated via volar plating at least one year prior and 14 healthy controls (group 2). All participants were tested isokinetically. Grip strength, radiological evaluation, wrist range of motion, disabilities of the arm, shoulder, and hand and visual analog scale scores were assessed for clinical and functional outcomes. Ultrasonography evaluated the pronator quadratus muscle thicknesses. Results: The peak supination torque (PT) and supination work per repetition (WPT) strength values significantly decreased (p:0.039, p:0.025, respectively). Although we determined an 11% pronation PT deficit and a 19% pronation WPT deficit, neither were significant. In group 1, the pronator quadratus muscle thickness decreased 5.9% ± 13.3 in the radial area and 9.7% ± 10.5 in the interosseous area according with ultrasonography; these results were not statistically significant compared to group 2. All clinical and functional outcomes were not statistically significant between the groups. Conclusion: The use of volar plating after distal radius fractures is a safe method regarding isokinetic strength and pronator quadratus muscle atrophy. Level of evidence III; Retrospective case-control study .

Epidemiology and Factors Affecting Functional Outcome of Distal Radial Fracture in an Urban Tertiary Medical Centre in Malaysia

Introduction

Distal radial fracture is a commonly encountered fracture. This study aims to study the epidemiology of distal radial fracture and factors affecting the patients' functional outcome one to two years after the injury.

Materials and methods

This is a retrospective cohort study. The records of patients, fulfilling the radiographical diagnosis of distal radial fracture, and aged 18 and above, who presented to our Emergency Department from 1st January 2018 to 31st December 2018 were retrieved. According to AO classification, we grouped our patients into A (extra-articular), B (partial articular) and C (complete articular). Patients with congenital abnormalities were excluded. Epidemiological data and relevant medical history were obtained and tabulated. A Malaysian language translation of Disability of the Arm, Shoulder and Hand (DASH) questionnaire was used to assess the functional outcome.

Results

Out of 168 patients' data retrieved, only 110 patients' data were found complete for purposes of this study. The mean DASH score was 13.7 ± 7.87 approximately one to two years post-injury regardless of treatment method. Increasing age was associated with higher DASH score with r=0.407(p<0.001). Several variables had significantly better functional outcome: male gender (p=0.01), Type A fracture configuration (p=0.007) and non-operational treatment (p=0.03). There was no significant difference between treatment modalities in Type A fracture (p=0.094), but Type B (p=0.043) and Type C (p=0.007) had better outcome without surgery. There was no significant difference between different ethnic groups, open or closed fracture and mechanism of injury.

Conclusion

Better functional outcome after sustaining distal radial fracture was associated with young age, male gender, type A fracture and treated non-operatively. Interestingly, more complex fracture pattern had better functionality were observed without surgery.

Evaluating cone-beam CT in the diagnosis of suspected scaphoid fractures in the emergency department: preliminary findings

OBJECTIVES

Scaphoid fractures are challenging to accurately diagnose with delayed and missed diagnoses risking poor patient outcomes. Cone beam CT (CBCT) is an emerging technology facilitating alternative access to multi-planar imaging. The aim of this study was to evaluate the use of early CBCT in the diagnosis of suspected scaphoid fractures presenting via the Emergency Department (ED).

METHODS

In this single centre the imaging pathway was adapted to include early CBCT in adult patients with a persisting high index of clinical suspicion for scaphoid fracture despite normal radiographs. Evaluation of referrals between September 2019 and February 2020 was undertaken. Statistical analysis and temporal pathway metrics were assessed including interrater agreement for CBCT and radiography examinations.

RESULTS

Over the six-month timeframe 100 CBCT wrist scans were performed on 99 adult patients. 94% of CBCT scans were performed within 1 day of referral. 25% of scans demonstrated acute injuries including 12 radius, 6 trapezium and 2 scaphoid fractures. For fracture, CBCT had a sensitivity of 96.2% and specificity of 100%. There was a highly significant difference in interobserver variation between fracture detection on CBCT and radiographs.

CONCLUSION

CBCT heralds the potential for early accurate diagnosis of radiocarpal fractures, at lower cost, shortening clinical pathways and reducing clinical risk in the ED.

Cast OFF-2: 1 week of plaster cast immobilization for non-reduced distal radius fractures-a study protocol for an implementation study

BACKGROUND

The distal radius fracture (DRF) is a common fracture, with the majority of these fractures being stable. Of all diagnosed fractures, 17% is a DRF, of which a large part is extra-articular and one-third is non-displaced. There is a large variation in treatment advisements for non-reduced DRF. Four to 5 weeks of immobilization is often the usual practice. Existing evidence shows that 1 week of immobilization is safe and does not lead to an increase in secondary displacement. Additionally, shorter immobilization periods may lead to less outpatient clinic visits and less home care for elderly people and may lead to earlier return to work and other social activities. Therefore, shorter immobilization periods for non-reduced distal radius fractures may also prove to be cost-effective. In this study, we aim to successfully implement 1 week of plaster cast immobilization for non-reduced distal radius fractures in twelve medical centers and to evaluate the functional outcome and cost-effectiveness.

METHODS

This study will be performed using a multicenter randomized stepped wedge design in 12 centers. We aim to include in the study 440 patients with an isolated non-reduced DRF between the age of 18 and 85 years old. The patients in the intervention group will be treated with plaster cast immobilization for 1 week. Acceptability of the study protocol, patient-reported outcomes, quality of life, complications, pain catastrophizing score, pain and patient satisfaction, and cost-effectiveness will be measured. The total follow-up will be 12 months.

DISCUSSION

The strength of this study is the combination of implementing 1 week of plaster cast immobilization for non-reduced DRF and the evaluation of functional outcome, acceptability of the study protocol, and cost-effectiveness in actual practice.

TRIAL REGISTRATION

Netherlands Trial Register NL9278 . Registered on 17 February 2021.

Distal radius sections offer accurate and precise estimates of forearm fracture load

BACKGROUND

Forearm fracture risk can be estimated via factor-of-risk: the ratio of applied impact force to forearm fracture load. Simple techniques are available for estimating impact force associated with a fall; estimating forearm fracture load is more challenging. Our aim was to assess whether failure load estimates of sections of the distal radius (acquired using High-Resolution peripheral Quantitative Computed Tomography and finite element modeling) offer accurate and precise estimates of forearm fracture load.

METHODS

We scanned a section of the distal radius of 19 cadaveric forearms (female, mean age 83.7, SD 8.3), and 34 women (75.0, 7.7). Sections were converted to finite element models and failure loads were acquired for different failure criteria. We assessed forearm fracture load using experimental testing simulating a fall on the outstretched hand. We used linear regression to derive relationships between ex vivo forearm fracture load and finite element derived distal radius failure load. We used derived regression coefficients to estimate forearm fracture load, and assessed explained variance and prediction error. We used root-mean-squared coefficients of variation to assess in vivo precision errors of estimated forearm fracture load.

FINDINGS

Failure load estimates of sections of the distal radius, used in conjunction with derived regression coefficients, explained 89-90% of the variance in experimentally-measured forearm fracture load with prediction errors <6.8% and precision errors <5.0%.

INTERPRETATION

Failure load estimates of distal radius sections can reliably estimate forearm fracture load experienced during a fall. Forearm fracture load estimates can be used to improve factor-of-risk predictions for forearm fracture.

Modifiable Factors Associated With Chronic Pain 1 Year After Operative Management of Distal Radius Fractures: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Despite appropriate treatment, many patients who sustain distal radius fractures (DRFs) report persistent wrist pain. Chronic musculoskeletal pain is among the leading health problems in the elderly population associated with significant personal and societal burden.

OBJECTIVE

To identify modifiable preoperative factors that are significantly associated with developing chronic pain.

DESIGN, SETTING, AND PARTICIPANTS

This is a secondary analysis of the Wrist and Radius Injury Surgical Trial (WRIST), a randomized multicenter clinical trial of 24 study sites in the United States, Canada, and Singapore that enrolled patients from April 10, 2012, to December 31, 2016. Adults older than 60 years who sustained closed extra-articular DRFs, were treated operatively, and completed 12-month Michigan Hand Outcomes Questionnaires (MHQs) were included in this study. Analysis was conducted from September to December 2019.

INTERVENTIONS

Volar locking plate internal fixation, external fixation, or percutaneous pinning.

MAIN OUTCOMES AND MEASURES

12-month MHQ pain domain score. Inverse probability weighted logistic regression was used to identify factors associated with of chronic pain.

RESULTS

A total of 146 patients with DRF who were treated operatively and had 12-month MHQ scores met inclusion criteria. The mean (SD) patient age was 68.9 (7.2) years, 128 (87.6%) were women, and 93 (63.7%) were retired. Chronic pain was present in 87 patients (59.6%) and absent in 59 patients (40.4%) at 1-year follow-up. A 1-week delay in surgery was associated with more than triple the odds of developing chronic pain (odds ratio [OR], 3.65; 95% CI, 1.48-9.00), and each 10-point increase in preoperative pain was associated with a 17% increase in the odds of experiencing chronic pain (OR, 1.17; 95% CI, 1.02-1.34). Internal fixation was associated with decreased odds of developing chronic pain compared with the other 2 procedures (OR, 0.29; 95% CI, 0.10-0.90).

CONCLUSIONS AND RELEVANCE

In this study, preoperative pain, time to surgery, and procedure type were modifiable factors associated with chronic pain 1 year after DRF treated with surgery. Adequate pain control in patients with acute DRFs even before definitive surgical management and earlier fixation for patients requiring surgery may decrease the risk of developing chronic pain. Internal fixation may decrease the risk of chronic pain after DRF surgery, compared with percutaneous pinning or external fixation.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01589692.

Diagnostic accuracy of history taking, physical examination and imaging for non-chronic finger, hand and wrist ligament and tendon injuries: a systematic review update

OBJECTIVE

The diagnostic work-up for ligament and tendon injuries of the finger, hand and wrist consists of history taking, physical examination and imaging if needed, but the supporting evidence is limited. The main purpose of this study was to systematically update the literature for studies on the diagnostic accuracy of tests for detecting non-chronic ligament and tendon injuries of the finger, hand and wrist.

METHODS

Medline, Embase, Cochrane Library, Web of Science, Google Scholar ProQuest and Cinahl were searched from 2000 up to 6 February 2019 for identifying studies. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 checklist, and sensitivity (Se), specificity (Sp), accuracy, positive predictive value (PPV) and negative predictive value (NPV) were extracted.

RESULTS

None of the studies involved history taking. Physical examination, for diagnosing lesions of the triangular fibrocartilage complex (TFCC), showed Se, Sp, accuracy, PPV and NPV ranging from 58% to 90%, 20% to 69%, 56% to 73%, 53% to 71% and 55% to 65%, respectively. Physical examination in hand and finger injuries the Se, Sp, accuracy, PPV and NPV ranged from 88% to 99%, 75% to 100%, 34% to 88%, 91% to 100% and 75% to 95%, respectively. The accuracy of MRI with high-resolution (3 T) techniques for TFCC and interosseous ligaments of the proximal carpal row ranged from 89% to 91% and 75% to 100%, respectively. The accuracy of MRI with low-resolution (1.5 T) techniques for TFCC and interosseous ligaments of the proximal carpal row ranged from 81% to 100% and 67% to 95%, respectively.

CONCLUSIONS

There is limited evidence on the diagnostic accuracy of history taking and physical examination for non-chronic finger, hand and wrist ligament and tendon injuries. Although some imaging modalities seemed to be acceptable for the diagnosis of ligament and tendon injuries in the wrist in patients presenting to secondary care, there is no evidence-based advise possible for the diagnosis of non-chronic finger, hand or wrist ligament and tendon injuries in primary care.

Instability in the Setting of Distal Radius Fractures: Diagnosis, Evaluation, and Treatment

Distal radius fractures with severe displacement or concomitant triangular fibrocartilage complex tears may be accompanied by distal radioulnar joint instability. Clinicians should examine the distal radioulnar joint closely when managing wrist fractures and treat coexisting instability appropriately. Chronic instability from distal radius malunion may require osteotomy or radioulnar ligament reconstruction. With proper management, most patients recover forearm stability and rotational motion after distal radius fracture.

Off-axis loads cause failure of the distal radius at lower magnitudes than axial loads: A side-to-side experimental study

Off-axis loading associated with a fall onto the outstretched hand has been hypothesized to induce distal radius failure at lower magnitudes than axially directed loading commonly used in biomechanical models for estimating fracture risk. However, this hypothesis has not been tested with side-to-side experimental testing. The objective of this study was to compare distal radius failure loads between forearm pairs experimentally tested in an axial or off-axis loading configuration. We acquired 18 pairs of cadaveric forearms from 18 female donors (mean age (standard deviation): 84.4 (7.9) years). Each forearm pair was tested to failure using either an axial compression test (vertical orientation with 0° dorsal inclination, 3°-6° radial inclination) or an off-axis test corresponding to the hand position during a fall (15° dorsal inclination, 3°-6° radial inclination). Failure testing was performed at 3 mm/s onto the palm of the hand until fracture occurred. Of the 18 pairs, 11 sustained a distal radius fracture. We compared failure loads between the two groups using a paired t test. Results indicated that failure load under off-axis loading was 29% lower than failure load under axial compressive loading (mean difference: -0.31 kN; 95% confidence interval: -0.47 to -0.16 kN, P = .001). In conclusion, off-axis loading associated with a fall onto the outstretched hand resulted in a 29% lower failure load. Integrating an off-axis loading configuration into current biomechanical models of distal radius bone strength may prevent overestimating of failure load and may offer a clinically relevant option to estimate distal radius fracture risk and monitor therapy efficacy.

Computer-aided diagnosis systems for osteoporosis detection: a comprehensive survey

Computer-aided diagnosis (CAD) has revolutionized the field of medical diagnosis. They assist in improving the treatment potentials and intensify the survival frequency by early diagnosing the diseases in an efficient, timely, and cost-effective way. The automatic segmentation has led the radiologist to successfully segment the region of interest to improve the diagnosis of diseases from medical images which is not so efficiently possible by manual segmentation. The aim of this paper is to survey the vision-based CAD systems especially focusing on the segmentation techniques for the pathological bone disease known as osteoporosis. Osteoporosis is the state of the bones where the mineral density of bones decreases and they become porous, making the bones easily susceptible to fractures by small injury or a fall. The article covers the image acquisition techniques for acquiring the medical images for osteoporosis diagnosis. The article also discusses the advanced machine learning paradigms employed in segmentation for osteoporosis disease. Other image processing steps in osteoporosis like feature extraction and classification are also briefly described. Finally, the paper gives the future directions to improve the osteoporosis diagnosis and presents the proposed architecture. Graphical abstract.

Diagnostic accuracy of history taking, physical examination and imaging for phalangeal, metacarpal and carpal fractures: a systematic review update

Background

The standard diagnostic work-up for hand and wrist fractures consists of history taking, physical examination and imaging if needed, but the supporting evidence for this work-up is limited. The purpose of this study was to systematically examine the diagnostic accuracy of tests for hand and wrist fractures.

Methods

A systematic search for relevant studies was performed. Methodological quality was assessed and sensitivity (Se), specificity (Sp), accuracy, positive predictive value (PPV) and negative predictive value (NPV) were extracted from the eligible studies.

Results

Of the 35 eligible studies, two described the diagnostic accuracy of history taking for hand and wrist fractures. Physical examination with or without radiological examination for diagnosing scaphoid fractures (five studies) showed Se, Sp, accuracy, PPV and NPV ranging from 15 to 100%, 13–98%, 55–73%, 14–73% and 75–100%, respectively. Physical examination with radiological examination for diagnosing other carpal bone fractures (one study) showed a Se of 100%, with the exception of the triquetrum (75%). Physical examination for diagnosing phalangeal and metacarpal fractures (one study) showed Se, Sp, accuracy, PPV and NPV ranging from 26 to 55%, 13–89%, 45–76%, 41–77% and 63–75%, respectively.

Imaging modalities of scaphoid fractures showed predominantly low values for PPV and the highest values for Sp and NPV (24 studies). Magnetic Resonance Imaging (MRI), Computed Tomography (CT), Ultrasonography (US) and Bone Scintigraphy (BS) were comparable in diagnostic accuracy for diagnosing a scaphoid fracture, with an accuracy ranging from 85 to 100%, 79–100%, 49–100% and 86–97%, respectively. Imaging for metacarpal and finger fractures showed Se, Sp, accuracy, PPV and NPV ranging from 73 to 100%, 78–100%, 70–100%, 79–100% and 70–100%, respectively.

Conclusions

Only two studies were found on the diagnostic accuracy of history taking for hand and wrist fractures in the current review. Physical examination was of moderate use for diagnosing a scaphoid fracture and of limited use for diagnosing phalangeal, metacarpal and remaining carpal fractures. MRI, CT and BS were found to be moderately accurate for the definitive diagnosis of clinically suspected carpal fractures.

Long term outcomes of open reduction internal fixation versus external fixation of distal radius fractures: A meta-analysis

Distal radius fractures are among the most common fractures encountered in the clinical setting. Of these common fractures, it has been said that up to 60% are intraarticular in nature. Intra-articular or unstable and comminuted fractures represent severe and high energy injuries. Despite a large amount of literature, it is surgeon preference which determines the fixation method employed. There are only a few randomised control trials that report 2-year outcomes. There has yet to be a meta-analysis comparing the long-term outcomes of open reduction internal fixation (ORIF) and external fixation (EF). The aim of this metaanalysis is to identify any difference in the outcomes of either fixation method in the long term. We pooled the data of all the available randomised control trials that followed the patients for a minimum of 2 years and compared outcomes of ORIF against EF of distal radius fractures as per PRISMA guidelines from inception of the databases to December 2016. We then performed our meta-analysis using RevMan 5.3 software. Flexion/extension arcs were significantly improved in ORIF, and 7 of the 10 analysed outcomes supported ORIF, although most not to a significant degree. The meta-analysis indicated that there is no difference in outcomes with either form of treatment. Even though the flexion extension arc was statistically better in the ORIF group, the difference is not clinically meaningful.

The distal radius palmar cortical angle in adolescent versus adult populations

PURPOSE

Volar distal radius plates are pre-contoured to aid restoration of anatomy during open reduction internal fixation of distal radius fractures. Incorrectly contoured plates can result in malreduction, leading to malunion, pain, and loss of function. The purpose of this study was to investigate whether adolescent distal radius anatomy on the palmar cortical surface differs from that in adults, in order to determine whether adult plates are suitable for use in adolescents.

METHODS

Lateral wrist radiographs were used to measure the distal radius palmar cortical angle (PCA) in adolescent age groups (12-13, 14-15, and 16-17 years old) and compared to a skeletally mature control group (30-50 years old). Two assessors measured 423 PCAs twice.

RESULTS

There was a statistically significant ( p = <0.05) difference in the PCA of the control group compared to each adolescent group. The mean PCA for both males and females decreased as age increased (increasing curvature of the volar distal radius with age). The mean PCA (male/female) was 164.38°/163.00° in ages 12-13, 162.14°/160.92° in ages 14-15, 157.52°/158.18° in ages 16-17, and 149.65°/154.03° in the control group aged 30-50 years. Agreement between assessors was high with an Interclass correlation coefficient (ICC) of 0.97.

CONCLUSION

There is a statistically significant and potentially clinically important difference in the curvature of the distal radius volar cortex between adolescents and adults. This difference persists even in the 16-17 age group. As the PCA curvature is significantly greater in adults compared to adolescents, plates pre-contoured for adults may lead to malreduction of distal radius fractures into flexion in adolescent patients.

Concurrent Proximal Fractures Are Rare in Distal Forearm Fractures: A National Cross-sectional Study

Introduction

Distal forearm fractures (DFF) account for 1.5% of emergency department (ED) visits in the United States. Clinicians frequently obtain imaging above/below the location of injury to rule out additional injuries. We sought to determine the incidence of associated proximal fractures (APF) in the setting of DFF and to evaluate the imaging practices in a nationally representative sample of EDs.

Methods

We queried the 2013 National Emergency Department Sample using International Classification of Diseases, 9th edition, diagnostic codes for DFF and APF. Current Procedural Technology codes identified associated imaging studies. We calculated national estimates using a weighted analysis of patient and hospital-level characteristics associated with APF and imaging practices. An analysis of costs estimated the financial impact of additional imaging in patients with DFF using Medicare reimbursement to approximate costs according to the 2018 Medicare Physician Fee Schedule.

Results

In 2013, an estimated 297,755 ED visits (weighted) were associated with a DFF, of which 1.6% (4836 cases) had an APF. The incidence of APF was lower among females (odds ratio [OR] (0.76); 95% confidence interval [CI], 0.64–0.91) but higher in metropolitan teaching hospitals compared to metropolitan non-teaching hospitals (OR [2.39]; 95% CI, 1.43–3.99) and Level 1 trauma centers (OR [3.9]; 95%, 1.91–7.96) compared to non-trauma centers. Approximately 40% (n = 117,948) of those with only DFF received non-wrist radiographs and 19% (n = 55,236) underwent non-wrist/non-forearm imaging. Factors independently associated with additional imaging included gender, payer, patient and hospital rurality, hospital region, teaching status, ownership, and trauma center level. Nearly $3.6 million (2018 U.S. dollars) was spent on the aforementioned additional imaging.

Conclusion

Despite the frequency of proximal imaging in patients with DFF, the incidence of APF was low. Further study to identify risk factors for APF based on mechanism and physical examination factors may result in reduced imaging and decreased avoidable healthcare spending.

Carpal Translocation Following Dorsal Bridge Plate Fixation of Distal Radius Fractures: A Cadaveric Study

Background  Dorsal bridge plate fixation is an effective technique for stabilization of highly comminuted, complex distal radius fractures. However, it is unknown whether fixation to the second or third metacarpal is optimal. Given dorsal bridge plating spans the radiocarpal joint, it is unclear if the dorsal spanning plate affects carpal position. This study investigates differences in carpal translocation resulting from bridge plate distal fixation to either the second or third metacarpal. Methods  Ten paired cadaveric upper extremities without evidence of gross deformity or prior surgery distal to the elbow were evaluated with three-view wrist fluoroscopic images for baseline radiographic measurements. An unstable distal radius fracture model was created via a volar approach using a 1-cm osteotomy. Following fracture creation, a dorsal bridge plate was applied with random to the second metacarpal on one limb, and the third metacarpal on the contralateral limb. Laterality for distal fixation was chosen randomly. Fluoroscopic images were repeated and radial inclination, radial height, radiocarpal angle, volar tilt, ulnar variance, radiolunate angle, radioscaphoid angle, radial rotation index, and carpal translocation were measured. Results  Radial inclination, radial height, radiocarpal angle, volar tilt, ulnar variance, radiolunate angle, and radioscaphoid angle were not statistically different before and after fixation, or when comparing the second or third metacarpal fixation. Additionally, there was no difference in Taleisnik's ulnar translocation index, Chamay's ulnar translation index, or McMurtry's carpal translation index based on which metacarpal was used for distal fixation. Conclusions  Dorsal bridge plate fixation of distal radius fractures restores preoperative physiologic measures of the radius, ulna, and carpus. Carpal translocation was similar when comparing distal fixation to the second or third metacarpal in distal radius fractures stabilized with a bridge plate. Level of Evidence  This is a Level V, therapeutic study.

The efficacy of using 3D printing models in the treatment of fractures: a randomised clinical trial

Background

The aim of this study was to evaluate the efficacy of the use of three-dimensional (3D) printing models for preoperative planning in cases of complex fracture.

Methods

In total, 48 patients with AO type C fractures of the distal radius were enrolled in the study between January 2014 and January 2015. They were divided randomly into 3D model (n = 23) and routine treatment (n = 25) groups. A 3D digital model of each distal radius fracture in the former group was constructed. The model was exported to a 3D printer for construction of a full solid model. During each operation, the operative time, amount of blood loss, and frequency of intraoperative fluoroscopy were recorded, which were regarded as primary outcome measures. Patients were followed to evaluate surgical outcomes by Gartland–Werley scores, radiological evaluation, and range of motion of wrist, and these were regarded as the secondary outcome measures. In addition, we invited surgeons and patients to complete questionnaires.

Results

The treatment of complex fractures using the 3D printing approach reduced the frequency of intraoperative fluoroscopy, blood loss volume, and operative time, but did not improve postoperative function compared with routine treatment. The patients wanted the doctor to use the 3D model to describe the condition and introduce the operative plan because it facilitated their understanding. The orthopaedic surgeons thought that the 3D model was useful for communication with patients, but were much less satisfied with its use in preoperative planning.

Conclusion

Our study revealed that 3D printing models effectively help the doctors plan and perform the operation and provide more effective communication between doctors and patients, but can not improve postoperative function compared with routine treatment.

Trial Registration

This trial was registered at the Chinese Clinical Trial Registry on May 9, 2017 (ChiCTR-IRP-17011343, http://www.chictr.org.cn/showproj.aspx?proj=19264).

The Effect of Socioeconomic Factors on Outcomes of Distal Radius Fractures: A Systematic Review

BACKGROUND

Socioeconomic factors are known to affect outcomes for both medical and surgical conditions. The purpose of this systematic review was to assess the current evidence regarding the effect of socioeconomic factors such as income, geographic location, educational level, and occupation on clinical outcomes after distal radius fractures.

METHODS

A systematic search strategy was performed to identify studies commenting on the effect of socioeconomic factors on clinical outcomes following open or closed distal radius fracture repair. Abstract and full-text screening was performed by 2 independent reviewers, and articles were evaluated by Structured Effectiveness Quality Evaluation Scale (SEQES). Treatment outcomes of interest included, but were not limited to, pain, function, range of motion, and grip strength.

RESULTS

There were 1745 studies that met our inclusion and exclusion criteria for abstract screening. Of these, 48 studies met our inclusion criteria for full-text screening and 20 studies met our criteria for quality analysis with the SEQES score. There were 3 studies of high quality, 16 of moderate quality, and 1 of low quality. Meta-analyses were not possible due to the variability in outcomes of interest across papers.

CONCLUSIONS

Patient factors indicative of socioeconomic status are relevant predictors of functional outcome after distal radius fractures. There is currently limited evidence in this area of research, and further examination should be considered to improve outcomes from a patient and system standpoint.

Traumatic fractures in adults: missed diagnosis on plain radiographs in the Emergency Department

Radiography remains the imaging standard for fracture detection after trauma. The radiographic diagnosis of most fractures and dislocations poses little difficulty to radiologists: however, occasionally these injuries are quite subtle or even impossible to detect on radiographs. Missed diagnoses of fracture potentially have important consequences for patients, clinicians, and radiologists. Radiologists play a pivot role in the diagnostic assessment of the trauma patients: emergency radiologists who are more practiced at seeking out and discerning traumatic fractures can provide an invaluable service to their clinical colleagues by ensuring that patients do not endure delayed diagnoses. This is a narrative review article aims to highlight the spectrum of fractures in adults potentially missed on plain radiographs, the causes of error in diagnosis of fractures in the emergency setting and the key elements to reduce misdiagnosis of fractures. (www.actabiomedica.it)

Preexisting Carpal and Carpometacarpal Osteoarthritis Has No Impact on Function after Distal Radius Fractures

Background  Functional outcomes of distal radius fractures vary widely regardless of treatment methods. Purpose  This study aims to verify whether preexisting carpal and carpometacarpal (CMC) osteoarthritis (OA) will negatively impact wrist functional outcome in patients with distal radius fractures. Patients and Methods  A retrospective case-control study was done using a prospective trauma database. Patients were matched 1:1 in two groups based on the presence of wrist or carpal arthritis (OA). The groups were matched for sex, follow-up, and treatment type. Patients were followed up for a minimum of 1 year and functional outcomes were assessed using validated scores. Results  A total of 61 patients were included. Mean age was 63 years (range: 20-85) and average follow-up was 26 months. There were 31 patients in the OA+ group and 30 in the OA- group. Forty-one patients were treated surgically and 20 nonoperatively. None of the patients in the OA- developed OA during follow-up. Both groups were comparable for sex, residual deformity, and follow-up. There was no significant difference for the visual analog scale, Short Form-12, Quick Disability Arm Shoulder Hand, and Patient-rated Wrist Evaluation, or for radiographic outcomes. Conclusion  Preexisting OA in the wrist or CMC does not seem to impact outcomes of distal radius fractures, regardless of treatment, age, or sex. Although this is a negative study, the results are important to help counsel patients with distal radius fractures. Further work must be done to identify other potential causes for negative outcomes. Level of Evidence  Level III, prognostic study.

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

BACKGROUND

Although secondary displacement following closed reduction and plaster immobilisation is high, several guidelines still recommend non-operative treatment for displaced distal radius fractures with an adequate closed reduction.

PURPOSE

The purpose of this study was to evaluate functional outcomes, measured with the Disability of the Arm, Shoulder and Hand (DASH) questionnaire, in non-operative treated patients with displaced distal radius fractures and an adequate closed reduction confirmed on radiograph.

MATERIALS AND METHODS

From a retrospective database, we reviewed non-operative treated adult patients with an unilateral displaced distal radius fracture and adequate closed reduction confirmed on radiograph. The primary outcome was the DASH score at 12months. DASH scores were prospectively collected pre-trauma and at three, six and 12months. Secondary outcome was the number of subsequent surgeries due to secondary displacement or a symptomatic malunion, and their possible predictors. Additionally, the difference in DASH scores between patients who were treated due to secondary displacement and asymptomatic malunion was compared.

RESULTS

One-hundred and sixteen patients were included. The median age was 62 years and 79% was female. Fractures were classified according to the AO/OTA classification as follows: AO/OTA type A (49%), AO/OTA type B (3%), AO/OTA type C (48%). After 12months the median DASH score was 15. Forty-six (40%) patients underwent subsequent surgery due to a secondary displacement or symptomatic malunion. No significant differences in DASH scores between patients who were treated non-operatively and patients who received subsequent surgery were found. Younger patients were more likely to undergo subsequent surgery. Patients with a symptomatic malunion had significant higher DASH scores compared to patients with secondary displacement.

DISCUSSION

Non-operative treatment of displaced distal radius fractures after adequate closed reduction confirmed on radiograph leads to acceptable functional outcomes after 12months, however, at the expense of 40% subsequent surgeries.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Patient Reported Pain and Disability Following a Distal Radius Fracture: A Prospective Study

BACKGROUND

Fractures of the distal radius are common. Few studies investigating the extended long term outcomes of participants following a distal radius fracture (especially beyond 2 years) and they have relied on subjective measures or single objective tests to measure participant's final outcome.

OBJECTIVES

The objective of this study was to describe the pain and disability in long-term follow-up of participants after a distal radius fracture. Participants who had previously participated in a prospective study, where baseline and standardized one-year follow-up were performed, were contacted to volunteer to participate in this follow-up (FU) study. Sixty-five participants (17 males, 48 females) with an average age of 57 (SD 13) years at the time of injury and 67 (SD 13 years) at follow-up were evaluated at an average of 11(SD 6) years (range 2-20 years).

RESULTS

The majority of patients (85%) participants reported no change or had less pain and disability (PRWE) (<5 point difference) at their long-term follow-up compared to their one year PRWE scores. One year PRWE scores were found to be predictive (19.1%) of the variability in long term PRWE score (p=0.02). Age, gender, and mechanism of fall were not significant predictors of worsened outcome.

CONCLUSION

The majority of people that are experiencing no or low patient reported pain and disability one year following a DRF can expect to retain their positive outcome 10-20 years later. This study did not identify how to predict worsened outcome.

Epidemiology and time trends of distal forearm fractures in adults - a study of 11.2 million person-years in Sweden

Background

A distal forearm fracture is a very common injury causing both suffering and substantial health care costs. The incidence of this fracture type seemed to increase worldwide until the middle 1980’s, but thereafter most reports have shown stable or decreasing rates. As few large studies have been presented lately we aimed to describe recent epidemiology and time trends of distal forearm fractures in adults. We paid special attention to fractures in working ages as they present challenges in terms of treatment and costs for sick-leave, and have not previously been thoroughly investigated.

Methods

By use of population data from Statistics Sweden and official in- and out-patient register data of men and women (≥17 years) in Sweden (Skåne region), we ascertained distal forearm fractures and estimated age- and sex-specific rates and time-trends from year 1999 to 2010 (11.2 million person-years (py)).

Results

The total incidence rate was 278 per 100,000 py (31,233 fractures) with 23% higher annual numbers 2010 compared with 1999. An increase in the annual age standardized incidence was found in men, +0.7% per annum (95% confidence interval (CI) 0.1, 1.4), and women, +0.9% (95% CI 0.5, 1.3), driven mainly by an increasing incidence in working ages (17–64 years). Also, expected demographic changes including a 25% population increase may result in 38% more fractures until 2050, compared to 2017.

Conclusions

The incidence of distal forearm fractures in adults in southern Sweden is increasing, mainly driven by an increase in working ages. In combination with expected demographic changes these findings may present substantial challenges for the future.

Acute Isolated Flexor Tendon Laceration Associated With a Distal Radius Fracture

BACKGROUND

Subacute rupture of the flexor tendons secondary to distal radius fractures is well documented. Recently, accounts of flexor tendon rupture following open reduction internal fixation have been associated with volar plate fixation. However, discovery of an occult traumatic flexor tendon laceration during fixation of an acute distal radius fracture is not well described. This case indicates the importance of careful preoperative and intraoperative examination of the flexor tendons in the setting of comminuted distal radius fractures.

METHODS

A forty-seven-year-old male sustained a comminuted, dorsally displaced distal radius fracture. Initial and post-reduction examinations revealed no gross functional abnormalities. Upon operative fixation of the fracture, laceration of the flexor digitorum profundus (FDP) tendon to the index finger was incidentally noted at the level of the fracture site.

RESULTS

Due to extensive dorsal comminution, shortening, and the presence of a lunate facet fragment, we performed volar fragment-specific and dorsal spanning bridge plate fixation. The proximal and distal ends of the FDP tendon were marked, but repair was deferred until implant removal. This allowed for proper informed consent and avoided potential compromise of the repair given the presence of a volar implant.

CONCLUSIONS

Acute flexor tendon rupture secondary to closed distal radius fractures may go unnoticed if a high index of suspicion is not maintained. Delayed diagnosis of these ruptures convolutes the mechanism of injury and disrupts the recovery process. Hand surgeons should be vigilant in examining flexor tendon function during the preoperative evaluation, especially in the setting of acute high-energy injury.

Correlation between obesity and severity of distal radius fractures

INTRODUCTION

The incidence of obesity has increased significantly worldwide. Our hypothesis was that patients with obesity have a more severe distal radius fracture and we realized a study to evaluate this correlation between obesity and severity of distal radius fractures caused by low-energy injuries.

MATERIALS AND METHODS

A total of 114 patients with distal radius fracture were examined in a cross-sectional, observational study. Fractures were classified according to the international AO-Müller/Orthopedic Trauma Association (AO/OTA) classification in order to determine the severity. The patient's Body Mass Index (BMI) was calculated and a Pearson correlation was performed.

RESULTS

The patients were predominantly female, and left side was more frequently affected. Most of the fractures were AO/OTA type A (71 patients). The majority of the involved patients in our study were overweighed or obese. We do not observe a direct correlation between grade of obesity and distal radius fracture severity.

CONCLUSIONS

Based on the results of this study obesity and severity of distal radius fractures do not correlate.

LEVEL OF EVIDENCE

Prognostic. Level IV.

Examining the influence of distal radius orientation on distal radioulnar joint contact using a finite element model

Distal radius malunion is a problem that is common to distal radius fractures and can affect the contact mechanics of the distal radioulnar joint (DRUJ). The goal of this study was to use a computational model of the DRUJ to investigate the influence distal radius orientation has on its contact mechanics. Detailed, finite element models of the radius and ulna bones were constructed from magnetic resonance imaging data. The orientation of the distal radius was rotated in 2° increments about three orthogonal axes representing dorsal-palmar rotation, radial-ulnar rotation and anteversion-retroversion. A computational model was used to predict joint contact at the DRUJ in each condition. Joint contact was found to be most sensitive to dorsal rotation of the distal radius, while radial and ulnar rotation did not substantially affect joint contact pressure. Slight retroversion was found to lower joint contact pressure. In most cases, more than 6° rotation in a given direction resulted in dislocation of the DRUJ, so that adaptation at the joint would be required to maintain articular contact. The joint contact model implemented in this study allowed the relationship between distal radius orientation and DRUJ contact to be examined systematically, in a way that is difficult to achieve using a cadaver-based approach. The results demonstrated the distal radius displacements most critical for maintaining healthy joint mechanics at the DRUJ. It is important that clinicians consider the influence of distal radius malunion and its treatment on DRUJ mechanics, in addition to its consequences for wrist function and forearm rotation. Copyright © 2016 John Wiley & Sons, Ltd.

In vivo precision of three HR-pQCT-derived finite element models of the distal radius and tibia in postmenopausal women

Background

The distal radius is the most common osteoporotic fracture site occurring in postmenopausal women. Finite element (FE) modeling is a non-invasive mathematical technique that can estimate bone strength using inputted geometry/micro-architecture and tissue material properties from computed tomographic images. Our first objective was to define and compare in vivo precision errors for three high-resolution peripheral quantitative computed tomography (HR-pQCT, XtremeCT; Scanco) based FE models of the distal radius and tibia in postmenopausal women. Our second objective was to assess the role of scan interval, scan quality, and common region on precision errors of outcomes for each FE model.

Methods

Models included: single-tissue model (STM), cortical-trabecular dual-tissue model (DTM), and one scaled model using imaged bone mineral density (E-BMD). Using HR-pQCT, we scanned the distal radius and tibia of 34 postmenopausal women (74 ± 7 years), at two time points. Primary outcomes included: tissue stiffness, apparent modulus, average von Mises stress, and failure load. Precision errors (root-mean-squared coefficient of variation, CV%_RMS) were calculated. Multivariate ANOVA was used to compare the mean of individual CV% among the 3 HR-pQCT-based FE models. Spearman correlations were used to characterize the associations between precision errors of all FE model outcomes and scan/time interval, scan quality, and common region. Significance was accepted at P < 0.05.

Results

At the distal radius, CV%_RMS precision errors were <9 % (Range STM: 2.8–5.3 %; DTM: 2.9–5.4 %; E-BMD: 4.4–8.7 %). At the distal tibia, CV%_RMS precision errors were <6 % (Range STM: 2.7–4.8 %; DTM: 2.9–3.8 %; E-BMD: 1.8–2.5 %). At the radius, Spearman correlations indicated associations between the common region and associated precision errors of the E-BMD-derived apparent modulus (ρ = −0.392; P < 0.001) and von Mises stress (ρ = −0.297; P = 0.007).

Conclusion

Results suggest that the STM and DTM are more precise for modeling apparent modulus, average von Mises stress, and failure load at the distal radius. Precision errors were comparable for all three models at the distal tibia. Results indicate that the noted differences in precision error at the distal radius were associated with the common scan region, illustrating the importance of participant repositioning within the cast and reference line placement in the scout view during the scanning process.

Recent Update in the Diagnosis and Treatment of Bone Frailty in Patients with a Distal Radius Fracture

Distal radius fracture (DRF) is the most common upper extremity fracture in the elderly. Patients with a DRF have a two to fourfold higher risk of a subsequent fracture than those with no history of fractures, and DRFs occur on average 15 years earlier than hip fractures. Therefore, patients with a DRF offer physicians an important opportunity to diagnose and treat osteoporosis to prevent a secondary fracture. In this review, we provide recent update in the diagnosis and treatment of bone frailty in patients with a DRF.

Wrist function in malunion: Is the distal radius designed to retain function in the face of fracture?

Introduction Fractures of the distal radius are the most common fracture in humans and are the sempiternal hazard of 3.5 million years of bipedalism. Despite the antiquity of the injury, one of the most controversial topics in current orthopaedics is the management of distal radius fractures. It has been suggested that radiographic appearances rarely correlate with functional outcomes. As the success of the human species is predicated almost exclusively on its dexterity and intelligence, it is conceivable that the distal radius has evolved to preserve function even in the face of injury. We therefore hypothesise that the distal radius is designed to accommodate the possibility of fracture. Methods We conducted a review of studies comparing fracture pattern and form with function. We also explore the paleoanthropological evidence and comparative studies with other primates. Findings The evidence points to the human distal radius being highly tolerant of post-fracture deformity in terms of preservation of function. In addition, the distal radius appears to have apparently anatomically 'redundant' features that confer this capability. We believe these phenomena to be an evolved trait that developed with bipedalism, increasing the chances of survival for a species whose success depends upon its dexterity.

Single-Incision Carpal Tunnel Release and Distal Radius Open Reduction and Internal Fixation: A Cadaveric Study

BACKGROUND

The safety of surgical approaches for single- versus double-incision carpal tunnel release in association with distal radius open reduction and internal fixation remains controversial.

PURPOSE

The purpose of this study was to identify critical structures to determine if a single-incision extension of the standard flexor carpi radialis (FCR) approach can be performed safely.

METHODS

Nine cadaveric arms with were dissected under loupe magnification, utilizing a standard FCR approach. After the distal radius exposure was complete, the distal portion of the FCR incision was extended to allow release of the carpal tunnel. Dissection of critical structures was performed, including the recurrent thenar motor branch of the median nerve, the palmar cutaneous branch of the median nerve (PCBm), the palmar carpal and superficial palmar branches of the radial artery, and proximally the median nerve proper. The anatomic relationship of these structures relative to the surgical approach was recorded.

RESULTS

Extension of the standard FCR approach as described in this study did not damage any critical structure in the specimens dissected. The PCBm was noted to arise from the radial side of the median nerve an average of 6.01cm proximal to the proximal edge of the transverse carpal ligament. The PCBm became enveloped in the layers of the antebrachial fascia and the transverse carpal ligament at the incision site, protecting it from injury. The recurrent motor branch of the median nerve, branches of the radial artery and the median nerve proper were not at risk during extension of the FCR approach to release the carpal tunnel.

CONCLUSIONS

Extension of the standard FCR approach to include carpal tunnel release can be performed with minimal risk to the underlying structures. This exposure may offer benefits in both visualization and extent of carpal tunnel release.

Are validated outcome measures used in distal radial fractures truly valid? A critical assessment using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist

OBJECTIVES

Patient-reported outcome measures (PROMs) are often used to evaluate the outcome of treatment in patients with distal radial fractures. Which PROM to select is often based on assessment of measurement properties, such as validity and reliability. Measurement properties are assessed in clinimetric studies, and results are often reviewed without considering the methodological quality of these studies. Our aim was to systematically review the methodological quality of clinimetric studies that evaluated measurement properties of PROMs used in patients with distal radial fractures, and to make recommendations for the selection of PROMs based on the level of evidence of each individual measurement property.

METHODS

A systematic literature search was performed in PubMed, EMbase, CINAHL and PsycINFO databases to identify relevant clinimetric studies. Two reviewers independently assessed the methodological quality of the studies on measurement properties, using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Level of evidence (strong / moderate / limited / lacking) for each measurement property per PROM was determined by combining the methodological quality and the results of the different clinimetric studies.

RESULTS

In all, 19 out of 1508 identified unique studies were included, in which 12 PROMs were rated. The Patient-rated wrist evaluation (PRWE) and the Disabilities of Arm, Shoulder and Hand questionnaire (DASH) were evaluated on most measurement properties. The evidence for the PRWE is moderate that its reliability, validity (content and hypothesis testing), and responsiveness are good. The evidence is limited that its internal consistency and cross-cultural validity are good, and its measurement error is acceptable. There is no evidence for its structural and criterion validity. The evidence for the DASH is moderate that its responsiveness is good. The evidence is limited that its reliability and the validity on hypothesis testing are good. There is no evidence for the other measurement properties.

CONCLUSION

According to this systematic review, there is, at best, moderate evidence that the responsiveness of the PRWE and DASH are good, as are the reliability and validity of the PRWE. We recommend these PROMs in clinical studies in patients with distal radial fractures; however, more clinimetric studies of higher methodological quality are needed to adequately determine the other measurement properties.Cite this article: Dr Y. V. Kleinlugtenbelt. Are validated outcome measures used in distal radial fractures truly valid?: A critical assessment using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Bone Joint Res 2016;5:153-161. DOI: 10.1302/2046-3758.54.2000462.

Role of endocortical contouring methods on precision of HR-pQCT-derived cortical micro-architecture in postmenopausal women and young adults

Precision errors of cortical bone micro-architecture from high-resolution peripheral quantitative computed tomography (pQCT) ranged from 1 to 16 % and did not differ between automatic or manually modified endocortical contour methods in postmenopausal women or young adults. In postmenopausal women, manually modified contours led to generally higher cortical bone properties when compared to the automated method.

INTRODUCTION

First, the objective of the study was to define in vivo precision errors (coefficient of variation root mean square (CV%RMS)) and least significant change (LSC) for cortical bone micro-architecture using two endocortical contouring methods: automatic (AUTO) and manually modified (MOD) in two groups (postmenopausal women and young adults) from high-resolution pQCT (HR-pQCT) scans. Second, it was to compare precision errors and bone outcomes obtained with both methods within and between groups.

METHODS

Using HR-pQCT, we scanned twice the distal radius and tibia of 34 postmenopausal women (mean age ± SD 74 ± 7 years) and 30 young adults (27 ± 9 years). Cortical micro-architecture was determined using AUTO and MOD contour methods. CV%RMS and LSC were calculated. Repeated measures and multivariate ANOVA were used to compare mean CV% and bone outcomes between the methods within and between the groups. Significance was accepted at P < 0.05.

RESULTS

CV%RMS ranged from 0.9 to 16.3 %. Within-group precision did not differ between evaluation methods. Compared to young adults, postmenopausal women had better precision for radial cortical porosity (precision difference 9.3 %) and pore volume (7.5 %) with MOD. Young adults had better precision for cortical thickness (0.8 %, MOD) and tibial cortical density (0.2 %, AUTO). In postmenopausal women, MOD resulted in 0.2-54 % higher values for most cortical outcomes, as well as 6-8 % lower radial and tibial cortical BMD and 2 % lower tibial cortical thickness.

CONCLUSIONS

Results suggest that AUTO and MOD endocortical contour methods provide comparable repeatability. In postmenopausal women, manual modification of endocortical contours led to generally higher cortical bone properties when compared to the automated method, while no between-method differences were observed in young adults.

Utilization of Post-Acute Care Following Distal Radius Fracture Among Medicare Beneficiaries

PURPOSE

To examine the utilization and cost of post-acute care following isolated distal radius fractures (DRFs) among Medicare beneficiaries.

METHODS

We examined utilization of post-acute care among Medicare beneficiaries who experienced an isolated DRF (n = 38,479) during 2007 using 100% Medicare claims data. We analyzed the effect of patient factors on hospital admission following DRF and the receipt of post-acute care delivered by skilled nursing facilities, inpatient rehabilitation facilities, home health care agencies, and outpatient occupational therapy/physical therapy for the recovery of DRF.

RESULTS

In this cohort of isolated DRF patients, 1,694 (4.4%) were admitted to hospitals following DRF, and 20% received post-acute care. Women and patients with more comorbid conditions were more likely to require hospital admission. The utilization of post-acute care was higher among women, patients who resided in urban areas, and patients of higher socioeconomic status. The average cost per patient of post-acute care services from inpatient rehabilitation facilities and skilled nursing facilities ($15,888/patient) was significantly higher than the average cost other aspects of DRF care and accounted for 69% of the total DRF-related expenditure among patients who received inpatient rehabilitation.

CONCLUSIONS

Sociodemographic factors, including sex, socioeconomic status, and age, were significantly correlated with the use of post-acute care following isolated DRFs, and post-acute care accounted for a substantial proportion of the total expenditures related to these common injuries among the elderly. Identifying patients who will derive the greatest benefit from post-acute care can inform strategies to improve the cost efficiency of rehabilitation and optimize scarce health care resources.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Comparison of conservative and operative treatment for distal radius fracture: a meta-analysis of randomized controlled trials

BACKGROUND

The authors conducted a meta-analysis to compare the effectiveness and safety of conservative and operative treatment for distal radius fracture.

METHODS

PubMed, EMBASE, and the Cochrane Library were searched to identify the relevant studies published up to February of 2015. All randomized controlled trials published to compare the conservative and operative treatment were included in the study. Results were pooled using meta-analysis to compare the efficacy and safety of conservative and operative treatment for distal radius fracture.

RESULTS

The databases were derived from seven qualified studies that included a total of 523 patients in which 269 cases adopted conservative treatment while 253 cases adopted operative treatment. Overall, compared with the conservative treatment- treated the distal radius fracture, operative therapies resulted in significantly better radiographic (P<0.05), however, no significant differences of the functional outcomes and complication rate were observed between the two methods (P>0.05).

CONCLUSION

Surgical treatment seems to be more effective distal radius fracture compared with conservative treatment when the radiographic outcomes were analyzed, and no significant differences were deteched in the functional outcomes and complication rate.

Volar locking plates versus K-wire/pin fixation for the treatment of distal radial fractures: a systematic review and quantitative synthesis

INTRODUCTION

Volar locking plate and Kirschner wire/pin fixations are the most commonly used methods for surgical fixation of distal radius fractures.

SOURCES OF DATA

A literature search was performed using PubMed, CINAHL, Cochrane Central and Embase Biomedical databases, selecting studies comparing two or more different surgical treatments including Kirschner wire fixation and volar locking-plate fixation. This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Methodological quality of all selected articles was assessed.

AREAS OF AGREEMENT

A total of 14 publications (1306 patients) were included in this review, 10 of which were prospectively designed (8 randomized controlled trial). A total of 659 (50.5%) patients underwent volar locking plating (VLP group), while 647 of 1306 (49.5%) were treated with Kirschner wire/pin fixation (KW group). No differences were recorded in terms of ROM, grip strength, radiographic variables and total rate of complications. There is no clear superiority of either fixation method for the surgical management of distal radius fractures.

AREAS OF CONTROVERSY

At a pooled analysis, VLP obtained statistically significant better DASH value compared to KW (18.1 ± 7.8 vs. 12.8 ± 6.4%, P = 0.026). Costs and surgical times were significantly higher for plate fixation.

GROWING POINTS

Both techniques provide excellent clinical and radiographic results, without a clear superiority of either fixation method for the surgical management of distal radius fractures.

RESEARCH

There is a need for more randomized trials performing standardized measurements at fixed follow-up, with results divided by subtypes of distal radius fractures.

Determination of radiography requirement in wrist trauma

OBJECTIVES

The purpose of this study was to evaluate predetermined physical examination and function tests recommended to identify severe injury among patients presenting with wrist injury to the emergency department and to establish a reliable clinical decision rule capable of determining the need for radiography in wrist injuries.

MATERIALS AND METHODS

This was a multicenter prospective derivation study of wrist injuries. All patients were assessed in terms of mechanism of trauma, inspection findings, heart rate, sensitivity at palpation, presence of pain with active movement, grasp strength, and functional tests using an examination form under main headings. Sensitivity, specificity, and positive and negative predictive values were expressed for each sign and each examination finding.

RESULTS

One hundred nineteen adult patients were enrolled during the 6-month study period. Fracture was identified in 24.3% (n = 29). Presence of pain on the radial deviation, dorsal flexion, distal radioulnar drawer, and axial compression tests exhibited high sensitivity (82.8%, 89.7%, 82.8%, and 86.2%, respectively) and high negative predictive values (88.6%, 81.3%, 87.5%, and 93.6%, respectively) for wrist fracture. Sensitivity of 96.6% was observed when these 4 tests were evaluated together.

CONCLUSIONS

The presence of one of these examination findings increases the likelihood of fracture and is adequate to recommend wrist radiography. In addition, there is a strong possibility of radiography being unnecessary if all 4 test results are negative in patients presenting with wrist injury, potentially preventing many nonessential radiographs being performed.

Easily Missed Fractures of the Upper Extremity

Radiographs remain the mainstay for initial imaging of suspected fracture in the emergency setting. Missed fractures potentially have significant negative consequences for patients, referring physicians, and radiologists. Most missed fractures are owing to perceptual errors. In this review, we emphasize knowledge of 3 categories of pitfalls as they pertain to the upper extremity: the common but challenging; the out of mind, out of sight; and those related to satisfaction of search. For specific injuries, emphasis is placed on helpful radiographic signs and important additional radiographic views to obtain.

Epidemiology of distal forearm fractures in Austria between 1989 and 2010

Only few studies have been published hitherto on country-specific incidence of distal forearm fracture. In the prevailing study, incidences were estimated, and trend analyses were performed for the entire Austrian population aged ≥50á. Incidence decreased significantly in women, but not in men, over the past 12 years of observation.

INTRODUCTION

To estimate incidence of distal forearm fracture and assess incidence trends in the entire Austrian population aged ≥50á from 1989-2010 for inpatient fractures and from 1999 to 2010 for all fractures.

METHODS

The number of inpatient forearm fractures was obtained from the Austrian Hospital Discharge Register (AHDR) for the entire population aged ≥50á from 1989 to 2010. Total number of distal forearm fractures was modeled using patient-level data on 36,327 patients with distal forearm fractures. Crude and age-standardized incidence rates (cases per 100,000) were estimated in 5-year age intervals. To analyze the change in incidence over time, average annual changes expressed as incidence rate ratios (IRR) were calculated.

RESULTS

For all distal forearm fractures, age-standardized incidence in women in 1999 and 2009 were estimated at 709 (95 % CI 675-743) and 607 (578-637), respectively. The age-standardized incidences in men the same years were estimated at 171 (156-185) and 162 (151-174), respectively. IRR analyses showed a significant decrease in women (-1.1 %, p < 0.01) but not in men (-0.8 %, p > 0.05) over the last 12 years (1999-2010).

CONCLUSION

Incidence of distal forearm fracture in the entire Austrian population is comparable to hip fracture incidence which is known to be among the highest worldwide. However, trend analyses reveal a significant decrease for all distal forearm fractures in women, but not in men, over the last 12 years.

Differentiating common causes of radial wrist pain

Radial wrist pain is a common patient complaint with a broad differential. Because treatment and prognosis differ, determining the underlying cause is key. This article reviews a case of intersection syndrome and compares it to other causes of radial wrist pain.

A cohort study of one-year functional and radiographic outcomes following intra-articular distal radius fractures

BACKGROUND

The purpose of this study was to describe the outcomes of a series of patients followed prospectively after intra-articular distal radius fractures.

METHODS

One hundred forty-eight patients with intra-articular fractures (mean age, 47 years; age range, 44-54 years; gender distribution, 60 males and 88 females) were treated with cast only, arthroscopy/closed reduction plus pins, arthroscopy/closed reduction with external fixation, open reduction and internal fixation (ORIF) alone, and ORIF with external fixation according to surgeon preference and fracture characteristics. The 1-year outcomes across the groups were measured radiographically (n = 148) and functionally (n = 113; 1-year Wrist Outcome Measure score, Grip Strength, SF-36, and PRWE scores).

RESULTS

Radiographically, the groups had statistically significant differences in radial inclination, volar tilt, intra-articular step-off, and radial shortening in the pre-treatment X-rays. However, following treatment, treatment groups demonstrated no difference statistically in their follow-up radiographic measures. One-year PRWE scores were found to be statistically different across groups. Across groups, the ORIF-alone treatment group had the highest PRWE score reflecting greatest amount of pain and disability. One-year wrist outcome measure scores and grip strength scores were also found to be significantly different across treatment groups. The general health status as measured by the SF-36 was not found to be different across treatment groups.

CONCLUSIONS

These findings are consistent with treatment by indication; suboptimal ORIF outcomes may reflect older practice patterns with dorsal plating. A randomized control trial that compares treatments controlling for fracture severity and studies that develop formal clinical prediction rules for treatment assignment are needed.

Distal radius fractures: an epidemiological review

OBJECTIVE

Distal radius fractures are among the most common fractures encountered in clinical practice. Although multiple epidemiological studies have been done in Western populations, there is a lack of data within Asia. Our study aims to fill this knowledge gap.

METHODS

This study included all patients aged 16 years and above with distal radius fractures seen between November 2008 and May 2009 by the Department of Hand and Reconstructive Microsurgery at the Singapore National University Hospital. A retrospective analysis was done. Information captured included clinical data, hand dominance, AO classification of fractures, mechanism of injury, associated injuries as well as treatment modalities.

RESULTS

Of the 431 fractures, 238 were males, 181 were females. These fractures occur at all ages, peaking at the 50 to 60 years age group. The peak incidence of distal radius fractures in females occurred in the perimenopausal age group, whereas the incidence for males peaked between age of 30 to 50. By AO classification, 53% were type A; 13% were type B and 32% were type C. A fall on the outstretched hand from a standing position is the most common mechanism of injury. As the intensity of the injury mechanism increased, the percentage of type C fractures increased correspondingly. Older patients were more likely to be treated conservatively compared to younger patients. AO severity classification correlated well with the clinician's decision to surgically fix the fracture. No correlation between hand dominancy and fracture site found was found.

CONCLUSION

We compared our data with that of previous similar studies, and found similarities as well as differences in results. Nevertheless, the epidemiogical data gathered in this study has added to our knowledge of distal radius fractures in an Asian population.