Accelerated rehabilitation compared with a standard protocol after distal radial fractures treated with volar open reduction and internal fixation: a prospective, randomized, controlled study

Action observation intervention using three-dimensional movies improves the usability of hands with distal radius fractures in daily life-A nonrandomized controlled trial in women

OBJECTIVE

Prolonged immobilization of joints after distal radius fracture (DRF) causes cerebral disuse-dependent plasticity (DDP) and deterioration of upper extremity function. Action observation therapy (AOT) can improve DDP.

TRIAL DESIGN

This nonrandomized controlled trial (UMIN 000039973) tested the hypothesis that AOT improves hand-use difficulties during activities of daily living in patients with DRF.

METHOD

Right-handed women with volar locking plate fixation for DRF were divided into AOT and Non-AOT groups for a 12-week intervention. The primary outcome was difficulty in using the fractured hand, assessed with the Japanese version of the Patient-related Wrist Evaluation (PRWE). The secondary outcomes were range of motion (ROM) of the injured side and gap between measured ROM and patient-estimated ROM. The survey was administered immediately post operation and at postoperative weeks 4, 8, and 12. The AOT group used a head-mounted display and three-dimensional video during ROM exercises. The Non-AOT group used active ROM exercises alone. A generalized linear model (GLM) was used to confirm interactions and main effects by group and time period, and multiple comparisons were performed.

RESULTS

Thirty-five patients were assigned to the AOT group (n = 18, median age, 74 years) or the Non-AOT group (n = 17, median age, 70 years). In the GLM, PRWE Total, PRWE Specific, and PRWE Usual scores revealed interactions between groups and periods. The post-hoc test revealed that the PRWE Specific scores (z = 3.43, p = 0.02) and PRWE Usual scores (z = 7.53, p<0.01) were significantly lower in the AOT group than in the Non-AOT group at 4 weeks postoperatively, whereas PRWE Total scores (z = 3.29, p = 0.04) were lower at 8 weeks postoperatively.

CONCLUSIONS

These results suggested that AOT can improve hand-use difficulties in right-handed women after DRF surgery. AOT positively affects the motor imagery of patients with DRF and can reverse the patient's perceived difficulty in using the fractured hand during rehabilitation.

Combined home and clinic-based therapy versus home-based exercise programme after distal radial fracture: a randomized controlled study

We investigated outcomes of clinic-based hand therapy combined with a home-based exercise programme after anterior plating for distal radial fractures. A total of 102 patients were randomly assigned to one of three groups: a home-based exercise programme alone; a home-based exercise programme combined with four hand therapy sessions in the clinic; and a home-based exercise programme with seven sessions in the clinic. Mean Patient-Rated Wrist Evaluation scores at 6 weeks were significantly better for the group of patients with seven sessions in the clinic than in those with only home exercises (12 vs. 30), but the difference was no longer significant at 12 weeks. Grip strength was significantly better at 6 and 12 weeks. Combined home- and clinic-based hand therapy may facilitate an earlier return of function after anterior plating for distal radius fractures.Level of evidence: II.

Comparison between Volar Locking Plate and Kirschner Wire Fixation for Unstable Distal Radius Fracture: A Meta-Analysis of Randomized Controlled Trials

Objective  This study aims to compare the outcomes of volar locking plating (VLP) versus percutaneous Kirschner wires (K-wire) fixation for surgical management of unstable distal radius fractures. Methods  We systematically searched multiple databases, including MEDLINE, EMBASE, Cochrane Central till January 2022 for randomized controlled trials (RCTs) that met eligibility criteria. Following outcomes were evaluated at 6-week, 3-, 6-, and 12-month follow-up period: Disabilities of the Arm, Shoulder, and Hand (DASH) score, Patient Rated Wrist Evaluation (PRWE) score, grip strength, range of motion, and complication incidence. Meta-analysis was performed using random effects models and results presented as risk ratios (RRs) or mean differences (MDs) with 95% confidence interval. Results  Fourteen RCTs with 1,450 participants met the inclusion criteria. DASH scores were significantly better for VLP fixation at 6th week (MD = 19.02; p  < 0.001), 3rd (MD = 10.79; p  < 0.001), 6th (MD= 7.78; p  < 0.001), and 12th month (MD = 2.94; p  < 0.001) postoperation. At 3-month follow-up period, VLP treatment exhibited better grip strength (MD = - 10.32; p  < 0.001) and PRWE scores (MD = 8.78; p  < 0.001). There was a statistically significant early advantage in flexion, extension, pronation, supination, radial deviation, and ulnar deviation in the VLP group at 6-week follow-up, but at 1-year follow-up only significantly better extension was observed. At 1 year, radiographic outcomes were similar except for volar tilt favoring VLP fixation ( p  < 0.001). Superficial infections were more common in patients treated with K-wire (RR = 2.89; p  = 0.001), but there was no difference in total complications or reoperation rates ( p  > 0.05). Conclusion  This meta-analysis suggests that VLP fixation and K-wire fixation are both effective procedures, but existing literature does not provide sufficient evidence to demonstrate the superiority of either method. Although VLP fixation improves DASH score, extension and volar tilt at 12-month follow-up, the difference is small and unlikely to be noticeable to the patients.

Distal Radius Fracture Rehabilitation

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

The effectiveness of therapeutic craft-making activities in treating lower-third forearm fracture: study protocol for a randomized controlled trial

BACKGROUND

Occupational Therapists use craft-making activities as therapeutic interventions to improve physical and psychological functioning of injured people. Despite the therapeutic effects, craft-making is not routinely used in hand rehabilitation as an intervention for patients with upper limb fractures. These patients often experience physical and psychosocial issues; however, without supportive evidence, therapists hesitate to integrate craft-making into upper limb rehabilitation.

PURPOSE

This study aims to determine the effect of a conventional therapy combined with therapeutic craft-making on disability, post-traumatic stress, and physical performance in patients with lower-third forearm fractures.

METHODS

Priori analysis determined that 38 patients will be needed for this superiority randomized controlled trial to be conducted in a hand and upper limb rehabilitation center. Eligible participants must comprehend English, be diagnosed with lower-third forearm fracture(s) stabilized by open reduction internal fixation, and referred to therapy within 2-4 weeks of surgery. Following the CONSORT guidelines, participants will be randomly assigned to a Control (conventional therapy) group or an Intervention (conventional therapy and craft) group. Twice weekly for 6 weeks, Therapist A will provide both groups with 1-h of conventional therapy while the Intervention group will also receive 15 min of craft-making supervised by the Researcher. The primary outcome of disability will be measured with the Quick-Disabilities of Arm, Shoulder and Hand. The secondary outcome measurements include the Patient-Rated-Wrist-Evaluation; Impact of Event Scale-revised and physical performance, i.e., the Purdue Pegboard Test, AROM, and grip strength. All outcome measures will be obtained by Therapist B prior to the 1st therapy visit and after the 12th visit. Descriptive analysis will be done for the categorical and continuous data and a mixed model ANOVA for analysis of the initial and final assessment scores within and between groups.

RESULTS

This study is ongoing.

DISCUSSION

The intent of this study is to determine if therapeutic crafts have value as an intervention when used in combination with conventional therapy for patients with lower-third forearm fractures. If the value of crafts is supported, this evidence may reduce hesitancy of therapists to implement craft-making with patients referred to hand therapy after upper limb fracture.

CONCLUSION

This study is ongoing.

TRIAL REGISTRATION

ANZCTR, ACTRN12622000150741. Retrospectively registered on 28 January 2022 https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382676&isReview=true ..

Impact of early rehabilitation therapy on functional outcomes in patients post distal radius fracture surgery: a systematic review and meta-analysis

BACKGROUND

This meta-analysis aims to investigate the efficacy of early rehabilitation on patients who have undergone surgery for distal radius fractures (DRFs) with palmar plating, focusing on multiple outcome measures including upper limb function, wrist function, back extension mobility, pain levels, and complications.

METHODS

A rigorous search strategy adhering to the PRISMA guidelines was employed across four major databases, including PubMed, Embase, Web of Science, and the Cochrane Library. Studies were included based on stringent criteria, and data extraction was performed independently by two reviewers. Meta-analysis was conducted employing both fixed-effect and random-effects models as dictated by heterogeneity, assessed by the I2 statistic and chi-square tests. A total of 7 studies, encompassing diverse demographic groups and timelines, were included for the final analysis.

RESULTS

The meta-analysis disclosed that early rehabilitation yielded a statistically significant improvement in upper limb function (SMD -0.27; 95% CI -0.48 to -0.07; P < 0.0001) and back extension mobility (SMD 0.26; 95% CI 0.04 to 0.48; P = 0.021). A notable reduction in pain levels was observed in the early rehabilitation group (SMD -0.28; 95% CI -0.53 to -0.02; P = 0.03). However, there were no significant differences in wrist function (SMD -0.13; 95% CI -0.38 to 0.12; P = 0.36) and complications (OR 0.99; 95% CI 0.61 to 1.61; P = 0.96).

CONCLUSIONS

Early rehabilitation post-DRF surgery with palmar plating has been found to be beneficial in enhancing upper limb functionality and back extension mobility, and in reducing pain levels. Nevertheless, no significant impact was observed regarding wrist function and complications.

Postoperative mobilization after terrible triad injury: systematic review and single-arm meta-analysis

BACKGROUND

Terrible triad injury is a complex injury of the elbow, involving elbow dislocation with associated fracture of the radial head, avulsion or tear of the lateral ulnar collateral ligament, and fracture of the coronoid. These injuries are commonly managed surgically with fixation or replacement of the radial head and repair of the collateral ligaments with or without fixation of the coronoid. Postoperative mobilization is a significant factor that may affect patient outcomes; however, the optimal postoperative mobilization protocol is unclear. This study aimed to systematically review the available literature regarding postoperative rehabilitation of terrible triad injuries to aid clinical decision making.

METHODS

We systematically reviewed the PubMed, Embase, Cochrane, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The inclusion criteria were studies with populations aged ≥16 years with terrible triad injury in which operative treatment was performed, a clear postoperative mobilization protocol was defined, and the Mayo Elbow Performance Score (MEPS) was reported. Secondary outcomes were pain, instability, and range of motion (ROM). Postoperative mobilization was classified as either "early," defined as active ROM commencement before or up to 14 days, or "late," defined as active ROM commencement after 14 days.

RESULTS

A total of 119 articles were identified from the initial search, of which 11 (301 patients) were included in the final review. The most common protocols (6 studies) favored early mobilization, whereas 5 studies undertook late mobilization. Meta-regression analysis including mobilization as a covariate showed an estimated mean difference in the pooled mean MEPS between early and late mobilization of 6.1 (95% confidence interval, 0.2-12) with a higher pooled mean MEPS for early mobilization (MEPS, 91.2) than for late mobilization (MEPS, 85; P = .041). Rates of instability reported ranged from 4.5% to 19% (8%-11.5% for early mobilization and 4.5%-19% for late mobilization).

CONCLUSION

Our findings suggest that early postoperative mobilization may confer a benefit in terms of functional outcomes following surgical management of terrible triad injuries without appearing to confer an increased instability risk. Further research in the form of randomized controlled trials between early and late mobilization is advised to provide a higher level of evidence.

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

INTRODUCTION

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

HYPOTHESIS

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE: 3

Influence of surgical performance on clinical outcome after osteosynthesis of distal radius fracture

INTRODUCTION

Clinical outcome after surgery depends on the surgeon's level of expertise or performance. The present study of minimally invasive plate osteosynthesis (MIPO) with anterior plate for distal radius fracture assessed whether clinical outcome correlated with surgeon performance.

METHODS

The series included 30 distal radius fractures: 15 operated on by 4 level III surgeons (Group 1) and 15 by 4 level V surgeons (Group 2), utilizing the MIPO technique. The surgical performance of all 8 surgeons was assessed using the OSATS global rating scale. Clinical outcomes were assessed at 3 months' follow-up using the modified Mayo score (MMS), in 4 grades: 0-64 (poor), 65-79 (moderate), 80-89 (good), and 90-100 (excellent). The QuickDASH score (QDASH) was also calculated, and complications were recorded.

RESULTS

Median MMS was better for level V (75 = fair result) than level III surgeons (62 = poor result). Median QDASH score likewise was better in group 2 (9.1) than group 1 (22.7). In group 1, there were 2 paresthesias in the median nerve territory, 1 type-1 complex regional pain syndrome, and 1 hypoesthesia in the scar area. Mean correlation between the 2 scores was -0.68. Group 1 patients were on average 7 years older. The number of patients, number of surgeons and distribution of OA A and C fractures were almost identical in the two groups. On MMS, the overall result of the two groups was moderate (70.5), which can be explained by short mean follow-up.

DISCUSSION

Quality of the clinical outcome on MMS and QDASH increased with surgical performance, with fewer complications. In the patients' interest, protocols for improving surgical performance should be implemented, for example, through deliberate practice.

Patient Adherence With At-Home Hand and Wrist Exercises: A Randomized Controlled Trial of Video Versus Handout Format

BACKGROUND

Patient adherence is important for maximizing patient outcomes. The purpose of this randomized controlled trial was to determine patient adherence and confidence in home therapy exercises of the hand and wrist at multiple time points when distributed by either paper handout or video.

METHODS

Patients were prospectively enrolled and randomized in orthopedic clinics to either the handout or video exercise group. Exclusion criteria included patients less than 18 years old. Questionnaires were electronically distributed each week for 4 weeks following enrollment. Questionnaires assessed the frequency of exercise performance, percentage of exercises utilized, and confidence in performing the exercises correctly. The handout and video groups were compared via 2-sample t tests for continuous data and χ2 tests for categorical data.

RESULTS

Of the 89 patients enrolled, 71 patients responded to the initial follow-up survey (80% of randomized patients), and 54 of these patients (76%) completed all surveys at each time point. The handout group (37 patients) and the video group (34 patients) had no differences in response rate or demographics. There were no differences in frequency, exercise utilization rate, or confidence in performing exercises between groups at week 1. However, the video group reported higher exercise utilization and confidence than the handout group at subsequent time points.

CONCLUSIONS

Video-format distribution of home therapy exercises is superior to that of paper handout distribution for the distal upper extremity rehabilitation. Patients in the video group utilized more exercises and had higher confidence in completing them correctly following initiation of the exercise program.

Early Mobilization After Basal Joint Arthroplasty: Clinical Results

Background: Traditional rehabilitation for basal joint arthroplasty involves postoperative immobilization. We hypothesize that early motion is safe and will result in equivalent clinical outcomes to traditional rehabilitation. Methods: Patients undergoing ligament reconstruction and tendon interposition were randomized into 2 rehabilitation protocols. All patients were immobilized postoperatively in a thumb-spica splint for 2 weeks. The accelerated group (Group 1) was transitioned into a removable Carpometacarpal (CMC)-wrap with activity as tolerated, while the traditional group (Group 2) were immobilized for an additional 4 weeks. Patients were examined preoperatively and at 6 weeks, 12 weeks, 6 months, and 1 year postoperatively. Outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) score, a visual analog scale for pain (VAS), pinch and grip strength and thumb range of motion. Results: Ninety-three thumbs were randomized, 48 in group 1 and 45 in group 2. There were no statistically significant differences between the 2 groups preoperatively. DASH scores were significantly lower in the accelerated rehabilitation group at 6 weeks postoperatively compared to the traditional rehabilitation group, but these became equivalent by 12 weeks postoperatively. There were no statistically significant differences between the 2 groups with respect to postoperative VAS, key, pinch, or grip strength or thumb range of motion at all time points postoperatively. Conclusions: Early (12-week and 1-year) outcomes suggest early mobilization of patients following CMC arthroplasty does not compromise clinical results. Long-term data will determine the lasting effects of accelerated rehabilitation but may offer earlier return to function than traditional rehabilitation.

LIMPER trials: immediate mobilisation versus 2-week cast immobilisation after distal radius fracture treated with volar locking plate - a study protocol for a prospective, randomised, controlled trial

INTRODUCTION

Open reduction and internal fixation with volar locking plate has become the most common fixation method in the treatment of unstable distal radius fracture (DRF). There is, however, no consensus as to whether or for how long a wrist should be immobilised after operative treatment. To date, there have been relatively few studies that have evaluated the effect of immediate postoperative mobilisation on functional outcomes. The aim of postoperative rehabilitation is to obtain a good function and to reduce impairment, recovery time, socioeconomical costs and absence from work. Therefore, there is a need for studies that evaluate the optimal method of postoperative rehabilitation to optimise wrist function and return to work.

METHODS AND ANALYSIS

This study is a prospective, randomised, controlled trial in which a total of 240 working-age patients who undergo volar plating for DRF will be randomly assigned to either an early mobilisation group or a postoperative 2-week casting group. The aim of the study will be to compare early postoperative outcomes between the study groups. The primary outcome will be patient-rated wrist evaluation at 2 months after operation. A coprimary outcome will be the total length of sick leave. Our follow-up period will be 1 year, and secondary outcomes will include pain, patient satisfaction, perceived ability to work and complications identified at different time points. We expect those patients who undergo immediate mobilisation will have at least as rapid a return to work and function as those patients who undergo postoperative immobilisation, indicating/meaning that there will be no need for postoperative casting.

ETHICS AND DISSEMINATION

This study will be conducted according to the Standard Protocol Items: Recommendations for Interventional Trials statement. The Ethics committee of Tampere University Hospital has approved the protocol. Ethics committee approval number is R21111, and it is accepted on 7 September 2021. The results of this study will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05150925.

Use of Hand Therapy After Distal Radius Fracture: A National Perspective

PURPOSE

To assess whether certain distal radius fracture (DRF) patients, such as opioid users or complex regional pain syndrome (CRPS) patients, receive more hand therapy.

METHODS

Using the IBM MarketScan Research Databases from January 1, 2012, to December 31, 2016, we identified a cohort of DRF patients and created 4 subgroups of interest: frequent follow-up patients, persistent opioid users, prior opioid users, and patients with CRPS. We measured rates and demographic characteristics associated with therapy use in our populations of interest.

RESULTS

In this cohort of 87,313 patients, 21% received hand therapy after primary DRF treatment. Patients with CRPS had a higher rate of therapy than non-CRPS patients (44% vs 21%, respectively). Frequent follow-up patients used more therapy than those with less follow-up (30% vs 17%, respectively). Persistent opioid users demonstrated slightly increased therapy use compared to the remaining population (25% vs 22%, respectively). Prior opioid users underwent less therapy than patients without prior opioid use (19% vs 22%, respectively). Female sex, residing in the Northeast, being on a preferred provider organization plan, and having more intense surgical treatments were associated with increased therapy use.

CONCLUSIONS

This study showed variations in therapy use after DRF in subpopulations of interest. Patients with CRPS, persistent opioid use, and frequent follow-ups had higher rates of therapy. Patients with prior opioid use had lower rates of therapy.

CLINICAL RELEVANCE

Therapy is more common in patients with DRF with CRPS, persistent opioid use, or more follow-up visits.

A Volar Locking Plate With Fossa Specific Fixation Provides Comparable Stability Between Articular and Nonarticular Cadaveric Models of Distal Radius Fracture

BACKGROUND

Distal radius fractures often present with a 3-part articular fragmentation pattern, with separation of the dorsal and volar lunate fossa. The column concept of distal radius fixation addresses the importance of stabilizing both the scaphoid fossa lateral column and the lunate fossa intermediate column. Recent evidence strengthens the value of immediate postoperative mobilization. Satisfactory outcomes following these protocols are predicated on volar locking plates (VLPs) providing adequate stability to the fracture repair. We hypothesize that a VLP which individually supports both lateral and intermediate distal radius columns may provide comparable stability between articular and non-articular cadaveric fracture models under parameters meant to simulate postoperative loading.

METHODS

Eleven cadaveric matched pair specimens were randomized to receive a simulated AO Type A2 non-articular distal radius fracture on one side with an AO Type C3 articular fracture on the contralateral side. Stiffness during cyclic loading was compared between fracture groups. A matched-paired Student t-test was used to determine statistical significance (P = .05).

RESULTS

There were no significant differences (P = .35) in stiffness between the articular models (mean 370.0 N/mm, +/-93.5) and the non-articular models (360.4 N/mm, +/-60.0) of distal radius fracture.

CONCLUSION

A VLP that individually supports the scaphoid and lunate fossa with fixed angle subchondral support may provide comparable fixation strength with resistance to displacement between articular and non-articular fracture patterns. The current results suggest that fossa-specific VLP fixation in articular fractures can maintain construct stability during postoperative loading.

Comparative clinical and radiographic outcomes between early and delayed wrist mobilization after volar fixed-angle plate fixation of distal radius fracture

Postoperative immobilization protocols after volar fixed-angle plate fixation of distal radius fractures (DRF) vary among surgeons. This study aimed to compare functional outcomes, radiographic parameters, and complications between early and delayed mobilization after volar fixed-angle plate fixation of DRF. This study is a randomized controlled trial. The early group was allowed to perform wrist motion exercise immediately after surgery and the delayed group was allowed to perform it after 2 weeks of external immobilization. Postoperative patient-rated wrist evaluation (PRWE), disabilities of arm, shoulder, and hand (DASH), wrist range of motion, visual analog scale (VAS) pain score, and grip strength were evaluated. Forty-eight patients with DRF were enrolled and randomly allocated to the early or delayed mobilization groups. The PRWE, DASH, VAS pain score, grip strength, and wrist motion of both groups significantly improved over time. However, there were no significant differences between groups at any timepoint. Radiographic parameters were not different between groups. There were no significant differences in functional outcomes, radiographic parameters, and complications between early and delayed mobilization after volar fixed-angle plate of DRF. Immediate postoperative wrist range-of-motion exercise can be safely initiated after volar fixed-angle plate fixation of DRF without external immobilization.Clinical trial registration: Thaiclinicaltrials.org identifier: TCTR20180927005. Registered 27/09/2018-retrospectively registered. https://www.thaiclinicaltrials.org/show/TCTR20180927005 .

Traditional Versus Digital Media-Based Hand Therapy After Distal Radius Fracture

PURPOSE

Distal radius fractures (DRFs) are common injuries with a rising incidence. A substantial portion of the cost of care is attributable to therapy services. Our purpose was to evaluate the effectiveness of a self-directed hand therapy program guided by digital media compared with that of traditional therapy.

METHODS

We conducted a randomized controlled trial in patients aged 18 years or older who underwent open reduction and internal fixation of a DRF with volar plating. Subjects were randomized to traditional hand therapy using a 12-week protocol or an identical protocol presented in digital videos and performed at home. Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores were collected as the primary outcome at 2 weeks (baseline), 6 weeks, and 12 weeks or greater. Pain visual analog scale (VAS) scores, Veterans RAND 12-Item Health Survey (VR-12) scores, wrist and forearm range of motion, wrist circumference, and grip strength were recorded as secondary outcomes.

RESULTS

Fifty-one patients were enrolled. Forty-nine patients were included in the analysis-21 in the digital media group and 28 in the traditional group. Both groups demonstrated significant improvements in QuickDASH scores between baseline and 12-week or greater time points. The QuickDASH scores in the digital media group were slightly more improved than those in the traditional group at the 6-week and 12-week or greater time points; however, these differences were not statistically significant. Pain VAS and VR-12 scores were comparable between group differences at each time point.

CONCLUSIONS

Our digital media program was at least as effective as traditional therapy for patients undergoing volar plating of DRF. These results may help inform the design of future trials investigating the effectiveness of digital media-based hand therapy programs.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Efficacy of Hand Therapy After Volar Locking Plate Fixation of Distal Radius Fracture in Middle-Aged to Elderly Women: A Randomized Controlled Trial

PURPOSE

This study aimed to evaluate the efficacy of hand therapy after volar locking plate fixation of distal radius fractures in middle-aged to elderly women.

METHODS

Fifty-seven patients diagnosed with distal radius fractures who had undergone volar plate fixation were enrolled in a prospective, randomized controlled trial. Patients were randomized into the hand therapy and independent exercise (IE) groups, in which they exercised independently under the surgeon's direction with and without hand therapy, respectively. The primary outcome was the functional outcome measured using the Disability of Arm, Shoulder, and Hand questionnaire after 6 weeks. The secondary outcomes were functional outcomes measured using the Patient-Rated Wrist Evaluation questionnaire, active and passive ranges of motion (ROMs), grip strength, key pinch strength, and pain measured on a visual analog scale. Patients were followed up in the outpatient department at 2, 4, 6, and 8 weeks and at 3 and 6 months.

RESULTS

The Disability of Arm, Shoulder, and Hand scores were significantly lower in the hand therapy group at 6 weeks after surgery (12.5 vs 19.4 in the IE group). The postoperative visual analog scale pain scores were significantly lower in the hand therapy group at 2, 4, and 6 weeks (10.2 vs 17.6 in the IE group). The active ROM of the wrist flexion-extension arc at 2, 4, 6, and 8 weeks; active ROM of the pronation-supination arc at 6 and 8 weeks; and passive ROM of the wrist flexion-extension arc at 2, 4, and 8 weeks were significantly greater in the hand therapy group.

CONCLUSIONS

Hand therapy improved the outcomes after volar locking plate fixation for distal radius fracture in middle-aged to elderly women at 8 weeks after surgery. No significant between-group differences were observed in any functional outcome measure at 6 months after surgery, as previously reported.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Is early mobilization after volar locking plate fixation in distal radius fractures really beneficial? A meta-analysis of prospective randomized studies

STUDY DESIGN

This was a systematic review with a meta-analysis.

INTRODUCTION

Despite rising trends toward surgical treatment of distal radius fractures (DRF) with volar locking plate (VLP) fixation, there is a lack of consensus on when to start vigorous wrist range of motion (ROM) exercises after surgery.

PURPOSE

We performed a meta-analysis to compare early and late mobilization after VLP fixation in patients with DRF.

METHODS

Four prospective randomized controlled trials with a minimum of 6 months of follow-up were retrieved through MEDLINE (PubMed), EMBASE, Web of Science, the Cochrane Library, and the KoreaMed databases in March 2021. We divided patients into an early group (patients who started ROM exercises of the wrist within 2 weeks after surgery), and a late group (patients who started ROM exercises 5 or 6 weeks after surgery). The primary outcome was treatment efficacy which was measured through improvement in pain score, function score, ROM, and grip power. The secondary outcome was the incidence of postoperative complications.

RESULTS

This meta-analysis included 127 patients in the early group and 131 patients in the late group. The outcomes were compared at 6 weeks, 3 months, and 6 months postoperatively. There was no significant difference in pain score, though the early group had a lower average visual analog scale score. The early group had a lower arm, shoulder, and hand disability score than the late group (95 % CI, -16.25 to -8.35 points; P < .001) at 6 weeks postoperatively, suggesting significantly superior outcomes. A similar trend persisted at 3 (n = 74 in the early group and n = 77 in the late group; 95% CI, -5.45 to -0.30; P = .029) and 6 months (n = 102 in the early group and n = 100 in the late group; 95% CI, -4.81 to 0.21; P = .073), but the differences were smaller. The early group had a higher grip power at all follow-up periods, but the difference was only significant at 6 months postoperatively (n = 88 in the early group and n = 83 in the late group; 95% CI, 0.50 to 6.99; P = 0.024). The early group also had more favorable ROM in all directions at 6 weeks, but only in supination at 6 months. The complication rate was not significantly different between the 2 groups. There were no differences in the rates of secondary operation and reduction loss.

CONCLUSION

Early ROM exercise after VLP in DRF resulted in superior functional scores and grip power until 6 months postoperatively. The dominance of the joint ROM, which was seen at 6 weeks after surgery in the early exercise group, decreased with time and ultimately showed little difference at 6 months. Early exercise is safe and did not increase complication rates.

Home exercise in the dart-throwing motion plane after distal radius fractures: A pilot randomized controlled trial

INTRODUCTION

During daily functions, our wrist moves through an oblique plane, named the dart-throwing motion (DTM) plane. This plane is considered a more stable plane because the proximal carpal row remains relatively immobile. However, rehabilitation programs that incorporate exercising in the DTM plane have yet to be explored.

PURPOSE OF THE STUDY

The purpose of this study was to evaluate the rehabilitation outcomes after treatment in the DTM plane compared with outcomes after treatment in the sagittal plane after distal radius fracture.

STUDY DESIGN

This is a pilot randomized controlled trial.

METHODS

Subjects after open reduction internal fixation were assigned into a research group (N = 12; ages 48.7 ± 7.3) and a control group (N = 12; ages 50.8 ± 15). The control group activated the wrist in the sagittal plane, whereas the research group activated the wrist in the DTM plane. Range of motion, pain levels, functional hand motor skills tests, and satisfaction from self-training exercise were measured before and after a 12-session intervention.

RESULTS

The outcome measures were similar between the treatment groups. The research group reported significantly higher satisfaction rates than the control group on topics such as general satisfaction (research group: 3.4 ± 0.7, control group: 2. 5 ± 1.2, P = .030), motivation to exert oneself (research group: 2.8 ± 1.0, control group: 2.3 ± 1.2, P = .009), progressed function (research group: 3.4 ± 0.7, control group: 2.4 ± 1.1, P = .012), and self-training contribution to the daily function (research group: 3.4 ± 0.7, control group: 2.5 ± 1.2, P = .030).

DISCUSSION AND CONCLUSION

Pilot results do not favor one treatment method over the other. However, exercising in the DTM plane may contribute to the satisfaction of the client and increase self-training motivation.

Immediate mobilization of distal radius fractures stabilized by volar locking plate results in a better short-term outcome than a five week immobilization: A prospective randomized trial

OBJECTIVE

To evaluate the impact of immediate (first day after surgery) mobilization compared to standard five weeks cast immobilization on the functional outcome after volar locking plate fixation of distal radius fractures.

DESIGN

Prospective randomized parallel group comparative trial.

SETTING

Trauma Hospital, Austria.

PARTICIPANTS

Patients with isolated unstable distal radius fractures, stabilized with volar angular stable locking plate.

INTERVENTIONS

The immediate mobilization group received a removable forearm splint for one week and active supervised group physiotherapy and home exercises for the shoulder, elbow, wrist, and fingers from the first postoperative day. The cast immobilization group received a non-removable cast for five weeks. In the first five weeks supervised group physiotherapy and home exercises were performed for shoulder, elbow, and fingers. Thereafter additional supervised and home exercises for the wrist were started.

MAIN MEASURES

At regular intervals of six and nine weeks, three and six months, and one year post surgery range of motion, grip strength, and x-rays were evaluated. Additionally, the shortened disabilities of the arm, shoulder and hand (QuickDASH) score, Patient-rated Wrist Evaluation, Mayo Wrist score, and pain according to the Visual Analog Scale score were analyzed.

RESULTS

One hundred and sixteen patients were prospectively randomized into two study groups. At the one-year follow-up, patients in the immediate mobilization group showed a significantly higher range of motion in extension/flexion (mean difference 10.2°, 99% confidence interval 0.6-19.8), grip strength (mean difference 5.1 kg, 99% confidence interval -0.5 to 10.7), and Mayo Wrist score (mean difference 7.9 points, 99% confidence interval 2.3-13.5) than the cast immobilization group. Range of motion in supination/pronation (mean difference 13.4°, 99% confidence interval 1.5-25.3) and in radial/ulnar deviation (mean difference 6.3°, 99% confidence interval 0.9-11.7) differed significantly up to nine weeks favoring the immediate mobilization group. The Patient-rated Wrist Evaluation revealed significantly better scores after three months (mean difference 9.3 points, 99% confidence interval 0.5-18.1) and QuickDASH after six months (mean difference 7.3 points, 99% confidence interval 0.3-14.3) in the immediate mobilization group. All other subsequent follow-up examinations indicated no significant differences in respect of pain, range of motion, and patient-reported outcome measurements between the study groups. There were no significant differences in respect of radiological loss of reduction and complications between the groups.

CONCLUSIONS

Immediate mobilization in combination with supervised physiotherapy of the wrist after volar locking plate fixation of unstable distal radius fractures results in a significantly improved range of motion and grip strength after one year compared to cast immobilization. No increased risk for loss of reduction and other complications was observed.

In adults, early mobilization may be beneficial for distal radius fractures treated with open reduction and internal fixation: a systematic review and meta-analysis

Objectives

It remains debatable if early mobilization (EM) yields a better clinical outcome than the late mobilization (LM) in adults with an acute and displaced distal radial fracture (DRF) of open reduction internal fixation (ORIF). Therefore, we aimed to perform a systematic review and meta-analysis of randomized controlled trials (RCTs), comparing clinical results with the safety of EM with LM following ORIF.

Methods

Databases such as Medline, Cochrane Central Register, and Embase were searched from Jan 1, 2000, to July 31, 2021, and RCTs comparing EM with LM for DRF with ORIF were included in the analysis. The primary outcome of study included disabilities of the Arm, Shoulder, and Hand (DASH) score at different follow-up times. Wherever the secondary outcomes included patient-rated wrist evaluation (PRWE), grip strength (GS), visual analog scale (VAS), wrist range of motion (WROM), and associated complications, the two independent reviewers did data extraction for the analysis. Effect sizes of outcome for each group were pooled using random-effects models; thereafter, the results were represented in the forest plots.

Results

Nine RCTs with 293 EM and 303 LM participants were identified and included in the study. Our analysis showed that the DASH score of the EM group was significantly better than LM group at the six weeks postoperatively (− 10.15; 95% CI − 15.74 to − 4.57, P < 0.01). Besides, the EM group also had better outcomes in PRWE, GS and WROM at 6 weeks. However, EM showed potential higher rate for implant loosening and/or fracture re-displacement complication (3.00; 95% CI 1.02–8.83, P = 0.05).

Conclusion

Functionally, at earlier stages, EM for patients with DRF of ORIF may have a beneficial effect than LM. The mean differences in the DASH score at 6 weeks surpassed the minimal clinically important difference; however, the potentially higher risk of implant loosening and/or fracture re-displacement cannot be ignored. Due to the lack of definitive evidence, multicenter and large sample RCTs are required for determining the optimal rehabilitation protocol for DRF with ORIF.

PROSPERO registration number: CRD42021240214 2021/2/28.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02837-0.

Comparison of immobilization periods following open reduction and internal fixation of distal radius fracture: A systematic review and meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

INTRODUCTION

The use of volar locking plate (VLP) in the fixation of fracture fragments promised a new era in the management of distal radius fracture (DRF).

PURPOSE OF THE STUDY

To compare the patient-reported outcomes, functional outcomes, pain, and adverse events between the different periods of immobilization following open reduction and internal fixation of DRFs with VLP.

METHODS

We searched Medline/Pubmed, Web of Science, Ovid, and CINAHL. The inclusion criteria was randomized controlled trials that compared different immobilization periods after open reduction and internal fixation of DRFs with VLP. The last search was performed on 2 June 2020. The different immobilization periods were divided into the following 3 groups: ≤1-week group, 2-3-week group, and 5-6-week group.

RESULTS

Seven eligible randomized controlled trials provided data on 509 patients. We found that compared to 5-6-week group, ≤1-week and 2-3-week groups showed a reduction in overall Patient-Reported Wrist Evaluation score (SMD = -0.48, 95% CI -0.73 to -0.22, P < .001; SMD = -0.69, 95% CI -0.97 to -0.41, P < .001, respectively). We also found that there were improvements in the other patient-reported outcomes including overall Disabilities of the Arm, Shoulder, and Hand score and pain; and functional outcomes including overall grip strength and range of motion measures in favor of ≤1-week and 2-3-week groups.

CONCLUSION

This systematic review and meta-analysis showed that compared to immobilization for 5 to 6 weeks after DRF repair, immobilization for ≤1 week or 2-3 weeks showed improvements in the patients-reported outcomes and functional outcomes. The differences between the 3 immobilization groups may not be clinically important considering the small changes as follow up progresses.

Early Retrieval of Spanning Plates Used for Fixation of Complex Fractures of the Distal Radius

Background  Spanning plates are being increasingly used for the treatment of complex fractures of the distal radius. The traditional recommendation is to leave the hardware in place for at least 12 weeks. Questions/Purpose  This study assesses the comparative outcomes of spanning plates removed at or before 10 weeks. We hypothesized that acceptable healing and functional outcomes can be achieved with earlier hardware removal to allow for earlier range of motion, rehabilitation, and return to function. Patients and Methods  All patients treated for a comminuted, intra-articular distal radius fracture with a temporary spanning plate were identified. Outcomes of bridge plates removed before 10 weeks were compared with plates removed after 12 weeks. Twenty patients in the short duration cohort were compared with 40 patients in the long duration cohort. Results  All fractures healed and there were 10 complications (4 short duration, 6 long duration) and 2 reoperations (1 short duration, 1 long duration) in the study population. There were no significant differences in final Quick-DASH scores (27.4 short duration, 20.9 long duration) or radiographic alignment. Mean values for wrist extension and ulnar deviation were significantly worse in the long duration cohort, although these differences are of unclear clinical significance. Conclusion  It may be safe to remove spanning bridge plates earlier than what is traditionally recommended. Plate removal at or before 10 weeks did not detract from healing or radiographic alignment. Prospective investigations assessing the optimal duration of fixation for this technique are needed. Level of Evidence  This is a Level IV study.

Is Therapy Needed After Distal Radius Fracture Treatment, What Is the Evidence?

The role of hand therapy in management of distal radius fractures remains unclear. Some evidence demonstrates that initiating early range of motion and urging patients to return to routine activities of daily living as soon as possible may produce favorable outcomes that are as effective as formal supervised therapy. Extended supervised therapy does not appear to impact outcomes and a single instruction session with a home-based program produces similar results. Although we feel that formal structured therapy may have a role in select high-risk patients, the literature remains unclear on which patients would benefit most from formal supervised therapy.

Serious game versus standard care for rehabilitation after distal radius fractures: a protocol for a multicentre randomised controlled trial

INTRODUCTION

Distal radius fractures are among the most prevalent traumatic injuries worldwide. These injuries are associated with high healthcare-related and socioeconomic costs, mainly resulting from loss of productivity. To optimise recovery and return to work, wrist exercises are recommended. However, adherence to standard exercise regimens is low. Serious games provide a treatment platform for standardised postoperative care, uniting meaningful recovery with entertainment. Also, mobile serious games, for example, smartphone or tablet applications, are able to send practice reminders believed to improve self-efficacy.

METHODS AND ANALYSIS

To test the effectiveness of a mobile serious game for distal radius fracture rehabilitation compared with standard care, a multicentre, randomised controlled clinical trial was designed. Primary outcome will be the Patient-Rated Wrist Evaluation (PRWE) score after 6 weeks of treatment. Secondary outcomes are range of motion, grip strength, pain scores, and self-reported treatment adherence after 2, 6 and 12 weeks of treatment.Adult patients with any type of closed distal radius fracture are included directly after non-operative or operative fracture treatment. Patients are recruited in the outpatient clinics of four teaching hospitals. The intended sample size is 92 patients, based on the minimal clinically important difference of the PRWE score at 6 weeks, using a superiority model.Patients are randomised between using the wearable-controlled mobile serious game ReValidate! (intervention group) and standard care consisting of unsupervised exercises and a referral for physiotherapy or exercise therapy upon request or recommendation by the treating clinician (control group).

ETHICS AND DISSEMINATION

The protocol has been approved by the Medical Ethical Review Board of the Amsterdam University Medical Centres, location Academic Medical Centre in Amsterdam, the Netherlands. Results will be made available to involved healthcare providers, funders, and to the general public including patients via peer-reviewed academic journals and international conferences.

TRIAL REGISTRATION NUMBER

Dutch Trial Registry (NTR), NL6140, protocol V.2.

Some outcomes of patients treated operatively for distal humerus fractures are affected by hand dominance

PURPOSE

This study sought to compare postoperative outcomes and complications between patients with distal humerus fractures treated with open reduction and internal fixation (ORIF) of their non-dominant versus dominant arm.

METHODS

A retrospective review of all patients who sustained a distal humerus fracture treated operatively with ORIF at one academic institution between 2011 and 2015 was performed. Measured outcomes included complications, time to fracture union, painful hardware, removal of hardware, Mayo Elbow Performance Index (MEPI), and elbow range of motion. Differences in outcomes between patients who underwent surgery of their dominant upper extremity and those who underwent surgery of their non-dominant extremity were assessed.

RESULTS

Sixty-nine patients met inclusion criteria. Forty (58.0%) underwent ORIF of a distal humerus fracture on their non-dominant arm and 29 (42.0%) on their dominant arm. Groups did not differ with respect to demographics, injury information, or surgical management. Mean overall follow-up was 14.1 ± 10.5 months, with all patients achieving at least 6 months follow-up. The non-dominant cohort experienced a higher proportion of postoperative complications (P = 0.048), painful hardware (P = 0.018), and removal of hardware (P = 0.002). At latest follow-up, the non-dominant cohort had lower MEPI scores (P = 0.037) but no difference in elbow arc of motion (P = 0.314).

CONCLUSION

Patients who sustained a distal humerus fracture of their non-dominant arm treated with ORIF experienced more postoperative complications, reported a greater incidence of painful hardware, underwent removal of hardware more often, and had worse functional recovery in this study. Physicians should emphasize the importance of physical therapy and maintaining arm movement especially when the non-dominant arm is involved following distal humerus fracture repair.

LEVEL OF EVIDENCE

Level III.

Effectiveness of early versus delayed motion in patients with distal radius fracture treated with volar locking plate: A systematic review and meta-analysis

The aim of this study was to determine the effectiveness of early versus delayed motion on the functional outcomes in patients with distal radius fracture (DRF) treated with a volar locking plate. A systematic review and meta-analysis of randomized clinical trials was performed. An electronic search was performed in the Medline, Central, Embase, PEDro, Lilacs, Cinahl, SPORTDiscus, and Web of Science databases. The eligibility criteria included randomized clinical trials that compared the effect of early versus delayed motion on wrist and/or upper limb function, pain, grip strength, and wrist range of motion in subjects older than 18 years with DRF treated with a volar locking plate. Five clinical trials were included that met the eligibility criteria for the quantitative synthesis. At 6 weeks, the PRWE questionnaire showed a mean difference (MD) of -10.6 points (p < 0.001), the MD was -11.1 points for the DASH questionnaire (p < 0.001), -0.56 cm for pain on VAS (p = 0.01), 5.0 kg for grip strength (p = 0.01), 12.5 degrees for wrist flexion (p = 0.07), and 12.8 degrees for wrist extension (p = 0.05). All differences favored the early motion treatment. At 3 months of follow-up, only the DASH, pain on VAS, and grip strength showed significant differences in favor of early motion. At 1 year of follow-up, none of the variables studied were different between groups. In the short term, there was moderate to high evidence of clinically and statistically significant differences in the functional outcomes in favor of early versus delayed motion in patients with DRF treated with a volar locking plate. But these differences were not observed at 1 year of follow-up. PROSPERO registration no.: CRD42020158706.

Early Mobilization After Volar Locking Plate Osteosynthesis of Distal Radial Fractures in Older Patients-A Randomized Controlled Trial

PURPOSE

To investigate if early mobilization after open reduction internal fixation of distal radius fractures improved the functional outcome. We hypothesized that early mobilization would lead to improved patient-reported outcome. Second, we aimed to assess whether early mobilization increased the risk of postoperative implant loosening or breakage.

METHODS

All included patients were treated with a volar locking plate. After surgery, patients were randomized to either early mobilization (E-MOB) with a removable orthosis (wrist lacer) and daily wrist exercises or to late mobilization (L-MOB) with a standard dorsal plaster cast for 2 weeks and, after that, a removable orthosis and exercises. We measured all patients at 4 weeks and at 3, 6, and 12 months after surgery. At each postoperative visit, we measured range of motion and grip strength and patients filled out the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Radiographic implant loosening or breakage was assessed 14 days after surgery.

RESULTS

A total of 47 patients were allocated to E-MOB and 48 to L-MOB. The DASH score improved substantially throughout the follow-up period with no significant differences between the 2 groups at any time point. Implant loosening and fracture redisplacement was observed in 1 patient in the E-MOB group. Range of motion and grip strength were similar between the 2 groups at all time points.

CONCLUSIONS

Early mobilization after surgical treatment of distal radius fractures does not lead to improved patient-reported outcome.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

A systematic review of how daily activities and exercises are recommended following volar plating of distal radius fractures and the efficacy and safety of early versus late mobilisation

Introduction

Following surgical repair of distal radius fractures, mobilisation timeframes and interventions vary. Early mobilisation (<2 weeks postoperatively) usually includes range of motion exercises and may include recommendations to perform daily activities. The review investigated (i) how early mobilisation was recommended, particularly with respect to wrist use during daily activities and (ii) the efficacy and safety of early versus delayed mobilisation (< or ≥2 weeks).

Methods

The study protocol was registered on PROSPERO (CRD42019136490). Five databases were searched for studies that compared early and delayed mobilisation in adults with volar plating of distal radius fractures. The Downs and Black Quality Index and the Template for Intervention Description and Replication checklist were used for quality evaluation. Effect sizes were calculated for range of movement, function and pain at 6–8, 10–12 and 26 weeks. A descriptive analysis of outcomes and mobilisation regimes was conducted.

Results

Eight studies with a mean Quality Index score of 20 out of 28 (SD=5.6) were included. Performing daily activities was commonly recommended as part of early mobilisation. Commencing mobilisation prior to two weeks resulted in greater range of movement, function and less pain at up to eight weeks postoperatively than delaying mobilisation until two weeks or later.

Discussion

Performance of daily activities was used alongside exercise to promote recovery but without clearly specifying the type, duration or intensity of activities. In combination with exercise, early daily activity was safe and beneficial. Performing daily activities may have discrete advantages. Hand therapists are challenged to incorporate activity-approaches into early mobilisation regimes.

Early Mobilization Versus Splinting After Surgical Management of Distal Radius Fractures

BACKGROUND

After the surgical management of distal radius fractures (DRF) in older patients, further treatment with a splint often follows. It is unclear whether early mobilization might be superior to splinting in this group of patients, as it is in others. In this prospective, randomized, controlled trial, we attempted to determine whether early mobilization yields better outcomes.

METHODS

50 patients over age 70 with DRF were included in the trial. Group A (the splint group) was treated with postoperative immobilization, group B with early mobilization. Clinical follow-up examinations were performed at 2, 6, and 12 weeks and at 6 and 12 months. X-rays were obtained preoperatively, postoperatively, at 6 weeks, and at 6 months. The primary outcome parameter was the modified Mayo Wrist Score (MMWS) at 6 weeks.

RESULTS

At 6 weeks, the functional outcome was better to a statistically significant extent in group B (MMWS; 65/100 vs. 55/100 [q25 : 55/40 - q75 : 70/70; p = 0.025]). No difference between the two groups was demonstrable in their further clinical course. The estimated regression model revealed a statistically significant effect of the method of treatment (p = 0.023). There were no differences in hand strength or in x-ray findings.

DISCUSION

Early mobilization is associated with better wrist function on initial follow-up, without any demonstrable disadvantage with respect to secondary dislocation. The psychological benefit and protective function of wrist splinting in patients who are in danger of falling should nonetheless be investigated in further studies.

Current Concepts in Rehabilitation Protocols to Optimize Patient Function Following Musculoskeletal Trauma

Musculoskeletal (MSK) trauma is a major cause of disability and pain worldwide. Despite surgical advances following MSK injuries, poor functional outcomes following surgery remain a major public health concern. Traditional methods of rehabilitation involving bed rest and immobilization led to muscle weakness, joint stiffness, and an inability to return to previous levels of activity. Recent research has provided evidence that early rehabilitation with a multidisciplinary team can prevent these negative outcomes and improve functional outcomes following MSK trauma. In order to continue to optimize recovery, standardized rehabilitation protocols and technological advances are required.

Rehabilitation after distal radius fractures: is there a need for immobilization and physiotherapy?

Although the literature generally agrees that displaced distal radius fractures require surgery, no single consensus exists concerning the length of immobilization and type of post-operative physiotherapeutic rehabilitation program. Palmar locking plate fixation represents a very stable fixation of the distal radius, and was assessed biomechanically in various studies. Surprisingly, most authors report additional immobilization after plate fixation. One reason might be due to the pain caused during active wrist mobilization in the early post-operative stages or secondly to protect the osteosynthesis in the early healing stages preventing secondary loss of reduction. This article addresses the biomechanical principles, current available evidence for early mobilization/immobilization and impact of physiotherapy after operatively treated distal radius fractures.

Evaluating the necessity of bone augmentation for distal radius fracture fixed with a volar locking plate: a retrospective study

Background

Multiple approaches for fixation of distal radius fractures exist; nonetheless, there is no consensus on the optimal treatment for these injuries. Although using volar locking plates has become increasingly common as a surgical intervention, the usefulness of bone augmentation remains debatable. Therefore, this study aimed to evaluate the necessity of bone augmentation for distal radius fractures fixed with a volar locking plate.

Methods

This retrospective study enrolled patients with a single distal radius fracture treated with a volar locking plate between January 2014 and December 2016. Overall, 105 fractures were included and divided into two groups (non-bone augmentation: group 1, n = 88; bone augmentation: group 2, n = 17). Images were reviewed, and dorsal cortex collapse, volar tilting, and radial height and inclination were measured immediately after surgery and at the 6-month follow-up.

Results

Both groups exhibited significant differences in dorsal collapse (p < 0.001 and p = 0.001, respectively) and radial height shortening (p < 0.001 and p = 0.039, respectively); volar tilting and radial inclination did not differ significantly. There was no difference in the degree of dorsal collapse (p = 0.715) and radial height shortening (p = 0.651) between the two groups. Of the 105 fractures, 54 were identified as comminuted type according to the AO classification (A3, C2, and C3), and similar radiographic outcomes were noted.

Conclusions

Volar locking plates for the treatment of distal radius fractures with or without bone augmentation do not affect the radiographic outcomes. In comminuted fractures, additional bone augmentation is unnecessary if intraoperative anatomical reduction and fixation are performed when possible.

Linking commonly used hand therapy outcome measures to individual areas of the International Classification of Functioning: A systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION

Identifying outcome measures that correspond to the International Classification of Functioning (ICF) provides insight into selecting appropriate outcome tools in hand therapy practice.

PURPOSE OF THE STUDY

The objective of this study is to systematically review patient-reported outcome measures commonly used in hand therapy to determine the extent to which the content represents the biopsychosocial view of the ICF.

METHODS

A comprehensive literature search was conducted. Studies that met inclusion criteria were identified, and outcome measures were extracted. The meaningful concept was determined for each item on the measure and linked to the most specific ICF category. Summary linkage calculations were completed.

RESULTS

Eleven patient-reported outcomes were identified from 43 included studies. Activity and participation had the highest content coverage followed by body functions. There was linking to personal factors and not defined-disability and mental health. Environmental factors were not represented in any of the included outcome measures. The core set representation of unique codes ranged from 8.55% to 18.80% (mean: 11.97%) for the Comprehensive ICF Core Set for Hand Conditions and from 30.43% to 47.83% (mean: 31.40%) for the Brief ICF Core Set for Hand Conditions. The percent representation of the Comprehensive ICF Core Set for Hand Conditions for unique disability ranged from 21.62% to 43.24% (mean: 20.33%) and from 62.50% to 87.50% (mean: 72.22%) for the Brief ICF Core Set for Hand Conditions.

DISCUSSION

None of the included measures represent all categories of the ICF Core Sets for Hand Conditions.

CONCLUSION

Utilizing the most recent refinement rules for the linking process, this study provides comparisons of measures along with clarity of content coverage for the most commonly used tools in the practice of hand therapy.

The Relationship between Hand Therapy and Long-Term Outcomes after Distal Radius Fracture in Older Adults: Evidence from the Randomized Wrist and Radius Injury Surgical Trial

BACKGROUND

Older patients are frequently referred to hand therapy after distal radius fracture. Supervised therapy sessions place a transportation burden on patients and are costly on both the individual and systematic levels. Furthermore, there is little evidence that supervised therapy or home exercises improve long-term outcomes.

METHODS

Data were collected for the Wrist and Radius Injury Surgical Trial, a multicenter, international, pragmatic, randomized trial of distal radius fracture treatment in patients aged 60 years and older. Referral to therapy and therapy protocol were at the discretion of the treating surgeon and therapist. The authors examined outcomes between participants who underwent therapy and those who did not and assessed the duration of therapy. The authors also analyzed the effect of therapy on subgroups at risk for poor outcomes: older participants and those who had more comorbidities or lower baseline activity.

RESULTS

Eighty percent of participants underwent therapy; 70 percent participated in both supervised therapy and home exercises. Participants had a mean 9.2 supervised sessions over 14.2 weeks. There were no differences in patient-reported outcomes between participants who underwent therapy and those who did not. Participants who did not have therapy recovered more grip strength. Participants who engaged in therapy for a shorter time reported greater function, ability to work, and satisfaction. There were no relationships revealed in subgroup analyses.

CONCLUSIONS

Hand therapy after distal radius fracture may not be necessary for older patients. Encouraging participants to resume activities of daily living as soon as possible may be as effective as formal therapy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

A retrospective analysis of the number of therapy visits after distal radius fractures using a new provider-scored clinical severity scale

STUDY DESIGN

Retrospective study.

INTRODUCTION

Fractures of the distal radius are common as is a postfracture referral to occupational therapy (OT). This article examines factors that cause greater morbidity and a greater number of OT visits.

PURPOSE OF THE STUDY

This study aims to analyze which of 5 common sequelae of the distal radius fracture is most significant for increasing the number of therapy visits.

METHODS

Three-hundred Sixty charts were reviewed, and 89 were selected. Multiple regression was used to determine which of our 5 independent variables had the greatest predictive power for the total number of therapy visits.

RESULTS

The regression model demonstrated significance at P ≤ .01. Total active motion (TAM) of the digits (P ≤ .01) and TAM of the forearm (P ≤ .01) were the only complications that demonstrated statistical significance and a positive relationship with the number of therapy visits. In addition to this, TAM of the forearm and digits showed a strong correlation with the number of therapy visits. TAM of the wrist, pain, and edema had a weak correlation. Patients with high total group score on the clinical severity scale also had a moderate correlation.

DISCUSSION

The results of the study illustrate the importance of digital contractures on a patient's morbidity, function, and their need for OT visits.

CONCLUSION

The information from this study is important for the clinician as it identifies patients at risk for increased morbidity and identifies the complications that the clinician may want to stress early in the rehabilitation of that patient.

LEVEL OF EVIDENCE

3.

Minimum Clinically Important Difference: Current Trends in the Orthopaedic Literature, Part I: Upper Extremity: A Systematic Review

BACKGROUND

The minimum clinically important difference (MCID) attempts to define the patient's experience of treatment outcomes. Efforts at calculating the MCID have yielded multiple and inconsistent MCID values. The purposes of this review were to describe the usage of the MCID in the most recent orthopaedic literature, to explain the limitations of its current uses, and to clarify the underpinnings of MCID calculation. Subsequently, we hope that the information presented here will help practitioners to better understand the MCID and to serve as a guide for future efforts to calculate the MCID. The first part of this review focuses on the upper-extremity orthopaedic literature. Part II will focus on the lower-extremity orthopaedic literature.

METHODS

A review was conducted of the 2014 to 2016 publications in The Journal of Arthroplasty, The Journal of Bone & Joint Surgery, The American Journal of Sports Medicine, Foot & Ankle International, Journal of Orthopaedic Trauma, Journal of Pediatric Orthopaedics, and Journal of Shoulder and Elbow Surgery. Only clinical science articles utilizing patient-reported outcome measure (PROM) scores were included in the analysis. A keyword search was then performed to identify articles that calculated or referenced the MCID. Articles were then further categorized into upper-extremity and lower-extremity publications. MCID utilization in the selected articles was subsequently characterized and recorded.

RESULTS

The MCID was referenced in 129 (7.5%) of 1,709 clinical science articles that utilized PROMs: 52 (40.3%) of 129 were related to the upper extremity, 5 (9.6%) of 52 independently calculated MCID values, and 47 (90.4%) of 52 used previously published MCID values as a gauge of their own results. MCID values were considered or calculated for 16 PROMs; 12 of these were specific to the upper extremity. Six different methods were used to calculate the MCID. Calculated MCIDs had a wide range of values for the same PROM (e.g., 8 to 36 points for Constant-Murley scores and 6.4 to 17 points for American Shoulder and Elbow Surgeons [ASES] scores).

CONCLUSIONS

Determining useful MCID values remains elusive and is compounded by the proliferation of PROMs in the field of orthopaedics. The fundamentals of MCID calculation methods should be critically evaluated. If necessary, these methods should be corrected or abandoned. Furthermore, the type of change intended to be measured should be clarified: beneficial, detrimental, or small or large changes. There should also be assurance that the calculation method actually measures the intended change. Finally, the measurement error should consistently be reported.

CLINICAL RELEVANCE

The MCID is increasingly used as a measure of patients' improvement. However, the MCID does not yet adequately capture the clinical importance of patients' improvement.

Effectiveness of the graded motor imagery to improve hand function in patients with distal radius fracture: A randomized controlled trial

STUDY DESIGN

Single-blinded randomized controlled trial.

INTRODUCTION

Pain management is essential in the early stages of the rehabilitation of distal radius fractures (DRFx). Pain intensity at the acute stage is considered important for determining the individual recovery process, given that higher pain intensity and persistent pain duration negatively affect the function and cortical activity of pain response. Graded motor imagery (GMI) and its components are recent pain management strategies, established on a neuroscience basis.

PURPOSE OF THE STUDY

To investigate the effectiveness of GMI in hand function in patients with DRFx.

METHODS

Thirty-six participants were randomly allocated to either GMI (n = 17; 52.59 [9.8] years) or control (n = 19; 47.16 [10.5] years) groups. The GMI group received imagery treatment in addition to traditional rehabilitation, and the control group received traditional rehabilitation for 8 weeks. The assessments included pain at rest and during activity using the visual analog scale, wrist and forearm active range of motion (ROM) with universal goniometer, grip strength with the hydraulic dynamometer (Jamar; Bolingbrook, IL), and upper extremity functional status using the Disability of the Arm, Shoulder and Hand Questionnaire, and the Michigan Hand Questionnaire. Assessments were performed twice at baseline and at the end of the eighth week.

RESULTS

The GMI group showed greater improvement in pain intensity (during rest, 2.24; activity, 6.18 points), wrist ROM (flexion, -40.59; extension, -45.59; radial deviation, -25.59; and ulnar deviation, -26.77 points) and forearm ROM (supination, -43.82 points), and functional status (Disability of the Arm, Shoulder and Hand Questionnaire, 38.00; Michigan Hand Questionnaire, -32.53 points) when compared with the control group (for all, P < .05).

CONCLUSION

The cortical model of pathological pain suggests new strategies established on a neuroscience basis. These strategies aim to normalize the cortical proprioceptive representation and reduce pain. One of these recent strategies, GMI appears to provide beneficial effects to control pain, improve grip strength, and increase upper extremity functions in patients with DRFx.

Early Mobilization and Physiotherapy Vs. Late Mobilization and Home Exercises After ORIF of Distal Radial Fractures: A Randomized Controlled Trial

Volar locking plates have permitted early mobilization, omitting the need for prolonged cast immobilization, after distal radial fractures (DRFs). However, the type of rehabilitation following plate fixation of DRFs remains an unresolved issue. The purpose of this study was to evaluate the effect of physiotherapy after volar plate fixation of DRFs. At a 2-year follow-up, we compared the results of immediate physiotherapy (early mobilization) with those of home exercises following 2 weeks in a dorsal plaster splint (late mobilization).

Association between Functional Outcomes and Radiographic Reduction Following Surgery for Distal Radius Fractures

Background: Quality of reduction in distal radius fractures (DRF) is assessed using radiographic parameters, however few studies examine the association between radiographic measurements and functional outcomes. Our purpose was to evaluate the relationship between radiographic measurements and clinical outcome measures following surgery for DRF using detailed testing to demonstrate further associations between post-surgical radiographic measurements and function.

Methods: Measurements were performed on postoperative radiographs of 38 patients following ORIF of DRF. Measurements included: radial inclination, radial height, ulnar variance, volar tilt, radiocarpal interval (d2/w2), and the intra-articular step-off. Clinical outcome measures included motion, grip strength, functional dexterity testing, Moberg pick-up test, specific activities of daily living, DASH score, pain scale, manual-assessment questionnaire.

Results: Different radiographic parameters correlated with different specific tasks. The parameter correlated with most functional tasks was ulnar-variance. Radial inclination, radial-styloid scaphoid distance, and fracture classification correlated with some functions. Intraarticular step-off, and radial height were not associated with functional testing.

Conclusions: Surgical radiographic results may affect post-operative function. Detailed task specific testing may enable a better evaluation of surgical outcomes. Further study and refinement of functional assessment may change our surgical goals in DRF.

Management of Unstable Distal Radius Fractures: A Survey of Hand Surgeons

Background  Length of immobilization after operative fixation of unstable distal radius fractures and management in elderly patients is an area of debate. Purpose  The purpose of this study is to delineate common practices of fellowship-trained hand surgeons and how they compare with current evidence-based protocols. Methods  Surveys were distributed to American Society for Surgery of the Hand members on preferred methods of fixation, postoperative immobilization, and variations in treatment of elderly patients with unstable distal radius fractures. Responses were analyzed in comparison to a literature review. Subgroups were compared with regard to training, practice type, and years in practice. Results  Four-hundred eighty-five surveys were analyzed. Volar fixed-angle plating was the most common choice of fixation (84.7%). Patients are most often immobilized for 1 to 2 weeks (40.0%) with range of motion (ROM) therapy begun most commonly between 1 and 4 weeks (47.2%). The majority of surgeons do not treat fractures differently in patients more than 65 years old. Physicians with more than 20 years of experience were significantly more likely to begin wrist ROM sooner with volar plating versus other fixation techniques compared with physicians with less than 20 years of experience (40.7% vs. 34.2%, respectively). Also, physicians in academic-only practices were more likely to immobilize patients for a shorter time after volar plating compared with those in privademics. Conclusion  Volar fixed-angle plating is the dominant fixation method for unstable distal radius fractures among fellowship-trained hand surgeons. Elderly patients are not treated more conservatively and rigid immobilization after operative fixation remains the treatment of choice despite current evidence-based protocols.

Influence of postoperative immobilization on pain control of patients with distal radius fracture treated with volar locked plating: A prospective, randomized clinical trial

OBJECTIVES

The purpose of this study was to compare the pain scores and the rates and doses of opioid use in patients undergoing volar locked plate fixation of intra-articular distal radius fractures using or not postoperative immobilization.

METHODS

This was a prospective randomized controlled trial. Thirty-nine patients with distal radius fractures scheduled to receive volar plate fixation were randomly assigned to receive a short forearm splint for two weeks postoperatively or conventional bandage with early wrist mobilization. Thirty-six patients completed the follow-up. The outcome measurements included pain scores (0-10 points); rates and doses of tramadol use; DASH score; wrist range of motion; patient satisfaction; and complication rates. The last follow-up assessment was performed at 6 months.

RESULTS

The pain scores were similar between the groups during hospital stay, as well as after hospital discharge within the first week and in subsequent assessments up to six months. The rates of tramadol use were greater in the No splint group during hospital stay, but this difference was not statistically significant (No splint = 65%; Splint = 47%; p = 0.296). Likewise, the doses of tramadol intake were higher in the No splint group during hospital stay (No splint = 218 mg; Splint = 167 mg; p = 0.273) and after discharge (2^nd day: No splint = 112 mg; Splint = 75 mg; p = 0.286), with no statistically significant differences. The functional results and complication rates were similar between the groups.

CONCLUSIONS

In this study, there was a trend to a greater use of tramadol in patients who did not use immobilization and started early wrist mobilization after volar locked plating of distal radius fracture, compared with patients who were immobilized for two weeks. The pain scores were similar but may have been influenced by the unbalanced use of opioids between the groups. The functional results and complication rates were not influenced by the use of immobilization.

LEVEL OF EVIDENCE

Therapeutic Level I.

Pain Management during Rehabilitation after Distal Radius Fracture Stabilized with Volar Locking Plate: A Prospective Cohort Study

Introduction

Internal fixation with volar locking plate (VLP) was widely adopted as a first-line choice in treatment of distal radius fracture (DRF).

Methods

Total 315 patients with distal radius fracture receiving VLP fixation were included for analysis in this study. The rehabilitation protocol was started immediately after surgery for all patients. During the initial two weeks after surgery, 149 patients received 200 mg celecoxib twice per day, 89 received buprenorphine transdermal patch at 5 μg/h, and 77 received 13 mg codeine plus 200 mg ibuprofen twice per day for pain management. Visual analog scale (VAS) scores of pain at rest, daily activity, and rehabilitative exercise were measured, respectively, every week according to the experiences of the past week in the initial six weeks after surgery. Functional outcomes including range of motion (ROM) for extension, flexion, pronation, supination, ulnar and radial abduction, the disabilities of arm, shoulder, and hand (DASH) score and the validated patient rated wrist evaluation (PRWE), and grip strength were collected at one, three, and six months after surgery.

Results

We showed that patients receiving transdermal buprenorphine and codeine/ibuprofen had decreased VAS scores during rehabilitative exercise, better compliance to the rehabilitation program, and thus faster functional recovery.

Conclusions

We recommend transdermal buprenorphine or codeine/ibuprofen for pain management during rehabilitation after distal radius fracture stabilized with VLP.

Forces in the Distal Radius During a Pushup or Active Wrist Motions

PURPOSE

To determine the 6 degrees of freedom forces and moments in the distal radius that occur during a pushup or other active wrist motions.

METHODS

Eight fresh-frozen cadaveric wrists were moved through 6 physiological motions and held at 1 static pushup position while the force through the distal radius was measured with a 6 degrees of freedom load cell. Three levels of compressive force were applied at the pushup position.

RESULTS

Active wrist motions caused axial forces up to 283 N and moments up to 0.7 N-m. Those motions with a smaller range had significantly smaller axial forces than the larger flexion-extension or dart-thrower's motions. With an 89-N pushup force applied, the average maximum axial force was 69 N, the radially directed force was 12 N, and the moment about the radioulnar axis was 2.3 N-m. Linear extrapolation of the forces to 100% body weight indicate that the axial force going through the distal radius would be 663 N, the radial force would be 147 N, and the moment about the radioulnar axis would be 18.6 N-m.

CONCLUSIONS

Large distal radius forces and moments can occur during pushup and active wrist motions. There are not only large axial compressive forces but also nontrivial radially directed forces.

CLINICAL RELEVANCE

This study may help surgeons and therapists better treat complicated distal radius fractures as well as provide for better comparisons of existing or new distal radius plates and constructs that are designed to treat these complicated loading patterns.

Rehabilitation after plate fixation of upper and lower extremity fractures

Post-operative rehabilitation and weight-bearing protocols are important to fracture fixation outcomes, yet there is a dearth in the literature concerning universal treatment guidelines following plate fixation of extremity fractures. There are controversies regarding time to allow weight-bearing and range of motion for most fractures of the upper and lower extremity. This lack of a consensus has led to varying practice guidelines and differing anecdotal protocols between treating surgeons. This review attempts to establish consensus guidelines for the post-operative rehabilitation required for patients following plate fixation of common upper and lower extremity fractures.

Intrarater Reliability of Range of Motion Measurements of the Uninjured Wrist in Women After Distal Radius Fracture

PURPOSE

To determine the intrarater reliability of serial wrist and forearm range of motion (ROM) measurements of the uninjured limb, by 1 evaluator using a standardized technique of measurement, in women who have sustained a distal radius fracture.

METHODS

From December 2007 to December 2014, skeletally mature women who had sustained an isolated distal radius fracture routinely had sequential measurements of wrist extension and flexion as well as forearm supination and pronation in both their injured and their uninjured limbs, at a minimum of 3-week intervals. The senior author (G.H.F.J.) used a standardized technique of measurement of ROM throughout this period, and these data related to the uninjured wrist and forearm were retrospectively reviewed.

RESULTS

Of 508 women who had a distal radius fracture, 506 had the measurements made of the uninjured wrist and forearm on 2, 300 on 3, and 128 on 4 separate occasions. The average age of the women was 61 years, with a range from 16 to 94 years. The intraclass correlation coefficients between measurements over time for extension, flexion, and supination measurements were 0.71, 0.63, 0.68, respectively, and 0.47 for pronation. The intraclass correlation coefficient varied according to patient age, but without specific progression in any age group for any ROM. Extension, flexion, and supination decreased significantly as age increased, whereas forearm pronation did not.

CONCLUSIONS

Measurement of wrist and forearm motion of the uninjured limb can be reliably reproduced by a single rater, most so for extension, flexion, and supination, and less so for pronation. Interrater reliability assessment remains to be evaluated.

CLINICAL RELEVANCE

Given the intrarater reliability of wrist and forearm motion measurement, the opposite (uninjured) wrist probably represents a useful reference metric for motion restoration for recovery from injury to the opposite limb.