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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Epidemiology of Distal Forearm Fracture: A Population-Based Study of 5426 Fractures

BACKGROUND

Despite intensive research into the epidemiology of adult distal forearm fractures, the literature is limited. This study aimed to provide a full overview of adult distal forearm fracture epidemiology, including incidence, fracture classification, mode of injury, and trauma mechanism in patients sustaining a distal forearm fracture, based on an accurate at-risk population with manually validated data leading to a high quality in data.

METHODS

This was a population-based cohort study with a manual review of X-rays and charts. The primary outcome measure was the incidence of adult distal forearm fractures. The study was based on an average at-risk population of 522 607 citizens. A total of 5426 adult distal forearm fractures were included during the study period. Females accounted for 4199 (77%) and males accounted for 1227 (23%) of fractures.

RESULTS

The overall incidence of adult distal forearm fractures was 207.7/100 000/year. Female incidence was 323.4/100 000/year, and male incidence was 93.3/100 000/year. A marked increase in incidence with increasing age was observed for females after 50 years of age. The incidence of distal radius fractures was 203.0/100 000/year, and the incidence of isolated ulna fractures was 3.8/100 000/year. The most common fracture type was an extra-articular AO type 2R3A (69%), and the most common mode of injury was a fall from own height (76%). A small non-trending year-to-year variation was observed during the 5-year study period.

CONCLUSION

Results show that adult distal forearm fractures are very common in women after the postmenopausal period. The overall incidence of adult distal forearm fractures was 207.8/100 000/year. Female incidence was 323.4/100 000/year.

How common are refractures in childhood?

Aims

The aim of this study was to describe the incidence of refractures among children, following fractures of all long bones, and to identify when the risk of refracture decreases.

Methods

All patients aged under 16 years with a fracture that had occurred in a bone with ongoing growth (open physis) from 1 May 2015 to 31 December 2020 were retrieved from the Swedish Fracture Register. A new fracture in the same segment within one year of the primary fracture was regarded as a refracture. Fracture localization, sex, lateral distribution, and time from primary fracture to refracture were analyzed for all long bones.

Results

Of 40,090 primary fractures, 348 children (0.88%) sustained a refracture in the same long bone segment. The diaphyseal forearm was the long bone segment most commonly affected by refractures (n = 140; 3.4%). The median time to refracture was 147 days (interquartile range 82 to 253) in all segments of the long bones combined. The majority of the refractures occurred in boys (n = 236; 67%), and the left side was the most common side to refracture (n = 220; 62%). The data in this study suggest that the risk of refracture decreases after 180 days in the diaphyseal forearm, after 90 days in the distal forearm, and after 135 days in the diaphyseal tibia.

Conclusion

Refractures in children are rare. However, different fractured segments run a different threat of refracture, with the highest risk associated with diaphyseal forearm fractures. The data in this study imply that children who have sustained a distal forearm fracture should avoid hazardous activities for three months, while children with a diaphyseal forearm fracture should avoid these activities for six months, and for four and a half months if they have sustained a diaphyseal tibia fracture.

Conservative treatment of ulnar styloid fractures following volar-plate fixation of distal radius fractures: incidence of nonunion evaluated by computed tomography

PURPOSE

The first aim of this study was to investigate the incidence of ulnar styloid fractures (USFs) accompanied by distal radius fractures (DRFs), treated with volar locking plates. The fracture type of DRFs was evaluated by the classifications, based on computed tomography (CT) scan findings. The second aim was to investigate the bone union rate of USFs, depending on the fracture type of DRFs, by comparing union and nonunion groups in the USFs groups.

METHODS

Between May 2012 and December 2019, 239 consecutive patients with DRFs were treated. Of these patients, 177 DRFs met inclusion criteria. The fracture patterns of the DRFs, based on the classification, using CT scans, which included the AO classification, sagittal angulation, and axial fracture patterns of the articular surface of the distal radius in two-part intra-articular fractures were evaluated. The size of USFs, classified as a tip or base fracture was also investigated.

RESULTS

The incidence of USFs was significantly higher for AO types A and C than for type B. Analysis of the sagittal angulation of DRFs showed that the incidence of USFs was higher for the extension type than for the flexion type. Axial CT classification of two-part fractures revealed that DRFs with a dorsal fracture line was more frequent than the volar type of DRFs. These results suggested that dorsal displacement of DRFs was associated with a higher incidence of USFs. Finally, the analysis of the bone union rate of USFs revealed that AO classification and sagittal angulation were not correlated with bone union in USFs. However, it was found that a fracture line on the radial side of the radius had a significantly low rate of bone union, compared to a fracture line on the dorsal side. The size of USFs was also not correlated with the bone union rate.

CONCLUSIONS

The incidence and the bone union rate of USFs have different patterns. The incidence of USFs was higher in the dorsal displacement type of DRFs. However, the bone union rate of USFs was lower for a fracture line on the radial side. Therefore, USFs with DRFs that have a fracture line on the radial side is a candidate for fixation to prevent nonunion.

Identifying Risk Factors for Elbow Injury in Children Presenting to the Emergency Department With Distal Forearm Fractures

BACKGROUND

Pediatric distal forearm fractures are one of the most common injuries seen in the emergency department. Orthopedic teaching instructs providers to radiograph the joint above and the joint below the fracture site for concurrent injury. Despite this teaching, there is little evidence to suggest that elbow injuries are common in children with distal forearm fractures. Similarly, there are few data that help the clinician predict which children are at higher risk for co-injury.

METHODS

We conducted a cross-sectional analysis of the 2011 National Emergency Department Sample data set. Children aged 2 to 17 years with an International Classification of Disease, Ninth Revision, code for a distal forearm fracture were included in the study. The primary outcome of interest was an "elbow" injury, defined as an International Classification of Disease, Ninth Revision, code for proximal radius, proximal ulna, or distal humeral fracture or dislocation. Multivariable logistic regression was performed using patient demographics, injury severity score, mechanism of injury, and underlying medical conditions.

RESULTS

A total of 54,262 children with a distal forearm fracture were identified. Of these children, only 0.8% (n = 463) had an elbow injury. Supracondylar fractures of the humerus were the most common elbow injury seen (48.2% of elbow injuries seen). Children were more likely to have a co-injury if they were younger (9.8 years vs 8.3 years, P < 0.01), female (36% vs 44%, P < 0.01), injured via fall (68% vs 76%, P < 0.01), had a higher injury severity score (4.1 vs 4.5, P < 0.01), or were admitted for their injuries (1.5% vs 15.7%, P < 0.01). In the adjusted model, only age and disposition were predictors of co-injury. Isolated buckle fracture of the radius and metaphyseal fracture of the radius with dorsal angulation were protective against elbow injury (odds ratio = 0.39 and 0.60, respectively).

CONCLUSIONS

Children with distal forearm fractures very rarely have concurrent elbow injuries. These injuries are more likely in younger female children.

The Pediatric Open Supracondylar Fracture: Associated Injuries and Surgical Management

BACKGROUND

While supracondylar (SC) fractures are relatively common in children, the incidence of open injuries is believed to be only 1%. Two prior studies on open SC fractures in children reported an increased incidence of vascular injuries. The purposes of our study were to clarify the incidence, associated conditions, and current treatment for open SC fractures.

METHODS

The Pennsylvania Trauma Outcome Study database was queried. Subjects age 25 to 156 months old admitted to trauma centers between January 2000 and December 2015 with a SC fracture were included. Controls were those with closed fractures and the study group, those with open injuries. Study variables were age, sex, weight, injury severity score, length of stay (LOS), nerve injury, ipsilateral forearm fracture, compartment syndrome/fasciotomy, requirement for a vascular procedure. Other variables were mode of treatment, provisional reduction, repeat reduction, time interval between referring facility admission and operation, and time from emergency department admission to operation.

RESULTS

A total of 4308 subjects were included, 104 (2.4%) of whom had an open SC fracture. LOS was 2 days for the study group versus 1 day for controls (P<0.001). Open SC fractures were more likely than closed to be associated with a nerve injury (13.5% vs. 3.7%), ipsilateral forearm fracture (18.3% vs. 6.4%) and/or a vascular procedure (6.7% vs. 0.3%) (P<0.001). 5.9% of those in the study group required repeat surgery compared with 0.4% for controls (P<0.001). Time from emergency department admission to operation was 3.2 versus 10.3 hours (P<0.001).

CONCLUSIONS

We report the largest series to date of open SC fractures in children. Surgeons caring for such patients should be aware of their increased risks for both associated injuries and potential requirement for vascular reconstruction. The majority of children with an open SC fracture are managed with 1 operation and in the absence of vascular injury, seldom require an extended LOS.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Association between hand-grip strength and site-specific risks of major osteoporotic fracture: Results from the Japanese Population-based Osteoporosis Cohort Study

OBJECTIVES

To investigate the association between hand-grip strength and site-specific risks of major osteoporotic fracture.

STUDY DESIGN

Prospective cohort study.

MAIN OUTCOME

Associations between low hand-grip strength and increased risk of fracture at the distal forearm, vertebrae, and hip.

MEASURES

We enrolled 1342 postmenopausal women aged 50 years or more into baseline and follow-up surveys of the Japanese Population-based Osteoporosis Cohort Study in 1996, 1999, 2002, or 2006. Fracture events were ascertained by follow-up surveys until 2011 or 2012. The Cox proportional hazards model was used to estimate hazard ratios (HRs) of hand-grip strength on fracture event.

RESULTS

During a median follow-up of 15.2 years, 162 women sustained at least one osteoporotic fracture and 135 of these women sustained at least one major osteoporotic fracture, the larger group including 65, 38, 35, and 8 women with fractures of the distal forearm, vertebrae, hip, and proximal humerus, respectively. In the crude models, the associations between low hand-grip strength and increased risk of fracture at the distal forearm, vertebrae, and hip were significant; the HRs (95% confidence interval) of the lowest tertile of hand-grip strength were 2.02 (1.10-3.71), 11.35 (4.07-31.63), and 4.72 (1.79-12.47), respectively. Age adjustment attenuated the significance of hip fracture risk, and adjusting for bone mineral density attenuated the significance of distal forearm fracture risk. After additional adjustment for body mass index, history of diabetes mellitus, and calcium intake, the HR for vertebral fracture risk was 4.55 (1.56-13.27). When limiting the follow-up period to 5 and 10 years, low hand-grip strength was associated with an increased risk of distal forearm fracture independently of the aforementioned covariates; the HRs were 4.22 (1.12-15.95) and 2.52 (1.03-6.17), respectively.

CONCLUSIONS

Low hand-grip strength is specifically associated with the risk of distal forearm fractures within 10 years and clinical vertebral fractures within 15 years or more in Japanese postmenopausal women.

Incidence patterns of traumatic upper limb fractures in children and adolescents: Data from medical university-affiliated hospitals in Chongqing, China

China's child population ranked second in the world. However, data on the overall patterns and epidemiologic trends of TULFs among children and adolescents in Chongqing, China are scarce. With development of urbanization, motorization, building industry, the incidence patterns of traumatic upper limb fractures in children and adolescents might be about to change. To investigate the incidence patterns of traumatic upper limb fractures in children and adolescents (≤18 years old) according to age (≤3 years old, 3-6 years old, 6-12 years old, and 12-18 years old), gender, time, and etiology groups in Chongqing, China, we retrospectively reviewed 1078 children and adolescents who had traumatic upper limb fractures and who came to our university-affiliated hospitals from 2001 to 2010. The patients were grouped into different age groups, genders, year of admission range groups, and aetiologies. We used Pearson chi-square tests and independent samples t tests to assess differences of the grouped data and continuous variables, respectively. This study enrolled 1078 patients (849 males, 229 females) aged 11.0 ± 4.7 years old. The most common aetiologies and fracture sites of patients were low falls (705, 65.4%) and humerus (492, 45.6%). A total of 146 (13.5%) patients suffered a nerve injury, 94 (8.7%) patients sustained associated injuries, and 106 (9.8%) patients sustained complications. The proportion of injuries due to motor vehicle collisions increased with increasing age and year of admission. Female patients presented with significantly higher proportion of injuries due to motor vehicle collisions and significantly lower proportion of injuries due to hit by others. The proportion decreased from 63.2% to 33.3% in humeral fracture, increased from 8.8% to 35.5% in radius fracture, increased from 7.4% to 28.9% in ulna fracture with increasing age. Female patients presented with significantly higher proportion of humeral fracture, clavicle fracture and significantly lower proportion of radius fracture, ulna fracture, and hand fracture. Low falls and humerus fractures were the most common aetiologies and fracture sites. The pattern of traumatic upper limb fractures has specific age, gender, time, and etiology differences.

Does regional loss of bone density explain low trauma distal forearm fractures in men (the Mr F study)?

The pathogenesis of low trauma wrist fractures in men is not fully understood. This study found that these men have lower bone mineral density at the forearm itself, as well as the hip and spine, and has shown that forearm bone mineral density is the best predictor of wrist fracture.

INTRODUCTION

Men with distal forearm fractures have reduced bone density at the lumbar spine and hip sites, an increased risk of osteoporosis and a higher incidence of further fractures. The aim of this case-control study was to investigate whether or not there is a regional loss of bone mineral density (BMD) at the forearm between men with and without distal forearm fractures.

METHODS

Sixty-one men with low trauma distal forearm fracture and 59 age-matched bone healthy control subjects were recruited. All subjects underwent a DXA scan of forearm, hip and spine, biochemical investigations, health questionnaires, SF-36v2 and Fracture Risk Assessment Tool (FRAX). The non-fractured arm was investigated in subjects with fracture and both forearms in control subjects.

RESULTS

BMD was significantly lower at the ultradistal forearm in men with fracture compared to control subjects, in both the dominant (mean (SD) 0.386 g/cm² (0.049) versus 0.436 g/cm² (0.054), p < 0.001) and non-dominant arm (mean (SD) 0.387 g/cm² (0.060) versus 0.432 g/cm² (0.061), p = 0.001). Fracture subjects also had a significantly lower BMD at hip and spine sites compared with control subjects. Logistic regression analysis showed that the best predictor of forearm fracture was ultradistal forearm BMD (OR = 0.871 (0.805-0.943), p = 0.001), with the likelihood of fracture decreasing by 12.9% for every 0.01 g/cm² increase in ultradistal forearm BMD.

CONCLUSIONS

Men with low trauma distal forearm fracture have significantly lower regional BMD at the ultradistal forearm, which contributes to an increased forearm fracture risk. They also have generalised reduction in BMD, so that low trauma forearm fractures in men should be considered as indicator fractures for osteoporosis.

Fracture of the Distal Ulna Metaphysis in the Setting of Distal Radius Fractures

BACKGROUND

Fracture of the metaphyseal region of the distal ulna is an uncommon injury that has been reported to occur concomitantly with distal radius fracture. We aimed to report the incidence and types of distal ulnar head and neck fractures associated with distal radius fractures and compare outcomes in operatively versus non-operatively treated patients.

METHODS

Over a 5-year period a distal radius fracture registry was maintained at our institution. Eleven of 512 consecutive patients had metaphyseal distal ulna fractures in association with distal radius fractures and at least 1-year follow-up. Baseline radiographs and functional data were obtained, and patients were followed at 1-week, 2-week, 3-week, 6-week, 3-month, 6-month, 1-year, and 2-year intervals. Patients were split into two treatment groups: Group 1 consisted of five non-operatively treated patients, and Group 2 consisted of six operatively treated patients.

RESULTS

Four separate fracture patterns were observed: simple transverse or oblique fracture of the ulnar neck just proximal to the ulnar head, fracture of the neck region with concomitant fracture of the tip of the ulnar styloid, simple fracture of the ulnar head, and comminuted fracture of the ulnar head. There were no statistical differences between the two groups with regard to flexion, extension, supination, pronation, and functional outcomes.

CONCLUSIONS

Ulnar fracture patterns observed did not easily fall into previously described categories, and we have proposed a new classification system. Simple fractures of the ulnar neck or head often do not require operative fixation.

The Epidemiology of Multifocal Upper Limb Fractures

Aim:

The aim of this study is to identify the epidemiology of multifocal upper limb fractures and define any commonly occurring patterns.

Patients:

Patients included were those over the age of 13 years who presented to one orthopaedic trauma unit, in an eight-year period, and who sustained a multifocal upper limb fracture.

Results:

There were 83 patients with 171 multifocal upper limb fractures. Mean age 60 years; range 13 to 92 years. 78 patients had bifocal fractures and 5 had trifocal. The most common pairing of fourteen different combinations was distal radius and proximal humerus. All but nine patients had involvement of the proximal humerus or distal radius. The most common injuries were the two-part proximal humerus fracture, the simple intra-articular olecranon fracture and the extra-articular fracture of the distal radius with metaphyseal comminution.

Conclusion:

This study has shown that multifocal fractures of the upper limb are most likely to occur in the middle aged to elderly women who have had a fall from standing height. As previously demonstrated osteopenic fractures are increasing in incidence in developed countries, where the population is ageing, which implies that the incidence of multifocal fractures of the upper limb is likely to increase.

Wrist Fracture and Risk of Subsequent Fracture: Findings from the Women's Health Initiative Study

Wrist fractures are common in postmenopausal women and are associated with functional decline. Fracture patterns after wrist fracture are unclear. The goal of this study was to determine the frequency and types of fractures that occur after a wrist fracture among postmenopausal women. We carried out a post hoc analysis of data from the Women's Health Initiative Observational Study and Clinical Trials (1993-2010) carried out at 40 US clinical centers. Participants were postmenopausal women aged 50 to 79 years at baseline. Mean follow-up duration was 11.8 years. Main measures included incident wrist, clinical spine, humerus, upper extremity, lower extremity, hip, and total non-wrist fractures and bone mineral density (BMD) in a subset. Among women who experienced wrist fracture, 15.5% subsequently experienced non-wrist fracture. The hazard for non-wrist fractures was higher among women who had experienced previous wrist fracture than among women who had not experienced wrist fracture: non-wrist fracture overall (hazard ratio [HR] = 1.40, 95% confidence interval [CI] 1.33-1.48), spine (HR = 1.48, 95% CI 1.32-1.66), humerus (HR = 1.78, 95% CI 1.57-2.02), upper extremity (non-wrist) (HR = 1.88, 95% CI 1.70-2.07), lower extremity (non-hip) (HR = 1.36, 95% CI 1.26-1.48), and hip (HR = 1.50, 95% CI 1.32-1.71) fracture. Associations persisted after adjustment for BMD, physical activity, and other risk factors. Risk of non-wrist fracture was higher in women who were younger when they experienced wrist fracture (interaction p value 0.02). Associations between incident wrist fracture and subsequent non-wrist fracture did not vary by baseline BMD category (normal, low bone density, osteoporosis). A wrist fracture is associated with increased risk of subsequent hip, vertebral, upper extremity, and lower extremity fractures. There may be substantial missed opportunity for intervention in the large number of women who present with wrist fractures.

Results of 70 consecutive ulnar nightstick fractures

BACKGROUND

Adult isolated ulnar shaft fractures (IUSFs) are uncommon, and treatment remains controversial. The purpose of this study was to compare results of operative (reduction internal fixation (RIF)) and nonoperative treatment (NOT) in patients with IUSF.

MATERIAL AND METHODS

A retrospective case-control analysis was undertaken on patients diagnosed with IUSF between 2002 and 2008 at a Level I teaching trauma center. Clinical outcomes consisted of complications and functional ability.

RESULTS

Seventy patients had a mean age of 44.6 years (18-86) and a body mass index (BMI) of 27.9 (17-47). The mechanism of injury included high-energy injuries (60/70, 85.7%), low-energy falls (8/70, 11.4%), and sports (2/70, 2.9%). Treatment consisted of 33/70 (47.1%) NOT and 37/70 (52.9%) RIF. The AO/OTA fracture classification was 48 A1, 20 B2, and two C1. The level of activity (LOA) was 60 without restrictions, six with restrictions, and three who did not return to work. The function determined by range of motion was 55/70 (78.6%) full, 11 slightly limited, and one severely limited. A total of 14 nonunions (NUs) and 17 malunions (MUs) occurred. NOT was associated with NU (χ(2)=0.001) and MU (χ(2)=0.000), respectively. Fracture angulation ≥8° was related to the inability to return to previous LOA (ρ=0.406, p=0.001). Secondary displacement >2mm contributed to MU (R(2)=0.238, p=0.000) and NU (R(2)=0.076, p=0.021). NU was related to a minor functional result (ρ=0.315, p=0.009).

CONCLUSIONS

IUSF treatment remains challenging in the adult population. Nonoperative treatment of displaced fractures produces a high risk of complications, and the fracture characteristics determine patient outcome.

LEVEL OF EVIDENCE

Level III.

Does thyroid function influence fracture risk? Prospective data from the HUNT2 study, Norway

OBJECTIVE

To prospectively study the relation between TSH and risk of hip and forearm fractures.

DESIGN

A population-based cohort study.

METHODS

In a substudy of the second survey of the Nord Trøndelag Health Study, Norway (HUNT2, 1995-97), linked with a hospital-based fracture registry, we investigated the relation between baseline TSH and risk of hip and/or forearm fractures.

POPULATION

A total of 16 610 women and 8595 men aged 40 years or more, without previous self-reported thyroid disease and hip or forearm fractures.

RESULTS

During 12.5 years follow-up, a total of 1870 women and 342 men experienced hip or forearm fractures. Overall, there was no relation between baseline TSH and fracture risk. However, there was weak evidence that women with TSH <0.5 and >3.5 mU/l had a slightly increased risk of hip fractures (hazard ratio (HR) 1.30, 95% CI 0.97-1.94 and HR 1.19, 95% CI 0.93-1.52) compared with the reference group with TSH of 1.5-2.4 mU/l. Supplementary analyses showed higher hip fracture risk in women with TSH >4.0 mU/l and negative thyroid peroxidase antibodies (TPOAb) compared with the reference group (HR 1.75, 95% CI 1.24-2.46).

CONCLUSION

We found no statistically significant relation between baseline TSH and subsequent fracture risk, but the data suggest a weak positive association with hip fracture risk among women with both low and high TSH. The latter association was confined to women with negative TPOAb status.

Adherence to osteoporosis drugs and fracture prevention: no evidence of healthy adherer bias in a frail cohort of seniors

We examined new users of osteoporosis drugs among seniors in Pennsylvania and found no evidence of healthy adherer bias on observed associations between adherence to treatment and non-vertebral fracture risk; we document fracture reduction with better adherence to bisphosphonates, yet no fracture reduction with better adherence to calcitonin or raloxifene.

INTRODUCTION

We examined the potential for "healthy adherer bias" when studying the effects of adherence to osteoporosis pharmacotherapy on fracture risk. Based on clinical trial evidence, bisphosphonates, calcitonin, and raloxifene reduce vertebral fracture risk; yet only bisphosphonates are documented to reduce non-vertebral fracture risk.

METHODS

This is a cohort study of older women in Pennsylvania who initiated osteoporosis drugs between 1995 and 2005. We included new users of bisphosphonates, calcitonin, and raloxifene. Adherence was categorized based on a measure of compliance as high [proportion of days covered (PDC) ≥ 80%], intermediate (50% < PDC < 80%), or low (PDC ≤ 50%) according to a 180-day ascertainment period. Non-vertebral fracture rates within 365 days after the ascertainment period were compared between adherence categories (reference = low) using Cox proportional hazard models and adjusting for fracture risk factors. Primary and secondary prevention cohorts were examined separately. Adherence to calcitonin and raloxifene were control analyses.

RESULTS

We found little difference in fracture rates between levels of adherence to calcitonin, bisphosphonates for primary prevention, or raloxifene for secondary prevention. We document lower fracture rates among high versus low adherent bisphosphonate users for secondary prevention (HR = 0.53, 95%CI = 0.38-0.74) and higher fracture rates among high versus low adherent raloxifene users for primary prevention (HR = 2.01, 95%CI = 1.04-3.87).

CONCLUSIONS

We document little evidence of healthy adherer bias when studying the association between better adherence to osteoporosis drugs and fracture risk reduction, with only better adherence to bisphosphonates reducing fracture risk. The higher fracture risk among highly adherent raloxifene users for primary prevention is likely due to residual confounding.

Upper extremity fractures in pedestrian versus motor vehicle accidents: an underappreciated concern

BACKGROUND

Though pedestrian versus motor vehicle (PVMV) accidents are a common cause of trauma admission and subsequent orthopaedic consult, the prevalence of upper extremity fracture (UEF) in such events and its association with lower extremity injury (LEI) is unknown. We sought to describe UEF in PVMV accident patients at the time of orthopaedic consult.

METHODS

A retrospective chart review was conducted for all pedestrian hit by motor vehicle cases for which an orthopaedic consult was performed at Jackson Memorial Hospital between July 2006 and January 2008. Fractures were recorded by location along with relevant clinical information. Logistic regression was used to calculate odds ratios (O.R.) and 95% confidence intervals (C.I.) for variables associated with UEF.

RESULTS

336 cases were identified and reviewed. LEI was the most frequent injury type (67% of cases). UEF was also common, found in 25% of cases (humerus 11%, ulna 7%, radius 6%, hand 4%, and wrist 2%). Tibia or fibula fracture, femur fracture, and spine fracture were negatively associated with UEF in univariate analyses and after controlling for other associated factors.

CONCLUSIONS

In PVMV accident populations, UEF is a frequent injury often seen in the absence of any LEI. These findings emphasize the importance of carefully screening all PVMV accident patients for UEF and may call into question the usefulness of currently discussed injury pattern.

Feline combined diaphyseal radial and ulnar fractures. A retrospective study of 28 cases

Feline combined diaphyseal radial and ulnar fractures were reviewed in a retrospective study of cases that were admitted to two university teaching hospitals. A high incidence of complications was noted, with 6/26 (23.1%) of cases requiring revision surgery. Open fractures were significantly more likely to require revision surgery. The two main repair methods were external skeletal fixation (ESF) or radial plating. The success rate was greater for radial plating, with only 1/10 (10%) cases requiring revision versus 4/14 (28.6%) for ESF. However, ESF tended to be applied to the more complicated fractures. Stabilisation of both bones proved to be an effective repair strategy with only 1/8 cases (12.5%) requiring revision versus 5/18 cases (27.8%) where only one bone was stabilised. Synostoses and radiohumeral luxation were noted as complications associated with the fractures stabilised by ESF. Final limb function following recovery was assessed as 'good' or 'excellent' in 93.3% of cases.

The healing forearm fracture: a matched comparison of forearm refractures

BACKGROUND

Forearm fractures in children usually heal rapidly after closed treatment. Recent studies report forearm refracture rates of 5%. The purpose of this study was to identify risk factors for refracture based on radiographic variables.

METHODS

We performed a retrospective review of patients that sustained a second forearm fracture (refracture) between 1998 and 2005. Refractures were defined as having a second fracture of the same forearm within 18 months of the original fracture. A comparison group of single-fracture patients followed in a capitated insurance plan were included and matched based on age and sex. Radiographic assessment included initial/final angulation, displacement, and fracture-line visibility at latest follow-up.

RESULTS

Sixty-three refractures were compared with 132 age- and sex-matched single-fracture patients. Time to refracture averaged 10 months. Thirty-eight percent of the initial fractures in the refracture group occurred in the proximal or middle third of the forearm compared with 15% for the single-fracture patients (P < 0.001). Because location of the fracture was found to be a risk factor for refracture, a secondary analysis was performed with refracture patients matched to single-fracture patients based on age, sex, bone fractured, fracture location, and treatment method. Fracture-line visibility of the radius at latest follow-up was clearly visible in 48% of refractures compared with 21% of controls (P = 0.05). Initial fracture severity and residual deformity were not significantly different.

CONCLUSIONS

Proximal and middle one third forearm fractures are at greater risk of refracture compared with distal one third forearm fractures. There was a trend toward incomplete healing seen more commonly in those that refractured, emphasizing the importance of longer immobilization in these fractures.

LEVEL OF EVIDENCE

Prognostic study, level III, case-control study.

Contribution of in vivo structural measurements and load/strength ratios to the determination of forearm fracture risk in postmenopausal women

Bone structure, strength and load-strength ratios contribute to forearm fracture risk independently of areal BMD.

INTRODUCTION

Technological and conceptual advances provide new opportunities for evaluating the contribution of bone density, structure, and strength to the pathogenesis of distal forearm fractures.

MATERIALS AND METHODS

From an age-sratified random sample of Rochester, MN, women, we compared 18 with a distal forearm fracture (cases) to 18 age-matched women with no osteoporotic fracture (controls). High-resolution pQCT was used to assess volumetric BMD (vBMD), geometry, and microstructure at the ultradistal radius, the site of Colles' fractures. Failure loads in the radius were estimated from microfinite element (microFE) models derived from pQCT. Differences between case and control women were assessed, and the risk of fracture associated with each variable was estimated by logistic regression analysis.

RESULTS

Given similar heights, estimated loading in a fall on the outstretched arm was the same in cases and control. However, women with forearm fractures had inferior vBMD, geometry, microstructure, and estimated bone strength. Relative risks for the strongest determinant of fracture in each of the five main variable categories were as follows: BMD (total vBMD: OR per SD change, 4.2; 95% CI, 1.4-12), geometry (cortical thickness: OR, 4.0; 95% CI, 1.4-11), microstructure (trabecular number: OR, 2.3; 95% CI, 1.02-5.1), and strength (axial rigidity: OR, 3.8; 95% CI, 1.4-10); the factor-of-risk (fall load/microFE failure load) was 24 % greater (worse) in cases (OR, 3.0; 95% CI, 1.2-7.5). Areas under ROC curves ranged from 0.72 to 0.82 for these parameters.

CONCLUSIONS

Bone geometry, microstructure, and strength contribute to forearm fractures, as does BMD, and these additional determinants of risk promise greater insights into fracture pathogenesis.

Refractures of the upper extremity in children

PURPOSE

To investigate the etiologic factors related to refractures of the upper extremity in children.

PATIENTS AND METHODS

Eighteen refractures were divided into three groups according to the location of the initial fractures. They were analyzed in terms of the type of refractures, fracture patterns, and the existence of an underlying deformity.

RESULTS

Of nine supracondylar fractures of the humerus, two involved refractures at the supracondylar region, and the other seven involved the lateral condyle. Underlying cubitus varus was present in six cases. Of three lateral condylar fractures of the humerus, one had a refracture at the supracondylar region, and two cases involved the lateral condyle. One had an underlying cubitus varus. All but one case in the humeral fractures group were late refractures, and were treated with surgery. Of six repeat forearm fractures, five were early type and occurred at the original site within nine weeks, four at the diaphysis of both bones of the forearm, and one at the diaphysis of the ulna. All cases in the forearm fractures group, save one, had volar angulation before the refracture, and were treated conservatively.

CONCLUSION

In the humerus, the underlying cubitus varus was the most important predisposing factor for refractures and lateral condyle fractures were common. In the forearm, volar angulation of the diaphysis was related to refractures, and complete and circular consolidation of the primary fracture of the forearm was thought to be important in prevention.

Paediatric trauma epidemiology in an urban scenario in India

PURPOSES

To identify the epidemiology of paediatric trauma in an urban scenario of India and compare results with studies from developed countries, and to formulate preventive measures to decrease such traumas.

METHODS

Between January 2004 and 2005 inclusive, 500 paediatric, orthopaedic trauma patients presenting to our hospital were prospectively studied. Information was recorded in a prescribed proforma.

RESULTS

The children's ages ranged from 0 to 16 years; 274 were males. Most fractures occurred in children aged 7 to 12 years and decreased in older children. The ratio of fractures in left versus right upper extremity was 2:1. In children aged 0 to 6 years, the most common injured site was the elbow, whereas in children aged 7 to 16 years it was the distal radius. In descending order, most injuries were sustained at home (47%), in school (21%), due to sports (17%), and due to vehicular accidents (13%).

CONCLUSION

An effective accident prevention programme in developing countries requires changes in lifestyle and environment, and overcoming obstacles such as ignorance, illiteracy, and inadequate resources.

[Results of treatment of forearm fractures in the child]

OBJECTIVE

To describe epidemiology and to bring back the results of the treatment of the fractures of the forearm fracture.

POPULATION AND METHOD

During 3 years and 3 months, we studied the forearm fractures of the children from 0 to 15 years. For each one of them, we studied, the age, the sex, the aetiology and the characteristics of the fracture, the treatment carried out and their evolution.

RESULTS

Sixty-nine forearm fractures were listed, the frequency was 23 fractures per years. The sex ratio was 2,63 and the average age was 8 years and 2 months with 13 month and 15 years as extremes. The accidents of play accounted for 93% of the aetiologies. The cutaneous injuries were associated to the fracture in 30 cases (43%). The fractures with displacement was observed in 25 cases (36%), green steak fracture in 21 case (30%), fracture without displacement in 13 case (19%) and other displacements 10 cases (15%). The treatment was orthopaedic (reduction and immobilisation) in 97% of the cases. We observed 3 cases (4%) of secondary displacements under plaster and 6 cases (9%) of the vicious cal.

CONCLUSION

The orthopaedic treatment is usually indicated for the Key words: fractures with anatomical restitution. The failures of the orthopaedic treatment need to be treated surgically.

Incidence and cost of osteoporotic fractures in France during 2001. A methodological approach by the national hospital database

The objective of this study was to describe the hospital incidence rate and the in-patient costs of three peripheral "osteoporotic" fractures (proximal humerus and hip, distal radius and/or ulna) in women and men aged over 45 in France during 2001. Each stay for fracture was selected from the dataset of the French national hospital database in 2001. The incidence rate (CI 95%) was standardized by age and gender according to the last census of the French population (1999). The effect of age and existence of geographical difference in incidence rates has been studied. For each fracture, we described the number of stays, rate of surgical procedure and in-patient costs according to the 2004 French list of cost per diagnosis-related group (2004 Euros); 118,839 fractures were registered during 2001 (61% hip, 28% distal radius and 11% proximal humerus; sex ratio 0.26). The incidence rate for all fracture was 7,567 (7,519-7,615) and 2,312 (2,283-2,341) for 10(6) inhabitants in women and men aged over 45 years, respectively. The incidence increased significantly whatever type of fracture and gender. There were more fracture incidents in the east of France compared to the west and in the south compared to the north, whatever type of fracture in women and only for hip fracture in men. Surgical procedures were performed in 91% of proximal hip fractures, 83% of distal radius fractures and 53% of proximal humerus fractures. The median in-patient costs were 3,786 Euros for the humerus, from 2,363 to 2,574 Euros for the radius and from 8,048 to 8,727 Euros for the hip. The evaluation of the burden of peripheral fractures is possible using national hospital data in France. The incidence of fractures increased with age and is more common in women. Hip fracture with its higher occurrence, rate of procedure and in-patient costs could be used as a marker of osteoporosis for evaluating strategies of management.

The most frequent traumatic orthopaedic injuries from a national pediatric inpatient population

Pediatric trauma remains a leading cause of morbidity and mortality of children in the United States and entails exorbitant costs. A 1997 national pediatric inpatient database, the Kids' Inpatient Database, was reviewed for current trauma and practice patterns and was found to contain over 84,000 patients admitted for orthopaedic trauma. These patients accrued an estimated 932.8 million dollars in hospital charges. Femur fracture was the most frequent injury among this patient group (21.7% of orthopaedic trauma), followed by tibia and/or fibula fracture (21.5%), humerus fracture (17.0%), radius and/or ulna fracture (14.8%), and vertebral fracture (5.2%). While the majority of pediatric orthopaedic trauma was treated at non-children's hospitals (70.4%), patients with certain diagnoses such as femur, humerus, vertebral, pelvic, or hand/finger fracture or a back sprain/strain were directed to children's hospitals more frequently compared with the total number of pediatric orthopaedic trauma patients. Practice patterns varied for certain subgroups (eg, femoral shaft fractures) of patients, depending on the type of hospital where the child was treated. Children who sustained a femoral shaft fracture in the 6-to-10-year age group were significantly more likely to receive internal fixation versus casting or traction if they were treated at a children's hospital. Understanding the patterns in which traumatic injuries occur in children is paramount to establishing effective injury prevention, as well as adapting treatment to optimize outcomes.

Atypical distal radial fractures in children

In a prospective study of paediatric injuries secondary to the use of the non-motorized microscooter, we found a high rate of upper limb trauma, and a distinct injury associated with the scooter. The most common single injury was a fracture of the distal third of radius and ulna, characterized by volar angulation of the distal fragment. This injury, akin to the Smiths fracture in adults, was predictive of scooter use in all cases. This pattern of injury was not repeated by any another mechanism of injury during the course of the study period. The mechanism of injury, seemingly specific to the scooter, is produced by a fall while continuing to clutch the handlebars, leading to palmar flexion and pronation of the wrist as they strike the ground. Fourteen children required admission and manipulation under anaesthesia. Four of these patients subsequently needed remanipulation under anaesthesia. This study suggests that the scooter is associated with a forearm fracture which is both distinctive and unstable.

The incidence of distal forearm fractures in Zaragoza (Spain)

We present the results of a retrospective study of the epidemiology of distal forearm fractures in patients over 15 years of age in Zaragoza (Spain) during 1998-1999. We analysed a total of 2506 fractures of the distal forearm. Fractures were classified according to age, sex, Frykman classification and mechanism of injury. Fractures were Frykman type III in 23.5% of cases, Frykman II in 17.9%, Frykman IV in 14.5% and Frykman I in 12.8%. The rest of fractures were distributed homogeneously between the remaining fracture types. The mechanisms of injury was low energy in 78.2% of cases and high in 21.8%. Analysis of the age distribution showed an increase in the incidence of this type of fracture over 50 years of age, with a peak between 60 and 69 years as a result of accidental falls. We found an increased incidence in males below 49 years of age, as a result of traffic accidents, and a predominance of females over 50 years of age due to osteoporosis and an increased number of falls.

Secondary screening for osteoporosis in patients admitted with minimal-trauma fracture to a major teaching hospital

AIMS

The aim of the present study was to determine: (i) the prevalence of the investigation and treatment of osteoporosis in patients admitted to hospital with a minimal-trauma fracture, (ii) the prevalence of osteoporosis using bone mineral density assessment by dual X-ray absorptiometry (DEXA) in such patients and (iii) a clinical pathway for the management of osteoporosis in such patients.

METHODS

A cross-sectional study was undertaken involving all patients admitted with a fracture to Westmead Hospital, Sydney, Australia, between January 1999 and June 2000 (n = 327). Of these, 264 were excluded because of: (i) the fracture following significant trauma (n = 83), (ii) unavailability of medical records for review (n = 38), (iii) nursing home status (n = 37), (iv) previous malignancy (n = 18), (v) deceased (n = 11), (vi) recent osteoporosis screening and/or treatment (n = 18), (vii) refusal to participate (n = 37), (viii) uncontactable (n = 16) and (ix) inadequate English (n = 6). The remaining 63 patients underwent DEXA assessment and the following laboratory investigations: (i) liver function tests, (ii) urea, (iii) electrolytes, (iv) calcium, (v) phosphate, (vi) full blood count, (v) 25-hydroxyvitamin D level and (vi) thyroid-function tests. In men, levels of serum free testosterone, luteinizing hormone, follicle-stimulating hormone and prolactin were also obtained.

RESULTS

Of the 63 study participants, 87% of the 47 women were either osteoporotic (T <-2.5) or osteopenic (-2.5 <T <-1) at a mean of 12.7 +/- 5.4 months post-fracture. Of the 16 men screened, 75% had a T-score < or =-1. Forty-four per cent of the study sample had a low 25-hydroxyvitamin D level, 6% were biochemically hyperthyroid and 40% of the men had a low serum free testosterone. Only 16% had an effective anti-osteoporotic medication added following the fracture.

CONCLUSIONS

Secondary screening and treatment of osteoporosis in patients following minimal-trauma fracture are low. The implementation of a clinical pathway for osteoporosis management in these patients may be useful.

Incidence of childhood distal forearm fractures over 30 years: a population-based study

CONTEXT

The incidence of distal forearm fractures in children peaks around the time of the pubertal growth spurt, possibly because physical activity increases at the time of a transient deficit in cortical bone mass due to the increased calcium demand during maximal skeletal growth. Changes in physical activity or diet may therefore influence risk of forearm fracture.

OBJECTIVE

To determine whether there has been a change in the incidence of distal forearm fractures in children in recent years.

DESIGN, SETTING, AND PATIENTS

Population-based study among Rochester, Minn, residents younger than 35 years with distal forearm fractures in 1969-1971, 1979-1981, 1989-1991, and 1999-2001.

MAIN OUTCOME MEASURE

Estimated incidence of distal forearm fractures in 4 time periods.

RESULTS

Comparably age- and sex-adjusted annual incidence rates per 100 000 increased from 263.3 (95% confidence interval [CI], 231.1-295.4) in 1969-1971 to 322.3 (95% CI, 285.3-359.4) in 1979-1981 and to 399.8 (95% CI, 361.0-438.6) in 1989-1991 before leveling off at 372.9 (95% CI, 339.1-406.7) in 1999-2001. Age-adjusted incidence rates per 100 000 were 32% greater among male residents in 1999-2001 compared with 1969-1971 (409.4 [95% CI, 359.9-459.0] vs 309.4 [95% CI, 259.3-359.5]; P =.01) and 56% greater among female residents in the same time periods (334.3 [95% CI, 288.6-380.1] vs 214.6 [95% CI, 174.9-254.4]; P<.001). The peak incidence and greatest increase occurred between ages 11 and 14 years in boys and 8 and 11 years in girls.

CONCLUSIONS

There has been a statistically significant increase in the incidence of distal forearm fractures in children and adolescents, but whether this is due to changing patterns of physical activity, decreased bone acquisition due to poor calcium intake, or both is unclear at present. Given the large number of childhood fractures, however, studies are needed to define the cause(s) of this increase.

Ulnar styloid fractures associated with distal radius fractures: incidence and implications for distal radioulnar joint instability

Ulnar-sided injuries of the wrist have received more attention recently for their potential negative impact on the outcome of distal radius fractures. Radiographs and medical records were retrospectively reviewed for 166 distal radius fractures treated during a 1-year interval. Distal radius fractures were classified according to the AO system, and accompanying ulnar styloid fractures were evaluated for both size and displacement. Each distal radius fracture was also evaluated for radiographic and clinical evidence of distal radioulnar joint instability. The distribution of ulnar styloid fractures was not random; greater than one third involved the base. All distal radius fractures complicated by distal radioulnar joint instability were accompanied by an ulnar styloid fracture. A fracture at the ulnar styloid's base and significant displacement of an ulnar styloid fracture were found to increase the risk of distal radioulnar joint instability.

Fractures of the olecranon: a 15- to 25-year followup of 73 patients

The incidence of olecranon fractures in adults and the long-term outcome of closed olecranon fractures in 45 women and 28 men (mean age, 54 and 36 years at the time of fracture, respectively), were examined at a mean of 19 years after the fracture. The uninjured elbows served as controls. Thirteen percent of the original fractures were displaced less than 2 mm, 65% more than 2 mm, and 22% were multifragmental. Primary treatment consisted of mobilization in 4%, application of a plaster cast in 12%, and open reduction and internal fixation in 84% of the elbows. The incidence of an isolated fracture of the olecranon in individuals older than 16 years was 1.15 per 10,000 person-years. Eighty-four percent of the 73 patients had no complaints at followup, 12% had occasional pain, and 4% had daily pain. Ninety-six percent had an excellent or good outcome. Elbow flexion and extension were reduced but most patients had no or only occasional subjective complaints. Radiographic signs of degenerative changes were found in more than 50% of the formerly fractured elbows, which was more than in the uninjured (11%). Radiographic signs of osteoarthritis were found in 6% of the formerly fractured elbows versus zero percent in the uninjured, of which only two patients had a poor outcome. Isolated, closed fractures of the olecranon in adults have a favorable, long-term outcome.

Fractures of the olecranon during growth: a 15-25-year follow-up

Ten girls and 13 boys with mean age 11 years when sustaining a fracture of the olecranon were examined at a mean of 19 years after the injury. Ten fractures were displaced less than 2 mm, three 2-3 mm, eight more than 3 mm and two were multifragmental. The treatment consisted of mobilization in three cases, plaster treatment in nine and open reduction and internal fixation in 11 cases. At follow-up, 21 children had no subjective complaints while two had occasional mild pain. The upper arm circumference was thinner in the former injured extremities than in the uninjured (P<0.05). No other objective deficits were found. None had developed non-union or elbow osteoarthritis. Olecranon fractures during growth have an excellent long-term outcome.

The frequency and epidemiology of hand and forearm fractures in the United States

The purpose of this study was to estimate the frequency and describe the epidemiology of hand and forearm fractures in the United States. We extracted cases with ICD-9-CM diagnostic codes of 813.0 to 817.1 from the 1998 National Hospital Ambulatory Medical Care Survey. In 1998 there were 1,465,874 estimated cases of hand/forearm fractures, accounting for 1.5% of all emergency department cases. Radius and/or ulna fractures comprised the largest proportion of fractures (44%). The most affected age group was 5 to 14 years of age (26%). Private insurance paid for 49% of the cases. Most of the fractures occurred at home (30%); the street/highway was the second most likely fracture location (14%). Accidental falls caused the majority (47%) of fractures. Large database analysis provides important information that can be used to target interventions toward vulnerable populations and to allocate adequate resources for treating upper extremity fractures.

Osteoporosis Follow-up After Wrist Fractures Following Minor Trauma

BACKGROUND

Patients presenting with low-trauma wrist fractures are an ideal target population for early case finding of osteoporosis. We decided to investigate whether this early detection occurred in practice.

METHODS

This study was conducted at a single center in Edmonton, Alberta. A structured interview format was used to contact 112 (72%) of 156 patients older than 40 years who were diagnosed as having an atraumatic fracture of the distal radius/ulna from April 1997 to March 1998 and from January 1999 to February 1999. Information on osteoporosis follow-up and drug therapy was obtained from the patient.

RESULTS

The time between fracture and telephone interview ranged from 6 months to 3 years, with the majority of the sample being interviewed at least 1 year after fracture. Of the 112 patients in this study, 44 had sustained previous fractures, 17 of which had occurred at the wrist, vertebrae, or hip. Sixteen patients in the sample had already sustained a subsequent clinical fracture before our telephone contact. Thirty-two patients had received treatment for osteoporosis before fracture. A further 24 patients (21%) had undergone osteoporosis follow-up after fracture. After fracture, 42 (38%) of all patients were receiving either hormone replacement therapy or using a bisphosphonate.

CONCLUSIONS

Only 50% of the study population had received osteoporosis follow-up after fracture. Few patients had any change in their medication use after fracture. The findings in this study population suggest that recognition of the potential for osteoporosis in such patients is inadequate. Given the magnitude of this public health care problem, it is clear that attention to case finding and treatment of osteoporosis should be increased.

Risk factors for proximal humerus, forearm, and wrist fractures in elderly men and women: the Dubbo Osteoporosis Epidemiology Study

Fractures of the proximal humerus, forearm, and wrist account for approximately one third of total osteoporotic fractures in the elderly. Several risk factors for these fractures were evaluated in this prospective study of 739 men and 1,105 women aged > or =60 years in Dubbo, Australia. During follow-up (1989-1996), the respective incidences of humerus and of forearm and wrist fractures, per 10,000 person-years, were 22.6 and 33.8 for men and 54.8 and 124.6 for women. Independent predictors of humerus fracture were femoral neck bone mineral density (FNBMD) (relative risk (RR) = 2.3, 95% confidence interval (CI): 1.2, 4.5) in men and FNBMD (RR = 2.4, 95% CI: 1.7, 3.5) and height loss (RR = 1.1, 95% CI: 1.0, 1.2) in women. For forearm and wrist fractures, risk factors were FNBMD (men: RR = 1.5, 95% CI: 1.0, 2.3; women: RR = 1.5, 95% CI: 1.2, 1.9) and height loss (men: RR = 1.2, 95% CI: 1.0, 1.3; women: RR = 1.1, 95% CI: 1.0, 1.2). In addition, dietary calcium (men: RR = 2.0, 95% CI: 1.0, 3.6) and a history of falls (women: RR = 1.9, 95% CI: 1.4, 2.6) were also significant. These data suggest that elderly men and women largely share common risk factors for upper limb fractures and that FNBMD is the primary risk factor.

Open fractures of the forearm in children

OBJECTIVE

To describe the epidemiology, early results of treatment, and complications associated with open fractures of the forearm in children.

DESIGN

Retrospective review of patients treated according to protocol.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

All children with an open fracture of the forearm during a four-year period (n = 76). Fourteen patients were excluded because of inadequate follow-up or incomplete medical records.

INTERVENTION

All fractures were treated with irrigation and debridement, and parenteral antibiotics. Twenty-five patients were managed with cast immobilization only, and the remaining thirty-seven, with internal fixation either with transcutaneous pins, intramedullary pins, or plates and screws, followed by immobilization in a cast.

MAIN OUTCOME MEASUREMENTS

Time to union, angular alignment at union, and incidence of complications.

RESULTS

The average time to union was 8.9 weeks (median, eight weeks; range, 6 to 17 weeks). There were no nonunions, but three of the sixty-two fractures had delayed union. Eight of the sixty-two fractures healed with an angular deformity of more than 10 degrees, and two developed infections, one deep and one superficial. There were three preoperative and four postoperative nerve palsies, which all resolved spontaneously.

CONCLUSIONS

Open fractures of the forearm in children, treated with prompt administration of parenteral antibiotics followed by debridement, were associated with a fairly low incidence of complications. Although we found that the use of some form of internal fixation tended to reduce both the need to remanipulate these fractures (p = 0.08), and to minimize the incidence of angular deformity greater than 10 degrees (p = 0.16), these findings did not reach statistical significance.

Distal forearm fractures in New Zealand children: annual rates in a geographically defined area

AIMS

To estimate the annual incidence of distal forearm fractures in New Zealand children and to describe circumstances associated with this fracture.

METHODS

The ages and dates of fracture of all girls and boys aged three to fifteen years with distal forearm fractures treated at Fracture Clinic, Dunedin Public Hospital in one calendar year were recorded.

RESULTS

The age-standardised annual incidence rates for Dunedin girls and boys aged three to fifteen years were 10.4 per 1000 (95% CI 8.3-12.4 per 1000), and 10.4 per 1000 (95% CI 8.3-12.6 per 1000), respectively. The peak incidence in girls was observed at ten years of age (23.5 fractures per 1000) and for boys at thirteen years of age (25.3 fractures per 1000). Extrapolation of these rates to all New Zealand suggest that in children aged three to fifteen years, 3659 (95% CI 2906-4413) distal forearm fractures occur per year in girls, and 3845 (95% CI 3087-4603) per year in boys, representing about 20 fractures per day. Many of the fractures for the girls and boys resulted from apparently slight trauma (62.2% and 61.6%, respectively).

CONCLUSIONS

Distal forearm fractures are very common events in New Zealand children and adolescents, and are usually caused by apparently slight trauma.

Forearm fractures in Malmö, Sweden. Changes in the incidence occurring during the 1950s, 1980s and 1990s

Between the 1950s and the 1980s, the incidence of forearm fractures increased in the city of Malmö. We have now collected data on all forearm fractures during 1991 and 1992 and compared them with previously published data from 1953-1957 and 1980-1981. During the 1990s, 1314 individuals with wrist fractures and 125 with shaft fractures were recorded. In men, we found a twofold increase in the standardized morbidity ratio (SMR) in the 1990s, compared with the 1950s. The 1990s, compared with the 1980s, showed a reduction in SMR to 0.85. In women, a comparison between the 1990s and the 1950s revealed a slight reduction in SMR, 0.9 during the 1990s. Comparison of the 1990s with the 1980s revealed a reduction in SMR to 0.7 after the age of 70 years. In individuals 60 years and older, we found a fivefold increase in the incidence of fractures of the shaft of the forearm, when comparing the 1990s with the 1980s. In women, the increase in incidence of wrist fractures appears to have been interrupted, when comparing the years 1991-1992 and 1980-1981. Among men, the incidence of wrist fractures appears to be increasing, even after the 1980s. The reduction in incidence among women may partly be explained by warmer winters during 1991-1992.

New observations on carrying angle

Based on experiments on fresh cadaveric and accidentally amputated 8 upper limbs of children, study of ulnae for presence and absence of non articular strip on the trochlear notch, measurements of carrying angle, length of forearm bones, pronation-supination, height and weight in 2250 infants, children and adults of various age groups and clinical observations on 800 cases of injuries around elbow many new facts have been observed about the development of the carrying angle and its significance in the etiopathogenesis of various types of fractures seen around the elbow. The carrying angle develops in response to pronation of the forearm and is dependent on length of the forearm bones. Lesser the length of forearm bones greater is the carrying angle. So the carrying angle is more in shorter persons as compared to taller persons. It is abduction at the shoulder and not the carrying angle which keeps the swinging upper limbs away from the side of the pelvis during walking. Carrying angle is not a secondary sex character. The type of fracture a child sustains after fall on outstretched hand is also determined by the value of the carrying angle. A new type of fracture hitherto undescribed in the literature, T-Y fracture of the distal humeral epiphysis is also reported.

Vitamin D receptor genotype and the risk of bone fractures in women

Several studies have confirmed an initial report of a relation between bone density and polymorphic forms of the calcitriol (vitamin D) receptor gene, whereas others have failed to find an association. We examined whether variants of the vitamin D receptor gene are associated with the risk of bone fracture, using a nested case-control analysis within the Nurses' Health Study cohort. The study women all were Caucasian and were 43-69 years of age when they provided a blood sample. Cases included the 54 proximal femur (hip) fractures and 163 distal radius (forearm) fractures that occurred subsequent to the blood draw. Cases and controls were genotyped by polymerase chain reaction for the BsmI polymorphism. The BB genotype, previously associated with lower bone density, was associated with a more than twofold increased risk of hip fracture compared with the bb genotype. Risk was greater for women who were older, leaner, or less physically active or who had a lower calcium intake. The heterozygous genotype was not associated with any increased risk of hip fracture, and we observed little association between vitamin D receptor genotype and forearm fracture. This study supports an association between vitamin D receptor genotype and hip fracture. It also implies that modification by other risk factors may have contributed to the conflicting results from previous studies of vitamin D receptor genotype and femoral bone density.

Different risk profiles for hip fractures and distal forearm fractures: a prospective study

In a prospective cohort of elderly persons, aged 70 years and over, we examined risk indicators for which data could be easily obtained, to construct risk profiles for hip fractures and distal forearm fractures. Participants lived independently, in apartment houses for the elderly or in homes for the elderly. At baseline, information was obtained in 2578 subjects on age, gender, residence, mobility and the frequency of going outdoors. Mobility was measured using a walking score ranging from 1 (not able to walk independently) to 3 (able to walk independently for a fair distance). During the study period (median duration 3.5 years, maximum 4 years) 106 participants sustained a hip fracture and 60 participants suffered a distal forearm fracture. Women compared with men, adjusted for age, had a higher risk of hip fracture (adjusted relative risk (RR) = 2.4, 95% confidence interval (CI) 1.3-4.3) and distal forearm fracture (RR = 3.7, 95% CI 1.5-9.2). Age, adjusted for gender, was related to hip fractures only: the relative risk of fracture for those in the highest age category (> 85 years) was 9.5 (95% CI 4.3-21.2) compared with those in the lowest age category (70-75 years). Moderately impaired walking ability compared with normal walking ability, adjusted for age and gender, was associated with a higher risk of hip fracture (RR = 1.8, 95% CI 1.2-2.7) but with a lower risk of distal forearm fracture (RR = 0.4, 95% CI 0.2-0.8). The outdoor score, adjusted for age and gender, was associated with distal forearm fractures only: going outdoors less than once a week, compared with three times or more, was associated with a lower risk of fractures (RR = 0.3, 95% CI 0.1-0.9). In those living in homes for the elderly the risk of hip fracture was higher compared with those living independently (RR = 2.4, 95% CI 1.4-4.2), adjusted for age and gender. Risk profiles were constructed using stepwise Cox's proportional-hazards regression. The risk profile predicted probabilities of sustaining a hip fracture in a 4-year period ranging from 0.4% to 25.9%, and of distal forearm fractures ranging from 0.2% to 4.5%, depending on the subject's characteristics as defined by the risk indicators. We conclude that easily obtainable risk indicators can be used in the prediction of fractures and can discriminate among fracture types.

Longer term functional outcome and societal implications of upper limb fractures in the elderly

To ascertain how they cope with upper limb fractures and the implications for health and social services (H&SS) a cohort of elderly patients was followed up. 42 of the original 51 (82%) patients were interviewed almost one and a half years after sustaining their fracture. Information was collected on ability to perform activities of daily living (ADL), general health, and use of H&SS help from informal carers. Although there was an overall improvement in the ability to perform ADL, many (26%) patients reported a residual difficulty. Informal carers provided most of the support with some contribution from the statutory agencies. Demographic changes with increasing numbers of elderly and increasing employment of married women--the traditional carers, and epidemiological changes with increasing age-specific incidence of upper limb fractures mean that H&SS provision in the future will need to be increased.

Isolated ulnar shaft fractures. Comparison of treatment by a functional brace and long-arm cast

In a prospective study, we randomly allocated 39 patients with isolated fractures of the lower two-thirds of the ulnar shaft to treatment either by a prefabricated functional brace or a long-arm cast. Significantly better wrist function and a higher percentage of satisfied patients were found in the braced group. Thirteen patients returned to employment while still wearing the brace but only one was able to work in a cast.

Fractures of the hip and distal forearm in West Africa and the United Kingdom

Comparison of age- and sex-specific incidence rates of fractures of the proximal femur and the distal forearm showed significantly lower rates in Ibadan than in two urban centres in England, with risk ratio of up to 20. In the Ibadan data no evidence of higher rates in women or of a prominent age-associated increase in rates was observed.

Refracture after the removal of plates from the forearm. An avoidable complication

The incidence of refracture following the removal of screws and plates from the diaphyses of 115 forearm bones in 80 patients has been studied. Refracture occurred in four adult patients as a result of minimal trauma, in two patients at the original fracture site after premature plate removal, at the site of a countersunk interfragmentary screw in one and at the original fracture site in another who had required three operative procedures to achieve 'union'. It is suggested that refracture could have been avoided in at least two of these patients. If the 3.5 mm plating system has been used, the incidence of refracture should be minimal.

Pathologic fracture of the proximal ulna through a bone graft donor site

Complications of harvesting autologous bone graft from the iliac crest and tibia are well known; exclusive use of upper extremity donor sites in hand surgery has therefore been advocated. Six weeks of postoperative elbow splinting has been recommended after harvest of large proximal ulnar grafts. We report two cases of pathologic fracture of the proximal ulna complicating local bone grafting and question whether the risk of fracture and the attendant patient inconvenience and potential joint stiffness incurred by postoperative immobilization are exceeded by the morbidity of carefully done iliac crest grafting.

Refractures after forearm plate removal

Debate continues over the need for removal of internal fixation devices. Nowhere has this been more intense than in the area of forearm fractures. Although basic biologic principles would dictate that fixation interferes with bone physiology, clinical experience has taught surgeons that every reoperation has potential complications. We therefore retrospectively reviewed all patients undergoing forearm plate removal during a 5 1/2-year period. There were four subsequent refractures in 63 patients, for an incidence of 6%. Factors that appeared to influence the refracture rate were degree of initial displacement and comminution, physical characteristics of the plate, early removal, and lack of postremoval protection.

Epidemiology of distal forearm fractures in Danish children

We recorded all the distal forearm fractures in inhabitants under 20 years of age in Frederiksborg County, Denmark, throughout 1985. The population at risk was 97,791 persons, and fractures occurred in 269 boys and 205 girls. The peak incidence in girls occurred at ages 10-12 (105 per 10,000) and in boys at ages 12-14 (100 per 10,000). Fractures occurred more often in the autumn than in the spring.