Wearable rehabilitation wristband for distal radius fractures

Background

Distal radius fractures are a common type of fracture. For patients treated with closed reduction with splinting, a period of rehabilitation is still required after the removal of the splint. However, there is a general lack of attention and low compliance to rehabilitation training during this period, so it is necessary to build a rehabilitation training monitoring system to improve the efficiency of patients' rehabilitation.

Methods

A wearable rehabilitation training wristband was proposed, which could be used in the patient's daily rehabilitation training scenario and could recognize four common wrist rehabilitation actions in real-time by using three thin film pressure sensors to detect the pressure change curve at three points on the wrist. An algorithmic framework for classifying rehabilitation training actions was proposed. In our framework, an action pre-detection strategy was designed to exclude false detections caused by switching initial gestures during rehabilitation training and wait for the arrival of the complete signal. To classify the action signals into four categories, firstly an autoencoder was used to downscale the original signal. Six SVMs were then used for evaluation and voting, and the final action with the highest number of votes would be used as the prediction result.

Results

Experimental results showed that the proposed algorithmic framework achieved an average recognition accuracy of 89.62%, an average recognition recall of 88.93%, and an f1 score of 89.27% on the four rehabilitation training actions.

Conclusion

The developed device has the advantages of being small size and easy to wear, which can quickly and accurately identify and classify four common rehabilitation training actions. It can easily be combined with peripheral devices and technologies (e.g., cell phones, computers, Internet) to build different rehabilitation training scenarios, making it worthwhile to use and promote in clinical settings.

Effect of platelet content on occurrence and prognosis of distal radius fracture

Fractures of the distal radius are a common fracture with an increasing incidence. However, the underlying factors for distal radius fractures (DRFs) remain unclear. A total of 123 patients with distal radial fractures were recruited. To document clinical and follow-up data, and measure the levels of white blood cells, hemoglobin, platelets, and red blood cells in the bloodstream for qualitative observation of their expression effects within the human body, specifically assessing whether the magnitudes of these indicators are associated with potential factors influencing DRF. Pearson chi-square test and Spearman correlation were used to analyze the relationship between DRF and related parameters. Univariate and multivariate logistic regression and multivariate Cox proportional risk regression were used for further analysis. Pearson chi-square test and Spearman correlation analysis showed a significant correlation between platelet and red blood cell levels and the occurrence of DRFs. Univariate logistic regression analysis demonstrated a significant correlation between platelet count (OR [odds ratio] = 6.286, 95% CI [confidence interval]: 2.862-13.808, P < .001) and red blood cell count (OR = 2.780, 95% CI: 1.322-5.843, P = .007) with DRFs. Increasing levels of both indicators were associated with a higher susceptibility to DRFs. Multivariate logistic regression showed that platelets (OR = 6.344, 95% CI: 2.709-14.855, P < .001) were significantly associated with DRFs. Multivariate Cox regression analysis showed sex (HR [hazard ratio] = 0.596, 95% CI: 0.381-0.931, P = .023) and platelet (HR = 3.721, 95% CI: 2.364-5.855, P < .001) were significantly associated with maintenance time from recovery to recurrence (MTRR) of DRFs. In other words, the platelet content in the body of different genders is different, and the MTRR of DRF is different. Platelets were significantly associated with DRFs. The higher the platelet count, the higher the risk of DRF and the shorter the time of DRF recurrence.

Accuracy of radiographic measurements of fracture-induced deformity in the distal radius

Background

Management of the distal radius fracture (DRF) is to some extent based on radiographic characterization of fracture displacement. It remains unclear, however, if the measurements used to quantify displacement are accurate.

Purpose

To quantify accuracy of two radiographic measurements: dorsal/volar tilt and fracture compression, measured indirectly as ulnar variance (UV), using radiostereometric analyses (RSA) as reference standard.

Material and Methods

Twenty-one fresh frozen non-fractured human cadaveric forearms (right = 11, left = 10) were thawed and eligible for inclusion. The forearms were mounted on a custom made platform that allowed for controlled forearm rotation, and they underwent two rounds of imaging (both rounds consisted of RSA and radiographs). In round one, the non-fractured forearms were radiographed. In round two, artificial DRF´s with compression and dorsal angulation were created and imaging procedures repeated. Change in tilt and UV between the non-fractured and later fractured forearms was defined as fracture-induced deformity. Deformity was measured radiographically and additionally calculated using RSA. Bland Altman analyses were used to estimate agreement between radiographically measured, and RSA calculated, fracture-induced deformity.

Results

Our results indicated that radiographs underestimate the amount of fracture-induced deformity. Mean measured differences (bias) in dorsal tilt deformity between radiographs and RSA were -2.5° for both observers. The corresponding values for UV were -1.4 mm and -1.5 mm.

Conclusion

Quantifying fracture-induced deformity on radiographs underestimated the actual deformity when compared to RSA calculated deformity. These findings suggest that clinicians, at least in part, base fracture management and potentially corrective surgery on inaccurate measurements.

Trends in Distal Radius Fixation Reimbursement, Charge, and Utilization in the Medicare Population

Background  Distal radius fractures (DRF) are the second most common fragility fracture experienced by the elderly, and surgical management constitutes an appreciable sum of Medicare expenditure for upper extremity surgery. Using Medicare data from 2012 to 2017, our primary aim was to describe temporal changes in surgical treatment, physician payment, and patient charges for DRF fixation. Methods  We examined surgical volumes and retrospective patient charge (services billed by surgeon) and surgeon payment (professional fee) data from 2012 to 2017 for four DRF surgeries: closed reduction percutaneous pinning (CRPP), open reduction internal fixation (ORIF) of extra-articular fractures, ORIF of intra-articular (IA) (2-fragment) fractures, and ORIF of IA (> 3 fragments) fractures. The reimbursement ratio was defined and calculated as the ratio of charges to payment. Rates were adjusted for inflation using the annual consumer-price index. Results  For these four surgeries from 2012 to 2017, total patient charges grew by 64% from $117 to 193 million, while surgeon payment grew by 42% from $30 to 42 million. CRPP cases fell by 47%, while ORIF increased by 17, 14, and 45% for extra-articular, IA (2-fragment), and IA (> 3 fragments) surgeries, respectively. After adjusting for inflation, payment to physicians increased by more than or equal to 16% for all procedures except for CRPP, which fell by 2%. Charges during this same period increased from 13 to 38%. Reimbursement ratios declined from -9.2% to -13% for each procedure. Conclusion  From 2012 to 2017, while charges have outpaced surgeon payment, payment has outpaced inflation for all forms of distal radius ORIF, aside from CRPP. There has been a continued sharp decline of CRPP. Level of Evidence is III, economic.

Assessment of Technical Competence in Distal Radius Fracture Fixation by a Volar Locking Plate: A Global Delphi Consensus Study

PURPOSE

Volar locking plate fixation of distal radius fractures is a common orthopedic procedure and should be mastered by graduating orthopedic residents. Surgical education is transitioning from a traditional time-based approach to competency-based medical education. Valid and objective assessment is essential for successful transition. The purpose of this study was to develop a comprehensive, procedure-specific assessment tool to evaluate technical competence in volar locking plate osteosynthesis of a distal radius fracture.

METHODS

International orthopedic/trauma experts involved in resident education participated as panelists in a four-round online Delphi process to reach consensus on the content of the assessment tool. Round 1 was an item-generating round, in which the panelists identified potential assessment parameters. In round 2, the panelists rated the importance of each suggested assessment parameter and reached consensus on which to include in the assessment tool. Round 3 yielded specific assessment score intervals for specific bone and fracture models and is not reported in this study. In round 4, the panelists assigned weights to the assessment parameters on a 1-10 scale to determine how each parameter should have an impact on the overall results.

RESULTS

Eighty-seven surgeons, representing 42 countries, participated in the study. Round 1 resulted in 45 assessment parameters, grouped into five procedural steps. After round 2, the number of parameters was reduced to 39. After the final round, an additional parameter was removed and weights were assigned to the remaining parameters.

CONCLUSIONS

Using a systematic methodology, a preliminary assessment tool to evaluate technical competence in distal radius fracture fixation was developed. A consensus of international experts supports the content validity of the assessment tool.

CLINICAL RELEVANCE

This assessment tool represents the first step in the evidence-based assessment essential for competency-based medical education. Before implementation, further studies exploring validity of variations of the assessment tool in different educational contexts are required.

Physiotherapeutic Approach for Volar Barton Fracture Left Side Without Neurological Deficits: A Case Report

Distal radius bone fracture termed a volar Barton fracture takes place when the ventral portion of the bone is displaced. This fracture happens obliquely within the joint itself. This is the case report of a 52-year-old female, who met with a road traffic accident and injured her left wrist. After the necessary investigation, she was diagnosed with a volar Barton fracture of the left wrist without any neurological deficits. After this, she was managed with open reduction and internal fixation with plate osteosynthesis. Postoperatively, the patient complained of pain around the left wrist joint and there was also restriction in the movements of the left wrist, which caused it to be difficult to perform everyday tasks. We report that following surgery, physical therapy intervention significantly reduced the intensity of pain, improved the range of motion, and strength of the muscle, and remarkable progress in the patient's functional independence. An Upper Extremity Functional Index was used as an outcome measure.

Change in capitate shift after osteotomy for distal radial fracture malunion

Loss of anterior tilt after a distal radial fracture can lead to carpal malalignment, which may cause functional impairment. The aim of this study was to establish whether distal radial osteotomy for malunion, which primarily restores the dorsal tilt, will also improve carpal malalignment as measured by capitate shift. Radiographs of 67 patients who underwent osteotomy after malunion of a distal radial fracture were reviewed. Measurements of capitate shift and dorsal tilt were recorded. Linear regression modelling was used to assess the relationship between dorsal tilt and capitate shift. Change in capitate shift was strongly associated with change in dorsal tilt following osteotomy. This relationship was maintained on long-term radiographs. Capitate shift is strongly related to dorsal tilt following a distal radial fracture. Correcting the dorsal tilt during an osteotomy, therefore, will improve capitate shift and carpal malalignment. Capitate shift is unrelated to age, sex and is easy to visually assess.Level of evidence: IV.

Is There a Critical Dorsal Lunate Facet Size in Distal Radius Fractures That Leads to Dorsal Carpal Subluxation? A Biomechanical Study of the Dorsal Critical Corner

PURPOSE

Intra-articular distal radius fractures are common and can be associated with carpal instability. Failure to address articular fragments linked to maintaining carpal stability can lead to radiocarpal subluxation or dislocation. The purpose of this study was to evaluate the size of a dorsal osteotomy in the dorsal/volar plane of the lunate facet that leads to dorsal carpal subluxation.

METHODS

Dorsal lunate facet fractures were simulated twice in each of nine fresh-frozen cadavers. After completing a partial dorsal osteotomy in the radial/ulnar plane between the scaphoid and lunate facets, an osteotomy in the dorsal/volar plane was completed. Using a cutting jig, first an estimated 5-mm osteotomy, and then a 10-mm osteotomy (from the dorsal rim of the distal radius) were completed. The wrist was mounted in a custom jig and loaded with 100 N. Displacement of the lunate in the dorsal/volar plane compared with displacement in an intact specimen was evaluated and used to assess carpal subluxation.

RESULTS

Lunate translation was 0 mm ± 0 mm in the intact state. The 5-mm osteotomy averaged 29% of the distal radius dorsal lunate facet in the dorsal/volar plane, and lunate translation was 0.7 mm ± 1.7 mm. The 10-mm osteotomy averaged 54% of the dorsal lunate facet in the dorsal/volar plane, and lunate translation was 2.8 mm ± 2.6 mm. Assuming a linear relationship from the osteotomies created, an osteotomy of an estimated ≥40% of the distal radius in the dorsal to volar plane resulted in substantial dorsal subluxation, although this specific osteotomy was not assessed in our study.

CONCLUSIONS

Sequentially increased dorsal osteotomies of the dorsal lunate facet result in increased dorsal carpal subluxation.

CLINICAL RELEVANCE

Distal radius fractures that include >40% of the "dorsal critical corner" are at risk for dorsal carpal subluxation and may require supplementary fixation.

Risk Factors for the Incidence of the Volar Lunate Facet Fragments in Distal Radius Fractures

Background  The volar lip of the distal radius is the key structure for wrist joint stability. Rigid fixation of the volar lunate facet (VLF) fragment is difficult because of its unique anatomy, and a high rate of postoperative displacement was demonstrated. Purposes  The aim of the study is to identify risk factors for VLF in distal radius fractures (DRFs) and to reconsider the important point for primary fixation. Patients and Methods  One hundred fifty-five patients who underwent open reduction and internal fixation for an DRF were included and classified into one of the following two groups: VLF(+)or VLF(-). Demographic data, including age, sex, body mass index (BMI), laterality, trauma mechanism, and AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification were recorded. Several parameters were investigated using wrist radiographs of the uninjured side and computed tomography scans of the injured side. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors for VLF. Results  There were 25 patients in the VLF(+) group and 130 patients in the VLF(-) group. The incidence of VLF was 16.1%. The VLF(+) group tended to have a higher BMI and higher energy trauma mechanism. The odds ratio for the sigmoid notch angle (SNA), volar tilt (VT), and lunate facet curvature radius (LFCR) were 0.84, 1.32, and 0.70, respectively, with multivariate analysis, which was significant. A smaller SNA, larger VT, and smaller LFCR are potential risk factors for VLF. Conclusion  Over-reduction of the VT at primary fixation should be avoided because it could place an excess burden on the VLF and cause subsequent postoperative fixation failure and volar carpal subluxation. Level of Evidence  IV.

Evaluation of Unicortical Locking Screw Placement for Torsional Loads in Distal Radius Fractures: A Biomechanical Study in Cadavers

Background We aimed to compare bio-mechanical outcomes of short-length 75%-length uni-cortical screw (SL75UCS) and full-length 100%-length screws (FL100S) under axial compression (AXC) and torsional compression (TRC) in cadaveric distal radius volar plate model. Methodology A total of 20 wrists from 10 fresh frozen cadavers were included. A 2.5 mm titanium alloy distal radius anatomical plate was placed to the distal radii in full anatomical position, just proximal to the watershed line. Three bi-cortical screws to the shaft of the radius, followed by uni-cortical drilling for distal screwing were placed. Measurement by pulling the drill once it reached the opposite cortex was applied. We selected the screw lengths such that they corresponded to the SL75UCS. In the same configuration for each of the cadavers, we delivered six screws from distal radius holes of the anatomical plate. An oscillating handsaw was used to create an extra-articular distal radius fracture model (AO 23-A3.2). We created a dorsal AP model by performing a 1-cm wedge osteotomy from the dorsal aspect. Complete separation of the volar cortex was achieved. Potting was performed by embedding the shaft of the prepared radius into the polyurethane medium. We placed aluminum apparatus into the distal end to ensure applying of AXC and TRC in bio-mechanistic tests. Results No statistically significant difference of stiffness between the SL75UCS and FL100S both under AXC (p=0.88) and TRC (p=0.82). SL75UCS and FL100S groups did not differ in elastic limit under AXC (p=0.71) and TRC (p=0.71). Maximal force on SL75UCS and FL100S groups were also similar under both AXC (p=0.71) and TRC (p=0.50). Conclusions Our study findings suggest that drilling the dorsal cortex may not be necessary in the management of distal radius fractures. Instead, utilizing SL75UCS could serve as a viable alternative. This approach offers potential advantages in reducing the risk of extensor tendon complications associated with drilling or screw protrusion. It is a safe method under torsional load to avoid drilling of the dorsal cortex and SL75UCS could be performed in order to prevent from extensor tendon complications secondary to drilling or screw protrusion.

The Effect of Steroid Use on Complications after Distal Radius Fracture Repair

Background  Distal radius fractures (DRFs) are the most common fracture of the upper extremity. Given that steroids are one of the most commonly prescribed drugs and are usually prescribed for chronic conditions, steroid use represents a key factor to consider in how to optimize perioperative outcomes. Questions/Purposes  The purpose of this study was to investigate if there are differences in perioperative outcomes for patients undergoing DRF open reduction and internal fixation based on preoperative steroid use. Patients and Methods  Adult patients who underwent operative treatment for DRF from 2007 to 2018 were identified in a national database. Patients were divided into two cohorts as follows: (1) no steroid usage and (2) preoperative steroid usage. In this analysis, various postoperative complications, as well as extended length of stay and reoperation, were assessed. Bivariate analyses and multivariable logistical regression were performed. Results  Among a total of 16,505 patients undergoing operative treatment for DRF, 16,145 patients (97.8%) did not have steroid usage and 360 (2.2%) had steroid usage. Following adjustment, an increased risk of extended length of hospital stay greater than 3 days (odds ratio [OR] = 1.646; p  = 0.012) was seen in the steroid usage group compared with those who did not use steroids within 30 days of surgery. Conclusion  Preoperative steroid use is associated with increased length of stay over 3 days after DRF open reduction and internal fixation surgery but is not associated with any of the other complications that were assessed in this study. Level of Evidence  This is a Level III, retrospective study.

Mini-dose Bier's block vs systemic analgesia in distal radius fractures: a promising reduction in emergency department throughput time

Aim: This study compared the effect of the conventional technique of procedural sedation and the mini-dose intravenous regional anesthesia (IVRA). Patients & methods: 45 patients received IVRA, and 47 received iv. ketamine. The pain score, emergency department (ED) length of stay and patients' satisfaction were compared. Results: The study revealed that not only the levels of hemodynamic parameters but also their stability, and the patient's satisfaction in the IVRA group were significantly better. The patients' pain score and ED length of stay were also significantly decreased in those who received IVRA. Conclusion: Mini-dose IVRA technique contributes to better hemodynamic stability, without prominent adverse events, and leads to significant pain control and improved ED throughput time. Clinical Trial Registration: NCT03349216 (ClinicalTrials.gov).

Comminuted lunate fracture combined with distal radius fracture and scaphoid fracture: A case report

RATIONALE

Incidence of lunate fractures is very low, less than 1% of all fractures. Lunate fractures generally come from high-energy injuries, often combined with other wrist fractures. Simple lunate fractures can be fixed with screws or Kirschner wires. However, Comminuted lunate fractures are difficult to reduce and fixe by conventional methods.

PATIENT CONCERNS

Here we report a 42-year-old male construction worker who was crushed by an excavator bucket and presented with comminuted lunate fracture combined with distal radius fracture and scaphoid fracture.

DIAGNOSES

Comminuted lunate fracture, distal radius fracture, and scaphoid fracture.

INTERVENTIONS

The posterior approach was used to reconstruct the radial lunate bone with polymethylmethacrylate cement, and cannulated screws were used to fix the scaphoid and distal radius fractures.

OUTCOMES

At the 3rd month after surgery, the movement of the right wrist joint improved. At the sixth month after surgery, the patient returned to the building site and began working at the same intensity as before the injury.

LESSONS

Although the incidence of comminuted lunate fractures is very low, they occur sometimes. For comminuted lunate fractures, early identification and intervention can preserve most of the function of the wrist joint.

Computed Tomography Evaluation of Distal Screw Penetration in Volar Locking Plate Fixation for Intra-Articular Distal Radius Fractures

PURPOSE

Volar locking plate fixation for distal radius fractures (DRFs) is a technically demanding procedure with a risk of distal screw penetration through the dorsal cortex or the articular surface. This study aimed to investigate the incidence and details of distal screw penetration after volar locking plate fixation for intra-articular DRFs using a CT scan and to evaluate the relationship between the incidence of screw penetration and fracture comminution severity and the clinical complications of screw penetration.

METHODS

This was a retrospective case series of 91 adult patients (mean age, 63 years; 27 men) who underwent volar locking plate fixation for intra-articular DRFs from 2015 to 2018. The positioning of the distal screws was evaluated using a postoperative CT scan, and radiological outcomes were compared between the AO C1 and C3 groups. At the final follow-up, tendon rupture and arthritis severity were assessed as clinical complications of dorsal and intra-articular screw penetration.

RESULTS

Distal screw penetration was observed in 44 wrists (48%), dorsal cortex screw penetration in 34, intra-articular screw penetration in 13, and both dorsal cortex and intra-articular screw penetration in three. The incidence of intra-articular screw penetration was significantly higher in the C3 group than in the C1 group. No tendon rupture was observed. Multivariable analysis revealed that intra-articular screw penetration was significantly related to high severity of arthritis.

CONCLUSIONS

Approximately half of the study patients with intra-articular DRFs had distal screw penetration. The incidence of intra-articular screw penetration was associated with the severity of fracture comminution, and the intra-articular screw penetration was associated with the incidence of early radiocarpal arthritis. Intra-articularly penetrating screws should be replaced as soon as they are discovered, regardless of the length of penetrated screw or absence of patients' subjective symptoms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Carpal Tunnel Release Performed during Distal Radius Fracture Surgery

Background  Carpal tunnel release (CTR) may be concomitantly performed along with distal radius fracture open reduction internal fixation (DRF ORIF) to prevent carpal tunnel syndrome; however, there is little to no literature investigating the rate, risk factors, and complications associated with CTR. Questions/Purposes  The purpose was to determine (1) the rate of CTR performed at time of DRF ORIF, (2) factors associated with CTR, and (3) whether CTR was associated with any complications. Patients and Methods  In this case-control study, adult patients who underwent DRF ORIF from 2014 to 2018 were identified from a national surgical database. Two cohorts were analyzed, (1) patients with CTR and (2) patients without CTR. Preoperative characteristics and postoperative complications were compared with determine factors associated with CTR. Results  Of the 18,466 patients, 769 (4.2%) had CTR. Rates of CTR in patients with intra-articular fractures with two or three fragments were significantly higher than the rate of CTR for patients with extra-articular fractures. Underweight patients underwent CTR at a significantly lower rate compared with overweight and obese patients. The American Society of Anesthesiologists ≥3 was associated with a higher rate of CTR. Male and older patients were less likely to have CTR. Conclusion  The rate of CTR at time of DRF ORIF was 4.2%. Intra-articular fractures with multiple fragments were strongly associated with CTR at time of DRF ORIF, while being underweight, elderly, and male were associated with lower rates of CTR. These findings should be considered when developing clinical guidelines to assess the need for CTR in patients undergoing DRF ORIF. This is a retrospective case control study and reflects level of evidence III.

Comparison of surgical treatments for distal ulna fracture when combined with anterior locking plate fixation of distal radius in the over 70 age group

We conducted a retrospective multicentre study to compare the clinical and radiographic outcomes, and complications of three surgical treatments of distal ulna fracture (DUF) when combined with anterior locking plate fixation for distal radial fracture (DRF) in patients over 70 years of age. We identified 1521 patients over 70 years of age who were diagnosed as having DRF and who underwent anterior locking plate fixation between 2015 and 2020, among which 122 cases of DUF were analysed. Three surgical treatment options for DUF were identified in this cohort: K-wire fixation (Group K), locking plate fixation (Group L) and Darrach procedure (Group D). The results of the analysis showed the total immobilization period in Group D to be the shortest among the three treatments. Functional outcomes were superior, and the rate of complications were smaller in Group D than in Group L. In addition, rotational range of motion was larger in Group D and Group L compared with Group K. In patients who are 70 years of age or older with combined unstable DRF and highly comminuted or displaced DUF, the Darrach procedure for DUF seems to be the most useful and reasonable treatment option once the fracture of the distal radius has been rigidly fixed.Level of evidence: IV.

Development of de Quervain Tenosynovitis After Distal Radius Fracture

BACKGROUND

We sought to determine the risk factors for the development of de Quervain tenosynovitis after distal radius fractures. Our hypothesis is that longer periods of immobilization and higher-energy fracture patterns will correlate with the development of de Quervain tenosynovitis.

METHODS

This is a 10-year retrospective study of 1451 consecutive patients with distal radius fractures presenting to a large academic institution. The incidence and relative risk of de Quervain tenosynovitis within 1 year of sustaining a distal radius fracture were analyzed.

RESULTS

In total, 41 patients developed posttraumatic de Quervain tenosynovitis at an average time of 6.5 months. In the operative cohort, the incidence was 2.2%, and that of the nonoperative group was 3.8%. Among all affected patients, 78% admitted to strenuous, overuse activities or careers. Compared with the unaffected cohort, the de Quervain tenosynovitis group was more likely to be female and black with similar age and body mass index. The traumatic cohort was less likely to respond to corticosteroid injections. A separate extensor pollicis brevis (EPB) sheath was noted in all patients requiring surgical release.

CONCLUSIONS

Patients with a nonoperative distal radius fracture were 4.2 times more likely to develop de Quervain's than the general population, and those treated operatively were 2.4 times more likely. These patients were more likely to be female, black, and engage in strenuous overuse activities or careers. They demonstrated higher-energy fracture patterns and worse response to corticosteroid injections, more frequently requiring surgical decompression. Among those requiring surgery, patients were 2.5 times more likely to have a separate EPB sheath than those with atraumatic Quervain's.

Impact of Time to Fixation on Outcomes of Operative Treatment of Intra-articular Distal Radius Fractures

BACKGROUND

The incidence of operative treatment of distal radius fractures (DRFs) has increased recently, but the optimal timing for surgical fixation remains unclear. We hypothesized that: (1) an increase in time to fixation of intra-articular DRFs would increase the likelihood of postoperative complications; and (2) increased time from injury to fixation would lead to longer surgical time and worse range of motion (ROM) outcomes.

METHODS

We retrospectively reviewed 299 fractures in 284 adult patients who underwent open reduction and internal fixation (ORIF) of a closed, intra-articular DRF at our institution over a 10.5-year period. Demographic information, time to surgery (TTS) from injury, surgical time, tourniquet time, complications, and final postoperative ROM were collected for logistic regression modeling to predict the risk of postoperative complication.

RESULTS

Twenty-seven (9.0%) patients experienced postoperative complications. The median TTS (Q1-Q3) for all patients was 7.0 (4.0-12.0) days. Patients who experienced an early postoperative complication had significantly longer median TTS (10.0 days) than those who did not (7.0 days). Patients with longer TTS were more likely to experience a complication (odds ratio, 1.11; 95% confidence interval, 1.04-1.19; P = .006). Tourniquet time and final wrist ROM were not related to TTS. A logistic regression analysis found that early complication rate doubles at 7.0 days after injury (from 3.5% to 6.9%).

CONCLUSIONS

Patients with operative intra-articular distal radius fractures should ideally be fixed within 7 to 10 days of injury to minimize the risk of early postoperative complications. The tourniquet time and final ROM were not associated with time to surgery.

Radiographic Analysis in Extra-Articular and Intra-Articular Distal Radius Fractures Treated with Variable-Angle Volar Locking Plate Fixation

(1) Background: Different distal radial fracture types have different prognosis after fixation. Our study aim is to evaluate the differences in radiographic parameters by using variable-angle volar locking plate (VAVLP) fixation according to extra-articular and intra-articular distal radial fracture. (2) Methods: There are two groups: extra-articular group (21) and intra-articular group (25). Forearm radiographs immediately after surgery and at 3 months after operation were reviewed for analyzing radial height (RH), ulnar variance (UV), radial inclination (RI), volar tilt (VT), tear drop angle (TDA), distal dorsal cortical distance (DDD), and Soong classification (SC). (3) Results: There were no significant differences in the above parameters between two groups at either immediately post-operative or at 3-month follow-up, except for TDA (p = 0.048). Most patients in both groups were at low risk of flexor tendon rupture, except for two cases. We observed a positive correlation between post-operative DDD and 3-month change in the intra-articular group, but not the extra-articular group. (4) Conclusions: Our study demonstrates that VAVLP fixation is effective in maintaining the stability of most radiographic parameters and reduces the risk of tendon rupture in both extra-articular and intra-articular distal radial fractures. Post-operative DDD can be used to predict the degree of subsequent displacement in patients with intra-articular fractures fixed with VAVLP.

Delayed open surgery for distal radius epiphyseal plate fracture in children

OBJECTIVES

This study assessed the feasibility of open surgery and determined outcome predictors for late management of epiphyseal plate fracture of the distal radius in children.

METHODS

This retrospective study included 25 patients (22 male, 3 female) who underwent open surgery for late management of epiphyseal plate fracture of the distal radius. Wrist function was evaluated on Cooney score. Potential predictors comprised age, gender, fracture type, days after injury (DAI), degree of violence (DOV), and dorsal angulation before surgery (DABS).

RESULTS

Overall, wrist function after surgery was classified as excellent for 16 patients (64%), good for 6 (24%), and fair for 3 (12%). The rate of excellent wrist function was 86.7% (13/15) in children older than 10 years but only 40% (4/10) for those aged under 10 years (p = 0.0280). Cooney score correlated positively with age, but there was no correlation with gender, fracture type, DAI, DOV or DABS.

CONCLUSION

Open reduction surgery for late management of distal radius epiphyseal fracture yielded good results in patients aged over 10 years.

LEVEL OF EVIDENCE

III.

Clinical Validation of an Artificial Intelligence Model for Detecting Distal Radius, Ulnar Styloid, and Scaphoid Fractures on Conventional Wrist Radiographs

This study aimed to assess the feasibility and performance of an artificial intelligence (AI) model for detecting three common wrist fractures: distal radius, ulnar styloid process, and scaphoid. The AI model was trained with a dataset of 4432 images containing both fractured and non-fractured wrist images. In total, 593 subjects were included in the clinical test. Two human experts independently diagnosed and labeled the fracture sites using bounding boxes to build the ground truth. Two novice radiologists also performed the same task, both with and without model assistance. The sensitivity, specificity, accuracy, and area under the curve (AUC) were calculated for each wrist location. The AUC for detecting distal radius, ulnar styloid, and scaphoid fractures per wrist were 0.903 (95% C.I. 0.887-0.918), 0.925 (95% C.I. 0.911-0.939), and 0.808 (95% C.I. 0.748-0.967), respectively. When assisted by the AI model, the scaphoid fracture AUC of the two novice radiologists significantly increased from 0.75 (95% C.I. 0.66-0.83) to 0.85 (95% C.I. 0.77-0.93) and from 0.71 (95% C.I. 0.62-0.80) to 0.80 (95% C.I. 0.71-0.88), respectively. Overall, the developed AI model was found to be reliable for detecting wrist fractures, particularly for scaphoid fractures, which are commonly missed.

Short-term results and complications of the operative treatment of the distal radius fracture AO2R3 C type, planned by using 3D-printed models. Prospective randomized control study

PURPOSE

3D-printed models rapidly evolving in orthopaedic. Studies show that 3D-printed models used for preoperative planning improve a better understanding of fracture morphology and reduce operative time, blood loss and frequency of fluoroscopy, but there are no studies that investigated possible advantages in the outcomes and complications for the treatment of distal radius fracture (DRF). Our study aims to evaluate short-term functional results and complications between two groups treated DRF using 3D-printed models for preoperative planning and without. We hypothesize that the addition of 3D-printed models would improve functional outcomes and reduce complication rates.

METHODS

66 randomized cases of DRF AO/OTA C type were enrolled and divided into "Control group" (n = 33) and "3D-printed model group" (n = 33). Personalized 3D-printed models were created. The primary outcomes were: Patient-Rated Wrist Evaluation questionnaire, Quick Disabilities of the Arm, Shoulder and Hand Score questionnaire, and complications. The secondary outcomes were: measurement of the range of motions, grip strength, radiological evaluation, and the visual analogue scale. Assessments were measured at 6 weeks, 3 months, and 6 months intervals.

RESULTS

We found that the integration of the 3D-printed model in preoperative planning decreased complication incidence significantly - from 30.3% in the "Control group" to 6.1% in the "3D-printed model group", p = .022. But we did not find a difference in functional and radiological outcomes.

CONCLUSION

The 3D-printed models for preoperative planning surgically treating DRF AO/OTA C type can help minimize the complication rate, however, they can't improve functional outcomes in the short-term results.

LEVEL OF EVIDENCE

Level I randomized controlled study.

Complete median nerve axonotmesis as a late postoperative complication in distal radius fracture

Locked volar plate fixation is currently the gold-standard treatment for distal radius fractures. Although volar plating is considered as a reasonably safe treatment option for distal radial fractures, several complications can be observed, such as median nerve injury. We present an 84-year-old male with an intra-articular comminuted fracture of the left distal radius that presented as a late postoperative complication a complete axonotmesis of the median nerve due to screw migration of a locked volar plate. An electromyography was performed confirming complete median nerve axonotmesis, and with proximal stimulation, a Martin-Gruber anastomosis in the proximal forearm was discovered.

Harms Reporting in Randomized Controlled Trials Underpinning the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines for Distal Radius Fractures

PURPOSE

The purpose of this study was to measure the harms-related reporting among randomized controlled trials (RCTs) cited as supporting evidence for the American Academy of Orthopaedic Surgeons clinical practice guidelines regarding the management of distal radius fractures.

METHODS

We adhered to the guidance for reporting metaresearch and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines throughout the course of this investigation. We used the American Academy of Orthopaedic Surgeons clinical practice guidelines for distal radius fractures available on Orthoguidelines.org. A linear regression analysis was conducted to model the relationship between the year of publication and the total Consolidated Standards of Reporting Trials percentage adherence over time.

RESULTS

Thirty-five RCTs were included in the final sample. The average number of Consolidated Standards of Reporting Trials Extension for Harms items adequately reported across all included RCTs was 9.2 (9.2/18, 50.9%). None of the included trials adequately reported all 18 items. Ten items had a compliance of more than 50% (10/18, 55.6%), 4 items had a compliance of 20%-50% (4/18, 22.2%), and 4 items had a compliance of less than 20% (4/18, 22.2%). The results of the linear regression model showed no significant improvement in Consolidated Standards of Reporting Trials Harms reporting over time.

CONCLUSIONS

Adverse events are incompletely reported among RCTs cited as supporting evidence for American Academy of Orthopaedic Surgeons clinical practice guidelines for the management of distal radius fractures.

CLINICAL RELEVANCE

Given our findings, specific attention should be paid to improving the standardization of the classification of adverse events to facilitate ease in the reporting process.

Radius palmar plate removal without carpal tunnel release: correlation between plate position and median nerve symptoms

We aimed to report the clinical results of volar plate removal without carpal tunnel release in patients with late-onset median neuropathy and to evaluate the relationship between plate position and median nerve symptoms. Part I. Twelve consecutive patients with late-onset median neuropathy treated with volar plate removal without carpal tunnel release were enrolled for analysis. Pre- and post-operative Tinel sign, Phalen and Ten test, subjective rating of tingling sensation, Mayo wrist score and Disabilities of the Arm, Shoulder and Hand (DASH) score were collected. Part II. 232 consecutive patients underwent volar plating for distal radius fracture. The relationships between median nerve symptoms and volar plate prominence on the Soong classification, fracture classification, gender and age were investigated. All cases except one showed complete symptom resolution at final follow-up, with negative Tinel sign and Ten test score of 10/10. Tingling was rated 0 at final follow-up. Mean Mayo wrist and DASH scores improved to 86.7 and 23.1, respectively. The incidence of the median nerve symptoms in our cohort was 5.6%. Even though the odds ratio in Soong grade 2 was 4.0957 (95% CI, 0.93-16.9) compared to the combination of grades 0 and 1, no statistically significant relationship was found between the median nerve symptoms and volar plate prominence (p > 0.05). Plate removal without carpal tunnel release adequately relieved symptoms of late-onset median neuropathy after volar plating in patients with distal radius fracture. Level of Evidence: IV; Therapeutic.

Redefining radiocarpal fracture-dislocations with injury specific management and a clinical classification system: a retrospective review

BACKGROUND

Unlike articular shear fractures of the distal radius, radiocarpal fracture-dislocations defined as complete dislocation of the lunate from its articular facet of the radius are relatively uncommon. The management principles of these fractures have not been defined and there is no consensus on approach to management of these injuries. The aim of this study is to review our series of radiocarpal fracture-dislocations and propose a radiographic classification to guide surgical management.

METHODS

This study is reported based on STROBE guidelines. A total of 12 patients underwent open reduction and internal fixation. All the fracture-dislocations were dorsal and satisfactory objective outcomes achieved were comparable to literature. Injury morphology-specific management approach was used based on the size of dorsal lip fragment and the volar teardrop fragment attached to the short radiolunate ligament assessed by preoperative CT scans.

RESULTS

All patients with known outcome (n = 10) went on to resume their prior occupation and hobbies that included high-demand activities and manual labour at mean follow-up of 27 weeks. Average wrist flexion was 43° and wrist extension was 41° while radial and ulnar deviation were 14° and 18° respectively. Average forearm pronation was 76° and supination was 64° at final follow-up.

CONCLUSION

We describe four injury patterns of radiocarpal fracture-dislocations based on preoperative CT scans that guide fixation. We believe that early recognition of radiocarpal fracture-dislocations and appropriate management can yield satisfactory outcomes.

Ultrasound-Guided Manipulation does not Prevent Malalignment Over Landmark-Based Fracture Reduction in Distal Radius Fracture (Colles)

Introduction

This systematic review aims to determine the relative risk of distal radius (Colles) fracture (DRF) malalignment between ultrasound (USG)-guided and conventional/landmark guided/blind manipulation and reduction (M&R).

Methods

We searched 3932 records from major electronic bibliographic databases on USG-guided manipulation of DRF. Studies with randomized, quasi-randomized, and cross-sectional study designs meeting the inclusion criteria were included in this review. USG and landmark-guided DRF manipulations were named cases and controls, respectively. The Newcastle-Ottawa Scale was used to assess the quality of included studies.

Results

Thirteen and nine studies were analysed for qualitative and quantitative analysis in this review. Nine hundred fifty-one DRF patients (475 cases and 476 controls) from 9 studies with mean ages of 51.52 ± 11.86 (22-92) and 55.82 ± 11.28 (18-98) years for cases and controls were pooled for this review. The pooled relative risk estimate from the studies included in the meta-analysis was 0.90 (0.74-1.09). There was a 10% decrease in the risk of malalignment with USG than the landmark guided M&R of DRF. The I2 statistic estimated a heterogeneity of 83%. Sensitivity analysis revealed a relative risk of 1.00 (0.96-1.05).

Conclusion

The USG-guided manipulation does not prevent malalignment over the landmark-based manipulation of DRF. The risk of bias across the included studies and heterogeneity of 83% mandates further unbiased, high-quality studies to verify the findings of this review.

Fracture Line Distributions of Undisplaced Distal Radius Fractures in Relation to Rupture of the Extensor Pollicis Longus Tendon

Rupture of the extensor pollicis longus (EPL) tendon is a known complication after undisplaced distal radius fracture (DRF). However, no report has revealed the relationship between EPL tendon rupture and the fracture pattern. Thus, this study aimed to investigate the characteristics of fractures at risk of EPL tendon rupture using fracture line mapping of undisplaced DRFs. This study used computed tomography imaging data of undisplaced DRFs with (n=18) and without EPL tendon rupture (n=52). Fracture lines obtained from 3D reconstruction data were drawn manually after matching with a 2D template wrist model. Fracture maps represented the fracture line distribution by superimposing the fracture lines of all 70 patients. Heat maps showed the relative frequency of the fracture lines as a gradual color change. Fracture lines of cases with EPL tendon rupture were concentrated in the proximal border of Lister's tubercle. By contrast, fracture lines of cases without EPL tendon rupture were relatively dispersed.

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

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

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

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

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

Prospective Evaluation of Two Cohorts of Non-Operatively Treated Patients with Displaced vs. Minimally and Non-Displaced Distal Radius Fractures

BACKGROUND

Distal radius fractures (DRFs) in the elderly are common. Recently, the efficacy of operative treatment of displaced DRFs in patients above 65 years of age has been questioned and it has been suggested that non-operative treatment should be the gold standard. However, the complications and functional outcome of displaced vs. minimally and non-displaced DRFs in the elderly has not been evaluated yet. The aim of the present study was to compare non-operatively treated displaced DRFs vs. minimally and non-displaced DRFs in terms of complications, PROMs, grip strength and range of motion (ROM) after 2 weeks, 5 weeks, 6 months and 12 months.

METHODS

We used a prospective cohort study that compared patients with displaced DRFs (n = 50), i.e., >10 degrees of dorsal angulation after two reduction attempts, with patients with minimally or non-displaced DRFs after reduction. Both cohorts received the same treatment of 5 weeks of dorsal plaster casting. Complications and functional outcomes (quick disabilities of the arm, shoulder and hand (QuickDASH), patient-rated wrist/hand evaluation (PRWHE), grip strength and EQ-5D scores) were assessed after 5 weeks, 6 months and 12 months post-injury. The protocol of the VOLCON RCT and present observational study has been published (PMC6599306; clinicaltrials.gov: NCT03716661).

RESULTS

One year after 5 weeks of dorsal below-elbow casting of low-energy DRFs in patients ≥ 65 years old, we found a complication rate of 6.3% (3/48) in minimally or non-displaced DRFs and 16.6% (7/42) in displaced DRFs (p = 0.18). However, no statistically significant difference was observed in functional outcomes in terms of QuickDASH, pain, ROM, grip strength or EQ-5D scores.

DISCUSSION

In patients above 65 years of age, non-operative treatment, i.e., closed reduction and dorsal casting for 5 weeks, yielded similar complication rates and functional outcomes after 1 year regardless of whether the initial fracture was non-displaced/minimally displaced or still displaced after closed reduction. While the initial closed reduction should still be attempted in order to restore the anatomy, failure to achieve the stipulated radiological criteria may not be as important as we thought in terms of complications and functional outcome.

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

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Relationship Between Malunion and Short-Term Outcomes of Nonsurgical Treatment of Distal Radius Fractures in the Elderly: Differences Between Early- and Late-Geriatric Patients

PURPOSE

Previous studies have suggested little association between radiographic malalignment and long-term functional outcomes of nonsurgical treatment of distal radius fractures in geriatric patients. However, no report has stratified the elderly by age and focused on short-term outcomes. The purpose of this study was to determine how the relationship between malunion and patient outcomes differs between early- and late-geriatric patients in the short and long terms after injury, thereby informing explanations and decision-making on treatment options for geriatric patients with distal radius fractures.

METHODS

One hundred patients treated nonsurgically for distal radius fractures were evaluated retrospectively; 52 were defined as early-geriatric patients (aged 60-72 years) and 48 as late-geriatric (aged >77 years). Malunion (dorsal tilt > 10°, ulnar variance > 3 mm, or intra-articular displacement or step-off > 2 mm), range of motion, and grip strength were investigated at 3 months. Multiple regression analysis was performed for each age group using Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores at 3 months as the dependent variable. QuickDASH scores over 1 year after injury were analyzed in the same way.

RESULTS

The early-geriatric patients included 33 acceptable unions and 19 malunions. The late-geriatric patients included 12 acceptable unions and 26 malunions. The significant predictors of QuickDASH scores at 3 months were malunion for the early-geriatric group and grip strength for the late-geriatric group (standardized coefficient β, 0.31 and -0.49, respectively). No factor significantly predicted the QuickDASH scores after at least 1 year in either group.

CONCLUSIONS

Malunion was associated with worse QuickDASH scores at 3 months after injury in the early-geriatric patients but not in the late-geriatric patients and did not predict the QuickDASH scores at 1 year after injury in either age group.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Is the Postoperative Outcome after Intraarticular Distal Radius Fracture Influenced by Age and Gender? A PROM Study

BACKGROUND

Although the most common fracture of the human body, so far, only few data concerning gender-specific outcomes after distal radius fracture exist. Typically, elderly women suffer from DRF due to a low-energy fall because of osteoporosis. The aim of this study was to analyze the outcome after a surgically treated intraarticular DRF with the help of patient-reported outcome measurement (PROM) and with special regard to gender and age impact.

PATIENTS AND METHODS

It is a retrospective case-control study in which all patients with an intraarticular DRF were enrolled. The control group was composed of healthy volunteers. Munich Wrist Questionnaire (MWQ) was used as Patient Related Outcome Measurement (PROM) for analyzing the outcome. Moreover, age, gender, handedness, fracture classification and follow-up interval were detected. The functional outcome of the fracture group was compared to a healthy control group. Analyses of gender, age and handedness-specific results compared to the healthy control groups were performed as well.

RESULTS

197 patients with distal radius fracture could be enrolled in the study (134 were female and 63 were male). Women (mean age 62 years) were significantly older than men (mean age 50 years). The control group comprised 110 healthy subjects, 71 females (mean age 56 years) and 39 males (mean age 53 years). The whole fracture group had significantly lower MWQ scores compared to the control group (p < 0.001). The male fracture group (90.6 ± 12.4) and the female fracture group (90.8 ± 11.4) had a significantly worse outcome compared to the corresponding control group (p < 0.001 male and p = 0.034 female). Although significantly younger, the male patients had a similar outcome compared to the female patients.

DISCUSSION

Even elderly patients can reach the preoperative level after operative treatment of an intraarticular distal radius fracture. Although significantly younger than the female patients, men have significantly worse functional outcomes compared to their control and cannot perform better than the significantly older female patients. Gender might influence the outcome as well; however, age seems to have a greater impact on the outcome than gender.

Complications After Volar Locking Plate Fixation of Distal Radius Fractures: A Retrospective Study of 822 Patients

PURPOSE

With the current routine use of volar locking plates as the preferred surgical treatment option for distal radius fractures, the purpose of this study was to investigate the incidence of postoperative complications following surgery and, second, investigate the correlation between demographic factors and the risk of complications.

METHODS

We retrospectively reviewed all patients who had been surgically treated for a distal radius fracture with open reduction and internal fixation using volar plating and screws during a 3-year period. Relevant demographic information and all postoperative complications of the 822 patients eligible for inclusion were recorded, with a mean follow-up time of 2.8 years.

RESULTS

We identified an overall complication rate of 12.3% (101 of the 822 patients), with 4.8% defined as experiencing major complications and 7.5% defined as experiencing minor complications. The most frequent were complications that led to hardware removal, observed in 2.7% (n = 22) of the patients; wound-related problems that did not require surgical revision, observed in 2.2% (n = 18) of the patients; and carpal tunnel syndrome, observed in 1.9% (n = 16) of the patients. Binary logistic regression modeling showed no correlation between demographic factors and the risk of complications.

CONCLUSIONS

In conclusion, a low overall complication rate of 12.3% was found. Further, 4.8% of the patients experienced a major complication and 7.5% of the patients experienced a minor complication following open reduction and internal fixation using volar plating of distal radius fractures. Age, sex, fracture type, and time from trauma to surgery were not found to be associated with an increased risk of postoperative complications.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

3D Reconstruction of Wrist Bones from C-Arm Fluoroscopy Using Planar Markers

In orthopedic surgeries, such as osteotomy and osteosynthesis, an intraoperative 3D reconstruction of the bone would enable surgeons to quickly assess the fracture reduction procedure with preoperative planning. Scanners equipped with such functionality are often more expensive than a conventional C-arm fluoroscopy device. Moreover, a C-arm fluoroscopy device is commonly available in many orthopedic facilities. Based on the widespread use of such equipment, this paper proposes a method to reconstruct the 3D structure of bone with a conventional C-arm fluoroscopy device. We focus on wrist bones as the target of reconstruction in this research as this will facilitate a flexible imaging scheme. Planar markers are attached to the target object and are tracked in the fluoroscopic image for C-arm pose estimation. The initial calibration of the device is conducted using a checkerboard pattern. In general, reconstruction algorithms are sensitive to geometric calibration errors. To assess the practicality of the method for reconstruction, a simulation study demonstrating the effect of checkerboard thickness and spherical marker size on reconstruction quality was conducted.

Flexor Tendon Attritional Ruptures Following Distal Radius Volar Plate Fixation

PURPOSE

To investigate patient and radiographic factors that may correlate with the time to flexor tendon rupture following volar plate fixation of distal radius fractures.

METHODS

A total of 31 patients who underwent volar plate removal because of flexor tendon rupture were analyzed. Patient demographics and the interval from operative fixation until rupture were determined retrospectively. Volar tilt and lateral carpal alignment were measured radiographically. The Soong classification was used to grade volar plate prominence. The correlation between the duration to tendon rupture and volar tilt, carpal alignment, and age was evaluated.

RESULTS

There were 7 men and 24 women. Mean age at the time of hardware removal and flexor tendon management was 66 years (n = 31). Radiographs were classified as Soong 1 (n = 24) and Soong 2 (n = 3). The mean measured volar tilt was -4° (range, -20°-+7°). The mean interval from operative fixation until complete tendon rupture was 4.9 years, (range, 0.3-13.1 years; n = 30). There was no correlation between the time interval to rupture and the magnitude of tilt, carpal alignment, or age at the time of operative fixation.

CONCLUSIONS

Although volar plate prominence was present in all patients with flexor tendon ruptures, radiographic parameters including the degree of dorsal tilt, lateral carpal alignment, and patient age did not correlate with the time interval from fixation to tendon rupture.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Outcome Analysis of Distal Radius Fracture with Orthosis Versus Cast Immobilization after Palmar Plate Osteosynthesis: A Randomized Controlled Study

Although the benefits of hand orthoses were shown in previous studies, they have not been able to establish themselves in clinical routines. With a focus on patient satisfaction, this study aimed to evaluate the latest generation of hand orthoses after palmar plate osteosynthesis for isolated distal radius fractures in comparison with circular plaster casts. 50 patients (16% dropout rate) were randomly assigned to an orthotic group (immobilization by orthosis, OG) or a control group (immobilization by a plaster cast, CG). Intra-articular fractures were present in 74% of the cases, and unstable AO C3 fractures in 26%. Questionnaires on patient satisfaction, documentation of the time required, clinical scores (DASH, SF-36), range of motion, grip measurements and radiographs were used for evaluation. The OG proved to be equivalent to the plaster treatment in terms of patient satisfaction, and stability of the reduction, as well as clinical scores DASH and SF-36. The OG was even superior in terms of personal hygiene (p = 0.011), handling (p = 0.008) and better adaptability (p = 0.013). Significantly less time was required to apply the orthosis (p < 0.001). In addition to the good results achieved so far, the study showed that the latest generation of orthoses has several advantages over plaster cast therapy, and could therefore become established in everyday clinical practice.

Are Radiographic Characteristics Associated With Outcome in Surgically Treated Distal Radius Fractures?

PURPOSE

Evidence to date shows that distal radius fracture displacement measured on radiographs does not correlate with patient-reported outcomes. Quantitative 3-dimensional computed tomography (CT) (Q3DCT) potentially captures fracture displacement more accurately. We aimed to assess the independent association between radiographic, CT, and Q3DCT measures of residual displacement and change in disability, quality of life, range of motion (ROM), and grip strength 12 weeks and 1 year after volar plating of intra-articular distal radius fractures.

METHODS

We performed a secondary analysis of data from a prospective multicenter trial. Seventy-one patients underwent volar plating of their AO Foundation/Orthopaedic Trauma Association type B or C distal radius fracture and were available at 12 weeks; 67 (94%) were available at 1 year. We recorded demographics, postoperative periapical radiographs (radial height, ulnarward inclination, ulnar variance, gap, and step off), lateral radiographs (palmar tilt, scapholunate angle, teardrop angle, and anteroposterior distance), postoperative CT scans (gap [coronal, sagittal and axial]) and step off [sagittal and coronal]), and in 3-dimensional models (number of articular fragments, mean fragment articular surface area, 3-dimensional fragment displacement, and gap surface area). Radiographs and CT scans were obtained within 10 working days after fracture fixation. Outcome measures were change in Patient-Rated Wrist Evaluation (PRWE) scores, EuroQol Group 5-Dimension questionnaire (EQ5D) results, grip strength, and composite wrist ROM at 12 weeks and 1 year compared to preinjury level.

RESULTS

At 1 year, greater recovery in PRWE scores was independently associated with older age. Greater recovery in composite ROM at 1 year was associated with injury to the dominant side and less step-off on posteroanterior radiographs.

CONCLUSIONS

Less posteroanterior step-off was associated with a small improvement in composite wrist ROM at 1 year. This should be considered when counseling patients on the risks and benefits of surgical treatment when radiographic and CT measures of displacement fall within the range found in this study, and in older, low-demand patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Ulnar Nerve Translocation Following a Routine Distal Radius Fracture

A 35-year-old right hand dominant male sustained a high energy closed right distal radius fracture with associated generalized paresthesias. Following closed reduction, the patient was found to have an atypical low ulnar nerve palsy upon outpatient follow-up. After continued symptoms and an equivocal wrist MRI the patient underwent surgical exploration. Intraoperatively, the ulnar nerve as well as the ring and small finger flexor digitorum superficialis tendons were found to be translocated around the ulnar head. The nerve and tendons were reduced, the median nerve was decompressed, and the fracture was addressed with volar plating. Post-operatively, the patient continued to have sensory deficits and stiffness of the ring and small fingers. After one year, he reported substantial improvements as demonstrated by full sensation (4.0 mm two-point discrimination) and fixed flexion contractures at the proximal and distal interphalangeal joints of the small finger. The patient returned to work without functional limitations. This case highlights a unique case of ulnar nerve and flexor tendon entrapment following a distal radius fracture. History, physical examination, and a high index of clinical suspicion is essential for proper management of this rare injury. Level of Evidence: V.

Is tendinitis in volar plating related to the dorsally protruding screw length and its compartment?

OBJECTIVES

The aim of this study was to evaluate the relationship between the length of the protruded screws from the dorsal cortex and extensor tendon damage in all compartments.

PATIENTS AND METHODS

Between May 2020 and April 2021, a total of 29 patients (13 males, 16 females; mean age: 52.3±13.0 years; range, 30 to 78 years) who were operated and followed in our clinic for AO A2 and A3 distal radius fractures were included in this prospective study. Surface ultrasound (US) imaging was made to the dorsal sides of both wrists of the operated patients at different timepoints postoperatively. The length of screws with radius dorsal cortex penetration and the presence of tendinitis were recorded.

RESULTS

In 15 of 23 patients, the presence of 29 protruding screws was accompanied by tendinitis and, in eight patients, no tendinitis was observed, despite the partial protrusion of screws. A statistically significant correlation was found between the screw protrusion and presence of tendinitis (p<0.05). The number of protruding screws and tendinitis were seen mostly in the second compartment. There was a statistically significant correlation between the protruding screw length of >1.6 mm and the presence tendinitis (p<0.05).

CONCLUSION

Dorsal cortex screw protrusions in the application of volar plate for distal radius fractures can cause tendinitis. Screw protrusions occur more frequently in the second compartment and the development of tendinitis in this compartment is associated with a screw length of >1.6 mm. Screw penetration can be easily identified with intraoperative US to prevent tendinitis and potential tendon ruptures.

Distal Radius Fracture Treatment Outcomes in Patients With Ipsilateral Hemiplegia or Hemiparesis

BACKGROUND

Little information exists to guide decision-making with regard to distal radius fractures in the setting of ipsilateral hemiparesis or hemiplegia.

METHODS

Patients who sustained a distal radius fracture in the setting of ipsilateral hemiparesis or hemiplegia secondary to brain injury were evaluated. Investigated variables included perioperative pain, preinjury House functional classification score, length of immobilization, radiographic outcome measurements, and time to union.

RESULTS

There were 15 patients with distal radius fractures with a mean age of 65.9 years. The mean clinical and radiographic follow-up was 2.8 and 2.9 years, respectively. Wrists were placed into the nonoperative group (NOG, n = 10) and operative group (OG, n = 5). Pain significantly decreased at final follow-up for both groups. Baseline House functional classification scores averaged 1.3 and 1.6 for the NOG and OG, respectively, and were maintained at final follow-up. Length of immobilization for the NOG was 46 days and OG was 37 days, P = .15. Radiographic outcomes at final follow-up in the NOG and OG, respectively, were a mean radial height of 9.3 versus. 11.6 mm, radial inclination of 18.3° versus 22.3°, 4.2° dorsal tilt versus 5.3° volar tilt, and tear drop angle of 45.6° versus 44.5°. There were no significant differences in these measurements. Time to radiographic union averaged 58 days for the NOG and 67 days for the OG, P = .42. There were no revision surgeries.

CONCLUSIONS

Based on this small case series, patients with distal radius fracture and ipsilateral hemiparesis or hemiplegia may have similar clinical, functional, and radiographic outcomes, regardless of nonoperative or operative treatment.

Functional Outcomes After a Physiotherapy Program in Elderly Patients With Complex Regional Pain Syndrome Type I After Distal Radius Fracture: A Prospective Observational Study

BACKGROUND

No published prospective studies have reported the clinical effects of physiotherapy at 1-year follow-up in patients with complex regional pain syndrome type I (CRPS I) after distal radius fracture (DRF). The purpose of this study was to evaluate at 1-year follow-up the functional effects of physiotherapy program in elderly patients with CRPS I after extra-articular DRF.

METHODS

A total of 72 patients with CRPS I after DRF were prospectively recruited. All patients were treated with a 6-week supervised physiotherapy treatment. Three evaluations were performed: at the beginning, at the end of the treatment, and at 1-year follow-up. Wrist function, upper limb function, grip strength, and pain intensity were assessed with the Patient-Rated Wrist Evaluation (PRWE), Disabilities of the Arm, Shoulder, and Hand (DASH), Jamar dynamometer, and Visual Analogue Scale (VAS), respectively.

RESULTS

At 1-year follow-up, the PRWE showed a decrease of 21.6 points (Cohen's d = 2.8; 95% confidence interval [CI] = 18.6-24.6; P < .05); the DASH showed a decrease of 23.8 points (Cohen's d = 2.9; 95% CI = 20.8-26.7; P < .05); grip strength showed an increase of 40.6% (Cohen's d = 5.0; 95% CI = 43.5-37.6; P < .05); and the VAS showed a decrease of 2.6 cm (Cohen's d = 1.9; 95% CI = 2.11-3.16; P < .05).

CONCLUSION

At 1-year follow-up, a physiotherapy program showed clinically and statistically significant results in all functional outcomes in elderly patients with CRPS I after extra-articular DRF.

Operative Treatment of Distal Radius Fractures in Patients With Parkinson Disease

BACKGROUND

Owing to the many unique disease characteristics of Parkinson disease (PD)-namely resting tremors, muscular rigidity, and poor bone quality-we hypothesized that this patient population would have inferior outcomes with surgical management of acute distal radius fractures (DRFs) compared with the literature available on the general population.

METHODS

This is a retrospective observational study performed at a single, level 1, academic center from 2001 to 2020 capturing all adult patients with an isolated, acute, and closed DRF that ultimately underwent operative treatment. International Classification of Diseases 10 codes were used to identify 30 patients for manual chart review. Several patient and fracture characteristics were accounted for and complications, reoperations, and failures of surgical intervention were recorded.

RESULTS

There was a total of 7/30 failures (23%), 6/30 reoperations (20%), and 12 complications in 9/30 wrists (complication rate, 30%) at a mean latest follow-up of 11 months (1.2-158 months). Of the 7 failures, 5 were due to loss of reduction, and 2 of them were deep infections with mean time to failure of 8.3 weeks (range, 11 days-5.2 months).

CONCLUSIONS

This study found a high rate of complications, reoperations, and early failure despite a short follow-up period and a small cohort of patients with PD treated surgically for a DRF. We recommend locked plating if suitable for the fracture type and early involvement of a multidisciplinary team to assist with medical optimization of PD to increase chances of a successful outcome.

Does Time to Imaging and Surgery for Distal Radius Fractures Vary based on Geographic Socioeconomic Disadvantage?

BACKGROUND

While disparities in aspects of distal radius fracture (DRF) management and orthopedics at large have been studied, disparities in time to DRF evaluation and treatment are unknown. We sought to determine if geographic socioeconomic disadvantage is associated with time to imaging in the emergency department (ED) and time to surgery for DRFs.

METHODS

We performed a time-to-event analysis of 105 patients undergoing DRF surgery after ED triage within our hospital system between January 1, 2015, and January 1, 2020. Area Deprivation Index (ADI) national percentile was used as the metric of geographic socioeconomic disadvantage for each patient's ZIP code of residence. We performed Cox regression analysis to determine hazard ratios to undergo DRF imaging and surgery for patients in each ADI group, adjusting for potential confounders, α = 0.05.

RESULTS

There was no association between geographic socioeconomic disadvantage and time to DRF imaging, after adjusting for confounders. However, compared to patients from the least disadvantaged areas, patients from the most disadvantaged areas (ADI Quartiles 3 and 4) had an adjusted hazard ratio for surgery of 0.55 [0.32, 0.94] (P = .03), and were thus 45% [6%, 68%] less likely to undergo surgery for DRF at any time following ED triage.

CONCLUSIONS

Operative patients from more socioeconomically disadvantaged neighborhoods see disparities in time to surgery for DRF. Equitable access to timely surgical care is needed and may be improved with increased access to orthopedic surgeons, patient education, support in navigating the health system, and improved continuity of fracture care.

LEVEL OF EVIDENCE

Level III.

Does Time to Operative Intervention of Distal Radius Fractures Influence Outcomes?

BACKGROUND

No investigation has analyzed the time from injury to operative intervention and its effect on complications and functional outcomes in distal radius fractures. This investigation aimed to establish whether the time to surgical intervention from injury was associated with the observed rate of complications in distal radius fractures.

METHODS

A retrospective review of all orthopedic trauma patients who came to our center was conducted from 2008 through 2014. Patients who sustained closed distal radius fractures were included. A postoperative complication following distal radius fracture was defined as reoperation, superficial or deep infection, complex regional pain syndrome, new-onset carpal tunnel syndrome, tendon irritation, and symptomatic hardware.

RESULTS

In all, 190 patients were included in the study with a mean age of 48 years (SD ±14.7). According to the AO-Müller/Orthopaedic Trauma Association classification, radiographs revealed 80 A fractures, 15 B fractures, and 95 C fractures. Thirty distal radii were fixed within 0 to 3 days after injury, 91 patients within 4 to 10 days, and 69 patients after 10 days. Overall, 28 complications (14.7%) were identified. There was no statistical difference in the rate of complications between the time interval groups (P = .17).

CONCLUSIONS

Despite the increased popularity of surgical intervention for distal radius fractures, the optimal parameters to maximize patient outcomes have yet to be clearly defined. Time to intervention did not affect the rate of postoperative complication and range of motion.

A Narrative Review of the Uses of Ultrasound in the Evaluation, Analgesia, and Treatment of Distal Forearm Fractures

BACKGROUND

Distal forearm fractures are a commonly encountered injury in the emergency department (ED), accounting for 500,000 to 1.5 million visits and 17% of ED fractures. The evaluation and management of these fractures frequently employs x-ray studies, conscious sedation, closed reduction, and splinting. Point-of-care ultrasound (POCUS) can offer significant benefit in the diagnosis and management of these common injuries.

OBJECTIVE OF THE REVIEW

To review the clinical utility of POCUS in the diagnosis of distal forearm fractures, as well as to demonstrate the performance of ultrasound-guided analgesia delivery and ultrasound-guided reduction technique.

DISCUSSION

The initial evaluation of forearm injuries frequently includes x-ray studies. However, multiple studies have shown ultrasound to be sensitive and specific for distal radius fractures, with the added value of detecting soft tissue injuries missed by conventional radiography. POCUS may also facilitate analgesia through the use of ultrasound-guided hematoma blocks, which removes the need for conscious sedation prior to manipulation. Finally, POCUS can be used after manipulation to assess cortical realignment of the bone fragments and spare the patient multiple reduction attempts and repeat radiographs.

CONCLUSION

Distal forearm fractures are common, and the emergency physician should be adept with the evaluation and management of these injuries. POCUS can be a reliable modality in the detection of these fractures and can be used to facilitate analgesia and augment success of reduction attempts. These techniques may decrease length of stay, improve patient pain, and decrease reduction attempts.

Complete Intra-Operative Image Data Including 3D X-rays: A New Format for Surgical Papers Needed?

Intra-operative 3D X-rays have been confirmed to decrease revision rates and improve optimal screw placement in complex fractures of the distal radius. Compared with traditional surgical publications, another advantage of whole intraoperative clinical imaging can be presented in electronic databases, e.g., the ICUC working group, through a link without size limitation. The detail of complete intra-operative image dataset includes essential technical details which can be analyzed secondarily for costs and complications, considering the technical performance bias. Furthermore, the new format complies with reading/learning preferences of young surgeons and allows secondary work-up by artificial intelligence. Intra-operative 3D X-ray is a new approach for better surgical outcomes, economic benefit, and educational purposes.

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

BACKGROUND

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

MATERIALS AND METHODS

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

PRIMARY OUTCOME

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

SECONDARY OUTCOMES

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

RESULTS

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

CONCLUSIONS

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

TAKE HOME MESSAGES

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

LEVEL OF EVIDENCE

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

Computer-Generated Radiographic Measurements of Distal Radius Fractures: Does It Help With Decision Making?

PURPOSE

Operative management of distal radius fractures (DRFs) has become increasingly common. Age, activity levels, and comorbid conditions are major factors influencing the treatment decision, although operative indications are still controversial. Radiographic parameters (RPs), such as radial inclination, dorsal tilt, and articular step-off, can provide objective support for effective decision making. However, manual measurement of RPs may be imprecise and subject to inconsistency. To address this problem, we developed custom software of an algorithm to automatically detect and compute 6 common RPs associated with DRF in anteroposterior and lateral radiographs. The aim in this study was to assess the effect of this software on radiographic interobserver variability among orthopedic surgeons. Our hypothesis was that precise and consistent measurement of RPs will improve radiographic interpretation variability among surgeons and, consequently, may aid in clinical decision making.

METHODS

Thirty-five radiograph series of DRFs were presented to 9 fellowship-trained hand and orthopedic trauma surgeons. Each case was presented with basic clinical information, together with plain anteroposterior and lateral radiographs. One of the 2 possible treatment options was selected: casting or open reduction with a locking plate. The survey was repeated 3 weeks later, this time with computer-generated RP measurements. Data were analyzed for interobserver and intraobserver variability for both surveys, and the interclass coefficient, kappa value, was calculated.

RESULTS

The interobserver reliability (interclass coefficient value) improved from poor to moderate, 0.35 to 0.50, with the provided RP. The average intraobserver interclass coefficient was 0.68. When participants were assessed separately according to their subspecialties (trauma and hand), improved interobserver variability was found as well.

CONCLUSIONS

Providing computed RPs to orthopedic surgeons may improve the consistency of the radiographic judgment and influence their clinical decision for the treatment of DRFs.

CLINICAL RELEVANCE

Orthopedic surgeons' consistency in the radiographic judgment of DRFs slightly improved by providing automatically calculated radiographic measurements to them.

Percutaneous Threaded Pin Fixation of Distal Radius Fracture in the Athlete

BACKGROUND

The purpose of this study was to examine the outcomes and return to play with early rehabilitation in athletes who sustained unstable extra-articular distal radius fractures treated with a purpose-designed threaded pin technique.

METHODS

This prospective study examined athletes with displaced and unstable distal radius fractures treated surgically with purpose-designed threaded pins. Patients were enrolled in an early rehabilitation protocol, with formal therapy initiated on postoperative days 1 to 3. Range of motion and strength measurements were documented throughout the postoperative period, noting the time until return to athletic competition. These results were compared with historical values using other forms of fixation.

RESULTS

Nineteen athletes, average age of 35 years, were treated with threaded pin technique with early rehabilitation; all had complete healing and maintained alignment based on radiographic evaluation. The average time span between surgery and release to competition was 8 weeks, with all but 1 patient returning to sport within 12 weeks of injury. Average postoperative flexion measured 58°, extension was 57°, pronation was 81°, and supination was 74°. JAMAR grip strength in position 3 measured 25.22 kg, which equated to 73% of the uninjured side's grip strength at the time of release to play.

CONCLUSIONS

Surgical fixation using a purpose-designed threaded pin is a useful alternative to volar plating for isolated radial styloid and extra-articular distal radius fractures in athletes. The purpose-designed threaded pin may afford athletes rapid recovery during the early postoperative period, preserving strength and dexterity and minimizing time lost before return to play.