Evaluation of an Image-Based Tool to Examine the Effect of Fracture Alignment and Joint Congruency on Outcomes after Wrist Fracture

Some mal-alignment of the wrist occurs in up to 71% of patients following a distal radius fracture. A multiple case study was used to provide proof of principle of an image-based technique to investigate the evolution and impact of post-traumatic joint changes at the distal radioulnar joint. Participants who had a unilateral distal radius fracture who previously participated in a prospective study were recruited from a single tertiary hand center. Long term follow-up measures of pain, disability, range of motion and radiographic alignment were obtained and compared to joint congruency measures. The inter-bone distance, a measure of joint congruency was quantified from reconstructed CT bone models of the distal radius and ulna and the clinical outcome was quantified using the patient rated wrist evaluation. In all four cases, acceptable post-reduction alignment and minimal pain/disability at 1-year suggested good clinical outcomes. However, 10 years following injury, 3 out of 4 patients had radiographic signs of degenerative changes occurring in their injured wrist (distal radioulnar joint/radio-carpal joint). Proximity maps displaying inter-bone distances showed asymmetrical congruency between wrists in these three patients. The 10-year PRWE (patient rated wrist evaluation) varied from 4 to 60, with 3 reporting minimal pain/disability and one experiencing high pain/disability. These illustrative cases demonstrate long-term joint damage post-fracture is common and occurs despite positive short-term clinical outcomes. Imaging and functional outcomes are not necessarily correlated. A novel congruency measure provides an indicator of the overall impact of joint mal-alignment that can be used to determine predictors of post-traumatic arthritis and is viable for clinical or large cohort studies.

Analgesic effect of nasal salmon calcitonin during the early post-fracture period of the distal radius fracture

OBJECTIVES

To investigate the analgesic effect of nasal salmon calcitonin on the post-fracture period of distal radius fracture.

METHODS

In this prospective randomized double-blind study, forty-one postmenopausal women with a recent distal radius fracture treated conservatively were randomly assigned to receive either 200 IU of intranasal salmon calcitonin or placebo daily for 3 months following fracture. The assessment of the patient's pain was recorded using the Visual Analogue Scale (VAS).

RESULTS

The average age of the calcitonin group was 67.11 (SD, ±8.68) years and 64.91 (SD, ±7.48) of the placebo group. In the calcitonin group, the mean VAS score improved from 4.05 to 0.53 while in the placebo group from 3.36 to 0.32. A higher decrease of VAS score during the first post-fracture period was observed in the calcitonin group.

CONCLUSIONS

In the study, there is a statistically significant calcitonin mediated analgesic effect in the immediate post fracture period (at 10 days) when compared to placebo group. These results are in accordance with literature referring to the analgesic effect of calcitonin in the acute osteoporotic vertebral compression fracture. Thus calcitonin administration could be recommended to a short term course in acute osteoporotic conservatively treated distal radius fractures.

Predicting a safe screw length for volar plate fixation of distal radius fractures: lunate depth as a marker for distal radius depth

PURPOSE

We hypothesized that the lunate depth as measured on plain lateral radiographs can be used to predict distal radius depth radially and ulnarly and serve as a useful reference for intraoperative screw placement in volar plate fixation of distal radius fractures.

METHODS

Plain radiographs and magnetic resonance imaging (MRI) of the wrists of 30 patients were reviewed. The lunate depth and the maximal depth of the distal radius were determined from plain lateral radiographs. Depth of the distal radius, measured in quartiles, was determined from axial MRI images, and the lunate depth was obtained from sagittal MRI images. The depth of the distal radius in each quartile was then calculated related to the lunate depth.

RESULTS

The mean depth of the lunate on plain radiographs and MRI was 17.5 mm and 17.4 mm, respectively. The depth of the distal radius from ulnar to radial was 18.4 mm, 20.2 mm, 19.4 mm, and 15.1 mm for the 1st through 4th quartiles, respectively. The depth of the distal radius is the least radially (4th quartile), with a mean 87% of the lunate depth, and greatest in the 2nd quartile, with a mean 116% of the lunate depth.

CONCLUSIONS

The depth of the lunate as measured on plain radiographs can be used as a marker for drilling and placement of safe screw lengths during volar plate fixation of distal radius fractures. We recommend that surgeons use the lunate depth as an estimate for the length of their longest screw when fixing distal radius fractures with volar plate techniques to avoid extensor tendon irritation and rupture.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Improving compliance to osteoporosis workup and treatment in postmenopausal patients after a distal radius fracture

OBJECTIVE

Distal radius fracture (DRF) in postmenopausal women is often the first clinical sign of osteoporosis (OP). Despite the availability of effective treatments, only a minority of patients who sustain a fragility fracture are tested for OP. The purpose of this study was to examine whether a simple intervention by the hospital staff increases rates of OP workup.

MATERIALS AND METHODS

We conducted a prospective randomized clinical trial. Ninety nine patients after DRF were randomized to two groups. Both groups were contacted after their fracture and were asked to answer a questionnaire and were informed about the possible relationship between DRF and OP. In the intervention group, patients were sent an explanatory pamphlet and a letter to their primary care physician. An additional survey was conducted to establish whether the intervention improved the number of patients who undergo OP workup.

RESULTS

The intervention increased the proportion of patients who turned to their primary care physician from 22.9% to 68.6%, and increased the proportion of patients undergoing OP workup from 14.3% to 40% (p < 0.001).

CONCLUSION

Women with DRF who receive an explanation about possible OP implications and are sent explanatory materials are more likely to undergo OP workup.

The impact of patient activity level on wrist disability after distal radius malunion in older adults

OBJECTIVE

To determine if high-activity older adults are adversely affected by distal radius malunion.

DESIGN

Cross-sectional study.

SETTING

Hand clinics at a tertiary institution.

PARTICIPANTS

Ninety-six patients 60 years or older at the time of fracture were evaluated at least 1 year after distal radius fracture.

INTERVENTION

Physical Activity Scale of the Elderly scores stratified participants into high- and low-activity groups. Malunions were defined radiographically by change of ≥20 degrees of lateral tilt, ≥15 degrees radial inclination, ≥4 mm of ulnar variance, or ≥4 mm intra-articular gap or step-off, compared with the uninjured wrist.

MAIN OUTCOME MEASURE

Patient-rated disability of the upper extremity was measured by the QuickDASH and visual analog scales (VAS) for pain/function. Strength and motion measurements objectively quantified wrist function.

RESULTS

High-activity participants with a distal radius malunion were compared with high-activity participants with well-aligned fractures. There was no significant difference in QuickDASH scores, VAS function, strength, and wrist motion despite statistically, but not clinically, relevant increases in VAS pain scores (difference 0.5, P = 0.04) between the groups. Neither physical Activity Scale of the Elderly score (β = 0.001, 95% confidence interval: -0.002 to 0.004) nor malunion (β = 0.133, 95% confidence interval: -0.26 to 0.52) predicted QuickDASH scores in regression modeling after accounting for age, sex, and treatment. Operative management failed to improve outcomes and resulted in decreased grip strength (P = 0.05) and more frequent complications (26% vs. 7%, P = 0.01) when compared with nonoperative management.

CONCLUSIONS

Even among highly active older adults, distal radius malunion does not affect functional outcomes. Judicious use of operative management is warranted provided heightened complication rates.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Morphology of distal radius curvatures: a CT-based study on the Malaysian Malay population

INTRODUCTION

The purpose of this study was to examine the differing curves of the volar distal radius of healthy Malaysian Malays, so as to obtain detailed morphological information that will further the understanding of volar plate osteosynthesis in Malaysian Malays.

METHODS

Computed tomography with three-dimensional reconstruction was performed on the wrists of 16 healthy Malaysian Malay volunteers. Profile measurements were made using a software program. A novel parameter, the pronator quadratus curve angle, was explored and introduced in this study. Interclass correlation coefficients were calculated to assess the level of agreement between the data collected by the principal investigator and that collected by an independent radiologist.

RESULTS

The mean ± standard deviation of the arc radii on the radial aspect was 17.50° ± 5.40°, while the median (interquartile range [IQR]) of the arc radii on the ulnar aspect was 25.27° (IQR 5.80°). The mean ± standard deviation of the curvature of the pronator quadratus line was 40.52° ± 2.48°. The arc radii on the radial aspect was significantly lower than the arc radii on the ulnar aspect (p = 0.001). Different radial and ulnar arcs were observed in 56.25% of the radii; the arc was deeper on the ulnar aspect in 93.75% of the radii.

CONCLUSION

Based on the findings of this study, the likelihood of achieving anatomical reduction with uniformly curved, fixed-angle volar plates is questionable. Changes in the design of these implants may be needed to optimise their usage in the Malaysian Malay population.

Fractures of distal radius: an overview

Fractures of distal radius account for up to 20% of all fractures treated in emergency department. Initial assessment includes a history of mechanism of injury, associated injury and appropriate radiological evaluation. Treatment options include conservative management, internal fixation with pins, bridging and non-bridging external fixation, dorsal or volar plating with/without arthroscopy assistance. However, many questions regarding these fractures remain unanswered and good prospective randomized trials are needed.

Baseline pain intensity is a predictor of chronic pain in individuals with distal radius fracture

STUDY DESIGN

Secondary analysis of cohort study.

OBJECTIVE

This study examined whether baseline pain intensity is a predictor of chronic pain and wrist/hand functions at 1 year following distal radius fracture (DRF). The study also examined the cutoff level for baseline pain intensity that best predicted chronic pain.

BACKGROUND

Many individuals experience wrist/hand pain and functional impairments for as long as 1 year after DRF. Early identification of individuals at risk of these adverse outcomes can facilitate the delivery of required interventions to mitigate the risk.

METHODS

Data for the Patient-Rated Wrist Evaluation (PRWE) pain and function subscales at baseline and 1 year after DRF, age, sex, injury to the dominant side, presence of comorbidity, education level, mechanism of fracture, smoking status, fall history, and energy of fracture were extracted from an existing data set. Multivariate regression analysis examined the utility of baseline pain intensity and the above variables in predicting pain and functional status at 1 year in individuals with DRF. Receiver operating characteristic curves examined the sensitivity/specificity of baseline pain intensity in predicting chronic pain and functional impairment.

RESULTS

Required data were available for 386 individuals. Baseline pain intensity was found to be a strong predictor of chronic pain, explaining 22% of the variance. A baseline score of 35 out of 50 on the pain subscale of the PRWE had the best sensitivity (85%) and specificity (79%) cutoff values for predicting chronic pain at 1 year after DRF.

CONCLUSION

Rehabilitation practitioners may be able to use a score of greater than 35/50 on the PRWE pain subscale to screen individuals at risk of chronic pain following DRF.

LEVEL OF EVIDENCE

Prognosis, level 4.

Nuts and bolts: dimensions of commonly utilized screws in upper extremity surgery

A plethora of screw designs and sizes are available from multiple companies for use in upper extremity surgery. Knowing the dimensions of screws is critical in the treatment of bone of varying dimensions for fractures, osteotomies, or arthrodeses. Although many screws are named by their major thread diameter, this is not always true. Because of this confusing nomenclature and vast number of options, we sought to review the most commonly used screws and codify their dimensions into a readily available article and reference chart. This article highlights the basic dimensions of commonly used headless screws, stand-alone lag screws, non-locking and locking screws for plating, and biocomposite screws. Commonly described treatments using these screws include fixation of elbow, wrist, carpal, metacarpal, and phalangeal fractures and osteotomies, as well as arthrodeses of upper extremity joints. This article and its tables are by no means exhaustive of all commercially available implants. The focus is on the most commonly used implants in the United States as of 2014.

Estimating osteoporotic fracture risk following a wrist fracture: a tale of two systems

The WHO fracture risk assessment (FRAX) and Canadian Association of Radiologists and Osteoporosis Canada (CAROC) tools can both be used to determine an individual's 10-year risk of osteoporotic fracture. However, these tools differ in their risk calculation. For participants <65 years with a wrist fracture, FRAX provides a lower fracture risk estimate than CAROC resulting in fewer decisions to initiate therapy.

PURPOSE

The purpose of the current report is to compare fracture risk prediction rates using the CAROC and the FRAX® tools.

METHODS

Individuals ≥50 years with a distal radius fracture resulting from a fall from standing height or less were recruited from a single orthopedic clinic. Participants underwent a DXA scan of their lumbar spine and hip. Femoral neck (FN) bone mineral density (BMD) and fracture risk factors were used to determine each participant's 10-year fracture risk using both fracture risk assessment tools. Participants were categorized as low (<10 %), moderate (10-20 %), or high (>20 %) risk. Stratified by age (<65 years, >65 years), the proportion of participants in each category was compared between the tools.

RESULTS

Analyses included 60 participants (mean age 65.7 ± 9.6 years). In those <65 years (n = 26), the proportion of individuals at low, moderate, and high risk differed between the FRAX and CAROC tools (p < 0.0001). FRAX categorized 69 % as low (CAROC 0 %) and 3 % as high (CAROC 12 %) risk. For individuals >65 years, almost all were at least at moderate risk (FRAX 79 %, CAROC 53 %), but fewer were at high risk using FRAX (18 vs. 47 %, p < 0.0003).

CONCLUSION

For participants <65 years with a wrist fracture, FRAX provides a lower estimate of 10-year fracture risk than CAROC resulting in fewer decisions to initiate therapy. However, almost all participants >65 years were at moderate or high risk under both FRAX and CAROC and should at least be considered for pharmacotherapy.

Main health-related quality-of-life issues in patients after a distal radius fracture

AIM

The aim of this study was to identify and assess the degree and clinical course of the main health-related quality-of-life (HRQoL) issues in patients after a distal radius fracture (DRF).

MATERIALS AND METHODS

Patients were eligible if they were between 18-80 years and were within 1-3 days after a non-comminuted DRF. All patients filled out the Polish version of the IOF QLQ, the SF-36 and a demographic questionnaire. Assessment points were set as soon as possible after the fracture, 7 days, 6 weeks, 3 months, and 6 after the fracture. Standard statistical analyses were performed.

RESULTS

During the 16 month recruitment period a total of 71 patients (55 women - 77.5%), with a mean age of 64.1 ± 12.4 years, were included in the study group. All patients suffered from Colles type fractures. Attrition to follow-up was acceptable. At baseline, basing on the IOF QLQ scale scores, DRF patients had the most significant problems with physical function (82.8/100; with 100 representing the worst possible HRQoL), and general health (78.1/100). Basing on SF-36 scale scores patients most significant problems were associated with role limitations due to physical health problems (15.1/100; with 100 representing the best possible HRQoL), and bodily pain (39.5/100).

CONCLUSIONS

Concluding, this study shows that the main issues with which patients with and extra-articular DRF struggle the most are pain of the fractured extremity and physical dysfunction. These symptoms are most pronounced in the early post-injury period, and in the majority of patients steadily decrease over a period of six months.

Prophylactic corticosteroid injection in ulnar wrist pain in distal radius fracture

BACKGROUND

Ulnar sided wrist pain is one of the most common complications of distal radius fractures. The simplest method for decreasing pain for this affliction is corticosteroid injection. The present study was designed to assess the effect of corticosteroid injection in the prevention of ulnar sided wrist pain.

MATERIALS AND METHODS

In this clinical trial patients with distal radius fractures scheduled for closed reduction and percutaneous pin fixation were divided into control and corticosteroid groups. In the corticosteroid group, the patient received a single betamethasone injection in the dorsoulnar side of the wrist before reduction, while the control group received placebo. The patients were to be followed for at least 6 months.

RESULTS

82 patients were followed for 6 months. At the end of the 3 months followup the difference between the two groups about the number of individuals without ulnar sided wrist pain was statistically significant (P = 0.038), so that less patients in the control group were painless, while this was not the case in the 6 months followup (P = 0.507), but in the both time frames the mean grip power, visual analog pain score and the disabilities of the arm, shoulder and hand (DASH) score showed statistically significant difference between the two groups, so that the corticosteroid groups demonstrated greater power grip and less scores in pain and DASH (P < 0.05).

CONCLUSION

Based on the findings of the present study it seems that prophylactic corticosteroid injection will be associated with a decrease in the severity of wrist pain in patients with acute distal radius fractures. With regard to the decrease in the number of painless individuals, it seems that the decrease is not persistent. Overall the need for a study with longer followup is obvious.

Post-traumatic osteonecrosis of the lunate after fracture of the distal radius

We present a case of post-traumatic osteonecrosis of the lunate after fracture of the distal radius. Post-traumatic osteonecrosis of the carpal lunate after a fracture of the distal radius has, to our knowledge, not been reported previously. We treated the patient with vascularised bone graft from the distal radius, with a satisfactory result.

Treatment strategy for distal radius fractures with ipsilateral arteriovenous shunts

PURPOSE

To describe our management of 3 patients with chronic renal failure who sustained distal radius fractures in limbs containing dialysis shunts.

METHODS

The 3 patients were 48-61 years old, and 2 of them were men. Because the injured limbs contained arteriovenous shunts, tourniquets were not used. Volar locking plate fixation was applied via the Henry approach. The patients' grip strength; visual analog scale scores; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores; modified Mayo scores; and their range of wrist joint motion were assessed during the final follow-up examination. In addition, complications and the presence/absence of dysfunction of the forearm shunt were also investigated.

RESULTS

The mean duration of the postoperative follow-up period was 9 months (range, 7-10 mo), and the subjects' mean wrist motion values were 75°, 79°, 78°, and 87° during flexion, extension, pronation, and supination, respectively. Grip strength on the affected side as a percentage of that seen on the healthy side ranged from 71% to 90%. The patients' visual analog scale; QuickDASH; and modified Mayo scores were all excellent, and bone union was achieved in all 3 cases. No shunt dysfunction or skin soft tissue complications were noted.

CONCLUSIONS

Volar locking plate fixation via the Henry approach might be useful for treating distal radius fractures in cases in which an arteriovenous shunt is present in the same limb. Shunt dysfunction and hemorrhaging are of concern during open surgery, but these were not issues in our patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Routine imaging after operatively repaired distal radius and scaphoid fractures: a survey of hand surgeons

Background There is currently no standard of care for imaging after hand and upper-extremity procedures, and current imaging practices have not been characterized. Questions/Purposes To characterize current imaging practices and to compare those practices to the best available evidence. Patients and Methods A survey was distributed to attending-level surgeons at a regional hand and upper-extremity surgery conference in the United States in 2013. 40 out of 75 surgeons completed the survey (53%). Results All results are presented for distal radius and scaphoid fractures, respectively. There was a high degree of variability between respondents in the number of radiographic series routinely ordered during follow-up of asymptomatic patients, with the number of series ranging from 1-6 and 1-6. On average, respondents did not order an excessive number of follow-up radiographs for asymptomatic patients, with means (± standard deviations) of 2.6 ± 1.0 and 3.3 ± 1.2 radiographic series. Radiographic series were taken at only 74% and 81% of postoperative visits with asymptomatic patients. Only 10% and 8% of respondents felt it was acceptable medical practice to save costs by ordering postoperative radiographs only when patients are symptomatic. Conclusions Among a sample of 40 fellowship-trained hand surgeons, these findings demonstrate a high degree of variability in number of radiographs obtained after operative repair of distal radius and scaphoid fractures. On average, respondents were relatively efficient with respect to total number of postoperative radiographs ordered. Level of Evidence Diagnostic study, level IV.

The effect of brachioradialis release during distal radius fracture fixation on elbow flexion strength and wrist function

PURPOSE

To identify whether brachioradialis (BR) release during volar plate fixation for a distal radius fracture affects elbow flexion strength and wrist function.

METHODS

A total of 42 consecutive patients who were treated by open reduction volar plate fixation for unstable distal radius fractures were enrolled in this study. The BR was not released in 20 of 42 patients (BR preserved group) and was released in 22 patients (BR released group). The primary outcome variable was isokinetic strength and endurance testing of elbow flexion measured by the Cybex isokinetic system 3 months after surgery. Measured at the same time, secondary outcome variables were grip strength, a visual analog scale score for wrist pain, Disabilities of the Arm, Shoulder, and Hand score, and radiographic parameters. We used Mann-Whitney U tests to compare these variables between groups.

RESULTS

Neither elbow flexion strength and endurance nor any of the secondary outcome variables differed significantly between groups.

CONCLUSIONS

Release of the BR during a volar approach for a distal radius fracture did not adversely affect elbow flexion strength and wrist function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

External fixation versus open reduction with locked volar plating for geriatric distal radius fractures

The optimal management of displaced dorsal radius fractures (DRFs) in older patients remains an issue of debate. Bridging external fixation is a well-accepted treatment modality for severely comminuted DRFs, while open reduction and internal fixation with locked volar plating has emerged as a promising alternative in recent years. The current body of randomized trials supports the trend toward locked volar plating, as it allows for quicker improvement in subjective and functional outcomes. There is no clear evidence to suggest that one technique carries significantly less complications than the other. Locked volar plating should be considered in patients for whom an accelerated functional recovery would be advantageous. Otherwise, both external fixation and locked volar plating provide good long-term clinical outcomes.

Fracture of the distal radius: epidemiology and premanagement radiographic characterization

OBJECTIVE

Fractures of the distal radius are common and frequently encountered by the radiologist. We review the epidemiology, classification, as well as the concept of instability. Salient qualitative and quantitative features of the distal radius fracture identifiable on the routine radiography series are highlighted. We conclude with a synopsis of descriptors that are of greatest utility to the clinician for treatment planning and that should be addressed in the radiology report.

CONCLUSION

A detailed understanding of the intricacies of the distal radius fracture is necessary for the radiologist to provide a clinically relevant description.

Readmissions after treatment of distal radius fractures

PURPOSE

To assess the rates and associated diagnoses of readmissions for patients having received an intervention for treatment of distal radius fracture.

METHODS

We analyzed patient discharges from 2005-2011 for California, Florida, and New York. We used Agency for Healthcare Research and Quality data sets: (1) State Inpatient Database, (2) State Ambulatory Surgery Database, and (3) State Emergency Department Database. We examined inpatient, outpatient, and emergency room treatment locations. We identified patients by diagnosis code for distal radius fracture (813.41). Patients were stratified based on procedure codes for open reduction, closed reduction, and external fixation. The cohort was followed for 30 days to examine all-cause 30-day inpatient admissions and emergency department visits.

RESULTS

We identified 35,241 discharges with a primary diagnosis of distal radius facture. Of those, 18,388 patients underwent a procedure for their fracture, and 1,679 (9%) were readmitted within 30 days of discharge. Readmission rates varied by procedure type: internal fixation 8%, closed reduction 14%, and external fixation 11%. The most common diagnosis codes associated with readmission were general distal radius fracture codes (11%) and pain diagnoses (10%). Open procedures had higher odds of having a readmission associated with pain compared with closed treatment and external fixation.

CONCLUSIONS

Readmissions after treatment of distal radius fracture care are common. Our results show many distal radius fracture patients return to the health care system for pain-related issues. As more emphasis is placed on quality health care delivery, implementation of better pain management will be important to health care providers and patients.

CLINICAL RELEVANCE

This study highlights that improved perioperative pain control may improve patient care and reduce readmissions.

Fractures of the distal radius: postmanagement radiographic characterization

OBJECTIVE

The purpose of this article is to describe the management options available for the treatment of the distal radius fracture as well as potential associated complications.

CONCLUSION

There are a wide variety of currently accepted and used treatment options for fractures of the distal radius, ranging from closed reduction with casting to various forms of invasive surgical management. The radiologist must be familiar with these various forms of management to recognize complications when present on follow-up radiographs.

Preventing functional loss during immobilization after osteoporotic wrist fractures in elderly patients: a randomized clinical trial

BACKGROUND

Distal radius fractures are among the most common fractures and account for approximately one-sixth of all fractures diagnosed. Therapy results after distal radius fracture, especially of elderly patients, are often suboptimal. The inevitable immobilization for several weeks leads to reduction in range of motion, deterioration of muscle strength, malfunction of fine motor skills as well as changes of motor and sensory representations in the brain. Currently, there are no strategies to counteract these immobilization problems. The overall aim of the study is to investigate the therapeutic potential of motor-cognitive approaches (mental practice or mirror therapy) on hand function after wrist fracture.

METHODS/DESIGN

This study is a controlled, randomized, longitudinal intervention study with three intervention groups. One experimental group imagines movements of the fractured upper extremity without executing them (mental practice). The second experimental group receives a mirror therapy program consisting of the performance of functional movement synergies using the unaffected forearm, wrist, and hand. The control group completes a relaxation training regime. Additionally, all patients receive usual care by the general practitioner. We include women aged 60 years and older having a distal radius fracture and sufficient cognitive function. All groups are visited at home for therapy sessions 5 times per week for the first 3 weeks and 3 times per week for weeks 4 to 6. Measurements are taken at therapy onset, and after 3, 6 and 12 weeks. The primary outcome measure will assess upper extremity functioning (Patient-Rated Wrist Evaluation [PRWE]), while secondary outcome measures cover subjective wrist function (Disabilities of the Arm and Shoulder; [DASH], objective impairment (range of motion, grip force) and quality of life (EuroQol-5D, [EQ5D]).

DISCUSSION

Results from this trial will contribute to the evidence on motor-cognitive approaches in the early therapy of distal radius fractures.

TRIAL REGISTRATION

The trial is registered at ClinicalTrials.gov with registration number NCT01394809 and was granted permission by the Medical Ethical Review Committee of the University of Tübingen in June 2011.

Carpal malalignment in malunion of the distal radius and the effect of corrective osteotomy

Introduction Malunions of the distal radius often induce carpal malalignment. Two different types can be distinguished: an adaptive midcarpal malalignment (so-called CIA wrist: carpal instability, adaptive) and a radiocarpal malalignment (dorsal translation of the whole carpus). The effect of distal radial osteotomy on the carpal alignment has hardly been studied. Material and Methods 31 wrists in 31 patients (mean age 44 years) with malunion of the distal radius after a Colles fracture were treated with a corrective osteotomy. The patients were divided on basis of effective radio-lunate flexion (ERLF) in the two patterns of carpal malalignment. The radiographic changes were evaluated. Results There were 20 patients with midcarpal malalignment (ERLF ≤ 25°) and 11 with radiocarpal malalignment (ERLF > 25°). There was a correction of radial tilt and ulnar variance in both groups. There was a significant improvement of the carpal alignment in the midcarpal malalignment group, up to normal parameters. Neither age nor delay between fracture and osteotomy correlated. In the radiocarpal malalignment group a significant effect on the ERLF was observed. In the patients with dorsal plating 70% of the hardware had to be removed. Conclusion Distal radial osteotomy is a reliable technique for correction of the deformity at the distal end of the radius and carpal malalignment.

Ulnar shortening osteotomy for distal radius malunion

Background Malunion is a common complication of distal radius fractures. Ulnar shortening osteotomy (USO) may be an effective treatment for distal radius malunion when appropriate indications are observed. Methods The use of USO for treatment of distal radius fracture malunion is described for older patients (typically patients >50 years) with dorsal or volar tilt less than 20 degrees and no carpal malalignment or intercarpal or distal radioulnar joint (DRUJ) arthritis. Description of Technique Preoperative radiographs are examined to ensure there are no contraindications to ulnar shortening osteotomy. The neutral posteroanterior (PA) radiograph is used to measure ulnar variance and to estimate the amount of ulnar shortening required. An ulnar, mid-sagittal incision is used and the dorsal sensory branch of the ulnar nerve is preserved. An USO-specific plating system with cutting jig is used to create parallel oblique osteotomies to facilitate shortening. Intraoperative fluoroscopy and clinical range of motion are checked to ensure adequate shortening and congruous reduction of the ulnar head within the sigmoid notch. Results Previous outcomes evaluation of USO has demonstrated improvement in functional activities, including average flexion-extension and pronosupination motions, and patient reported outcomes. Conclusion The concept and technique of USO are reviewed for the treatment of distal radius malunion when specific indications are observed. Careful attention to detail related to surgical indications and to surgical technique typically will improve range of motion, pain scores, and patient-reported outcomes and will reduce the inherent risks of the procedure, such as ulnar nonunion or the symptoms related to unrecognized joint arthritis.

LEVEL OF EVIDENCE

 Level IV.

Headless bone screw fixation for combined volar lunate facet distal radius fracture and capitate fracture: case report

We report a case of concomitant fractures of the volar lunate facet of the distal radius and capitate body. Surgical fixation was achieved with open reduction internal fixation using headless compression screws for both fractures. Because of the nature of complications seen after both operative and nonsurgical management, these fractures warrant particular attention.

Ultrasound-assisted closed reduction of distal radius fractures

PURPOSE

To assess the accuracy and ability of ultrasound for monitoring closed reduction for distal radius fractures.

METHODS

Consecutive patients undergoing ultrasound-guided closed reduction of acute, displaced distal radius fractures between January 2003 and December 2006 at our department were enrolled. The control group was extracted from patients who underwent a closed reduction for similar fractures under fluoroscopy or without any imaging assistance. To confirm the accuracy of the ultrasonography measurements, displacement distance values were compared with those on radiographic imaging before and after reduction. X-ray parameters for pre- and postreduction, reduction time, total cost, and success rate were compared between the ultrasound-guided and the control groups.

RESULTS

The ultrasound-guided group consisted of 43 patients (mean age, 68 y) and the control group consisted of 57 patients, which included 35 patients (mean age, 74 y) with fluoroscopic reduction and of 22 patients (mean age, 72 y) with reduction unaided by imaging. There were no significant displacement differences between radiographic and ultrasound measurements. In x-ray parameters for pre- and postreduction, there were no significant differences between the 2 groups. Ultrasound-guided reduction took longer than the other 2 methods. The success rate of the ultrasound and the fluoroscopic groups were similar (95% and 94%, respectively).

CONCLUSIONS

Our data suggest that ultrasound assistance can aid reduction of distal radius fractures as well as fluoroscopy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Complications associated with operative versus nonsurgical treatment of distal radius fractures in patients aged 65 years and older

PURPOSE

To compare complication rates for distal radius fractures treated operatively versus nonsurgical in patients older than 65 years. We hypothesized that surgical intervention would improve fracture alignment, but it would be associated with more complications and equivalent functional outcomes when compared with the nonsurgical group.

METHODS

Patients (operative, n = 129) and controls (nonsurgical, n = 129) were identified from a prospective clinical and operating room database. They were matched on fracture severity (AO-A/B/C1 vs AO-C2/C3), sex, age, and energy of injury. Data on complications were extracted from medical charts using a validated complications checklist, and radiologic data were collected for all patients. Functional outcomes (Patient-Related Wrist Evaluation) at 1 year were available in only a subset of patients. We determined differences in complication and reoperation rates using a chi-square test.

RESULTS

A significant number of patients experienced complications in the operative group (operative = 37 of 129; nonsurgical = 22 of 129). The most common complication was median neuropathy (n = 8 operative; n = 14 nonsurgical), followed by surgical site infections (n = 16 operative; 12 of 16 were pin site infections) and complex regional pain syndrome (n = 4 operative; 3 nonsurgical). The complication rate in patients treated with volar plate was 22% (16 of 74), for dorsal plate it was 50% (2 of 4), for external fixation it was 42% (16 of 38), and for percutaneous pinning it was 23% (3 of 13). The number of patients requiring reoperations was similar in both groups (11 [9%] operative; 7 [5%] nonsurgical). Our secondary radiologic and functional outcomes demonstrate that despite a higher incidence of malunion in nonsurgical patients (nonsurgical: 69% vs operative: 29%), a subset of patients from both groups (n = 140) had minimal pain and disability at 1 year (Patient-Related Wrist Evaluation operative: 16.9 ± 23.2; nonsurgical: 15.7 ± 17.5).

CONCLUSIONS

In a study matching fracture severity, sex, age, and energy of injury, we found that elderly patients with distal radius fractures who underwent surgery had higher complication rates than those treated nonsurgically.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Relationship of bone mineral density of spine and femoral neck to distal radius fracture stability in patients over 65

PURPOSE

We hypothesized that an increasing degree of osteopenia in the femoral neck and lumbar spine would be associated with loss of reduction after closed manipulation and splinting of distal radius fractures in patients over 65 years of age.

METHODS

We performed a retrospective review, evaluating 78 patients with displaced distal radius fractures managed with closed reduction and splinting. T-scores from the lumbar spine and femoral neck were recorded from dual-energy x-ray absorptiometry scans performed either within 1 year before or after injury. Volar tilt, radial height, radial inclination, and ulnar variance were evaluated from the initial fracture, postreduction, and final follow-up radiographs. We calculated the percentage of reduction maintained regarding reduction variable. We correlated T-scores of the lumbar spine and femoral neck with the percentage of retained reduction.

RESULTS

We found no correlation between T-scores of the lumbar spine or femoral neck and the amount of reduction lost throughout the healing process of distal radius fractures with respect to volar tilt, radial height, radial inclination, or ulnar variance. Reduction was of no anatomical benefit in 53% to radial height, 44% to radial inclination, and 54% to ulnar variance.

CONCLUSIONS

There appears to be no relationship between bone mineral density, based on T-scores of the lumbar spine and femoral neck, and the ability to maintain reduction after closed manipulation and splinting of displaced distal radius fractures in patients over 65 years of age.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

Incidence of osteoporotic fractures in elderly women and men in Finland during 2005-2006: a population-based study

BACKGROUND AND AIMS

Osteoporosis is a major health concern in elderly population. Low-trauma fractures offer one way of identifying these patients for treatment. Population-specific incidences of osteoporotic fractures are essential to validate tools for clinical decision making.

MATERIAL AND METHODS

To evaluate population-based osteoporotic fracture incidences in Central Finland, we performed a manual search of low-trauma fractures 2005-2006 from the records of all the local health-care organizations treating trauma patients. We identified low-trauma fracture patients from radiology reports from five health centers serving the inhabitants of nine municipalities and from the patient records of two hospitals in Central Finland. The manually collected data were then compared against data from the Finnish Health Care Register.

RESULTS

The crude incidence of all osteoporotic fractures in 2005-2006 in the population aged 50 years was 1254/100,000 person years: 694/100,000 person years in men and 1718/100,000 person years in women. Fracture numbers derived from register data were similar to those manually collected for hip and humerus fractures, but clearly smaller than those for wrist and ankle fractures.

CONCLUSIONS

Population-based low-trauma fracture incidences, reported here for Finland, constitute a basis for calibration of fracture risk evaluation tools (e.g. the World Health Organization fracture risk evaluation tool, FRAX). This study showed that register data underestimate the incidences of, in particular, distal radius and ankle fractures.

Distal radioulnar joint kinematics in simulated dorsally angulated distal radius fractures

PURPOSE

To examine the effects of dorsal angulation deformities of the distal radius with and without triangular fibrocartilage complex (TFCC) rupture on the 3-dimensional kinematics of the distal radioulnar joint (DRUJ) during simulated active motion.

METHODS

Nine fresh-frozen cadaveric specimens were tested in a forearm simulator that produced active forearm rotation. Dorsal angulation deformities of the distal radius with 10°, 20°, and 30° angulation were created. Changes in the position of the ulna relative to the radius at the DRUJ as a consequence of each dorsal angulation deformity were quantified during simulated active supination in terms of volar, ulnar, and distal displacement of the ulna. Testing was performed initially with the TFCC intact and repeated after complete sectioning of the TFCC at its ulnar insertion.

RESULTS

Increasing dorsal angulation deformities of the distal radius significantly increased volar, ulnar, and distal displacement of the ulna when the TFCC was intact. Sectioning of the TFCC significantly increased volar displacement of the ulna in dorsal angulation deformities. As little as 10° of dorsal angulation significantly increased distal displacement of the ulna with the TFCC intact and resulted in a significant increase in volar, ulnar, and distal displacement of the ulna with sectioned TFCC.

CONCLUSIONS

Dorsal angulation deformities of the distal radius affect the 3-dimensional kinematics of the DRUJ, especially with the TFCC sectioned.

CLINICAL RELEVANCE

The progressive change in DRUJ kinematics with increasing dorsal angulation may partially explain the relationship between the magnitude of dorsal angulation of distal radius fractures and functional outcomes in younger patients. The status of the TFCC should be evaluated carefully, as well as the magnitude of osseous deformity in patients with distal radius fractures and malunions, because changes in DRUJ kinematics caused by dorsal angulation are greater when the TFCC is ruptured.

Treatment of reducible unstable fractures of the distal radius: randomized clinical study comparing the locked volar plate and external fixator methods: study protocol

BACKGROUND

Various treatments are available for reducible unstable fractures of the distal radius, such as closed reduction combined with fixation by external fixator (EF), and rigid internal fixation using a locked volar plate (VP). Although there are studies comparing these methods, there is no conclusive evidence indicating which treatment is best. The hypothesis of this study is that surgical treatment with a VP is more effective than EF from the standpoint of functional outcome (patient-reported).

METHODS/DESIGN

The study is randomized clinical trial with parallel groups and a blinded evaluator and involves the surgical interventions EF and VP. Patients will be randomly assigned (assignment ratio 1:1) using sealed opaque envelopes. This trial will include consecutive adult patients with an acute (up to 15 days) displaced, unstable fracture of the distal end of the radius of type A2, A3, C1, C2 or C3 by the Arbeitsgemeinschaft für Osteosynthesefragen-Association for the Study of Internal Fixation classification and type II or type III by the IDEAL32 classification, without previous surgical treatments of the wrist. The surgical intervention assigned will be performed by three surgical specialists familiar with the techniques described. Evaluations will be performed at 2, and 8 weeks, 3, 6 and 12 months, with the primary outcomes being measured by the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and measurement of pain (Visual Analog Pain Scale and digital algometer). Secondary outcomes will include radiographic parameters, objective functional evaluation (goniometry and dynamometry), and the rate of complications and method failure according to the intention-to-treat principle. Final postoperative evaluations (6 and 12 months) will be performed by independent blinded evaluators. For the Student's t-test, a difference of 10 points in the DASH score, with a 95% confidence interval, a statistical power of 80%, and 20% sampling error results in 36 patients per group.

DISCUSSION

Results from this study protocol will improve the current evidence regarding to the surgical treatment these fractures.

TRIAL REGISTRATION

ISCRTN09599740.

Primary excision of the ulnar head for fractures of the distal ulna associated with fractures of the distal radius in severe osteoporotic patients

We performed primary excision of the ulnar head on 23 patients over 70 years of age with severe comminuted fractures of both the distal radius and ulna. The distal radius fracture was fixed rigidly with a volar locking plate, and the ulnar head was resected at the fracture site. All the distal radial fractures united without major complications. The mean wrist flexion/extension arc was 122°, the mean pronation/supination arc was 164°, and grip strength was 69% of that on the contralateral side. All patients returned to their daily activities within a short time without any additional surgical treatment. For elderly patients, primary excision of the ulnar head is an effective treatment for comminuted distal radius and ulna fractures.

Fixation of distal ulna fractures associated with distal radius fractures using intrafocal pin plate

Background Unstable distal ulna fractures in the setting of distal radius fractures can present a challenging problem, especially in the elderly population. Operative fixation of the subcapital distal ulna fracture may help to provide a stable ulnar buttress for attempting to reduce the distal radius fracture. Traditional fixation techniques of the distal ulna may prove unsatisfactory in the setting of osteoporosis and comminution. Description The intrafocal pin plate is placed through a small incision distally and uses the curve of the plate to obtain multiple points of fixation within the intramedullary canal. The overhang of the distal aspect of the plate helps to reduce the fracture. The plate is secured using unicortical locking screws in the ulnar head. Patients and Methods The most ideal fracture pattern for this fixation technique is a subcapital distal ulna fracture that is unstable and associated with a distal radius fracture. This technique is contraindicated in ulnar head fractures, segmental fractures with proximal extension, and open fractures with gross contamination as well as in the setting of active infection. Results This technique has provided a stable ulnar buttress and aided in the reduction of grossly unstable distal radius fractures. All of these patients have gone on to union, and we have not experienced a need for plate removal due to pain or soft tissue irritation. Conclusions We have found the intrafocal pin plate to provide both a stable ulnar buttress as well as intramedullary fixation to aid in the fixation of distal radius fractures associated with unstable distal ulna subcapital fractures.

Influence of ulnar translation of the radial shaft in distal radius fracture on distal radioulnar joint instability

It has been reported that the distal interosseous membrane (DIOM) of the forearm constrains the dorsal dislocation of the distal radius. A residual ulnar translation deformity of the radial shaft in distal radius fractures has the potential to cause distal radioulnar joint (DRUJ) instability when triangular fibrocartilage complex (TFCC) injury is also present, because it may result in detensioning of the DIOM. Correction of ulnar translation of the radial shaft is critical because it restores DIOM tension, which then firmly holds the ulnar head in the concavity of the sigmoid notch.

The results of volar locking plate fixation for the fragility fracture population with distal radius fracture in Japanese women

The purpose of this study was to determine whether volar locking plate fixation for distal radius fracture benefits the fragility fracture population as much as it benefits the non-fragility fracture population. This matched case-control study was conducted based on a multi-center clinical prospective cohort. A comparison of treatment outcomes after volar locking plate fixation was made between females 55 years of age and older (fragility fracture population) and males less than 75 years of age (non-fragility fracture population) by evaluating clinical, radiological, and subjective outcomes using Hand20, a validated patient-rated disability instrument. A total of 170 patients were enrolled in this study. The two cohorts were matched in terms of AO fracture type. The fragility fracture population group and the non-fragility fracture population group each consisted of 50 patients. All objective measurements including wrist range of motion and radiological evaluations, but excluding grip strength, were not significantly different between the two groups. However, the Hand20 at 18 months after surgery was worse in the fragility fracture population group than in the non-fragility fracture population group. Carpal tunnel syndrome was the most frequently encountered complication in the fragility fracture population group, with one case (2%) in the non-fragility fracture population group and six cases (12%) in the fragility fracture population group, but the difference was not significant. In conclusion, there was a significant deficit in the improvement in disability despite favorable radiological and functional outcomes in fragility fracture population patients. Therefore, the fragility fracture population, especially middle-aged or older women, needs to be informed about prolonged disability and the higher risk of upper extremity disorders prior to surgery.

One size does not fit all: distal radioulnar joint dysfunction after volar locking plate fixation

Background Fractures of the distal radius are among the most common injuries treated by orthopedic surgeons worldwide. Failure to restore distal radius alignment can lead to fracture malunion and poor clinical outcomes, including distal radioulnar joint (DRUJ) instability and limitation of motion. Case Description We present a unique case of DRUJ dysfunction following volar plate fixation of bilateral distal radius fractures and analyze the biomechanical causes of this complication. As a result of a relatively excessive tilt of the precontoured locking plate (in comparison to the patient's particular anatomy), the fracture on one side was "over-reduced," disrupting the biomechanics of the DRUJ, causing a supination block. Clinical Relevance Volar locking plates are not a panacea to all distal radius fractures. Plate selection and fixation technique must include consideration of patient anatomy. Robust plates offer the advantage of providing rigid fixation but can be difficult to contour when reconstructing normal anatomy. Restoration of patient-specific anatomy is crucial to the management of distal radius fractures.

Radiographic and Arthroscopic Assessment of DRUJ Instability Due to Foveal Avulsion of the Radioulnar Ligament in Distal Radius Fractures

Background As the triangular fibrocartilage complex (TFCC) anchors the distal radius to the ulna via the radioulnar ligament (RUL), a severely displaced distal fragment of the radius may be associated with a foveal avulsion of the TFCC. The purpose of this retrospective study was to assess, radiographically and arthroscopically, the relationship between displacement of the radius, the ulnar styloid, and avulsion of the RUL resulting in distal radioulnar joint (DRUJ) instability. Materials and Methods Twenty-nine wrists of 29 patients with intra- and extra-articular distal radius fractures/malunion who underwent reduction or a corrective osteotomy of the displaced/malunited fracture, and/or wrist arthroscopy, were assessed radiographically and arthroscopically. Radial translation, radial inclination, radial shortening, volar or dorsal tilt, and the presence of an ulnar styloid fracture with more than 4 mm of displacement were measured from the initial films. Radiocarpal arthroscopy was used to assess peripheral lesions of the TFCC, while DRUJ arthroscopy was used to assess the foveal attachment. The relationship between displacement of the distal radius or the ulnar styloid fracture and the TFCC injury, including avulsion of the RUL, was recorded. Results Univariate analysis revealed that increased radial translation, decreased radial inclination, increased radial shortening, and an ulnar styloid fragment radially displaced by more than 4 mm were significant predictors of RUL avulsion at the fovea. Volar or dorsal tilt of the radius and ulnar variance did not correlate with RUL avulsion or TFCC injuries. Multiple logistic regression analysis revealed that radial translation was an independent risk factor of foveal avulsion of the RUL. Conclusions Increased radial translation and radial shortening and decreased radial inclination of the distal fragment can be associated with a foveal avulsion of the RUL. Radial translation can be an independent risk factor of foveal avulsion of the RUL.

Pulmonary thromboembolism after operation for bilateral open distal radius fractures: a case report

BACKGROUND

Pulmonary thromboembolism after upper extremity operation is rare. We report a patient with thromboembolism after debridement open reduction and internal fixation for bilateral open distal radius fractures.

CASE PRESENTATION

The Japanese patient was an 80-year-old previously healthy female who was able to walk on her own. She fell down and was taken to our hospital. She was diagnosed with bilateral open distal radius fractures and we performed debridement open reduction and internal fixation on the same day. Although she could not walk and was depressed, she was discharged on the ninth postoperative day. However, on the eleventh postoperative day, she returned to our emergency department with complaints of dyspnea and cold sweat. Her serum D-dimer level was 19.0 μg/dl, troponin T was positive, and urgent contrast computed tomography scan of her thorax revealed thrombosis in the bilateral main pulmonary artery. She was diagnosed with pulmonary thromboembolism and admitted to our hospital again. On the second admission, although she had breathing problems, she did not require a respirator. Oxygen was supplied as well as anticoagulants. On the seventh day after being diagnosed with embolism, thrombosis in the bilateral main pulmonary arteries had disappeared.

CONCLUSION

The patient did not have any "strong" risk factors as reported in the Japanese Orthopedic Association Clinical Practice Guideline on the Prevention of Venous Thromboembolism in Patients Undergoing Orthopedic Treatments. In general, upper extremity operation carries a low risk for pulmonary thromboembolism. For patients with decreased activity of daily living and depression, we should consider postponing discharge and performing rehabilitation until activity of daily living is improved.

Preliminary validation of the IOF QLQ and comparison with the SF-36 in patients after a distal radius fracture

AIM

The aim of this study was to report preliminary validation data on the Polish version of the International Osteoporosis Foundation Quality of Life Questionnaire (IOF QLQ) for patients with a distal radius fracture (DRF).

MATERIALS AND METHODS

Patients were eligible if they were between 18-80 years and were within 1-3 days after a non-comminuted DRF. All patients filled out the Polish version of the IOF QLQ, the Short Form 36 (SF-36) and a demographic questionnaire. Assessment points were set as soon as possible after the fracture, 7 days, 6 weeks, and 3 months after the fracture. Standard va- lidity and reliability analyses were performed.

RESULTS

Fifty-eight patients (42 women - 72.4%) agreed to take part in the study (mean age of the group 65.7 ± 9.3 years). Cronbach's alpha coefficients showed positive internal consistency (0.82- 0.87). The interclass correlations for the IOF QLQ domains and the overall score ranged from 0.82 to 0.93. Satisfactory convergent and discriminant validity of the IOF QLQ was seen.

CONCLUSIONS

Preliminary data show that the Polish version of the IOF QLQ for patients with a DRF is a reliable and valid tool for measuring health-related quality-of-life (HRQoL). However, further studies are needed to demonstrate the full psychometric and clinical properties of the IOF QLQ in patients with a fracture of the wrist.

The effects of dorsally angulated distal radius fractures on distal radioulnar joint stability: a biomechanical study

Relationship between dorsal tilt of the distal radius and distal radioulnar joint stability was examined. Stiffness in dorsopalmar displacement of the radius (distal radioulnar joint stiffness) was recorded at 10° intervals until 30° of dorsal angulation from 10° of palmar tilt. Tests were repeated after partial sectioning of the radioulnar ligament, then after complete sectioning of the radioulnar ligament. All data were compared with control (intact triangular fibrocartilage complex, 10° of palmar tilt). The distal radioulnar joint stiffness in dorsal translation decreased significantly with dorsal tilt 10° and 20° in pronation. Partial sectioning of the radioulnar ligament indicated a decrease of the distal radioulnar joint stiffness in the dorsal translation at neutral tilt to 20° of dorsal tilt in the neutral position and in pronation. Distal radioulnar joint stiffness decreased significantly in both dorsal and palmar translations in all forearm positions at 10° and 20° of dorsal tilt. From these findings, the dorsal angulation of the radius should be corrected to less than 10° of dorsal tilt.

Flexor pollicis longus dysfunction after volar plate fixation of distal radius fractures

PURPOSE

To evaluate the natural history and etiology of decreased thumb interphalangeal (IP) joint flexion after volar plate fixation of distal radius fractures.

METHODS

A total of 46 patients who underwent volar plating of 48 distal radius fractures by a single surgeon were retrospectively studied. Of those patients, 24 (24 wrists) exhibited loss of thumb IP joint flexion (group 1) and 22 (24 wrists) retained thumb IP joint flexion (group 2) with attempted thumb opposition to the small finger after surgery. All patients were seen at regular intervals until IP joint flexion returned and fracture healing was confirmed radiographically. Patient demographics, fracture patterns, surgical variables, and final radiographs were compared between groups. Twenty patients in group 1 were seen after a mean of 6.5 months (range, 5-12 mo) for specific outcome measurements. Eight cadaveric specimens were used to replicate the flexor carpi radialis approach to the distal radius and evaluate flexor pollicis longus tendon excursion.

RESULTS

There were no significant differences in fracture pattern, patient age or sex, injured extremity dominance, time to surgery, incision length, plate composition, plate length, tourniquet time, or final wrist radiographs between groups. In group 1, active thumb IP joint flexion returned on average 52 days (range, 19-143 d) postoperatively. At final evaluation in this group, mean IP joint flexion was 11° less than the contralateral thumb IP joint; however, patient-determined outcomes were favorable in most cases. In the cadaveric specimens, excursion of the flexor pollicis longus tendon decreased with sequential soft tissue dissection and retraction.

CONCLUSIONS

Loss of thumb IP joint flexion after volar plating of distal radius fractures was common, and motion returned to near normal in most cases within 2 months. Partial stripping of the flexor pollicis longus muscle from investing fascia and bone and retraction of soft tissues are likely etiological factors.

Wrist and Radius Injury Surgical Trial (WRIST) Study Group. Reflections 1 year into the 21-Center National Institutes of Health--funded WRIST study: a primer on conducting a multicenter clinical trial

The Wrist and Radius Injury Surgery Trial (WRIST) study group is a collaboration of 21 hand surgery centers in the United States, Canada, and Singapore, to showcase the interest and capability of hand surgeons to conduct a multicenter clinical trial. The WRIST study group was formed in response to the seminal systematic review by Margaliot et al and the Cochrane report that indicated marked deficiency in the quality of evidence in the distal radius fracture literature. Since the initial description of this fracture by Colles in 1814, over 2,000 studies have been published on this subject; yet, high-level studies based on the principles of evidence-based medicine are lacking. As we continue to embrace evidence-based medicine to raise the quality of research, the lessons learned during the organization and conduct of WRIST can serve as a template for others contemplating similar efforts. This article traces the course of WRIST by sharing the triumphs and, more important, the struggles faced in the first year of this study.

Causes of a block to forearm rotation after distal radius fractures

Three cases of a block to forearm rotation after a distal radius fracture were presented. The unique feature is that the surgeon should be diligent in seeking and rectifying causes of distal radioulnar joint (DRUJ) instability and rotation loss after fracture treatment.

Functional consequence of distal brachioradialis tendon release: a biomechanical study

PURPOSE

Open reduction and internal fixation of distal radius fractures often necessitates release of the brachioradialis from the radial styloid. However, this common procedure has the potential to decrease elbow flexion strength. To determine the potential morbidity associated with brachioradialis release, we measured the change in elbow torque as a function of incremental release of the brachioradialis insertion footprint.

METHODS

In 5 upper extremity cadaveric specimens, we systematically released the brachioradialis tendon from the radius and measured the resultant effect on brachioradialis elbow flexion torque. We defined release distance as the distance between the release point and the tip of the radial styloid.

RESULTS

Brachioradialis elbow flexion torque dropped to 95%, 90%, and 86% of its original value at release distances of 27, 46, and 52 mm, respectively. Importantly, brachioradialis torque remained above 80% of its original value at release distances up to 7 cm.

CONCLUSIONS

Our data demonstrate that release of the brachioradialis tendon from its insertion has minor effects on its ability to transmit force to the distal radius.

CLINICAL RELEVANCE

These data imply that release of the distal brachioradialis tendon during distal radius open reduction internal fixation can be performed without meaningful functional consequences to elbow flexion torque. Even at large release distances, overall elbow flexion torque loss after brachioradialis release would be expected to be less than 5% because of the much larger contributions of the biceps and brachialis. Use of the brachioradialis as a tendon transfer donor should not be limited by concerns of elbow flexion loss, and the tendon could be considered as an autograft donor.

Aspects of current management of distal radius fractures in the elderly individuals

Diatal radius fractures (DRFs) are typical fractures of relatively fit persons with osteoporotic bone who remain active into older age. Traditionally, DRFs in older patients have been treated with closed reduction and cast immobilization. Considering the increasing life expectancy of the elderly population, appropriate management of these fractures is of growing importance. Decision making for surgical or nonsurgical approach to osteoporotic DRFs is difficult. These decisions are often made based on the data from treatments of much younger patients. The current literature concerning the treatment of DRFs in the elderly individuals is more controversial. Some investigators have recommended open reduction internal fixation (ORIF) as treatment for unstable DRFs in older patients, while others have suggested that elderly patients should be treated nonsurgically even if there is an unstable fracture situation because fracture reduction is not associated with functional outcomes as in younger patients. This article reviews the different treatment options for DRFs in the elderly individuals reported in the recent literature.

Pediatric hand and wrist injuries

In the last 40 years, childhood hand and wrist injuries have become progressively more common as children have become heavier and more active in high impact sports. The majority of children with such injuries do well, but treatment is not always straightforward. Distal radius fractures, scaphoid fractures, metacarpal and phalangeal fractures, nailbed injuries, and amputations are among the pediatric hand and wrist injuries most often seen by orthopedists. These are all discussed, with a focus on the most recent literature and areas of evolving controversy.

An Asian perspective on the management of distal radius fractures

There is limited data regarding the epidemiology, pathology, and management of distal radius fractures from centers in Asia. The advanced economies in Asia include Hong Kong, Japan, Korea, Singapore, and Taiwan, whereas the prominent emerging economies are China, India, Malaysia, Philippines, and Thailand. This article examines the available epidemiological data from Asia, compares the management of distal radius fractures in the advanced and emerging Asian economies and how they compare with the current management in the west. It concludes by offering solutions for improving outcomes of distal radius fractures in Asia.

The epidemiology of distal radius fractures

Distal radius fractures are one of the most common types of fractures. Although the pediatric and elderly populations are at greatest risk for this injury, distal radius fractures still have a significant impact on the health and well-being of young adults. Data from the past 40 years have documented a trend toward an overall increase in the prevalence of this injury in both the pediatric and elderly populations. Understanding the epidemiology of this fracture is an important step toward the improvement of treatment strategies and the development of preventive measures with which to target this debilitating injury.

Distal Radius Fracture Hematoma Block with Combined Lidocaine and Bupivacaine can induce Seizures while within Therapeutic Window: A Case Report

INTRODUCTION

Hematoma blocks are effective pain management modalities for closed reduction of distal radius fractures. Complications of hematoma blocks are associated with systemic reaction to anesthetic used.

CASE REPORT

We present a case report of an elderly patient who received a hematoma block of lidocaine and bupivacaine for a distal radius fracture and subsequently developed a generalized tonic clonic seizure. The dose of both lidocaine and bupivacaine were well within the suggested dose limit. The episode was self limiting and patient had the cast applied.

CONCLUSIONS

We conclude that hematoma blocks with a combination of anesthetics may decrease the threshold to neurologic complications, especially in elderly patients. Precautions and ready treatment measures should be made available while performing closed reduction.

Distal radioulnar joint injuries

Distal radioulnar joint is a trochoid joint relatively new in evolution. Along with proximal radioulnar joint, forearm bones and interosseous membrane, it allows pronosupination and load transmission across the wrist. Injuries around distal radioulnar joint are not uncommon, and are usually associated with distal radius fractures,fractures of the ulnar styloid and with the eponymous Galeazzi or Essex_Lopresti fractures. The injury can be purely involving the soft tissue especially the triangular fibrocartilage or the radioulnar ligaments. The patients usually present with ulnar sided wrist pain, features of instability, or restriction of rotation. Difficulty in carrying loads in the hand is a major constraint for these patients. Thorough clinical examination to localize point of tenderness and appropriate provocative tests help in diagnosis. Radiology and MRI are extremely useful, while arthroscopy is the gold standard for evaluation. The treatment protocols are continuously evolving and range from conservative, arthroscopic to open surgical methods. Isolated dislocation are uncommon. Basal fractures of the ulnar styloid tend to make the joint unstable and may require operative intervention. Chronic instability requires reconstruction of the stabilizing ligaments to avoid onset of arthritis. Prosthetic replacement in arthritis is gaining acceptance in the management of arthritis.