Comparison of treatment outcomes between nonsurgical and surgical treatment of distal radius fracture in elderly: a systematic review and meta-analysis

Outcomes of Distal Radius Fractures in Solid Organ Transplant Recipients

PURPOSE

Distal radius fractures (DRFs) are one of the most common conditions that musculoskeletal providers treat. As the frequency of solid organ transplants (SOT) increases, these providers are often called upon to manage DRFs in these patients. These patients are at increased risk for osteopenia and osteoporosis, given the altered bone metabolism after SOT and frequent use of glucocorticoid and immunosuppressive medications. This study aimed to examine both surgical and nonsurgical treatment outcomes of DRFs in the SOT population and the prevalence of decreased bone mineral density.

METHODS

A retrospective review of patients treated at a single institution who had previously undergone SOT and subsequently sustained DRF between 2013 and 2022 was completed. Patients were excluded for incomplete documentation and treatment initiation at an outside institution. Demographic variables, clinical outcomes, organ transplant, steroid use, and second metacarpal cortical percentage were collected for both groups. A telephone survey with the QuickDASH questionnaire was conducted for all available patients.

RESULTS

A total of 34 DRFs in 33 patients were included in the analysis. Of these, 15 fractures in 14 patients underwent surgical intervention, and 19 fractures in 19 patients were managed nonsurgically. The following three adverse events were observed in the patients managed operatively: hardware failure, postoperative carpal tunnel syndrome, and tendon irritation. No reported treatment complications were recorded in the patients managed nonsurgically. Of the 33 included patients, 32 had radiographic evidence of decreased bone mineral density and five were receiving treatment for osteoporosis.

CONCLUSIONS

Management of DRFs in SOT patients is challenging, given their increased medical complexity. Decreased bone mineral density was nearly universal and undertreated in this patient population. Most of these patients in both groups had good or excellent functional outcomes with both surgical and nonsurgical management. Additionally, surgery was well tolerated with no reported anesthesia complications, wound-healing issues, or infections.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Evaluation of the Efficacy of the Traditional Chinese Medicine Formulation Ru-Yi-Jin-Huang-Saan on Colles Fracture After Surgery: Protocol for a Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Colles fracture, a common wrist injury, often requires surgical intervention. After surgery, patients may experience persistent pain and reduced wrist function, potentially resulting in long-term disability. In clinical practice, traditional Chinese medicine practitioners frequently use Ru-Yi-Jin-Huang-Saan (RYJHS) to treat such patients in Taiwan. RYJHS is a traditional Chinese herbal formula with a history spanning centuries, primarily used topically for the treatment of bone fractures and the promotion of healing. However, there is currently a lack of substantial clinical evidence supporting its efficacy in the management of postsurgical Colles fractures. To the best of our knowledge, there are no studies evaluating the clinical effectiveness of RYJHS.

OBJECTIVE

This study aims to investigate the therapeutic potential of RYJHS in postsurgical Colles fracture cases. An additional objective is to provide an alternative treatment option for postoperative patients unable to take anti-inflammatory and pain relief medications.

METHODS

This is a protocol for a randomized, double-blind, placebo-controlled trial. A total of 100 postoperative patients with Colles fracture, aged 20-80 years, will be recruited for this study. They will be randomly assigned to either the experimental or control group in a 1:1 allocation ratio. Both groups will receive standard postoperative Colles fracture treatment. The primary outcome measure will assess wrist functional recovery using the Patient-Rated Wrist Evaluation score. Secondary outcomes will include C-reactive protein levels and ultrasound measurements of wrist swelling. All of these examinations will be assessed at baseline, 3 days after surgery, and 6 days after surgery. In addition, the Dyshidrotic Eczema Area and Severity Index will be used to monitor for adverse skin reactions.

RESULTS

This protocol was registered at ClinicalTrials.gov on December 6, 2022. It was performed in accordance with the approved guidelines and regulations of the participating institutions. Recruitment began in May 2023, with data collection expected to conclude in May 2025. Study completion is expected in December 2025.

CONCLUSIONS

This is the first protocol discussing the assessment of the therapeutic efficacy and safety of topical traditional Chinese medicine in patients after fracture surgery. The protocol will establish an integrated care model combining both traditional Chinese medicine and Western medicine for postsurgical fracture cases.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05638360; https://clinicaltrials.gov/ct2/show/NCT05638360.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56849.

Operation Rate for Displaced Distal Radius Fractures in the Elderly Decreased by 68% After the Implementation of Evidence-Based Practice

Background The increasing demand for orthopedic trauma surgery resources highlights the need for an efficient approach to implementing scientifically based interventions and de-implementation of interventions already in use that have been found no better than non-surgical treatments. Several factors have been identified as barriers or facilitators for translating evidence into clinical practice and behavioral changes. To facilitate a structured approach to applying these factors, we have adapted the generic theoretical domains framework (TDF) into the "CEBO model," providing a practical framework for implementing evidence in clinical decision-making in the hospital department of Zealand University Hospital, Koege, Denmark. Aim This study aims to evaluate the feasibility of the CEBO model for facilitating surgeon behavior change in an orthopedic surgery department. We will present clinical decision-making regarding the treatment of dorsally displaced distal radius fractures (DDDRF) in the elderly as an example. Methods Our department's standard of care for DDDRF in the elderly was surgical treatment. Under the evolving body of evidence, the CEBO model was applied to facilitate change in treating surgeons' behavior toward the increased use of non-surgical care. Following the four steps of the CEBO model, 1) leadership support was obtained, and relevant evidence was disseminated to all colleagues across the department; 2) stakeholders were invited to a symposium discussing best evidence and future practice; 3) conclusions from the symposium were summarized in a local clinical guideline stating non-surgical treatment as a new department standard and 4) to monitor the changes in treatment, patient charts were retrospectively reviewed from one year before and after the application of the CEBO model. Results In the first period, 95 of 120 (79%) were surgically treated, compared to 16 of 146 (11%) in the second period. An absolute decrease in the operation rate of 68% was observed. Conclusion We found the CEBO model highly feasible for facilitating surgeon behavior change in our orthopedic surgery department. Future studies will investigate the model's feasibility in other institutions and compare it to other behavior-targeted interventions.

Clinical and Radiographic Outcomes of Gap Osteotomy Versus Dorsal Opening Wedge Osteotomy for Extra-Articular Distal Radius Malunion and Internal Fixation Using a Volar Locking Plate Without Bone Graft

Purpose

Metaphyseal corrective osteotomy and fixed-angle volar locking plate fixation have reduced the need for additional bone grafting in symptomatic distal radius malunions. This study evaluated the outcomes of gap versus dorsal opening wedge and locking plate fixation without bone grafts for distal radius malunions and the correlation between the osteotomy defect and the osteotomy's distance from the articular surface with the union time.

Methods

We retrospectively reviewed 62 patients who underwent corrective osteotomy between 2010 and 2021. Gap osteotomy (n = 44) was performed to correct the coronal deformity predominantly, whereas an opening wedge osteotomy (n = 18) was performed to correct the sagittal deformity. No bone graft was used in any patient. Radiological outcomes comprised of correction of radial height, inclination, ulnar variance, volar tilt and the correlation between the osteotomy defect and the distance from the distal radial articular surface with the union time. The functional assessment comprised the disabilities of arm, shoulder, and hand questionnaire and the patient-rated wrist evaluation scores.

Results

All patients had a union of the osteotomy and statistically significant improvement in the radial height, inclination, ulnar variance, and tilt, irrespective of the osteotomy technique (P < .05). The mean defect length of the osteotomy, the time to the union, and the distance of the osteotomy were 4.7 mm (1-8.3 mm), 11.7 weeks (5-24 weeks), and 13.9 mm (1.6-35.8 mm), respectively. Time taken for union showed a weak positive correlation with the defect length of the osteotomy and no correlation with the distance of the distal osteotomy site from the articular surface. Opening wedge osteotomies took less time than the gap osteotomies. The mean postoperative disabilities of arm, shoulder, and hand questionnaire and the patient-rated wrist evaluation scores were 6.89 and 12.18, respectively.

Conclusions

Corrective osteotomy and fixed-angle volar plate fixation for distal radius malunion provide satisfactory union rates and clinical and radiological outcomes even without bone graft, irrespective of the osteotomy type, size, or location. However, length of the osteotomy defect influenced the union time.

Type of study/level of evidence

Therapeutic IV.

Surgical vs. Conservative Treatment of Distal Radius Fractures in the Elderly: A Systematic Review and Meta-Analysis

Elderly patients with distal radius fractures (DRFs) pose a significant medical challenge due to their high incidence and related healthcare costs. Both surgical methods like volar plate fixation and conservative approaches such as casting are common, yet their relative effectiveness remains unclear. This review and meta-analysis compare surgical and conservative treatments, focusing on wrist functionality, upper extremity performance, grip strength, and pain after one year. A literature search was conducted in PubMed, Cochrane Library, Scopus, and Web of Science up to November 6, 2024, to find randomized controlled trials (RCTs) for DRFs in patients aged 65 and older. Thirteen RCTs with 2400 participants were included. After one year, there was no significant difference in wrist function between groups (mean difference (MD)=-1.24; 95% confidence interval (CI) -2.61 to 0.13; p=0.78; I²=78%), but upper limb function favored surgery as measured by the Disabilities of the Arm, Shoulder, and Hand (DASH) score (MD=-2.32; 95% CI -3.66 to -0.98; p=0.0007; I²=83%). Surgical treatment significantly improved grip strength (MD=3.82; 95% CI 1.55 to 6.09; p=0.001) but resulted in higher pain levels (MD=2.73; 95% CI 1.16 to 4.31; p=0.0007). Results showed substantial heterogeneity and publication bias. Surgical treatment offers slight functional advantages in grip strength and DASH scores but is associated with higher pain; conservative treatment remains viable with minimal differences in long-term wrist function. Further high-quality studies are necessary to address heterogeneity and publication bias.

A meta-analysis comparing volar locking plates and cast immobilization for distal radius fractures in the elderly

BACKGROUND

The long-term outcomes (≥ 2 years of follow-up) of volar locked plate (VLP) fixation versus closed reduction and casting (CRC) for the treatment of displaced distal radial fractures (DRFs) remain unclear. This study aimed to conduct a meta-analysis comparing the long-term clinical outcomes of VLP and CRC in elderly patients (aged ≥ 60 years).

METHODS

A comprehensive search of PubMed, Web of Science, and Cochrane Library was performed to identify studies comparing the long-term outcomes of VLP and CRC for DRFs. Only randomized controlled trials (RCTs) with a mean follow-up duration of at least 2 years and participants aged 60 years or older were included. The risk of bias in the included studies was assessed. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE). Secondary outcomes included the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, EuroQol 5 Dimension 5-level score (EQ-5D-5 L), grip strength, and incidence of reoperation.

RESULTS

Four RCTs, comprising 423 patients, were included. The meta-analysis revealed that VLP fixation was associated with significantly improved outcomes compared to CRC in terms of PRWE score (pooled mean difference: -6.21; 95% CI: -10.28 to -2.15; p = 0.003), DASH score (pooled mean difference: -8.18; 95% CI: -13.35 to -3.01; p = 0.002), and grip strength (pooled mean difference: -6.63; 95% CI: 0.25 to 13.01; p = 0.04). There were no significant differences in EQ-5D-5 L score (95% CI: -0.08 to 0.05; p = 0.74) or incidence of reoperation (RR = 0.56; 95% CI: 0.22 to 1.42; p = 0.22).

CONCLUSIONS

A two-year follow-up of displaced DRFs in elderly patients showed no significant long-term clinical advantage of VLP fixation over CRC.

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.

Non-surgical vs. surgical treatment of distal radius fractures: a meta-analysis of randomized controlled trials

PURPOSE

To compare the clinical outcomes between nonsurgical and surgical treatment of distal radius fracture.

METHODS

We performed a systematic literature search by using multiple databases, including Medline, PubMed, and Cochrane. All databases were searched from the earliest records through February 2023. The study compared nonsurgical versus surgical treatment of distal radius fractures and included only randomized controlled trials (RCTS).

RESULTS

There were seventeen randomized controlled trials retrieved. A total of 1730 patients were included: 862 in the nonsurgical group and 868 in the surgical group. The results showed a significant reduction in DASH score with surgical treatment (WMD 3.98, 95% CI (2.00, 5.95), P < 0.001). And in grip strength (%), the results showed a significant improvement in surgical treatment compared with non-surgical treatment (WMD - 6.60, 95% CI (-11.61, -1.60), P = 0.01). There was significant difference in radial inclination, radial length, volar title, range of wrist pronation, range of wrist supination. However, no difference in radial deviation, ulnar deviation, ulnar variance, range of wrist extension and range of wrist flexion was observed.

CONCLUSIONS

The results of this meta-analysis suggest that some patients with surgical treatment of distal radius fractures not only improved the grip strength (%), decreased the DASH score, but also improved the range of wrist pronation and the range of wrist supination compared with nonsurgical treatment. Based on the present meta-analysis, we suggest that some patients with surgical treatment might be more effective in patients with distal radius fracture.

Analysis of factors influencing hospitalization cost of patients with distal radius fractures: an empirical study based on public traditional Chinese medicine hospitals in two cities, China

BACKGROUND

Distal radius fractures (DRFs) have become a public health problem for all countries, bringing a heavier economic burden of disease globally, with China's disease economic burden being even more acute due to the trend of an aging population. This study aimed to explore the influencing factors of hospitalization cost of patients with DRFs in traditional Chinese medicine (TCMa) hospitals to provide a scientific basis for controlling hospitalization cost.

METHODS

With 1306 cases of DRFs patients hospitalized in 15 public TCMa hospitals in two cities of Gansu Province in China from January 2017 to 2022 as the study object, the influencing factors of hospitalization cost were studied in depth gradually through univariate analysis, multiple linear regression, and path model.

RESULTS

Hospitalization cost of patients with DRFs is mainly affected by the length of stay, surgery and operation, hospital levels, payment methods of medical insurance, use of TCMa preparations, complications and comorbidities, and clinical pathways. The length of stay is the most critical factor influencing the hospitalization cost, and the longer the length of stay, the higher the hospitalization cost.

CONCLUSIONS

TCMa hospitals should actively take advantage of TCMb diagnostic modalities and therapeutic methods to ensure the efficacy of treatment and effectively reduce the length of stay at the same time, to lower hospitalization cost. It is also necessary to further deepen the reform of the medical insurance payment methods and strengthen the construction of the hierarchical diagnosis and treatment system, to make the patients receive reasonable reimbursement for medical expenses, thus effectively alleviating the economic burden of the disease in the patients with DRFs.

Effective Risk Assessment for Distal Radius Fractures: A Rigorous Multivariable Regression Analysis, Using a Novel 8-Item Modified Frailty Index

Introduction  Distal radius fractures (DRFs) are among the most common orthopaedic injuries. The prevalence of DRFs is increasing across all age groups but remains the second most common fracture in the elderly. The modified frailty index (MFI) often predicts morbidity and mortality in orthopaedic injuries. This study aims to determine the predictive value of MFI on complication rates following DRF and the patient length of stay and discharge outcomes. Methods  We utilized our MFI to perform a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database. Results  In a total of 22,313 patients, the average age was 46 ± 16. An increase in MFI led to an increase in the odds ratio of readmission and reoperation ( p  < 0.001). MFI predicted complications, doubling the rate as the score increased from 1 to 2 ( p  < 0.001). An MFI of 2 also led to a delayed hospital stay of 5 days ( p  < 0.001), as well as an increase in the odds of patients not being sent home at discharge ( p  < 0.001). Finally, life-threatening complications were also predicted with an increased MFI, the odds of a life-threatening complication increasing 488.20 times at an MFI of 3 ( p  < 0.001). Discussion and Conclusion  While surgical decision-making for frail patients with DRFs remains contentious, this novel 8-item MFI score was significantly associated with the probability of hospital readmission/reoperation, postoperative complications, and delayed hospital length of stay. Three new parameters were incorporated into our 8-item score compared with the conventional 5; hypoalbuminemia status (< 3.5 mg/dL), previous diagnosis of osteoporosis, and severe obesity (body mass index > 35) enhancing its sensitivity. Future studies are warranted for its prospective utility in ruling out postsurgical comorbidity.

Complex Regional Pain Syndrome after Distal Radius Fracture-Case Report and Mini Literature Review

This study explores the impact of the complex regional pain syndrome (CRPS) on the lives and mobility of patients, with a particular focus on its emergence as a late complication of distal radius fractures (DRFs), a common occurrence, especially among an aging population. The absence of a standardized treatment for the CRPS and the challenge of predicting its occurrence make it a complex medical issue. This research aims to shed light on the effects of treating the CRPS through a case study involving a 75-year-old woman with untreated osteoporosis who experienced a Colles fracture after a fall. The initial management involved repositioning and stabilizing the fractured forearm with a plaster cast, followed by an operation using percutaneous pinning via a Kirschner wire. Subsequently, the patient developed CRPS symptoms and was admitted to the rehabilitation department three months post-fracture. The affected forearm exhibited swelling, warmth, pain, and severely limited range of motion. Treatment involved a combination of medications, physiotherapy, and kinesiotherapy. Significantly, the patient experienced notable improvement following these interventions. This study underscores the absence of a definitive standard for CRPS treatment but suggests that proper rehabilitation and pharmaceutical interventions can contribute positively to patient outcomes. The case further highlights the potential association between DRF and CRPS development, emphasizing the need for continued research in this field.

Let's Agree to Disagree on Operative Versus Nonoperative Treatment for Distal Radius Fractures in Older People: Protocol for a Prospective International Multicenter Cohort Study

BACKGROUND

Distal radius fractures are the most frequently encountered fractures in Western societies, typically affecting patients aged 50 years and older. Although this is a common injury, the best treatment for these fractures in older patients is still under debate.

OBJECTIVE

This prospective study aims to compare the outcome of operatively and nonoperatively treated distal radius fractures in the older population. Only patients with distal radius fractures for which equipoise regarding the optimal treatment exists will be included.

METHODS

This prospective international multicenter observational cohort study will be designed as a natural experiment. Natural experiments are observational studies in which treatment allocation is determined by factors outside the control of the investigators but also (largely) independent of patient characteristics. Patients aged 65 years and older with an acute distal radius fracture will be considered for inclusion. Treatment allocation (operative vs nonoperative) will be based on the local preferences of the treating hospital either in Switzerland or the Netherlands. Hence, the process governing treatment allocation resembles that of randomization. Patients will be identified after treatment has been initiated. Based on the radiographs and baseline information of the patient, an expert panel of 6 certified trauma surgeons from 2 regions will provide their treatment recommendation. Only patients for whom the experts disagree on treatment recommendations will ultimately be included in the study (ie, for whom there is a clinical equipoise). For these patients, both operative and nonoperative treatment of distal radius fractures are viable, and treatment choice is predominantly determined by personal or local preference. The primary outcome will be the Patient-Rated Wrist Evaluation score at 12 weeks. Secondary outcomes will include the Physical Activity Score for the Elderly, the EQ questionnaire, pain, the living situation, range of motion, complications, and radiological outcomes. By including outcomes such as living situation and the Physical Activity Score for the Elderly, which are not relevant for younger cohorts, valuable information to tailor treatment to the needs of the older population can be gained. According to the sample size collection, which was based on the minimal important clinical difference of the Patient-Rated Wrist Evaluation, 92 patients will have to be included, with at least 46 patients in each treatment group.

RESULTS

Enrollment began in July 2023 and is expected to continue until summer 2024. The final follow-up will be 2 years after the last patient is included.

CONCLUSIONS

Although many trials on this topic have previously been published, there remains an ongoing debate regarding the optimal treatment for distal radius fractures in older patients. This observational study, which will use a fairly new methodological study design, will provide further information on treatment outcomes for older patients with distal radius fractures for which to date equipoise exists regarding the optimal treatment.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52917.

Factors Associated with Re-Displacement after Nonsurgical Treatment of Distal Radius Fractures in Adults: A Retrospective Study

OBJECTIVE

Closed reduction combined with external fixation is a frequently utilized approach for treating distal radial fractures in adults. Nonetheless, the potential for re-displacement following external fixation remains. Analyzing the factors influencing re-displacement after nonsurgical treatment of distal radial fractures in adults is vital for preventing re-displacement and making prognostic assessments.

METHODS

A retrospective analysis was performed on 884 patients who underwent nonsurgical treatment for distal radius fractures in the reduction room of the Orthopedics and Traumatology Department of Integrated Traditional Chinese and Western Medicine at Tianjin Hospital, Tianjin, China, between July 2019 and December 2022. Patients were categorized into two groups, namely displaced and nondisplaced, based on radiographic outcomes. Factors affecting fracture re-displacement were examined, including sex, age, side, AO/OTA type, external fixation, and radiographic outcomes at pre-reduction and immediate reduction. Logistic regression analysis was employed to identify the risk factors for fracture re-displacement, and ROC curves were constructed.

RESULTS

Among the 884 patients, 563 (63.69%) experienced re-displacement after fracture reduction. There were no statistically significant differences (p > 0.05) between the two groups in terms of gender, external fixation method, and palmar tilt angle at pre-reduction and immediate reduction, while significant differences (p < 0.05) were observed in age, side, AO/OTA type, and radial inclination, radial length, and radiographic outcomes of ulnar variance at pre-reduction and immediate reduction. Multifactorial logistic regression analysis revealed that age (odds ratio [OR] = 1.027, p < 0.001), AO/OTA type (OR = 2.327, p = 0.005), ulnar variance at pre-reduction (OR = 1.142, p = 0.048), and ulnar variance at immediate reduction (OR = 1.685, p < 0.001) were significant factors (p < 0.05) associated with re-displacement following nonoperative treatment of adult distal radius fractures. For patients aged ≥60 years, the amount of missing radiographic outcomes was positively correlated with age. The receiver operating characteristic curve demonstrated that age ≥65.5 years, ulnar variance >3.26 mm at pre-reduction, and ulnar variance >2.055 mm at immediate reduction were high-risk factors for fracture re-displacement.

CONCLUSIONS

Nonsurgical treatment of distal radius fractures exhibits a higher rate of re-displacement. Age, AO/OTA type, pre-reduction, and immediate reduction ulnar variance are key factors predicting fracture re-displacement.

The hematoma block is not enough as method of anesthesia in reduction of displaced distal radius fractures

BACKGROUND

Two out of three wrist fractures seen in the emergency are displaced but most can be treated conservatively after closed reduction. Patient-reported pain during closed reduction of distal radius fractures varies widely and the best method to decrease the perceived pain has not been well established. The purpose of this study was to assess the pain during closed reduction of distal radius fractures after using the hematoma block as method of anaesthesia.

PATIENTS AND METHODS

Cross-sectional clinical study including all patients who presented an acute fracture of the distal radius requiring closed reduction and immobilization during a six-month period in two University Hospitals. Demographic data, fracture classification, perceived pain using a visual analog scale at different times of reduction and complications were registered.

RESULTS

Ninety-four consecutive patients were included. Mean age was 61 years. Mean pain score at initial assessment was 6 points. After the hematoma block, the perceived pain during the reduction manoeuvre improved to 5.1 points at the wrist, but increased to 7.3 points at the fingers. Pain decreased to 4.9 points during cast placement and reached 1.4 point after sling placement. The reported pain was higher in women at all times. There were no significant differences according to the according to the type of fracture. No neurological or skin complications were observed.

CONCLUSIONS

The hematoma block is only a mild effective method to reduce the wrist pain during closed reduction of distal radius fractures. This technique decreases slightly the perceived pain in the wrist and does not reduce the pain in the fingers. Other reduction methods or other analgesic techniques may be more effective options.

LEVEL OF EVIDENCE

Therapeutic study. Cross-sectional study - Level IV.

Volar Locking Plating Compared to Conservative Treatment in Distal Radius Fractures in Elderly Patients (>60 years old): A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Purpose

We performed a systematic review and meta-analysis to compare the efficacy of volar locking plating (VLP) to conservative treatment in distal radius fractures in patients aged >60 years old.

Methods

English articles were searched in electronic databases including MEDLINE, CENTRAL, Embase, Web of science, and ClinicalTrial.gov from inception to October 2020. Relevant article reference lists also were reviewed. Two reviewers independently screened and extracted data from trials comparing VLP to nonsurgical treatment in distal radial fractures in the elderly. Starting with 3052 citations, 5 trials (539 patients) met the inclusion criteria. The primary outcomes were disabilities of the arm, shoulder, and hand, and patient-rated wrist evaluation scores, grip strength, and range of motion.

Results

All trials of this random effect meta-analysis were at a moderate risk of bias due to the lack of blinding. Differences in the disabilities of the arm, shoulder, and hand score (mean difference [MD] -5,91; 95% confidence interval [CI], -8,83; -3,00), patient-rated wrist evaluation score (MD -9.07; 95% CI, -14.57, -3.57), and grip strength (MD 5,12; 95% CI, 0,59-9,65) were statistically significant and favored VLPs, however without reaching clinical significance. No effect was observed in terms of the range of motion and reoperation rates.

Conclusion

This review was not able to demonstrate any clinical benefit to the surgical treatment of distal radius fractures with VLP in patients aged >60 years old compared to nonsurgical treatment.

Type of study/level of evidence

Therapeutic I.

[Translated article] The haematoma block is not enough as method of anaesthesia in reduction of displaced distal radius fractures

BACKGROUND

Two out of three wrist fractures seen in an emergency department are displaced but most can be treated conservatively after closed reduction. Patient-reported pain during closed reduction of distal radius fractures varies widely and the best method to decrease the perceived pain has not been well established. The purpose of this study was to assess pain during closed reduction of distal radius fractures after using haematoma block as method of anaesthesia.

PATIENTS AND METHODS

Cross-sectional clinical study including all patients who presented an acute fracture of the distal radius requiring closed reduction and immobilisation during a six-month period in two University Hospitals. Demographic data, fracture classification, perceived pain using a visual analogue scale at different times of reduction and complications were registered.

RESULTS

Ninety-four consecutive patients were included. Mean age was 61 years. Mean pain score at initial assessment was 6 points. After the haematoma block, the perceived pain during the reduction manoeuvre improved to 5.1 points at the wrist, but increased to 7.3 points at the fingers. Pain decreased to 4.9 points during cast placement and reached 1.4 point after sling placement. The reported pain was higher in women at all times. There were no significant differences according to the according to the type of fracture. No neurological or skin complications were observed.

CONCLUSIONS

Haematoma block is only a mildly effective method to reduce wrist pain during closed reduction of distal radius fractures. This technique slightly decreases the perceived pain in the wrist and does not reduce the pain in the fingers. Other reduction methods or other analgesic techniques may be more effective options.

LEVEL OF EVIDENCE

Therapeutic study. Cross-sectional study - Level IV.

Changes in the incidence and treatment of distal radius fractures in adults - a 22-year nationwide register study of 276,145 fractures

INTRODUCTION

The incidence of distal radius fractures (DRFs) is reported, with conflicting results. To ensure evidence-based practice, the variation in treatment over time should be monitored. Treatment in the elderly population is particularly interesting because newer guidelines find little indication for surgery. Our primary aim was to assess the incidence and treatment of DRFs in the adult population. Secondly, we assessed the treatment stratified on non-elderly (aged 18-64 years) and elderly (aged 65+ years) patients.

METHODS

This is a population-based register study comprising all adult patients (i.e. aged over 18 years) with DRFs in the Danish National Patient Register from 1997 to 2018. Data were extracted using the ICD-10 code for DRF (DS52.5), and the incidence was calculated using data from Statistics Denmark. We defined a case as surgically treated if a relevant procedure was performed within three weeks of the DRF diagnosis. Nordic procedure codes were used to define surgical treatments as either plate (KNCJ65), external fixation (KNCJ25), k-wire (KNCJ45), or 'other' (KNCJ35,55,75,85,95).

RESULTS

A total of 276,145 fractures were included, with an overall increase in DRFs of 31% during the study period. The overall incidence was 228/100,000/year, which increased by 20% during the study period. The increased incidence was especially notable among women and those aged 50-69 years. Surgical treatment steadily increased from 8% in 1997 to 22% in 2010, thereafter reaching a plateau at 24% in 2018. The surgical rate in the elderly group was as high as in the non-elderly group. In 1997, the treatment distribution of DRFs was as follows: 59% external fixation, 20% plate fixation, and 18% k-wire fixation. From 2007 and onwards, plating was the primary choice of surgery, and in 2018, 96% of patients were treated with a plate.

CONCLUSION

We found a 31% increase in DRFs over a 22-year period, mostly driven by an increase in the size of the elderly population. The surgical rate increased markedly even in the elderly group. There is a lack of evidence on how beneficial surgery is for elderly patients, and similar surgical rate between the elderly and non-elderly calls for hospitals to re-evaluate their treatment strategies.

Can elderly patients regain their preoperative functional level after distal radius fracture type A? Results from a fracture register study using PROM

Introduction

Although distal radius fractures (DRFs) are the most common fractures of the human body, there are still ongoing debates concerning the treatment for type A fractures, especially in elderly patients. In spite of good clinical outcomes, it remains unclear whether elderly patients, especially, could regain the preoperative functional level of the wrist. Therefore, we have quantified wrist function within a retrospective study design using patient-reported outcome measures (PROM) and we have analyzed the influence of age between control and patient collective and young vs. old, respectively.

Patients and methods

The retrospective study included all patients with a surgically treated DRF type A and a control group of healthy patients, age and gender matched. The function of the wrist was examined by using a self-assessment questionnaire called the Munich Wrist Questionnaire (MWQ) according to the patient-related outcome measurements PROM.

Results

We could enroll 110 patients and controls, and the average follow-up was 66 months. Subgroup matching induced similar age group distribution: in both groups, 7 individuals &lt;30 years, 67 between 31 and 64 years, 29 between 65 and 79 years, and 7 individuals &gt;80 years, were enrolled, respectively. In the fracture group, women were significantly older than men (59 ± 15 vs. 47 ± 17 (M ± SD). There was no significant difference between the control and the patient groups (96 ± 6 vs. 95 ± 7). The function was significantly different between controls and patients &lt;30 years (100 ± 1 vs. 98 ± 2). In the control group, there was a functional difference in the age group &lt;30 compared with 65–79 and &gt;80 and in the age group 30–64 compared with 65–79 and &gt;80. In the control group, the function was found to be significantly decreasing with advancing age, whereas in the patient group, this influence was absent. A correlation analysis showed a worse function with increasing age in the control group and therefore a negative correlation. In the fracture group, a similar result could not be obtained.

Discussion

Age has a relevant influence on wrist function. Although the wrist function decreases significantly with aging, in the patient group, this influence is absent, and the functional results after surgery are excellent. Even elderly patients can regain their preoperative functional level.

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.

Patient-centered management strategy for concurrent musculoskeletal complaints in elbows, shoulders, and neck after an isolated hand/forearm complaint: A prospective interventional study

The aim was to evaluate patient-reported outcomes before and after a patient-centered management strategy targeting concurrent proximal musculoskeletal complaints (MSCs) in patients with an isolated hand/forearm complaint. A prospective interventional study included 66 patients. Intervention targeting concurrent MSCs was implemented as a patient-centered add-on to standard treatment for primary hand/forearm complaints. The patient-centered management strategy included patient education, individualized exercises, and manual therapy. Patient-reported outcome measures and pain questionnaires regarding the location, frequency, and intensity of pain in hands, elbows, shoulders, and neck were collected at baseline, after the last session of the patient-centered management strategy, and at 3-month follow-up. There were significant improvements in all patient-reported outcomes between baseline and follow-up. DASH scores improved significantly, by 17-29 points on the 3 subscales. There was a significant improvement of 6 points in PCS, 2 points in HADS, and 0.051 points in EQ-5D index. Median pain intensity on NRS decreased from 6 (4-8) to 5 (2.5-7) in hands, 3 (0-6) to 0 (0-3) in elbows, 5 (2-7) to 2.5 (0-5) in shoulders, and 3 (0-6) to 2 (0-3) in the neck, between baseline and discharge. Patients reporting concurrent MSCs in the elbow, shoulder, and neck after an isolated hand/forearm complaint may benefit from patient-centered management comprising patient education, individualized exercises, and manual therapy targeting pain and functional deficits in the upper-limb and neck. LEVEL OF EVIDENCE: IV.

Clinical and functional analysis of closed reduction-plastering and volar locking plate methods in distal radius fractures in patients over 60 years of age

Aim: Many different methods have been described in the treatment of distal radius fractures (DRF) in the elderly population, and which one is the better method is a matter of debate among orthopedic surgeons. The aim of this study was to compare the results of closed reduction and plastering (CRP) and volar locking plate (VLP), which are used in the treatment of DRF in the elderly population. Materials and Methods: Between January 2019 and December 2020, 36 patients with DRF aged > 60 years were evaluated retrospectively. There were 19 patients in the CRP group and 17 patients in the VLP group. Wrist flexion, extension, pronation, supination, ulnar deviation, and radial deviation degrees and grip strength were measured in the first year of their treatment. The patients were evaluated functionally by patient-rated wrist evaluation (PRWE), modified Green and O'Brien score (MGOS), and resting and stress visual analogue scale (VAS). Results: In both groups, similar ROM values were obtained and no significant difference was observed. While the PRWE score was 17.5 ± 5.5 in the CRP group and 12.5 ± 4.8 in the VLP group, the MGOS score was 83.0 ± 7.4 in the CRP group and 86.8 ± 12.6 in the VLP group, and the scores were not significantly different (p = 0.802, p = 0.315). While there was almost no pain in both groups at rest, more pain was felt in the VKP group under stress. While grip strength was 20.9 ± 6.4 kg in the CRP group, it was 22.2 ± 6.8 kg in the VLP group, and there was no significant difference compared to the contralateral wrist. Conclusion: There is no clinical and functional difference between CRP and VLP in the one-year period after DRF treatment in the patient population aged > 60 years. Treatment should be planned according to the functional capacity of the patient.

Patient-reported outcomes after initial conservative fracture treatment in primary healthcare – a survey study

Background

Primary healthcare in Norway has first-line responsibility for medical emergencies, including traumas and fractures. Normally, patients with suspected fractures are referred to specialist care. However, some municipalities have X-ray facilities and handle minor fractures locally. We investigated patient-reported outcome measures after initial treatment of radiologically diagnosed fractures of the wrist, collarbone, and ankle at a primary healthcare centre in a rural municipality with a large ski resort. The patients’ general satisfaction with the treatment was also investigated.

Methods

Validated questionnaires were sent to patients with fractures of the wrist or collarbone (Quick DASH—Disability of Arm, Shoulder and Hand) or the ankle (FAOS -The Foot and Ankle Outcome Score). Patients with wrist and collarbone fractures also answered the Quality-of-life questions that are a subscale of the FAOS questionnaire for ankle fractures. Patient satisfaction was measured for all fracture groups. The Quick DASH scale ranges from 0 (no disability at all) to 100 (great disability), while for FAOS a score of 100 indicates no symptoms and 0 indicates extreme disabilities.

Results

A total of 148 of 238 patients answered the questionnaire (62% response rate). Patients with distal radius fractures had a mean Quick DASH score of 5.1 (median 0, range 0–77), and scores were significantly lower for males (p = 0.013) and increased with age (p = 0.024). Patients with collarbone fractures had a mean Quick DASH score of 2.1 (median 0, range 0–32) with no significant age or gender differences. Patients with ankle fractures had the following mean subscale-scores: Pain, 93.8; Symptoms, 71.4; Activities of daily living, 97.4; Sport, 90.0; and Quality of life, 92.1. The scores did not differ significantly by specialization of the physician. A total of 88% of the patients were highly or very highly satisfied with the handling of their fracture.

Conclusions

The patients reported low rates of functional disability and high rates of satisfaction after initial radiological diagnosis and treatment of their fracture at the primary healthcare centre. Specialisation of the treating physician was not associated with the outcome in any of the fracture types.

Treatment Patterns for Distal Radius Fractures Before and After Appropriate Use Criteria Adoption

BACKGROUND

The purpose of this study was to determine agreement with the American Academy of Orthopaedic Surgery Appropriate Use Criteria (AUC) for distal radius fractures (DRFs), before and after their adoption, and secondarily determine predictors of operative management.

METHODS

A single-institution retrospective cohort study comparing patients treated either nonoperatively (115 patients) or operatively (767 patients) for DRFs between May 1, 2008, and May 1, 2018, by 8 hand surgeons was performed. Data included demographics, injury characteristics, DRF radiographic measurements, treatment rendered, and their appropriateness according to the AUC. Statistical testing used the Fisher and χ2 tests, t test, and multiple variable logistic regression, with a significance level of .05.

RESULTS

Overall, there was a significant increase in AUC agreement for operatively treated DRFs (82.7%-89.3%, P = .01), but no difference in agreement for nonoperatively treated DRFs (12.5%-10.7%, P = .77). Age <80 years, AO classes other than B, intra-articular displacement >1 mm, radial inclination <18°, high-energy mechanism of injury, and greater than 1 week to treatment were independent predictors of operative treatment. The area under the curve for the validated regression model using the aforementioned predictors was 0.82.

CONCLUSION

Agreement with AUC for DRFs increased after its adoption for operatively treated, but not for nonoperatively treated, fractures. In addition, a predictive model for operative treatment was developed and validated. Future studies may benefit from further model refinement and testing in other patient cohorts.

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

Introduction

Materials and methods

Results

Conclusions

Reduction Techniques in Volar Locking Plate Fixation of Distal Radius Fractures

Distal radius fractures are the most common upper extremity fracture and volar locking plate fixation has become a common modality for operative management of these injuries over the last 2 decades. However, despite the widespread use of volar locking plates, there remains no comprehensive guide detailing the available reduction techniques using these systems. This review aims to consolidate the reduction techniques from the literature along with the authors' experiences into a blueprint for distal radius fracture reduction when using a volar plate. Techniques described include those with and without use of the plate and with supplementary means of fixation for both extra-articular and intra-articular fracture patterns.

Effectiveness of surgical versus conservative treatment of distal radius fractures in elderly patients: A systematic review and meta-analysis

BACKGROUND

The aim of this study was to determine whether surgical treatment is more effective than conservative treatment in terms of functional outcomes in elderly patients with distal radius fractures (DRFs).

METHODS

An electronic search of the Medline, Central, Embase, PEDro, Lilacs, CINAHL, SPORTDiscus, and Web of Science databases was performed, from inception until July 2021. The eligibility criteria for selecting studies were randomized clinical trials that compared surgical versus conservative treatment in subjects older than 60 years with DRFs. Two authors independently performed the search, data extraction, and assessed risk of bias (RoB) using the Cochrane RoB tool.

RESULTS

Twelve trials met the eligibility criteria, and nine studies were included in the quantitative synthesis. For volar plate versus cast immobilization at 1-year follow-up, the mean difference (MD) for PRWE was -5.36 points (p=0.02), for DASH was -4.03 points (p=0.02), for grip strength was 8.32% (p=0.0004), for wrist flexion was 4.35 degrees (p=0.10), for wrist extension was -1.52 degrees (p=0.008), for pronation was 2.7 degrees (p=0.009), for supination was 4.88 degrees (p=0.002), and for EQ-VAS was 2.73 points (p=0.0007), with differences in favor of volar plate. For K-wire versus cast immobilization at 12 months, there were no statistically significant differences in wrist range of motion (p>0.05).

CONCLUSIONS

There was low to high evidence according to GRADE ratings, with a statistically significant difference in functional outcomes in favor of volar plate versus conservative treatment at 1-year follow-up. However, these differences are not minimally clinically important, suggesting that both types of management are equally effective in patients older than 60 years with DRFs.

LEVEL OF EVIDENCE

I; Therapeutic (Systematic review and meta-analysis of randomized clinical trials).

Results of a Retrospective Fracture Register of Distal Radius Fractures Built Up Using PROM

Introduction

Although distal radius fractures (DRFs) are the most common fractures of the human body, the best treatment for every fracture type is still debatable. However, randomized controlled trials are difficult to perform. The quality of care can be determined primarily in the context of health care research using register studies. Registers enable standardized documentation of clinical observations over time. So far, no German register studies concerning DRFs exist, and therefore, the aim of this study was to develop a register with the help of patient-reported outcome measurements (PROM).

Patients and Methods

All patients treated surgically at our hospital with a DRF between 2006 and 2016 were enrolled. Patient data such as epidemiological data, treatment, complications, insurance status, etc. were collected and the register was built up as an in-house fracture register with the help of PROM. The Munich Wrist Questionnaire (MWQ) was used as a PROM tool.

Results

Of all 1,796 patients, 339 (19%) with a complete data set could be enrolled, 96 of the patients were male (28%), 243 were female (72%). Thirty-two percent were type A (n = 110), 9% (n = 31) were type B, and 58% (n = 198) were type C fractures. The average follow-up was 66 ± 31 months. Complications occurred in 25 cases (7%). The average postoperative function measured with the MWQ was 91 ± 11%. Patients suffering from a DRF type A had the best outcome. It was significantly better than the outcome of patients with a DRF type C (95 ± 7 vs. 89 ± 13%, p < 0.05 MWUT) and significantly better compared to the results from the whole fracture register (95 ± 7 vs. 91 ± 11%, p < 0.05 MWUT). Type B fractures had a better outcome than type C fractures (92 ± 11%).

Conclusions

Retrospective register studies created with the help of PROM have numerous advantages. Data collection is fast, easy and cost-effective and a huge amount of data can be achieved from numerous patients and the observation period after surgery is quite long. The drop-out rate might be high, but patients enrolled are a representative sample compared to the current literature. This is a valuable tool for monitoring of clinical treatment quality.

Trends in the Incidence and Treatment of Distal Radius Fractures in the United States in Privately Insured and Medicare Advantage Enrollees

Background: This study aims to determine the trends in the treatment of distal radius fractures (DRFs) in patients aged 18 years and older. Methods: An administrative claims database of more than 100 million patients was used to identify patients aged 18 years and older with a DRF between 2005 and 2014. A total of 137 130 DRFs were identified in 135 128 patients. Results: The proportion and rate of fractures were more predominant in those aged 55 years and older compared with a decreasing incidence in patients younger than 55 years. Age-adjusted rates of surgical treatment have significantly increased in both women and men by 15.9% (absolute change, 4.8%) and 5.0% (absolute change, 1.7%) change over time, respectively. Conversely, age-adjusted rates of nonsurgical treatment have significantly decreased overtime in both women and men by 6.9% and 2.6%, respectively. Conclusions: These data provide better understanding of the epidemiology of DRF, which is important to develop preventive strategies targeting high-risk populations and to develop effective treatment strategies.

Concurrent musculoskeletal complaints in elbows, shoulders, and necks after common hand and forearm injuries or conditions: A cross-sectional study among 600 patients

STUDY DESIGN

This is a cross-sectional study among 600 patients.

INTRODUCTION

Isolated hand and forearm injuries or conditions are common in the emergency and orthopedic departments. So far, little is known about whether these patients suffer from concurrent musculoskeletal complaints (MSCs) besides their hand and forearm complaints. Neglecting concurrent MSCs in the upper limbs and necks could hamper rehabilitation and prolong the time taken to return to daily and work-related activities.

PURPOSE OF THE STUDY

The purpose of this study was to investigate the prevalence of concurrent MSCs in the elbow, shoulder, and neck after common hand and/or forearm injuries or conditions.

METHODS

This study included 600 patients with any type of diagnosis referred to rehabilitation after hand and/or forearm injuries or conditions. Basic characteristics, diagnoses, and location of patients' symptoms were collected and analyzed.

RESULTS

The overall prevalence of concurrent MSCs was 40%. Twenty-eight percent of the whole sample developed concurrent MSCs after the hand and forearm injury or condition. The gender distribution was 68% women and 32% men. The most common location for complaints was the shoulder (62%), followed by the elbow (49%), and the neck (32%).

DISCUSSION

The present results suggest that MSCs from the elbows, shoulders, or necks are very common in patients with hand and/or forearm injuries or conditions.

CONCLUSION

Clinicians treating patients with isolated hand and forearm injuries or conditions should be aware of the high prevalence of concurrent MSCs. Future research should investigate if specific rehabilitation, focusing on concurrent MSCs, may influence the outcome in this population.

Evaluating the Impact of Social Deprivation on Mid-Term Outcomes Following Distal Radius Open Reduction Internal Fixation

Purpose

Although baseline biopsychosocial factors are associated with short-term patient-reported outcomes following distal radius fracture open reduction internal fixation (ORIF), their effect on mid-term outcomes is unclear. We aimed to evaluate the effect of social deprivation, previously established as a surrogate for depression, pain interference, and anxiety, on quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores >1 year following distal radius ORIF.

Methods

Adult patients (≥18 years) with an isolated distal radius fracture treated with ORIF by orthopedic trauma and hand surgeons at a single tertiary academic center over a 3-year period were included. Outcomes at ≥1 year postoperatively were evaluated using QuickDASH. Age, follow-up duration, area deprivation index (ADI; a measure of social deprivation), subspecialty (hand vs trauma), and postoperative alignment were assessed using linear regression with 95% confidence intervals after bootstrapping and a permutation test for P values to test for their association with the final QuickDASH score.

Results

Follow-up data were obtained for 98 of 220 (44.5%) patients at a mean of 3.1 ± 1.0 years after surgery. Mean age and ADI were 53.2 ± 15.4 years and 26.8 ± 18.7, respectively. Most fractures were intra-articular (67.3%), and 72.4% had acceptable postoperative alignment parameters, as defined by the American Academy of Orthopaedic Surgeons clinical practice guidelines. The mean QuickDASH score was 13.0 ± 16.5. There were no significant associations between the final QuickDASH score and any studied factor, including ADI, as determined using univariable analysis. Multivariable analysis showed no association between ADI and the final QuickDASH score, independent of age, sex, treating service, follow-up duration, and fracture alignment or pattern.

Conclusions

At mid-term follow up after distal radius ORIF, ADI did not correlate with QuickDASH scores, and the QuickDASH scores of the patients did not differ from those of the general population. However, our cohort mostly comprised patients with levels of deprivation below the national median. Although studies have shown that the short-term outcomes of distal radius ORIF are influenced by biopsychosocial factors, outcomes at the time of final recovery may not be associated with social deprivation.

Type of study/level of evidence

Prognostic IV.

Metacarpal squeezing reduces grip strength

Unduly tight plaster hand casts may narrow the metacarpal joint space, hindering rehabilitation. This study investigated how metacarpal narrowing affects grip strength. Forty-two adult volunteers with no other pathology were included. Dominant and non-dominant hand grip strength was measured with a digital hand dynamometer (Jamar plus, China). Metacarpal width was measured with a metal caliper, and the caliper was then fixed at 10% narrowing of the joint space, and a second measurement of grip strength was taken. The measurements were thus taken twice each in the dominant and non-dominant hand, and the average of the two was recorded. A total 336 measurements were taken in the dominant and non-dominant hands of 42 individuals at two time points. There was no significant difference in grip strength between dominant and non-dominant hands (p = 0.183). After 10% narrowing, both the dominant and the non-dominant hand showed a mean 33.4% reduction in grip strength: i.e., squeezing the metacarpus with a caliper significantly reduced grip strength in both dominant and non-dominant hands (p = 0.01). The study thus showed that grip strength will decrease significantly when the metacarpus is squeezed by a tight cast. Although the patient does not feel the 10% narrowing of the metacarpus, it is clear that hand muscle mass may be adversely affected in the long term.

Dorsally displaced distal radius fractures: introduction of Pacetti's line as radiological measurement to predict dorsal fracture displacement

BACKGROUND AND AIM OF THE WORK

In the best of our knowledge there is not yet in the literature a measurement able to assess post reduction stability of distal radius fractures.

AIM

to study the relationship between our newly introduced Pacetti's line, anatomical reduction of DRFs and post-reduction stability of fractures.

METHODS

Patients/Participants: 230 patients (122men, 108women) who sustained a dorsally displaced distal radius fracture. Close reduction procedures attempted; below elbow cast applied.

FOLLOW-UP

Pacetti's line used on true AP and lateral view xrays after reduction and casting (T0) and at 7-14 days (T1-T2).

MAIN OUTCOME MEASUREMENTS

Assessment and prediction of early displacement of DRFs.

RESULTS

The Pacetti's line intersected the lunate bone in 162 cases (70.4%) after anatomical reduction, of which 20.4% (N=33) lost anatomical reduction. Cramer's V test: significant relationship between transition of Pacetti's line through the semilunar bone and stability of anatomical reduction at T0 follow-up (p<0.001, Cramer's value=0.83). The Pacetti's line intersected the lunate bone in 119 cases (51.7%) at 7-14 days follow-up. None of patients lost anatomical reduction. Cramer's V test: significant relationship between transition of Pacetti's line through the semilunar bone and stability anatomical reduction at T1 and T2 follow-up (p<0.001, Cramer's value=0.73).

CONCLUSIONS

We strongly recommend the use of the Pacetti's line as it seems to provide reliable prediction of further fracture displacement and consequently of definitive management. The Pacetti's line seems to represent a very useful tool providing simple, feasible, efficient and reliable information on DRFs characteristics and natural course.

The external fixation can be a good alternative to plate-screw treatment in the surgical treatment of bilateral distal radius fractures: A retrospective cohort study

Objectives

We aimed to compare the outcomes of two surgical treatment options, external fixator (EF) or open reduction and internal fixation (ORIF), in patients with bilateral distal radius fractures (DRFs).

Patients and methods

Twenty-one patients (11 males 10 females; mean age: 40.0±16.0 years; range, 20 to 67 years) who underwent ORIF (n=10) or EF (n=11) due to bilateral DRF at between January 2011 and December 2019 were retrospectively analyzed. The Quick Disability of the Arm, Shoulder and Hand (Q-DASH) was used to calculate functional and symptomatic evaluation. The MAYO wrist scores were used to evaluate pain, functional status, ROM, and grip strength and the Michigan Hand Outcomes Questionnaire (MHOQ) was used to measure hand performance in daily life.

Results

The operation time was statistically significantly longer in the ORIF group, compared to the EF group (p<0.001). Radial shortening was statistically significantly greater in the EF group, compared to the ORIF group (p<0.001). While the Q-DASH score was lower in the EF group on Day 15 and at one and two months (p<0.001, for each), it was similar between the groups at one year (p=0.507). The MAYO wrist score was higher in the EF group on Day 15 and at one and two months and one year (p<0.05, for each). While the MHOQ score was higher in the EF group on Day 15 and at one and two months (p<0.001, for each), it was similar between the groups at one year (p=0.557).

Conclusion

In bilateral DRF cases, hand functions in the first two months after treatment were better in the EF group, compared to the ORIF group. This functional difference between the two groups gradually decreased in the first year and reached similar levels. Our results demonstrate that EF can be a good alternative in the surgical treatment of bilateral DRFs owing to its acceptable results, particularly in the short-term.

Closed Reduction Techniques for Distal Radius Fractures and Appropriate Casting Methods

Distal radius fractures are one of the most common orthopedic injuries. After history, physical examination, and diagnostic imaging, treatment begins with closed reduction and immobilization to restore an upper extremity that has both acceptable alignment and stability. Whether for definitive nonoperative management or in preparation for surgical fixation, it is important to understand the principles of closed reduction and immobilization. This article presents a brief review of indications and a technical guide to successful closed reduction and casting for the orthopedic surgeon.

Diabetes mellitus effect on rates of perioperative complications after operative treatment of distal radius fractures

PURPOSE

This study focuses on distal radius fractures that require surgical treatment. Patients with diabetes mellitus (DM) are at increased risk of bone fracture despite normal areal bone mineral density. The aim of this study is to identify the impact of DM on perioperative complications for patients undergoing operative treatment of distal radius fracture.

METHODS

A retrospective cohort study was conducted using data collected through the National Surgical Quality Improvement Program database. All patients who underwent operative treatments for distal radius fractures from 2007 through 2018 were identified. Data collected include demographic information, comorbidities, and complications occurring within 30 days of initial surgical intervention. The incidence of adverse events following surgery was evaluated with univariate and multivariate analyses where appropriate.

RESULTS

Patients with DM were found to have a low rate of complications postsurgical repair of distal radius fractures. Preoperative comorbidity analysis showed that the diabetic group had significantly higher rates of chronic obstructive pulmonary disease, hypertension, congestive heart failure, renal failure, steroid use, bleeding disorders, dyspnea, and poorer functional status. Diabetes was found to be an independent predictor for unplanned intubation, sepsis, and septic shock. Diabetes was not found to be an independent predictor of other postoperative complications.

CONCLUSION

Complications after surgical repair of distal radius fracture are low except when it comes to reintubation, sepsis, and septic shock. While the risks of independent complications remain relatively low, diabetes remains an important factor to consider when selecting surgical candidates and to ensure appropriate pre-operative risk assessment.

A Biomechanical Comparison of Fiberglass Casts and 3-Dimensional-Printed, Open-Latticed, Ventilated Casts

Background: The aim of this study was to quantify the stabilizing properties of a 3-dimensional (3D)-printed short-arm cast and compare those properties with traditional fiberglass casts in a cadaveric subacute distal radius fracture model. Methods: A cadaveric subacute fracture model was created in 8 pairs of forearms. The specimens were equally allocated to a fiberglass cast or 3D-printed cast group. All specimens were subjected to 3 biomechanical testing modalities simulating daily life use: flexion and extension of digits, pronation and supination of the hand, and 3-point bending. Between each loading modality, radiological evaluation of the specimens was performed to evaluate possible interval displacement. Interfragmentary motion was quantified using a 3D motion-tracking system. Results: Radiographic assessment did not reveal statistically significant differences in radiographic parameters between the 2 groups before and after biomechanical testing. A statistically significant difference in interfragmentary motion was calculated with the 3-point bending test, with a mean difference of 0.44 (±0.48) mm of motion. Conclusions: A statistically significant difference in interfragmentary motion between the 2 casting groups was only identified in 3-point bending. However, the clinical relevance of this motion remains unclear as the absolute motion is less than 1 mm. The results of this study show noninferiority of the 3D-printed casts compared with the traditional fiberglass casts in immobilizing a subacute distal radius fracture model. These results support the execution of a prospective randomized clinical trial comparing both casting techniques.

The Wrist and Radius Injury Surgical Trial: 12-Month Outcomes from a Multicenter International Randomized Clinical Trial

BACKGROUND

Optimal treatment for distal radius fractures in older adults remains uncertain. No randomized trials comparing the most frequently used treatments in this population have been conducted. Surgical treatment rates vary widely, and the sustained benefits of surgery are uncertain.

METHODS

The Wrist and Radius Injury Surgical Trial, a randomized, multicenter trial, enrolled 304 adults aged 60 years and older with isolated, unstable distal radius fractures at 24 institutions. Patients who wanted surgery (n = 187) were randomized to internal fixation, external fixation, or percutaneous pinning; patients who preferred conservative management (n = 117) received casting. The primary outcome was the 12-month Michigan Hand Outcomes Questionnaire (MHQ) summary score.

RESULTS

At 12 months, there were no differences by treatment in primary outcome. Twelve-month MHQ summary scores differed between internal fixation and external fixation by 3 points (97.5 percent CI, 6.0 to 11.5) and between internal fixation and pinning by -0.14 (97.5 percent CI, -9.2 to 8.9). However, at 6 weeks, the mean MHQ summary score for internal fixation was greater than for external fixation by 19 (p < 0.001), pinning by 11 (p < 0.001), and casting by 7 (p = 0.03). Internal fixation participants demonstrated significantly better radiologic alignment throughout the follow-up period. Malunion was experienced by 48 percent of casting participants.

CONCLUSIONS

Recovery was fastest for internal fixation and slowest for external fixation according to most measures, but by 12 months there were no meaningful differences in outcomes. Casting participants experienced satisfactory results despite loss of radiologic alignment.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Operative vs conservative treatment in distal radius fractures: A protocol

BACKGROUND

Given this lack of conclusive outcome data, there are currently no clear guidelines to direct the treatment of displaced distal radius fractures in the elderly. This retrospective clinical trial was performed to compare the outcomes of two methods that were used for the treatment of displaced and unstable distal radial fractures in patients 65 years of age or older: METHODS:: This study was performed and reported in accordance with the Strengthening the Reporting of Observational studies in Epidemiology checklist. Between January 2017 and May 2018, a total of 184 patients who presented to Huzhou Traditional Chinese Medicine Hospital with distal radius fractures were extracted from the hospital database and evaluated for eligibility. This retrospective cohort study was approved by the institutional review board in our hospital. Outcome measures included Patient-Related Wrist Evaluation score, patient satisfaction, complications, and radiographic outcomes. SPSS software package (version 21.0; SPSS Inc, Chicago, IL) was used for all statistical analyses.

RESULTS

The hypothesis was that the two groups would achieve similar functional scores and complications in distal radial fractures.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5689).

Volar Locked Plating Versus Closed Reduction and Casting for Acute, Displaced Distal Radial Fractures in the Elderly: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

It remains unclear whether volar locked plating (VLP) yields a better functional outcome than closed reduction and casting (CRC) for elderly patients with an acute, displaced distal radial fracture. Our purpose was to conduct a systematic review and meta-analysis of randomized controlled trials comparing outcomes of VLP and CRC for elderly patients (age, ≥60 years).

METHODS

Multiple databases, including MEDLINE, were searched for randomized controlled trials evaluating outcomes following distal radial fracture treatment. Raw data were obtained for studies that included patients of all ages, and the elderly subgroup was included for analysis. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score at ≥1 year of follow-up. Secondary outcomes included the 3-month DASH score, range of motion, final radiographic alignment, and complications. Effect sizes for the comparison of each outcome between groups were pooled across studies using random-effects models with the inverse variance weighting method. Changes in DASH score were compared with a minimal clinically important difference (MCID) estimate of 10 to assess clinical relevance.

RESULTS

Of 2,152 screened articles, 6 were included. Demographics were similar for the 274 VLP and 287 CRC patients. DASH scores were significantly better following VLP than CRC at the time of final follow-up (12 to 24 months postoperatively; score difference, -5.9; 95% confidence interval [CI], -8.7 to -3.1) and at 3 months (-8.9; 95% CI, -13.0 to -4.8). VLP yielded significantly better palmar tilt, radial inclination, and supination, with no differences in ulnar variance, flexion-extension, pronation, or total complication rates.

CONCLUSIONS

Functional outcome was significantly better following VLP than CRC 3 months into the treatment of acute, displaced distal radial fractures in an elderly population and up to 2 years after injury. However, the observed differences in the final DASH score did not exceed published estimates of the MCID, suggesting that clinical outcomes are similar for both treatment options.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

[Fractures of the Distal Radius]

The fracture of the distal radius is the most common human fracture. The optimal management of this injury requires extensive knowledge and skills regarding closed and open reposition maneuvers, plastering and various surgical osteosynthesis techniques. Typical as well as rare accompanying injuries must be recognized and included in the treatment regimen.

Nonoperative treatment versus volar locking plate fixation for elderly patients with distal radial fracture: a systematic review and meta-analysis

Background

This systematic review and meta-analysis assessed the role of nonoperative treatment and volar locking plate (VLP) fixation in elderly patients with distal radial fracture.

Methods

The systematic literature review identified randomized controlled trials (RCTs) and observational studies using VLP and nonoperative treatment for distal radial fractures in the elderly. Two investigators independently extracted data and evaluated the quality of the studies. A meta-analysis was performed using RevMan version 5.3.

Results

The five RCTs and six observational studies included 585 and 604 patients in the VLP and nonoperation groups, respectively. The quality of these 11 studies was moderate. Compared to nonoperation treatment, VLP did not improve the disabilities of the arm, shoulder and hand (DASH) score (weighted mean difference [WMD] = −1.67; 95% confidence interval [CI], −3.58–−0.24; P = 0.09), decrease complications (odds ratio = 1.05; 95% CI, 0.51–2.19; P = 0.89), or improve range of motion in flexion, extension, pronation, supination, and radial deviation. The VLP group had better grip strength (WMD = 10.52; 95% CI, 6.19–14.86; P < 0.0001) and radiographic assessment than the nonoperation group.

Conclusions

Although insufficient, the study evidence shows that VLP does not improve DASH scores, complications, or range of motion, but it might provide better grip strength and radiographic assessment than nonoperation treatment.

Relationship Between Hand Dominance and Treatment Outcomes for Distal Radius Fractures in the Elderly in the Short-Term

Purpose

Many studies have found no notable long-term differences in functional outcomes between operative and conservative treatments for distal radius fractures (DRFs) in elderly patients. However, those studies have not considered hand dominance. The current study compared outcomes between both treatments in a dominant wrist–injured group (dominant group) and nondominant wrist–injured group (nondominant group).

Methods

A total of 101 patients aged 65 years and older who experienced displaced DRF requiring reduction and who were managed for over 3 months with either operative or conservative treatment were examined. The dominant group included 46 subjects (operative, n = 26; conservative, n = 20), and the nondominant group included 55 subjects (operative, n = 28; conservative, n = 27). All operative treatments were performed with volar locking plate fixation, and all conservative treatments were immobilized with a sugar-tong orthosis or forearm cast. Functional outcomes and radiographic assessments were compared 3 months after treatment. The primary outcome measure was the Quick–Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; secondary outcomes were grip strength, range of motion, and Mayo wrist score. We also examined QuickDASH scores after at least 1 year.

Results

The QuickDASH score showed no significant differences between treatments by dominance at 3 months or more than a year. In the dominant group, operative treatment resulted in significant 7-kg greater grip strength at 3 months, whereas the nondominant group showed no significant differences in functional outcomes between treatments.

Conclusions

Although QuickDASH scores were similar at 3 months and 1 year between treatments regardless of hand dominance, surgery for dominant-side DRF resulted in better grip strength than conservative treatment at 3 months.

Clinical relevance

This study will help clarify potential outcomes differences between operative and conservative DRF treatment in patients aged over age 65 years.

Bedside ultrasound in the emergency department for reduction and radial manipulation of distal radial fractures

OBJECTIVE

Distal radial fracture reduction is a common procedure in the ED. Previous studies have suggested that ultrasound (US)-guided reduction improves outcomes for patients who undergo manipulation and reduction of distal radial fractures in the ED. We aimed to investigate this with the first randomised controlled trial looking at US-guided distal radial fracture reduction. Our primary objective was to compare rates of operative intervention between the study groups. Rate of re-manipulation was compared as a secondary outcome.

METHODS

ED patients were prospectively randomised to either standard landmark guided or US-guided closed reduction of distal radial fractures. The closed reductions were performed by senior emergency clinicians and the USs were performed by emergency physicians experienced in point-of-care US. Following reduction patients were managed equally and referred to the local orthopaedic service who were blinded to whether US was used to assist manipulation or not. This service decided on the need for re-manipulation or operative intervention.

RESULTS

One hundred patients were enrolled and randomised equally into each cohort. We found no statistically significant difference between the control and intervention groups of our study. In the control group, 46% of patients underwent operative fixation, compared to 48% in the US-guided group (P = 0.36). Our secondary intervention of re-manipulation in the ED or theatre following the initial reduction showed no statistically significant difference between the groups (P = 1.0).

CONCLUSION

US-guided reduction of dorsally displaced, distal radius fractures in the ED setting, did not improve measured clinical outcomes.

Operative vs Nonoperative Treatment of Distal Radius Fractures in Adults: A Systematic Review and Meta-analysis

IMPORTANCE

No consensus has been reached to date regarding the optimal treatment for distal radius fractures. The international rate of operative treatment has been increasing, despite higher costs and limited functional outcome evidence to support this shift.

OBJECTIVES

To compare functional, clinical, and radiologic outcomes after operative vs nonoperative treatment of distal radius fractures in adults.

DATA SOURCES

The PubMed/MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched from inception to June 15, 2019, for studies comparing operative vs nonoperative treatment of distal radius fractures.

STUDY SELECTION

Randomized clinical trials (RCTs) and observational studies reporting on the following: acute distal radius fracture with operative treatment (internal or external fixation) vs nonoperative treatment (cast immobilization, splinting, or bracing); patients 18 years or older; and functional outcome. Studies in a language other than English or reporting treatment for refracture were excluded.

DATA EXTRACTION AND SYNTHESIS

Data extraction was performed independently by 2 reviewers. Effect estimates were pooled using random-effects models and presented as risk ratios (RRs) or mean differences (MDs) with 95% CIs. Data were analyzed in September 2019.

MAIN OUTCOMES AND MEASURES

The primary outcome measures included medium-term functional outcome measured with the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and the overall complication rate after operative and nonoperative treatment.

RESULTS

A total of 23 unique studies were included, consisting of 8 RCTs and 15 observational studies, that described 2254 unique patients. Among the studies that presented sex data, 1769 patients were women [80.6%]. Overall weighted mean age was 67 [range, 22-90] years). The RCTs included 656 patients (29.1%); observational studies, 1598 patients (70.9%). The overall pooled effect estimates the showed a significant improvement in medium-term (≤1 year) DASH score after operative treatment compared with nonoperative treatment (MD, -5.22 [95% CI, -8.87 to -1.57]; P = .005; I2 = 84%). No difference in complication rate was observed (RR, 1.03 [95% CI, 0.69-1.55]; P = .87; I2 = 62%). A significant improvement in grip strength was noted after operative treatment, measured in kilograms (MD, 2.73 [95% CI, 0.15-5.32]; P = .04; I2 = 79%) and as a percentage of the unaffected side (MD, 8.21 [95% CI, 2.26-14.15]; P = .007; I2 = 76%). No improvement in medium-term DASH score was found in the subgroup of studies that only included patients 60 years or older (MD, -0.98 [95% CI, -3.52 to 1.57]; P = .45; I2 = 34%]), compared with a larger improvement in medium-term DASH score after operative treatment in the other studies that included patients 18 years or older (MD, -7.50 [95% CI, -12.40 to -2.60]; P = .003; I2 = 77%); the difference between these subgroups was statically significant (test for subgroup differences, P = .02).

CONCLUSIONS AND RELEVANCE

This meta-analysis suggests that operative treatment of distal radius fractures improves the medium-term DASH score and grip strength compared with nonoperative treatment in adults, with no difference in overall complication rate. The findings suggest that operative treatment might be more effective and have a greater effect on the health and well-being of younger, nonelderly patients.

Outcomes and Complications in the Management of Distal Radial Fractures in the Elderly

BACKGROUND

The purpose of the present study was to identify trends in management and to compare the outcomes and complications following nonoperative and operative management (including external fixation, closed reduction and percutaneous pinning, and open reduction and internal fixation) for distal radial fractures in patients ≥65 years of age.

METHODS

We performed a retrospective analysis, with use of the OptumLabs Data Warehouse database, of patients ≥65 years of age who had been managed for a distal radial fracture between 2009 and 2014 (as indicated by diagnosis codes according to the International Classification of Diseases, Ninth Revision, Clinical Modification). Ninety-day and 1-year complication rates per 1,000 fractures were analyzed overall and by treatment modality.

RESULTS

Thirteen thousand, seven hundred and thirteen distal radial fractures were analyzed. The overall 90-day complication rate was 36.5 per 1,000 fractures, and the 1-year upper-extremity-specific complication rate was 236.2 and 307.5 per 1,000 fractures for nonoperative and operative management, respectively. Overall, post-injury stiffness was the most common 1-year upper-extremity-specific complication (incidence, 11.5%). There was no significant difference between operative and nonoperative management in terms of 90-day complication rates. However, operative management had a higher 1-year complication rate than nonoperative management (307.5 versus 236.2 per 1,000 fractures). Overall, the 5 most common upper-extremity-specific complications following operative treatment of distal radial fracture were stiffness (16.0%), chronic regional pain syndrome (9.9%), median neuropathy (8.0%), implant-related complications (3.8%), and tendon-related complications (2.8%). Stiffness was significantly more frequent following operative management (16.0% versus 9.8%; p < 0.01).

CONCLUSIONS

Operative management of a distal radial fracture should be carefully considered when discussing treatment options with patients ≥65 years of age.

LEVEL OF EVIDENCE

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

Factors associated with the decision for operative versus conservative treatment of displaced distal radius fractures in the elderly

BACKGROUND

The treatment of senile distal radius fractures had not been clearly defined. The objective of this study was to identify the factors associated with the decision for operative treatment of displaced distal radius fractures in patients aged over 55 years.

METHODS

Data of 318 patients with displaced distal radius fractures were collected on patient-, fracture- and surgeon-related characteristics that were plausibly related to the decision for operation. Mean comparisons or chi-squared test were used for univariate analysis of the above-mentioned factors, and then multiple logistic regression was used to identify factors associated with the decision for operation.

RESULTS

Univariate analysis showed that age, osteoporosis, Charlson score, associated orthopaedic injuries requiring surgery, Orthopaedic Trauma Association (AO) and Fernandez classification, radial height, volar tilt, volar/dorsal comminution, ulnar variance, intra-articular displacement/step-off, associated distal radioulnar joint instability or radiocarpal joint dislocation and subspecialty of treating surgeons had statistically significant association with operative intervention. In the multivariate analysis, the predictors of operative intervention were younger patient age (P = 0.028), associated orthopaedic injuries requiring surgery (P = 0.020), higher AO classification (P = 0.037), higher Fernandez classification (P = 0.041), radial shortening >5 mm (P = 0.020), volar tilt > -10° (P = 0.020), volar/dorsal comminution (P = 0.020), ulnar variance >5 mm (P = 0.023), intra-articular displacement/step-off >2 mm (P = 0.004), associated distal radioulnar joint instability or radiocarpal joint dislocation (P = 0.047) and treatment by an upper extremity specialist (P = 0.038).

CONCLUSION

The decision for surgery was predominantly influenced by the characteristics and severity of the fracture. Patients' age and treatment by an upper extremity specialist were also significant factors associated with a higher likelihood of operative intervention.

Functional outcome and management pathways for adult patients presenting to an Australian health service with distal radius fracture

OBJECTIVE

Primarily to determine mid-term functional outcome for patients with distal radius fracture (DRF) and to compare this between operative and conservatively managed patients. Secondarily to examine for differences in age, gender and number of instability factors between management groups.

METHODS

Eligible patients (age 18 years or more, closed DRF managed to completion of care within Monash Health), presenting between 1 January and 31 December 2016. Completion of the patient-rated wrist evaluation (PRWE) questionnaire was sought at 6-12 months post-injury. Management was noted (operative or conservative). Age, sex and number of defined instability factors present (dorsal angulation >20°, intra-articular fracture, associated ulna fracture, dorsal comminution, radial shortening >2 mm) are reported and compared between management groups.

RESULTS

Of 369 eligible patients, 199 (54%) completed a PRWE. Median age was 60 years (interquartile range [IQR] 45-71), 150 (75%) were women, median number of instability factors present was 2 (IQR 1-4) and 45 (23%) underwent operative management. Difference in PRWE scores between operative and conservatively managed patients was not significant (20 [IQR 7-36] vs 16 [IQR 5-35]). Differences in age and gender between management groups were not significant. Significantly more in the operative group had presence of four or more instability factors (44% [95% confidence interval 30-60] vs 20% [14-27]).

CONCLUSION

The mid-term median PRWE score was 18 (IQR 5-36). This was not significantly different between operative and conservatively managed patients. Operation was more likely when four or more instability factors were present.

Nonoperative Treatment Compared with Volar Locking Plate Fixation for Dorsally Displaced Distal Radial Fractures in the Elderly: A Randomized Controlled Trial

BACKGROUND

The usage of volar locking plate fixation for distal radial fractures has increased in older patient populations, despite the fact that surgical treatment in the elderly population has not clearly been proven to be superior to nonoperative treatment. The purpose of the present study was to compare nonoperative treatment with volar locking plate fixation with regard to clinical outcome for elderly patients with dorsally displaced distal radial fractures.

METHODS

In this study, 140 patients were randomly allocated to nonoperative treatment with a plaster splint (n = 72) or volar locking plate fixation (n = 68). The outcome variables were the Patient-Rated Wrist Evaluation (PRWE) score, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire score, EuroQol-5 Dimensions (EQ-5D) score, range of motion, grip strength, radiographic outcomes, and complications. Evaluation was performed at 3 and 12 months by unblinded observers.

RESULTS

At 3 months, 122 patients were evaluated, and at 12 months, 119 patients were evaluated. At 3 months, the volar locking plate group, compared with the nonoperative treatment group, had a better median PRWE score (10.3 compared with 35.5 points; p = 0.002), DASH score (14.4 compared with 29.2 points; p = 0.016), and grip strength (71.0% of the uninjured hand compared with 53.9%; p < 0.001). Significant differences in favor of the volar locking plate group remained at 12 months; compared with the nonoperative treatment group, the volar locking plate group had a better median PRWE score (7.5 points compared with 17.5 points; p = 0.014), DASH score (8.3 points compared with 19.9 points; p = 0.028), and grip strength (96.8% compared with 80.0%; p = 0.001). Radiographic measurements favored volar locking plate fixation at 3 and 12 months. Complication rates were similar, with 11% major complications in the nonoperative group compared with 14% major complications in the volar locking plate group (p = 0.606) and 11% minor complications in the nonoperative group compared with 20% minor complications in the volar locking plate group (p = 0.197).

CONCLUSIONS

The PRWE scores, DASH scores, and grip strength were better for the volar locking plate group compared with the nonoperative group at 3 and 12 months. The complication rates were similar. Our results imply that there is a benefit for the elderly patient with an unstable dorsally displaced distal radial fracture to be treated with a volar locking plate.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.