Treatment goals for distal radius fractures in 2018: recommendations and practical advice

Current Management and Volar Locking Plate Fixation with Bone Cement Augmentation for Elderly Distal Radius Fractures-An Updated Narrative Review

Distal radius fractures (DRFs) are the most common among all kinds of fractures with an increase in incidence due to the rapidly expanded size of the elderly population in the past decades. Both non-surgical and surgical treatments can be applied for this common injury. Nowadays, more and more elderly patients with DRFs undergo surgical treatments to restore pre-injury activity levels faster. However, optimal treatment for geriatric DRFs is still debated, and careful evaluation and selection of patients are warranted considering clinical and functional outcomes, and complications following surgical treatments. Furthermore, osteoporosis is a predominant factor in elderly DRFs mostly deriving from a low-energy trauma, so many treatment modalities are developed to enhance better bone healing. Among various options for bone augmentation, bone cement is one of the most widely used measures. Bone cement such as calcium phosphate theoretically improves fracture stability and healing, but whether the elderly patients with DRFs can significantly benefit from surgical fixation with bone cement augmentation (BCA) remains controversial. Hence, in the present review, the latest literature regarding current concepts of management and evidence about volar locking plate fixation (VLPF) with BCA for elderly DRFs was searched in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science; out of >1000 articles, full texts of 48 and 6 articles were then examined and analyzed separately for management and VLPF with BCA for elderly DRFs. We aim to provide the readers with updates concerning the above issues.

Efficacy of electroacupuncture in assisting postoperative healing of distal radius fractures: study protocol for a randomized controlled trial

BACKGROUND

Manual reduction and surgical treatment are common methods for distal radius fractures (DRFs). The existing literature suggests that postoperative combined rehabilitation treatment and medication are effective for the healing of DRFs. However, the side effects of these treatments remain to be solved. Previous studies have shown that electroacupuncture (EA) can effectively relieve wrist swelling and improve the joint function in patients with DRFs, but more evidence is needed to prove the effectiveness of EA. This trial aims to explore the efficiency and feasibility of combined EA treatment in postoperative treatment of DRFs compared with routine treatment.

METHODS

This is a parallel randomized controlled trial. A total of 222 patients diagnosed with moderate DRFs will be recruited and randomly assigned to an EA group or a routine treatment group at a ratio of 1:1. Routine treatment group will receive medication and rehabilitation. Yangxi (LI 5), Yangchi (TE 4), Yanggu (SI 5), Hegu (LI 4), and Taiyuan (LU 9) will be selected in the EA group for intervention three times a week on the basis of routine treatment. Both groups will receive 8 weeks of treatment and 4 weeks of follow-up. The primary outcome will be ulnar positive variance. The secondary outcomes will include radiographic healing rate, bone strength, hemorheological indices, serum biochemical indicators and inflammatory factors, grip strength, wrist swelling score, patient-rated wrist evaluation, disabilities of arm, shoulder and hand, and visual analogue scale. Outcomes will be evaluated at baseline, postoperative 3rd day, 2nd, 4th, 6th, 8th, and 12th weeks.

DISCUSSION

The results of this study will help establish a more optimized scheme to treat patients with DRFs. Trial registration Chinese Clinical Trial Registry ChiCTR2200062857. Registered on 21 August 2022, www.chictr.org.cn/com/25/showproj.aspx?proj=175567 .

The Effect of Hand Dominance, Age, Gender, Fracture Comminution and ASA Status on Time to Fracture Healing Following Surgical Fixation of Distal Radius Fractures

Background: There is recent renewed interest in the effect of hand dominance on distal radius fractures. Current studies focus on functional or patient-reported outcomes, with lack of studies pertaining to radiological outcomes. The primary aim of this study is to examine the effect of hand dominance on time to fracture healing following surgical fixation of distal radius fracture. We also looked at the effect of age, gender, fracture comminution and American Society of Anaesthesiologists (ASA) status on time to fracture healing.

Methods: Patients who underwent distal radius fracture fixation surgery in our department from 1 January 2015 to 31 December 2015 were included. Time to fracture healing was taken from the day of surgery to when radiographic union was present as evidence by bridging callus or osseous bone. We looked at the effect of hand dominance, age, gender, fracture comminution and ASA status on time to fracture healing.

Results: One hundred and forty-five consecutive patients (80 females and 65 males) had a mean period of 56.2 ± 41.8 days to fracture healing post-operatively. Patients with dominant hand injury had a shorter duration to fracture healing than patients with non-dominant hand injury (mean 47.3 ± 31.1 days versus 62.1 ± 46.8 days, p = 0.023). Patients ≥ 65 years and with pre-existing medical conditions (ASA Class II and above) had a longer duration to fracture healing (mean 63.7 ± 53.0 days versus 51.9 ± 33.4 days, p = 0.036 and mean 47.9 ± 30.0 days versus 62.0 ± 47.7 days, p = 0.016, respectively). In addition, patients with comminuted fractures took longer to heal than patients with non-comminuted fractures (mean 57.6 ± 33.4 days versus 48.3 ± 20.8 days, p = 0.038).

Conclusion: Time to fracture healing post distal radius fracture fixation surgery was significantly related to hand dominance, as well as age, ASA classification and fracture configuration. Dominant wrist injuries had shorter time to fracture healing.

Level of Evidence: Level IV (Therapeutic)

Renal impairment and time to fracture healing following surgical fixation of distal radius fracture

INTRODUCTION

Despite the prevalence of renal impairments, the existing literature examining fracture healing in the upper limb in patients with renal impairment is sparse. This study hence aims to investigate the effect of renal impairment on time to fracture healing after distal radius fracture fixation surgery.

MATERIALS AND METHODS

Patients above 50 years old who underwent distal radius fracture fixation via volar plating were included. Time to fracture healing was defined as duration between day of surgery and presence of radiographic union as evidence by bridging of callus or osseous bone. To assess for renal impairment, estimated glomerular filtration rate (eGFR) was calculated based on the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Pre-existing comorbidities were also collected and analysed.

RESULTS

Ninety-nine consecutive patients took mean 65.5 ± 8.0 days to fracture healing post-operatively. Patients with renal impairment had longer time to fracture healing than patients without (67.1 ± 50.4 days versus 50.4 ± 31.8 days, p = 0.044). Patients ≥ 65 years also had a longer duration to fracture healing compared to patients < 65 years (mean 63.7 ± 53.0 days versus 50.2 ± 27.2 days, p = 0.033). Similarly, patients with ASA Class I had a shorter mean time to fracture healing than patients with ASA Class II and above (mean 42.5 ± 22.8 days versus 62.8 ± 47.6 days, p = 0.028).

CONCLUSIONS

Time to fracture healing post-distal radius fracture fixation was significantly related to renal impairment, age and ASA classification.

Analysis of Postoperative Complications and Related Factors Affecting Prognosis in 50 Patients with Distal Radius Fractures

Objective

To explore the postoperative complications of distal radius fractures and analyze the related factors that affect its prognosis.

Methods

The clinical data of 50 patients with distal radius fractures admitted to our hospital from October 2016 to September 2019 were retrospectively analyzed. All patients were followed up for 6–12 months, and their postoperative complications were recorded. Collect general patient information and related clinical data. During the follow-up process, Gartland and Werley wrist function scoring system was used to evaluate the prognosis of patients' joint function. Univariate analysis and multiple logistic regression models were used to analyze the related factors that affected the prognosis of patients.

Results

15 patients with postoperative complications were found during the follow-up period, with an incidence rate of 30.00%. Univariate analysis showed that the patient's age, cause of injury, AO classification, shortened deformity, whether it was osteoporosis, surgical method, whether it was combined with other fractures on the same side, whether it was comminuted fracture, and the time to start postoperative exercise were all related to the distal radius. The prognosis of fractures is related (P < 0.05). Multivariate logistic analysis showed that age, AO classification, surgical method, whether it was combined with other fractures on the same side, whether it was comminuted fracture, and the time to start postoperative exercise were the independent factors affecting the prognosis of distal radius fractures (P < 0.05).

Conclusion

The postoperative complications of distal radius fractures are higher. The prognosis is related to the patient's age, AO classification, surgical method, whether it is combined with other fractures on the same side, whether it is comminuted fracture, and the time to start postoperative exercise. Therefore, choosing an appropriate surgical method and starting exercise in time can effectively improve the recovery of the patient's wrist function and reduce the occurrence of complications.

A novel autologous bone graft substitute comprised of rhBMP6 blood coagulum as carrier tested in a randomized and controlled Phase I trial in patients with distal radial fractures

Bone morphogenetic proteins (BMPs) are known to induce new bone formation in vivo but treating trabecular bone defects with a BMP based therapeutic remains controversial. Here, we evaluated the safety and efficacy of a novel Autologous Bone Graft Substitute (ABGS) comprised of recombinant human BMP6 (rhBMP6) dispersed within an autologous blood coagulum (ABC) as a physiological natural carrier in patients with a closed distal radial fracture (DRF). We enrolled 32 patients in a randomized, standard of care (SoC) and placebo (PBO) controlled, double-blinded Phase I First in Human (FiH) clinical trial. ABGS was prepared from peripheral blood as 250 μg rhBMP6/mL ABC or PBO (1 mL ABC containing excipients only) and was administered dorsally via a syringe injection into the fracture site following closed fracture fixation with 3 Kirschner wires. Patients carried an immobilization for 5 weeks and were followed-up for 0 to 26 weeks by clinical examination, safety, serial radiographic analyses and CT. During the 13 weeks follow-up and at 26 weeks post study there were no serious adverse reactions recorded. The results showed that there were no detectable anti-rhBMP6 antibodies in the blood of any of the 32 patients at 13- and 26-weeks following treatment. Pharmacokinetic analyses of plasma from patients treated with ABGS showed no detectable rhBMP6 at any time point within the first 24 h following administration. The CT image and radiographic analyses score from patients treated with AGBS showed significantly accelerated bone healing as compared to PBO and SoC at 5 and 9 weeks (with high effect sizes and P = 0.027), while at week 13 all patients had similar healing outcomes. In conclusion, we show that intraosseous administration of ABGS (250 μg rhBMP6/mL ABC) into the distal radial fracture site demonstrated a good tolerability with no serious adverse reactions as well as early accelerated trabecular bone healing as compared to control PBO and SoC patients.

Distal radius fracture malunion in an adolescent patient treated with osteotomy and autologous iliac bone grafting: A case report

RATIONALE

Adolescent wrist trauma can cause epiphyseal dysplasia and even distal radius deformity malunion. At present, there is no uniform treatment standard for the malunion of the distal radius of adolescents. Osteotomy and autologous bone grafting are currently one of the effective ways to treat the disease. We treated an adolescent patient with distal radius deformity malunion, and used this surgical method to treat the patient and achieved satisfactory results.

PATIENT CONCERNS

A 16-year-old boy suffered from a serious distal radius deformity after trauma of the left wrist 8 years ago.

DIAGNOSES

Physical examination, X-rays examination, high-resolution computed tomography scan, and 3-dimensional reconstruction images of the affected limb helped us diagnose the distal radius fracture malunion.

INTERVENTIONS

The fracture malunion was treated by osteotomy and autologous iliac bone grafting.

OUTCOMES

At the 2-year follow-up, wrist flexion returned to 68°, wrist dorsiflexion to 55°, radial deviation to 14°, ulnar deviation to 12°, forearm pronation to 75°, supination to 67°. Grip strength increased to 35.1 kg after 2 years of operation, recovered to 87% of the uninjured side. Quick DASH score at 2-year follow-up was 9. No complication, such as nonunion or infection, was observed.

LESSONS

This rare case provides valuable insights for hand surgeons. High-resolution computed tomography scan and 3-dimensional reconstruction can help us effectively diagnose wrist diseases. Small lesions on the articular surface of the distal radius will change the position and function of the wrist joint, and cause traumatic arthritis of the wrist joint. Therefore, it is very important to reconstruct the normal structure of the distal radius articular surface. Osteotomy and autologous iliac bone grafting are effective treatments for serious distal radius fracture malunion in the adolescent patient. During the operation, care should be taken to protect the osteoepiphysis to avoid bone dysplasia.

Surgical comfort and clinical outcomes of MIPO with an extra-short plate designed for distal radius fractures

OBJECTIVES

Volar locking plates (VLPs) are increasingly used for distal radius fractures (DRFs) with minimally invasive plate osteosynthesis (MIPO), but surgery learning curves could be long. The purpose of this study was to assess a new extra-short plate with two locking diaphyseal divergent screws, specifically designed for MIPO, preserving the pronator quadratus muscle.

MATERIALS AND METHODS

This retrospective study consisted of three phases: (i) the evaluation of surgical comfort with the incision size and the duration of 59 consecutive surgeries using the extra-short plate in DRFs; (ii) the verification of the implant ability to maintain radiographic indices compared immediately postoperatively and at consolidation. They included radial inclination (RI), volar tilt (VT) and ulnar variance (UV); (iii) the assessment of clinical outcomes at last follow-up through: pain measured on the visual analogue scale (VAS), QuickDASH score, patient-rated wrist evaluation (PRWE) score, grip strength, range of motion and complications.

RESULTS

In the first phase: mean incision size was 32 mm, and mean operative time was 28.5 min. In the second phase, there was no statistical difference between the two measures of the indices studied. In the third phase, mean follow-up time was 14.2 months, VAS score was 1.1, QuickDASH score was 11.4/100, and PRWE score was 9.5/100. Flexion was 91%, extension was 94%, and grip strength was 86% compared to the contralateral side.

CONCLUSION

The surgical comfort may be related to short operative time and incision. The implant allowed maintaining the radiographic indices without secondary displacement. Functional clinical outcomes were satisfactory. This extra-short plate design belongs to a novel generation of VLPs.

Complication rates by surgeon type after open treatment of distal radius fractures

BACKGROUND

In distal radius fracture repair, complications often lead to reoperation and increased cost. We examined the trends and complications in open reduction internal fixation of distal radius fractures across hand specialist and non-hand specialist surgeons.

METHODS

We examined claims data from the Humana administrative claims database between 2007 and 2016. International Classification of Disease, 9th Edition and Current Procedural Terminology codes were searched related to distal radius fractures repaired by open reduction internal fixation. Patients were filtered based on initial treatment by a hand specialty or non-hand specialty surgeon. Complications were reported within 1 year of surgical treatment in the following distinct categories: non-union, malunion, extensor/flexor tendon repair, CRPS, infection. Descriptive statistics were reported.

RESULTS

Hand specialists accounted for 182 procedures compared with 7708 procedures by non-hand specialty orthopaedic or general surgeons. There was an increase in the total number of procedures performed by hand specialists across the years of study, with a higher percentage of intra-articular cases completed by hand specialists (80.7%) compared to non-hand specialists (70.1%). Overall, the complication rates of hand specialists (6.5%) were higher than that of non-specialists (4.7%).

CONCLUSIONS

The results of this study demonstrate a small difference in overall complications for open reduction internal fixation of distal radius fractures by hand specialists in comparison to non-specialists despite treating a higher percentage of intra-articular fractures. Future work controlling for factors unaccounted for in claims-based analyses, such as fracture complexity, patient comorbidities, and surgeon factors are needed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Treatment of the distal radius fractures with percutaneous pinning: evolution to the HK2 system

Displaced fractures of the distal radius often require reduction and fixation to improve outcome in active patients. The volar locking plate gained ground over pinning, which was the first surgical solution described. But pinning methods have since evolved with fewer complications. The authors present a clinical study of distal radius fracture fixation using the HK2 technique, where subchondral pins are connected to intra-focal pins. The results are satisfactory with a lower complication rate compared to other pinning methods. This technical improvement relaunches the pinning technique, with its two advantages, being faster and significantly cheaper than locking plates, with similar long-term functional results.