Outcome following nonoperative treatment of displaced distal radius fractures in low-demand patients older than 60 years

Incidence and Treatment of Carpal Tunnel Syndrome Following Distal Radius Fractures: A TriNetX Analysis of 39,603 Patients

Purpose

Distal radius fractures (DRFs) are among the most common fractures and occur among all age groups. Carpal tunnel syndrome (CTS) is a known sequela of DRFs, but its incidence is poorly understood. This study was undertaken to determine the incidence of CTS following a DRF, with the hypothesis being that CTS occurs more commonly after nonsurgical treatment of a DRF.

Methods

The TriNetX US Collaborative Network was queried for all patients diagnosed with DRFs from January 2016 to December 2022. Cohorts were defined by inclusion and exclusion of the procedure Current Procedural Terminology codes into surgical and nonsurgical groups and subsequent ICD-10 diagnosis codes of CTS. Statistical analysis was performed to determine differences in management across the study period.

Results

A total of 39,603 patients met inclusion with a diagnosis of a DRF. The incidence of CTS within one year of a DRF was 5.3%. Among all DRF cases, 10,279 (26%) patients underwent surgical treatment, whereas 29,324 (74%) patients underwent nonsurgical treatment. The incidence of CTS in the surgical group was 1194 (12%), whereas the incidence of CTS in the nonsurgical group was 915 (3%). Patients undergoing surgical treatment for a DRF had a 9% risk of developing CTS, whereas patients undergoing nonsurgical treatment had a 5% risk. Among all the patients having been diagnosed with CTS, 63% of those with an operatively treated DRF underwent surgical release, whereas 23% of those with a nonoperatively treated DRF underwent surgical release for CTS.

Conclusions

Patients having undergone surgical treatment for DRF had a four times higher rate of developing CTS, compared with those having undergone nonsurgical treatment. Among patients who underwent surgical treatment of a DRF with the subsequent development of CTS, there was a nearly three times higher rate of surgical release of CTS.

Type of study/level of evidence

Prognostic III.

Home exercises after volar locking plate fixation for distal radius fracture in the elderly are as effective as supervised physiotherapy -multicenter retrospective study

BACKGROUND

Although home exercises are used for postoperative rehabilitation of distal radius fractures (DRF), the superiority of home exercise over supervised physiotherapy rehabilitation is controversial. This study aimed to compare the function of home exercise and supervised physiotherapy rehabilitation during postoperative rehabilitation for DRF.

METHODS

We conducted a multicenter, retrospective study in which we included 1949 patients over 65 years old who underwent volar locking plate fixation for DRF. After propensity score matching, 308 patients were assigned to each of an independent home exercise group (IHG) and supervised physiotherapy group (SPG). Wrist function was assessed after 3, 6, and 12 months postoperatively.

RESULTS

The results showed that the Mayo Wrist Score did not differ significantly within the observation period. Range of motion of the wrist was better in the SPG up to 3 months postoperatively but was almost the same as that in the IHG at 6 months. However, the Numerical Rating Scale score was lower in the IHG during all observation periods.

CONCLUSIONS

Home exercise may be as effective as supervised physiotherapy in the medium term, but supervised physiotherapy rehabilitation should be considered if early recovery and good wrist function are desired.

The ageless approach: Nonoperative mastery competes head-on with surgery for elderly distal radius fractures

The aim of the current study is to compare the clinical outcomes of cast immobilization (CI) versus surgical treatment after 1 year for distal radius fractures (DRFs) in the elderly population. The cohort included patients aged 70-89 who suffered an acute, closed, and displaced DRF and who were treated conservatively or surgically at our clinic between August 2018 and January 2022. Those who had pathological fractures, open fractures, concomitant ulna fractures (except ulna styloid fractures), were not between the ages of 70 and 89, or refused to participate were excluded from the study. The study gathered data on patient demographics, initial radiological measurements, clinical measurements after 1 year, treatment models employed, and rates of complications. Of the total number of patients (276), CI was used on 77.2% (213), whereas the other 25 had volar-locked plates (VLP), 25 received external fixators with percutaneous pinning (EFPP), and 13 had isolated percutaneous pinning (IPP). 19 of 276 individuals had complications, with Complex Regional Pain Syndrome and Carpal Tunnel Syndrome being the most often documented. EFPP resulted in significantly higher Disability of the Arm, Shoulder, and Hand (DASH) score values than VLP and IPP at the 1st postoperative year (p < 0.05). No statistically significant difference was found between the DASH score and ROM values at the 1st postoperative year for patients who received CI versus those who underwent surgery (p > 0.05). In the first postoperative year, CI still retains its validity and performs similarly to surgery for DRFs in older individuals. VLPP and IPP methods outperformed EFPP surgeries.

Distal radius malunion: outcomes following an ulnar shortening osteotomy

PURPOSE

Positive ulnar variance following a distal radius malunion can lead to ulnar-sided wrist pain, loss of grip strength, and distal radioulnar joint impingement. The primary aim of this study is to describe upper limb-specific functional outcomes following ulnar shortening osteotomy (USO) for ulnar-sided wrist pain associated with malunion of the distal radius.

METHODS

We retrospectively identified 40 adult patients from a single centre over a 9-year period that had undergone an USO for symptomatic malunion of the distal radius. The primary outcome was the patient-rated wrist evaluation (PRWE). Secondary outcomes were the QuickDASH, EQ-5D-5L, complications, and net promoter score (NPS).

RESULTS

Outcomes were available for 37 patients (93%). The mean age was 56 years and 25 patients were female (68%). At a mean follow-up of 6 years (range 1-10 years) the median PRWE was 11 (IQR 0-29.5), the median QuickDASH 6.8 (IQR 0-29.5), and the median EQ-5D-5L index was 0.88 (IQR 0.71-1). The NPS was 73. Complications occurred in nine patients (24%) and included non-union (n = 4), early loss of fixation requiring revision surgery (n = 1), superficial wound infection (n = 2), neurological injury (n = 1), and further surgery for symptomatic hardware removal (n = 1).

CONCLUSIONS

For patients with a symptomatic distal radius malunion where the predominant deformity is ulnar positive variance, this study has demonstrated that despite 1 in 4 patients experiencing a complication, USO can result in excellent patient reported outcomes with high levels of satisfaction.

LEVEL OF EVIDENCE

III (Cohort Study).

Total Wrist Arthroplasty as a Motion-Sparing Option for Distal Radius Malunion in a Patient of Advanced Age: A Case Report

CASE

A 62-year-old woman presented with wrist pain secondary to a distal radius fracture malunion 4 months after a fall onto an outstretched hand. She was not an ideal candidate for osteotomy and bone graft because of the degree of displacement and osteoporosis, so after nonoperative treatment was unsuccessful, she was offered total wrist arthroplasty (TWA) or arthrodesis and opted for TWA.

CONCLUSION

At 14-month follow-up, the patient reported significant improvement in her pain and function. The current generation of TWA implants may allow use in the management of symptomatic distal radius malunions in older, low-demand patients.

Carpal Tunnel Release Performed during Distal Radius Fracture Surgery

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

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.

Retrospective Comparative Study of Clinical Outcomes and Cost-Effectiveness with Bone Substitutes on Volar Locking Plate Fixation of Unstable Distal Radial Fractures in the Elderly

Background: This multicenter retrospective study aimed to compare clinical outcomes and cost-effectiveness with bone substitutes on volar locking plate (VLP) fixation of unstable distal radial fractures (DRF) in the elderly. Methods: The data of 1,980 patients of ≥65 years of age who underwent surgery for the DRF with a VLP in 2015-2019 were extracted from a database (named TRON). Patients lost to follow-up or who received autologous bone grafting were excluded. The patients (n = 1,735) were divided into the VLP fixation alone (Group VLA) and VLP fixation with bone substitutes (Group VLS). Propensity score matching of background characteristics (ratio, 4:1) was performed. The modified Mayo wrist scores (MMWS) were evaluated as clinical outcomes. The implant failure rate, bone union rate, volar tilt (VT), radial inclination (RI), ulnar variance (UV) and distal dorsal cortical distance (DDD) were evaluated as radiologic parameters. We also compared the initial surgery cost and total cost for each group. Results: After matching, the backgrounds of Groups VLA (n = 388) and VLS (n = 97) were not significantly different. The MMWS values of the groups were not significantly different. Radiographic evaluation revealed no implant failure in either group. Bone union was confirmed in all patients in both groups. The VT, RI, UV and DDD values of the groups were not significantly different. The initial surgery cost and total cost in the VLS group were significantly higher than those in the VLA group ($3,515 vs. $3,068, p < 0.001). Conclusions: In patients of ≥65 years of age with DRF, the clinical and radiological outcomes of VLP fixation with bone substitutes did not differ from those of VLP fixation alone, yet the additional use of bone augmentation was associated with higher medical costs. The indications for bone substitutes should be more strictly considered in the elderly with DRF. Level of Evidence: Level IV (Therapeutic).

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.

Surgical Management of Acute on Chronic Distal Radius Fractures: Correcting Malunion Deformities Through the Secondary Fracture Plane

It is challenging to restore the clinically acceptable alignment of the distal radius after an acute on chronic fracture or after a secondary fracture occurring after malunion of a primary distal radius fracture. In cases of insignificant primary deformity, restoration to the primary deformity may suffice to obtain a successful clinical result. A borderline acceptable primary radial deformity can be unacceptable after the second injury, resulting in functional disability. If surgery is indicated, the surgeon must contend with both primary and secondary deformities to restore proper distal radius anatomy. We present our technique to correct both primary and secondary distal radius deformities through the new or secondary fracture plane.

Predictors of Management of Distal Radius Fractures in Patients Aged >65 Years

BACKGROUND

Treatment of distal radius fractures (DRFs) in patients aged >65 years is controversial. The purpose of this study was to identify what patient and fracture characteristics may influence the decision to pursue surgical versus nonsurgical treatment in patients aged >65 years sustaining a DRF.

METHODS

We queried our institutional DRF database for patients aged >65 years who presented to a single academic, tertiary center hand clinic over a 5-year period. In all, 164 patients treated operatively were identified, and 162 patients treated nonoperatively during the same time period were selected for comparison (total N = 326). Demographic variables and fracture-specific variables were recorded. Patient and fracture characteristics between the groups were compared to determine which variables were associated with each treatment modality (operative or nonoperative).

RESULTS

The average age in our cohort was 72 (SD: 11) years, and 274 patients (67%) were women. The average Charlson Comorbidity Index (CCI) was 4.1 (SD: 2.1). The CCI is a validated tool that predicts 1-year mortality based on patient age and a list of 22 weighted comorbidities. Factors associated with operative treatment in our population were largely related to the severity of the injury and included increasing dorsal tilt (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.05-1.12; P < .001) and AO Classification type C fractures (OR, 5.42; 95% CI, 2.35-11.61; P < .001). Increasing CCI was the only factor independently associated with nonoperative management (OR, 0.84; 95% CI, 0.72-0.997; P = .046).

CONCLUSION

Fracture severity is a strong driver in the decision to pursue operative management in patients aged >65 years, whereas increasing CCI predicts nonoperative treatment.

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.

The Fragility of Statistical Findings in Distal Radius Fractures: A Systematic Review of Randomized Controlled Trials

PURPOSE

Probability analysis with reporting of P values is often used to determine the statistical significance of study findings in the orthopedic literature. The fragility index (FI) has been used to evaluate the robustness of a significant result. The purpose of this study was to determine the utility of applying a fragility analysis to randomized controlled trials (RCTs) evaluating distal radius fractures (DRFs).

METHODS

We identified all dichotomous outcome data for randomized controlled trials of distal radius fractures (DRFs) published in 13 orthopedic journals from 2000 to 2020. The fragility index (FI) was determined by the number of event reversals required to change a P value from less than 0.05 to greater than 0.05, or vice-versa. The associated fragility quotient (FQ) was determined by dividing the FI by the sample size. The interquartile ranges (IQR) for the FI and FQ were calculated as the difference between the 25th and 75th percentiles for the overall study.

RESULTS

Of the 7352 studies screened, 221 met the search criteria, with 34 randomized controlled trials evaluating distal radius fractures and 151 total outcome events included for analysis. The overall FI was 9 (IQR 6.5-11) with an associated fragility quotient of 0.097 (IQR 0.060-0.140). However, a majority of outcomes (78.8%) were not significant. Fragility analysis of statistically significant outcomes had an FI of 4 (IQR 1-10). All of the studies reported lost to follow-up (LTF) data where 20.6% reported lost to follow-up of greater or equal to 9.

CONCLUSION

The RCTs in distal radius fracture outcomes have comparable statistical robustness to literature in other orthopedic surgical specialties, are not as statistically stable as previously thought and should be interpreted with caution. We recommend that orthopedic literature report the FI and FQ along with the P values to help the reader draw reliable conclusions based on the fragility of outcome measures.

LEVEL OF EVIDENCE

Level I.

Treatment of Distal Radius Fractures with Bridging External Fixator with Optional Percutaneous K-Wires: What Are the Right Indications for Patient Age, Gender, Dominant Limb and Injury Pattern?

The aim of this retrospective study was to evaluate the medium-term clinical and functional outcomes of patients with closed, displaced, and unstable, simple or complex, intra- and extra-articular distal radius fractures (DRFs) treated with a bridging external fixator (BEF) and optional K-wires (KWs). AO classification was used to differentiate the injuries radiographically. Clinical-functional outcomes were evaluated using the Patient-Rated Wrist and Hand Evaluation Score (PRWHE Score) and the Quick Disabilities of the Arm Shoulder and Hand Score (QuickDASH). A total of 269 dorsally displaced fractures of 202 female (75%) and 67 male subjects (25%) were included, with a mean follow-up of 58.0 months. Seventy-five patients (28%) were treated by additional KWs. No differences were found comparing the two groups of patients (BEF vs. BEF + KWs) regarding age, sex, and fracture side (dominant vs. non-dominant). PRWHE and QuickDASH scores were lower in the BEF + KWs group compared to the BEF group (p < 0.0001 and p = 0.0007, respectively). Thus, patients treated with KWs had a better clinical outcome. Beta multivariate regression analysis confirmed that patients of the BEF + KWs group exhibited a better PRWHE score but not a better QuickDASH score. Patients treated by the BEF + KWs with the fracture on the dominant site were characterised by better clinical outcomes. Older patients had a better PRWHE score independently from the treatment. Our findings suggest that the use of BEF for DRFs with optional KWs can be indicated in both young and elderly patients of any gender, independent of limb side and fracture pattern. As the best functional results were achieved in the elderly when KWs were added, the combination of BEF and KWs seems to be mainly indicated for the treatment of DRF, also complex, in the elderly population.

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).

Implicit and Explicit Factors That Influence Surgeons' Decision-Making for Distal Radius Fractures in Older Patients

PURPOSE

The purpose of this study was to evaluate factors that influence surgeons' decision-making in the treatment of distal radius fractures in older patients.

METHODS

Fourteen clinical vignettes of a 72-year-old patient with a distal radius fracture were sent to 185 orthopedic hand and/or trauma surgeons. The surgeons were surveyed regarding the demographic/practice details, treatment decision (surgical or nonsurgical), and factors that influenced management, including the Charlson Comorbidity Index, functional status, radiographic appearance, and handedness. Multivariable regression analyses were used to assess the effect of both surgeon-described (explicit) and given clinical (implicit) factors on the treatment decision and to evaluate for discrepancies.

RESULTS

Sixty-six surgeons completed the survey, and 7 surgeons completed 10-13 vignettes. Surgeons made the explicit determination to pursue nonsurgical treatment based on the presence of comorbidities (odds ratio [OR], 0.02 for surgery; 95% confidence interval [CI], 0.01-0.05), but the observation of the underlying clinical data suggested that the recommendation for surgical treatment was instead based on a higher functional status (OR, 3.54/increase in functional status; 95% CI, 2.52-4.98). Those employed by hospitals/health systems were significantly less likely to recommend surgery than those in private practice (OR, 0.42; 95% CI, 0.23-0.79) CONCLUSIONS: This study demonstrates that the presence of comorbidities, functional status, and practice setting has a significant impact on a surgeon's decision to treat distal radius fractures in older patients. The discrepancy between the surgeon-described factors and underlying clinical data demonstrates cognitive bias.

CLINICAL RELEVANCE

Surgeons should be aware of cognitive biases in clinical reasoning and should work through consequential patient decisions using an analytical framework that attempts to reconcile all available clinical data.

Radiographic Predictors of Delayed Carpal Tunnel Syndrome After Distal Radius Fracture in the Elderly

BACKGROUND

Delayed-onset carpal tunnel syndrome (DCTS) can develop weeks and months after distal radius fracture (DRFx). A better understanding of the risk factors of DCTS can guide surgeon's decision making regarding the management of DRFx and also provides another discussion point to be had with elderly patients when discussing outcomes of nonoperative management.

METHODS

We reviewed 216 nonoperatively managed DRFx between June 2015 and January 2019 at a single level 1 trauma center and senior author's office. We identified 26 patients who developed DCTS at a minimum of 6 weeks after DRFx, which constituted our case group. The remaining 190 patients served as the control group (non-carpal tunnel syndrome [CTS]). Differences between case and control group were evaluated through univariate and multivariate analyses.

RESULTS

The prevalence of DCTS among nonoperatively managed DRFx was 12%. In univariate analysis, volar tilt (VT) and teardrop angle (TDA) were significant independent predictors of development of DCTS. Multivariate logistic regression analysis determined that the odds of developing CTS increased by 12% and 24% for each degree of decrease in VT and TDA, respectively. No other significant risk factors were identified.

CONCLUSIONS

Decreasing VT and TDA are the most significant risk factors associated with DCTS in nonoperatively managed DRFx. These are simple and reliable radiographic measurements that provide significant prognostic value. These parameters can be used to guide surgeon decision making regarding management of DRFx in the elderly while aiding patient expectations and outcomes following nonoperative management of DRFx.

Treatment Modality of Distal Ulnar Head and Neck Fractures Associated With Operatively Treated Distal Radius Fractures Does Not Affect Outcomes

Background: This study compares the functional outcomes and complications between operatively and nonoperatively treated distal ulnar head and neck fractures associated with internal fixation of concomitant distal radius fractures. Methods: A 7-year retrospective chart review was performed to identify patients with operatively treated distal radius fractures associated with distal ulnar head and neck fractures. Ulnar styloid fractures were excluded. Fifty-eight patients who had a minimum of 6 months of follow-up were identified. Patients were divided into 3 treatment groups: nonoperative, open reduction internal fixation (ORIF), and distal ulna resection. Reviewed data included demographics, injury and treatment details, complications, and patient-reported outcome measures. Outcomes measures included Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity and Patient-Rated Wrist Evaluation (PRWE) surveys. Due to inadequate power, 5 patients treated with distal ulna resection were excluded from statistical analysis. Results: The average patient age was 56 years, with an average follow-up of 27 months. All patients underwent ORIF of the distal radius fracture. Distal ulna fractures were treated nonoperatively in 25 patients, with ORIF in 28 patients, and with distal ulna resection in 5 patients. There were no statistically significant differences in wrist or forearm range of motion, complication rates, secondary procedure rates, PRWE scores, or PROMIS scores between ORIF and nonoperative treatment. Conclusion: No differences in wrist or forearm range of motion, complication rates, secondary procedure rates, PRWE scores, or PROMIS scores were observed between ORIF and nonoperative treatment of distal ulnar head and neck fractures associated with operatively treated distal radius fractures.

Effectiveness and cost-effectiveness of surgery versus casting for elderly patients with isplaced intra-rticular type C distal adius fractures: protocol of a randomised controlled rial with economic evaluation (the DART study)

INTRODUCTION

Current literature is inconclusive about the optimal treatment of elderly patients with displaced intra-articular distal radius fractures. Cast treatment is less invasive and less expensive than surgical treatment. Nevertheless, surgery is often the preferred treatment for this common type of distal radius fracture. Patients with a non-acceptable position after closed reduction are more likely to benefit from surgery than patients with an acceptable position after closed reduction. Therefore, this study aims to assess non-inferiority of functional outcomes after casting versus surgery in elderly patients with a non-acceptable position following a distal radius fracture.

METHODS AND ANALYSIS

This study is a multicentre randomised controlled trial (RCT) with a non-inferiority design and an economic evaluation alongside. The population consists of patients aged 65 years and older with a displaced intra-articular distal radius fracture with non-acceptable radiological characteristics following either inadequate reduction or redisplacement after adequate reduction. Patients will be randomised between surgical treatment (open reduction and internal fixation) and non-operative treatment (closed reduction followed by cast treatment). We will use two age strata (65-75 and >75 years of age) and a web-based mixed block randomisation. A total of 154 patients will be enrolled and evaluated with the patient-rated wrist evaluation as the primary outcome at 1-year follow-up. Secondary outcomes include the Disabilities of the Arm, Shoulder and Hand questionnaire, quality of life (measured by the EQ-5D), wrist range of motion, grip strength and adverse events. In addition, we will perform a cost-effectiveness and cost-utility analysis from a societal and healthcare perspective. Incremental cost-effectiveness ratios, cost-effectiveness planes and cost-effectiveness acceptability curves will be presented.

ETHICS AND DISSEMINATION

The Research and Ethics Committee approved this RCT (NL56858.100.16). The results of this study will be reported in a peer-reviewed journal. We will present the results of this study at (inter)national conferences and disseminate the results through guideline committees.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov (NCT03009890). Dutch Trial Registry (NTR6365).

"Age Is Just a Number": Distal Radius Fractures in Patients Over 75

Background: Management of distal radius fractures in patients over 65 is a topic of significant study, but there are variations within this group in terms of independence and activity level. This study compares the outcomes of operative distal radius fracture treatment in patients over 75 with those aged 65 to 74, to evaluate the effects of patient demand and advanced age on outcome. Methods: A retrospective review of a single-institution distal radius fracture database was performed. All patients over age 65 were evaluated for inclusion. Patient factors including activity, independence level, and quick disabilities of the arm, shoulder and hand (QuickDASH) score were recorded. Patients were selected for open reduction and internal fixation (ORIF) based on a discussion between the patient and the treating surgeon. Outcome measures including QuickDASH were recorded at 1-year post-injury. Patients aged 65 to 74 and 75 and over were compared to evaluate for demographic, functional, and outcome differences. Results: In all, 75 patients were included in the study. Fifty-one patients were aged 65 to 74, and 24 patients were aged over 75. The majority of patients rated themselves as "completely independent" and "active," the highest levels of each. There was no difference in QuickDASH scores between those patients who rated themselves as completely partially independent, or active versus moderately active. There was no statistically significant difference in QuickDASH or range of motion parameters at final follow-up. Conclusions: This study demonstrates that, in a group of patients with high levels of independence and activity, outcomes are similar in patients aged 65 to 74 and over 75 at 1 year following distal radius ORIF.

Standard radiographic assessments of distal radius fractures miss involvement of the distal radioulnar joint: a diagnostic study

INTRODUCTION

Distal radius fractures account for one-fifth of all fractures in the emergency department. Their classification based on standard radiographs is common practice although low inter-observer reliabilities and superiority of computer tomography (CT) scanning in evaluation of joint congruency have been reported.

MATERIALS AND METHODS

We retrospectively analyzed 96 displaced distal radius fractures scheduled for open reduction and internal fixation using standard radiographic assessment. The radiographs were classified with the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA), Fernandez and Frykman classifications by three observers and inter-rater reliabilities were calculated. Additional CT scanning was performed in all cases and the following parameters were assessed: radiocarpal joint involvement, fracture extent into the radial sigmoid notch, i.e. the distal radio-ulnar joint, comminution of the metaphysis, and concomitant ulnar styloid fracture. The CT scans were used as a reference standard to determine sensitivity and accuracy of standard radiographic assessment in evaluation of distal radius fractures.

RESULTS

The inter-rater agreement for the AO classification was 35.4%, 68.8% for the Fernandez and 38.5% for the Frykman classification. Fracture extension into the radiocarpal joint was present in 81 cases (84.4%). Sigmoid notch involvement was found in 81 fractures (84.4%). Involvement of both joints was present in 72 cases (75%). The sensitivity of standard radiographs regarding radiocarpal joint involvement was 93.8%. Considering involvement of the distal radio-ulnar joint the false-negative rate using standard radiographs was 61.7% and the test's accuracy for sigmoid notch involvement was 45.8%.

CONCLUSION

This study demonstrates that involvement of the sigmoid notch is frequently missed in standard radiographs. The presented data support the frequent use of CT imaging to allow the holistic illustration of a fracture's complexion and to ensure optimal pre-operative planning.

Distal Radial Fracture Fixation in Adults using Intramedullary Elastic Wires Augmented with either Cast Immobilisation or External Fixation

Introduction:

The aim of this study was to evaluate the clinical outcomes following treatment of distal radial fractures using intramedullary elastic wires with a combination of either cast immobilisation or external fixation.

Materials and methods:

A total of 42 patients (24 females and 18 males) aged 40 to 78 years who presented with displaced and unstable, closed or grade I open, extra- and/or intra-articular fractures of the distal radius were included in the study. Twenty-seven fractures were AO/OTA Type A2-A3 and 15 Type C1-C2. Twenty-four patients were treated with antegrade intramedullary (IM) fixation with elastic wires followed by cast immobilisation and 18 required an external fixator in lieu of casting.

Results:

Final follow-up evaluation was conducted 12 months post-surgery using Sarmiento's modification of Lindstrom criteria and the demerit point system of Gartland and Werley. Successful fracture union was observed in all patients between eight to 14 weeks. Using Sarmiento's modification of Lindstrom criteria, 12 patients (28.6%) had excellent, 23 (54.8%) had good and 7 (16.6 %) had fair results. Based on the functional evaluation using the demerit point system of Gartland and Werley, 13 patients (31%) had excellent, 25 (59.5%) had good and four (9.5%) had fair results. None of the patients had a poor outcome using either of these criteria. Although a fracture union rate of 100% was confirmed clinically and radiographically, eight out of the 42 patients had minor complications in our study. One patient had uneventful IM migration of the wires, one patient reported a feeling of wire loosening, three patients complained of joint stiffness and soft tissue irritation, and three others reported on-going pain. The total cost of all implants used per case was less than INR 1,000.

Conclusions:

Good to excellent functional and radiographic outcomes with easy to manage complications are achieved with the techniques described. Patient selection is key to determining which particular method should be prescribed in a given case.

Artificial intelligence to diagnosis distal radius fracture using biplane plain X-rays

Background

Although the automatic diagnosis of fractures using artificial intelligence (AI) has recently been reported to be more accurate than those by orthopedics specialists, big data with at least 1000 images or more are required for deep learning of the convolutional neural network (CNN) to improve diagnostic accuracy. The aim of this study was to develop an AI system capable of diagnosing distal radius fractures with high accuracy even when learning with relatively small data by learning to use bi-planar X-rays images.

Methods

VGG16, a learned image recognition model, was used as the CNN. It was modified into a network with two output layers to identify the fractures in plain X-ray images. We augmented 369 plain X-ray anteroposterior images and 360 lateral images of distal radius fractures, as well as 129 anteroposterior images and 125 lateral images of normal wrists to conduct training and diagnostic tests. Similarly, diagnostic tests for fractures of the styloid process of the ulna were conducted using 189 plain X-ray anteroposterior images of fractures and 302 images of the normal styloid process. The distal radius fracture is determined by entering an anteroposterior image of the wrist for testing into the trained AI. If it identifies a fracture, it is diagnosed as the same. However, if the anteroposterior image is determined as normal, the lateral image of the same patient is entered. If a fracture is identified, the final diagnosis is fracture; if the lateral image is identified as normal, the final diagnosis is normal.

Results

The diagnostic accuracy of distal radius fractures and fractures of the styloid process of the ulna were 98.0 ± 1.6% and 91.1 ± 2.5%, respectively. The areas under the receiver operating characteristic curve were 0.991 {n = 540; 95% confidence interval (CI), 0.984–0.999} and 0.956 (n = 450; 95% CI 0.938–0.973).

Conclusions

Our method resulted in a good diagnostic rate, even when using a relatively small amount of data.

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.

Clinical outcomes comparison of distal radius fractures between two conservative treatment methods: Below-arm cast versus reverse sugar tong splint

BACKGROUND

The purpose of this prospective randomized study was to compare a new reverse sugar tong splint technique with a below-arm cast, in terms of patient radiological and clinical outcomes.

METHODS

One hundred and forty patients who presented to our clinic between April 2017 and March 2019 were randomly divided into two groups: 70 received reverse sugar tong (RST group) and 70 received below arm cast (BAC group). Clinical and radiological follow-up was performed 7-10 days, three weeks, 5 or 6 weeks, 12 weeks and one year after the treatment. Clinical outcomes including wrist range of motion, complication rates, Health Assessment Questionnaire (HAQ) score at end of treatment, Disabilities of the Arm, Shoulder, and Hand (Q-DASH) questionnaire and Mayo Elbow Performance score (MEPS) score at 12 weeks and last follow-up.

RESULTS

Finally, sixty-five patients were treated with BAC, and their average age was 58.2 years and sixty-two patients with an average age of 57.4 years were treated with RST were completed the radiological and clinical one-year follow-up. There were no significant differences in range of motion, radiological parameters, the Q-DASH and MEPS scores between the groups the 12th week and last visit; however, the HAQ score was significantly higher in the cast group during the 6th visit (p < 0.001). The BAC group had a higher complication rate (40%) than the RST group (19.3%) (p = 0.01).

CONCLUSION

Patient treated with RST had a higher functional status at end of treatment and lower complications when comparing traditional below arm cast.

LEVEL OF EVIDENCE

Level I prognostic randomized controlled trial.

Cost-Effectiveness of Treatments after Closed Extraarticular Distal Radius Fractures in Older Adults from the WRIST Clinical Trial

BACKGROUND

This study performs an economic analysis of volar locking plate, external fixation, percutaneous pinning, or casting in elderly patients with closed distal radius fractures.

METHODS

This is a secondary analysis of the Wrist and Radius Injury Surgical Trial, a randomized, multicenter, international clinical trial with a parallel nonoperative casted group of patients older than 60 years with surgically indicated, extraarticular closed distal radius fractures. Thirty-Six-Item Short-Form Health Survey-converted utilities and total costs from Medicare were used to calculate quality-adjusted life-years and incremental cost-effectiveness ratio.

RESULTS

Casted patients were self-selected and older (p < 0.001) than the randomized surgical cohorts, but otherwise similar in sociodemographic characteristics. Quality-adjusted life-years for percutaneous pinning were highest at 9.17 and external fixation lowest at 8.81. Total costs expended were $16,354 for volar locking plates, $16,012 for external fixation, $11,329 for percutaneous pinning, and $6837 for casting. The incremental cost-effectiveness ratios for volar locking plates and external fixation were dominated by percutaneous pinning and casting. The ratio for percutaneous pinning compared to casting was $28,717. Probabilistic sensitivity analysis revealed a 10, 5, 53, and 32 percent chance of volar locking plate, external fixation, percutaneous pinning, and casting, respectively, being cost-effective at the willingness-to-pay threshold of $100,000 per quality-adjusted life-year.

CONCLUSIONS

Casting is the most cost-effective treatment modality in the elderly with closed extraarticular distal radius fractures and should be considered before surgery. In unstable closed fractures, percutaneous pinning, which is the most cost-effective surgical intervention, may be considered before volar locking plates or external fixation.

Patient-Perceived Outcomes After Nonoperative Treatment of Distal Radius Fracture in Older Adults

Malunion after distal radius fracture is common in older patients; however, whether patient-perceived outcomes are influenced by radiologic outcome is controversial. This study evaluated patient-perceived outcomes according to radiologic parameters in older patients who underwent nonoperative treatment. The records of 167 patients older than 55 years who had a distal radius fracture were reviewed. All fractures were treated nonoperatively, and average length of follow-up was 7 years. Outcomes were evaluated using numeric rating scales for pain and satisfaction, as well as Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores. Radiographs were evaluated for dorsal tilt, radial inclination, and ulnar variance. Fifty-one patients (30%) developed malunion. The pain numeric rating scale score was 0.8 for patients with malunion and 0.4 for patients with acceptable alignment; this difference was not statistically significant. The QuickDASH score was higher for patients with malunion (14.9 vs 11.1 for patients with acceptable alignment); however, this difference was not clinically meaningful. Satisfaction scores were lower for patients with malunion than for patients with acceptable alignment (80.8 vs 92.3). Patients with malunion stated they would choose surgery rather than a cast (13.3% vs 7.2%) if they developed another fracture; this difference was not statistically significant. The subanalysis according to radiologic parameters showed dorsal tilt and ulnar variance affected patient satisfaction but not other outcomes. This study indicated nonoperative treatment in older adults obtained acceptable patient-perceived outcomes despite residual deformity. However, patients whose radiologic parameter exceeded the tolerable range were less satisfied. [Orthopedics. 2021;44(2):e190-e196.].

Comparison of 24-Month Outcomes After Treatment for Distal Radius Fracture: The WRIST Randomized Clinical Trial

IMPORTANCE

Distal radius fractures (DRFs) are common injuries among older adults and can result in substantial disability. Current evidence regarding long-term outcomes in older adults is scarce.

OBJECTIVE

To compare outcomes across treatment groups at 24 months among adults with DRFs who participated in the WRIST trial.

DESIGN, SETTING, AND PARTICIPANTS

The Wrist and Radius Injury Surgical Trial (WRIST) randomized, international, multicenter trial was conducted from April 1, 2012, through December 31, 2016. Participants were adults aged 60 years or older with isolated, unstable DRFs at 24 health systems in the US, Canada, and Singapore. Data analysis was performed from March 2019 to March 2021.

INTERVENTIONS

Participants were randomized to open reduction and volar locking plate system (VLPS), external fixation with or without supplementary pinning (EFP), and percutaneous pinning (CRPP). The remaining participants chose closed reduction and casting.

MAIN OUTCOMES AND MEASURES

The primary outcome was the 24-month Michigan Hand Outcomes Questionnaire (MHQ) summary score. Secondary outcomes were scores on the MHQ subdomains hand strength and wrist motion.

RESULTS

A total of 304 adults were recruited for the study, and 187 were randomized to undergo surgery, 65 to VLPS, 64 to EFP, and 58 to CRPP; 117 participants opted for closed reduction and casting. Assessments were completed at 24 months for 182 participants (160 women [87.9%]; mean [SD] age, 70.1 [8.5] years). Mean MHQ summary scores at 24 months were 88 (95% CI, 83-92) for VLPS, 83 (95% CI, 78-88) for EFP, 85 (95% CI, 79-90) for CRPP, and 85 (95% CI, 79-90) for casting, with no clinically meaningful difference across groups after adjusting for covariates (χ23 = 1.44; P = .70). Pain scores also did not differ across groups at 24 months (χ23 = 2.64; P = .45). MHQ summary scores changed from 82 (95% CI, 80-85) to 85 (95% CI, 83-88) (P = .12) between 12 and 24 months across groups. The rate of malunion was higher in the casting group (26 participants [59.1%]) than in the other groups (4 participants [8.0%] for VLPS, 8 participants [17.0%] for EFP, and 4 participants [9.8%] for CRPP; χ23 = 43.6; P < .001), but malunion was not associated with the 24-month outcome difference across groups.

CONCLUSIONS AND RELEVANCE

The study did not find clinically meaningful patient-reported outcome differences 24 months after injury across treatment groups, with little change between 12 and 24 months. These findings suggest that long-term outcomes need not necessarily be considered in deciding between treatment options. Patient needs and recovery goals that fit to relative risks and benefits of each treatment type will be more valuable in treatment decision-making.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01589692.

Did Covid-19 pandemic narrow the spectrum of surgical indications?

Introduction. The Covid-19 outbreak has changed orthopedic practices more than expected. We are going through a period in which conservative treatment will become prominent when deciding on fractures with indistinct surgical margins in guidelines. Considering global tendency for surgical interventions in the pre-pandemic period, we tried to find out the answer to the following question: will conservative treatment be the shining star in the post pandemic period? Materials and Methods. 262 patients who were with “gray zone fractures-injuries” like extraarticular distal radius fracture, proximal humerus fracture and Weber type B ankle fracture was treated conservatively during March and August, 2020. Open or pathological fracture, fractures with vascular or neurological injury and fractures involving the articular joint were excluded. Results. 59 patients with proximal humerus fracture followed with arm-sling. Mean ASES scores at 6th was 48.3 and 69.9 12th week. 91 patients with Weber B-type ankle fracture were followed up with below-knee plaster for 6 weeks. American Orthopedic Foot & Ankle Score was 48 in the 6th week and 75 in the 12th week. 90 patients with distal radius fracture were followed up with plaster. Malunion was detected at 5 patients. Mean Quick Dash score at 6th weeks was 52.3 and 29.5 at 12th weeks. Mean wrist flexion was 450, wrist extension was 350, forearm supination 600 and forearm pronation was 700 at final control. Conclusions. The conservative treatment experiences we have gained from pandemic periods probably will change our treatment algorithm.

Determinação dos parâmetros anatômicos limítrofes para melhor desfecho funcional da fratura de Colles: Um estudo prospectivo

Objective  The treatment of Colles fracture can deform the wrist. Some studies claim the resulting deformity rarely hinders daily activities, whereas others report the opposite; thus, anatomical reduction is desirable. Our objective was to analyze the anatomical and functional results of Colles fracture to find out the values of individual parameters corresponding to the best functional outcome.

Methods  The present prospective study included 70 elderly patients with Colles fracture. All patients were managed conservatively. The anatomical parameters were evaluated by measuring dorsal angulation, radial inclination, and radial height, and they were assessed as per Stewart et al. The functional result was assessed by the Mayo wrist score. The results were analyzed using the chi-squared test of association, and a p -value < 0.001 was considered statistically significant and to examine strengths of associations; we computed odds ratios (ORs) with 95% confidence intervals (CI).

Results  Excellent and good results were obtained in 68.5% of the cases anatomically and 78.5% functionally, which was statistically significant ( p  = 0.0009). Out of the three anatomical parameter dorsal angulation < 10° and loss of radial inclination < 9° showed statistically significant association with functional results ( p  = 0.0006), but loss of radial height < 6 mm did not ( p  = 0.0568), which became significant when loss of radial height was kept < 4 mm ( p  = 0.00062).

Conclusion  Fractures with anatomical reduction have better functional results. The acceptable borderline anatomical parameters for obtaining excellent or good functional results are dorsal angulation < 10°, loss of radial inclination < 9°, and loss of radial height < 4 mm.

Outcome Measurement for Distal Radius Fractures

Distal radius fractures (DRFs) are among the most common upper extremity injuries. Multiple medical conditions now are evaluated by standardized outcome sets that enable comparability. Recent international working groups have provided consensus statements for outcomes measurement after DRFs. These statements emphasized the growing importance of patient-reported outcome measures as well as traditional measures, including pain assessment, radiographic alignment, performance, and assessment of complications. A standardized instrument and timeline for measuring outcomes following DRFs offers clinicians, researchers, and health care economists a powerful tool. This article reviews the current evidence and provides recommendations for a DRF standardized outcome set.

A Critical Assessment of the Most Cited Papers on Distal Radius Fractures

This article reviews the impact of the most cited works on distal radius fractures. Judged by the most cited works in this field, distal radius fracture research has followed other paradigm shifts in the history of science. Landmark papers showed that restoring premorbid anatomy led to better outcomes, and a plurality of fixation strategies emerged. A breakthrough in technology came with volar plating, and the new paradigm emerged: precise anatomic reduction is achieved typically with volar plates, unless fragment-specific approaches are needed. This paradigm is being challenged as the association among malunion, arthritis, and function continues to be understood. The best treatment of distal radius fractures in the elderly has also evolved through time.

Assessing the Relationship Between Bone Density and Loss of Reduction in Nonsurgical Distal Radius Fracture Treatment

PURPOSE

Whether low bone mineral density affects loss of reduction for distal radius fractures (DRFs) managed without surgery is unknown. Our purpose was to understand how bone mineral density, based on second metacarpal cortical percentage (2MCP) measurement, affects DRF healing after nonsurgical treatment.

METHODS

We retrospectively reviewed 304 patients from 2 health systems with DRFs treated without surgery. The AO classification, 2MCP (<50% indicating osteoporosis), and fracture stability based on Lafontaine criteria were determined from prereduction radiographs. Radial inclination, radial height, volar tilt, ulnar variance, and intra-articular stepoff were measured on initial and 6-week final follow-up radiographs and compared. Bivariate analysis was used to evaluate the association between Lafontaine criteria or 2MCP and changes in radiographic parameters. Radiographic parameters with significant associations in bivariate analysis were evaluated in multivariable models adjusted for age, sex, initial radiographic parameters, reduction status, and AO fracture type.

RESULTS

Across all patients, after 6 weeks of nonsurgical treatment, ulnar variance (shortening of the radius) increased by an average of 1.4 mm. Bivariate analysis showed that lower 2MCP and unstable fractures per Lafontaine criteria were each significantly associated with an increase in ulnar variance (P < .05). In adjusted multivariable models, having both 2MCP less than 50% and an unstable fracture together was associated with an additional 1.2-mm increase in ulnar variance (P < .05).

CONCLUSIONS

A 2MCP in the osteoporosis range and unstable fractures by Lafontaine criteria were each associated with a significant increase in ulnar variance after nonsurgical treatment for DRFs. Patients with unstable fractures and 2MCP less than 50% are likely to have an additional increase of greater than 1 mm in ulnar variance at the end of nonsurgical fracture treatment than patients with similar injuries, but without these features. Using initial radiographs to identify patients with low bone mineral density that may be at risk for more substantial loss of reduction can assist with decision making for managing DRFs.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

What Is the Evidence in Treating Distal Radius Fractures in the Geriatric Population?

Distal radius fractures are common in the elderly population, second only to hip fractures in frequency. Historically, these injuries were treated almost exclusively without surgery, but an increase in operative management has occurred with development of volar locked plating in the early 2000s. Functional outcomes are similar between conservative and surgical treatment, but most studies assume low functional demands in older patients. Many elderly individuals today are active and independent. Decision-making in this higher-demand population is difficult. This article provides current evidence to facilitate informed, individualized decision-making when treating distal radius fractures in geriatric patients.

The Effect of Providing Audiovisual Surgical Information on Decisional Conflict in Patients Undergoing Plate Fixation for Distal Radius Fractures

Backgroud

Patients experiencing acute trauma have limited time for their involvement in shared decision making, which may lead to decisional conflict. The purpose of this study was to evaluate whether providing audiovisual surgical information can reduce decisional conflict when deciding between surgical and nonsurgical treatment in patients with distal radius fractures (DRFs) and to evaluate factors that may affect decisional conflict.

Methods

We prospectively enrolled 50 consecutive patients who presented with acute DRFs and chose to undergo surgery, for which volar plate fixation was recommended. We randomized these patients into 2 groups. The test group was given a video clip of audiovisual surgical information in addition to regular information while the control group was only given regular information. The video clip consisted of the purpose, procedure, and effect of the surgery, precautions and complications after the operation, and other treatment options that could be performed if operation was not performed. At 2 weeks after the surgery, we evaluated patients' decisional conflict using a decisional conflict scale (DCS). In addition, we evaluated factors that might affect decisional conflict, such as age, dominant hand, comorbidities, history of previous operations, perceived disability, and provision of the video clip.

Results

The test group showed significantly lower DCS scores than the control group (19.6 vs. 32.1, p = 0.001). In multivariate analysis, younger age and provision of the video clip were associated with lower DCS scores.

Conclusions

This study has demonstrated that providing information through audiovisual media such as video clips could reduce decisional conflict in patients who chose to undergo plate fixation for DRFs. This study also suggests that older patients may need more careful doctor-patient communication as they have more decisional conflict than younger patients.

Manual ability in hand surgery patients: Validation of the ABILHAND scale in four diagnostic groups

Background

Patients treated in hand surgery (HS) belong to different demographic groups and have varying impairments related to different pathologies. HS outcomes are measured to assess treatment results, complication risks and intervention reliability. A one-dimensional and linear measure would allow for unbiased comparisons of manual ability between patients and different treatment effects.

Objective

To adapt the ABILHAND questionnaire through Rasch analysis for specific use in HS patients and to examine its validity.

Methods

A preliminary 90-item questionnaire was presented to 216 patients representing the diagnoses most frequently encountered in HS, including distal radius fracture (n = 74), basal thumb arthritis (n = 66), carpal tunnel syndrome (n = 53), and heavy wrist surgery (n = 23). Patients were assessed during the early recovery and in the late follow-up period (0–3 months, 3–6 months and >6 months), leading to a total of 305 assessments. They rated their perceived difficulty with queried activities as impossible, difficult, or easy. Responses were analyzed using the RUMM2030 software. Items were refined based on item-patient targeting, fit statistics, differential item functioning, local independence and item redundancy. Patients also completed the QuickDASH, 12-item Short Form Survey (SF-12) and a numerical pain scale.

Results

The rating scale Rasch model was used to select 23 mostly bimanual items on a 3-level scale, which constitute a unidimensional, linear measure of manual ability with good reliability across all included diagnostic groups (Person-Separation Index = 0.90). The resulting scale was found to be invariant across demographic and clinical subgroups and over time. ABILHAND-HS patient measures correlated significantly (p<0.001) with the QuickDASH (r = -0.77), SF-12 Physical Component Summary (r = 0.56), SF-12 Mental Component Summary (r = 0.31), and pain scale (r = -0.49).

Conclusion

ABILHAND-HS is a robust person-centered measure of manual ability in HS patients.

The role of concomitant ligament injury in the development of post-traumatic osteoarthritis after distal radius fractures: a protocol for a systematic review

INTRODUCTION

Treatment of distal radius fractures (DRFs) aims to restore anatomic position of the fracture fragments and congruity of the articular surface to optimise functional outcomes and prevent osteoarthritis in the long term. While ligament injury of the wrist is often associated with DRFs and sole ligament injuries of the wrist lead to osteoarthritis, it is plausible that concomitant ligament injury in DRFs may aggravate degenerative changes of the wrist. The relationship between concomitant ligament injury and post-traumatic osteoarthritis in patients with DRFs is unclear. This study aims to identify the types of associated ligament injury in patients with a DRF and to elucidate the association of ligament injury on the development of post-traumatic osteoarthritis.

METHODS AND ANALYSIS

This protocol is written in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P) guidelines. An electronic search in MEDLINE, Embase, Web of Science, Cochrane Central Register of Trials and Google Scholar has been created and performed by a Health Sciences librarian with expertise in systematic review searching. Original research articles in English literature, which report on concomitant ligament injury of the wrist in relation to post-traumatic osteoarthritis, patient-reported outcome measures or clinician-reported outcome measures in patients (aged ≥18 years) with DRFs will be included. Two reviewers will independently screen and appraise articles and perform data extraction. In case of any disagreements, a third reviewer will be consulted. A systematic qualitative synthesis will be performed using text and tables.

ETHICS AND DISSEMINATION

No ethical approval is required, since this is a protocol for a systematic review. The systematic review will be submitted for publication in a peer-reviewed scientific journal and for presentation at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42020165007.

Combined Plating of Intra-Articular Distal Radius Fractures, a Consecutive Series of 74 Cases

Background  The distal radius fracture (DRF) is the most common fracture in adults. For unstable intra-articular fractures, the choice of treatment is often operative. The optimal choice of fixation remains a matter of discussion. Question/Purpose  Can combined volar and dorsal plating, using a dorsal frame plate, achieve a good functional and radiographic 1-year outcome in intra-articular DRFs? Methods  In a retrospective cohort study, we evaluated 74 consecutive patients operated with combined plating using a volar plate and a dorsal frame plate. The DRFs were operated between 2016 and 2017 and all cases were AO type C intra-articular fractures. The primary outcome was patient-reported outcome measures including radiographic examination 1 year postoperatively. Secondary outcome measures included wrist range of motion, visual analog scale (VAS) pain scores, and hand grip strength. Results  The median patient-rated wrist evaluation score was 18 points; the quick disabilities of the arm, shoulder, and hand score was 14.8 points. The median Batra radiographic score was 88. Wrist extension was 76% of the uninjured side, flexion was 74%, pronation was 94%, and supination was 94%. VAS pain scores were 0 at rest and 2 during activity. Hand grip strength was 82% compared with the uninjured side. The radiographic outcome according to Batra did not correspond to the patient-reported outcome. Patients older than 60 years had significantly better QuickDASH (quick disabilities of the arm, shoulder, and hand) and PRWE scores (patient-rated wrist evaluation scores) and less pain during activity compared with younger patients despite similar radiographic outcome. There were no tendon ruptures; hardware removal was performed in 21 of the 74 patients. Conclusion  The radiographic outcome did not correspond to the functional outcome 1 year postoperatively. Older patients report less pain and better functional outcome compared with younger patients. There were no tendon ruptures and the frequency of hardware removal was acceptable. Complex intra-articular DRFs AO type C can be managed with volar and dorsal frame-plate fixation to restore distal radius anatomy and achieve a good functional outcome.

A comparison of sugar-tong and volar-dorsal splints for provisional immobilization of distal radius fractures in the adult population

INTRODUCTION

Distal radius fractures are extremely common injuries affecting a wide range of patient demographics. The purpose of this study was to evaluate the outcomes of distal radius fractures managed initially with closed reduction and immobilization in either a below elbow volar-dorsal splint versus sugar-tong splint prior to conversion into a short arm cast.

METHODS

We performed a retrospective study of patients with distal radius fractures placed in a sugar-tong (n = 45) and volar-dorsal splint (n = 36). Anteroposterior and lateral radiographs were evaluated immediately after closed reduction and placement into either a sugar-tong or volar-dorsal splint. The radial inclination, radial length, volar tilt, and intra-articular displacement were measured.

RESULTS

The average age was not significantly different between groups (Diff: 1.1 years, P = 0.8766). Initial clinic follow-up radiographs illustrated significantly lower radial inclination in the sugar-tong group than volar-dorsal group (17.1 vs. 19, P = 0.0443). Follow-up mean radial length was not significantly lower in the sugar-tong than volar-dorsal group (8.4 vs. 9.2, P = 0.0858). Palmar tilt and articular step-off was not significantly different between splint types. The loss of reduction was 28.8% for the sugar-tong and 25.0% for the volar-dorsal group (P = 0.696).

CONCLUSION

Our results did not demonstrate a significant difference in loss of reduction rates between the two splint groups. There was no significant difference between the sugar-tong and volar-dorsal groups in terms of loss of radial length and volar tilt. Loss of reduction was similar between groups suggesting no advantage of a volar-dorsal splint compared to a sugar-tong splint.

LEVEL OF EVIDENCE

Therapeutic level III.

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.

Distal radius fractures in the elderly population

We found no clear evidence of the clinical superiority of distal radius fracture surgery among older adults at one year.

Surgical treatment, however, may yield a faster recovery to previous level of activity in elderly patients.

With operative treatment, hardware-based problems may warrant secondary operations and implant removal, whereas in non-operative treatment, symptomatic loss of alignment and malunion can occur.

In elderly patients, non-operative treatment can be considered to be the gold standard.

Cite this article: EFORT Open Rev 2020;5:361-370. DOI: 10.1302/2058-5241.5.190060

Two casting methods compared in patients with Colles' fracture: A pragmatic, randomized controlled trial

Background

Distal radius fractures are common fractures and the cornerstone of treatment remains immobilization of the wrist in a cast. At present, there is a scarcity of studies that compare different cast immobilization methods. The objective of the study was therefore to compare volar-flexion and ulnar deviation cast to functional cast position in the treatment of dorsally displaced distal radius fracture among elderly patients.

Methods and findings

We performed a pragmatic, randomized, controlled trial in three emergency centers in Finland. After closed reduction of the fracture, the wrist was placed in either volar-flexion and ulnar deviation cast or functional cast position. The follow-up was 12 months. The primary outcome was patient-rated wrist evaluation (PRWE) score at 12 months. The secondary outcomes were Quick-DASH score, grip strength, health-related quality of life (15D), and pain catastrophizing scale. The number of complications was also recorded. In total, 105 participants were included in the study. Of these, 88% were female and the mean age was 73.5 (range 65–94) years. In the primary analysis, the mean difference in patient-rated wrist evaluation measure between groups was -4.9 (95% CI: -13.1.– 3.4., p = .24) in favor of the functional cast position. Operative treatment due to loss of reduction of fracture was performed for four patients (8%) in the FC group and for seven patients (13%) in the volar-flexion and ulnar deviation cast group (OR: 0.63, 95% CI: 0.16–2.1).

Conclusion

In this study, the data were consistent with a wide range of treatment effects when comparing two different cast positions in the treatment of distal radius fracture among elderly patients at 12-month follow-up. However, the functional cast is more likely to be superior when compared to volar-flexion and ulnar deviation cast.

Trial registration

ClinicalTrials.gov identifier: NCT02894983 Accessible: https://clinicaltrials.gov/ct2/show/NCT02894983

Pre-injury activity predicts outcomes following distal radius fractures in patients age 60 and older

INTRODUCTION

One out of every 5 elderly patients will suffer a distal radius fracture and these injuries are often related to poor bone health. Several surgical subspecialties have demonstrated that pre-injury activity level can impact patient outcomes. To determine the importance of physical activity, we examined the relationship between pre-injury activity and patient-reported and functional outcomes among fracture patients.

METHODS

This is a retrospective analysis of prospectively collected data from participants enrolled in the Wrist and Radius Injury Surgical Trial (WRIST) from April 10, 2012 to December 31, 2016. This study included 304 adults, 60 years or older with isolated unstable distal radius fractures; 187 were randomized to one of three surgical treatments and 117 opted for casting. Participants opting for surgery were randomized to receive volar locking plate, percutaneous pinning, or external fixation. Participants who chose not to have surgery were treated with casting. All participants were stratified prior to analysis into highly and less-active groups based on pre-injury Rapid Assessment of Physical Activity Scores.

RESULTS

280 patients had 12-month assessments of outcomes. Highly active participants scored 8 and 5 points greater on the Michigan Hand Questionnaire at 6 weeks and 3 months respectively, p<0.05. Highly active participants demonstrated greater grip strength at the 3-month (p = 0.017) and 6-month (p = 0.007) time-points. Highly active participants treated with volar locking plate scored 10+ points greater on the Michigan Hand Questionnaire compared to the less-active group at the 6-week (p = 0.032), 3-month (p = 0.009) and 12-month (0.004) time points, with an effect size larger than 0.50, suggesting pre-injury level of activity had a significant clinical impact.

CONCLUSIONS

Higher levels of pre-injury activity are predictive of patient-reported and functional outcomes following distal radius fracture. Because of the greater PROs, the early mobility and lower risk of hardware infection reported in the literature, volar plating is preferable to other treatments for highly active patients who request and meet indications for surgery.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT01589692.

Distal Radius Malunion

Malunion remains the most common complication of nonsurgical treatment of fractures of the distal radius and represents a common clinical entity. Symptomatic treatment often involves corrective osteotomy. Surgical correction is a challenging problem with unpredictable clinical outcomes. Prevention of malunion of a distal radius fracture is the best course of action. With maintenance of volar cortical contact and the use of volar fixed-angle devices, bone grafting may not be necessary in certain cases of malunion correction. New technologies such as 3-dimensional modeling and computer-generated osteotomy guides are likely to have a positive impact on the outcomes of surgical treatment.

Complications after operatively treated distal radius fractures

In the recent years, treatment of distal radius fractures (DRF) has advanced considerably. Surgical fixation with palmar angular stable plate has gained popularity, due to a reported lower complication rate when compared to dorsal fixation. The type of trauma or injury, surgical procedure and impaired bone quality are all contributors to complications in DRF. The main aim of this review is to summarize the most common complications and possible therapeutic solutions. In addition, strategies for minimizing these complications will be discussed.

Radiological results of surgical management of fracture of the distal radius treated with volar locking plates

OBJECTIVES

Distal radius fracture (DRF) is the most common upper extremity fracture. The incidence of complications after surgical treatment still remains high. The objective of our study was to assess functional and radiological results of DRF treated with volar locking plate.

METHODS

We conducted a retrospective study including DRF treated by open reduction and internal fixation with a volar locking plate during a period of 8 years (2010-2018). Data were collected from clinical records and included patient demographics, fracture characteristics, radiological parameters (radial inclination, palmar tilt, ulnar variance, articular step-off), range of motion (ROM), complications and reinterventions.

RESULTS

A total of 170 patients (63.5% female) met the inclusion criteria with a mean age of 55.9 years [24.1-83.7; 13.76]. High energy injuries were more frequent in younger patients (25.56% vs 3.95%; p < 0.0001). AO classification was: 2R3A: 23.5%, 2R3B: 24.1% and 2R3C: 52.4%. Time until surgery was 8.5 days, longer in extraarticular fractures (AO-2R3A: 12.22 days, AO-2R3B: 7.97 days, AO-2R3C: 7.04 days, p = 0.018). Younger patients had better radial inclination (excellent in 85.1% vs 59.21%, p = 0.001) and radial shortening (excellent in 100% vs 88.15%, p = 0.001). ROM was: flexion 63° [0-90°; 19.73], extension 57.67° [5-90°; 21.61], pronation 78.94° [40-90°] and supination 81.76° [38-90°; 8.87]. We found a weak correlation between ROM in flexion-extension and radial shortening (r = 0.218; p = 0.001) and articular step-off (r = -0.269; p = 0.002). We had 39 complications (21.18% of patients). 10.6% of patients needed a re-operation, being the most frequent hardware removal (6.5%) and tendinous disruptions repairs (2.4%). Reintervention rate was higher in younger patients (14.9% vs 5.3%; p = 0.042), complete articular fractures (AO-2R3A: 2.5%; AO-2R3B: 7.3%; AO-2R3C: 15.7%; p = 0.037) and high energy injuries (8.4% vs 22.2%; p = 0.044). Patients undergoing reintervention had a decreased flexion-extension (94.44° vs 123.83°, p = 0.007).

CONCLUSION

Radial shortening and articular step-off seem the most important predictors for postoperative range of motion. Worse radiological outcomes are observed in complete articular fractures and those affecting elder population. Although radiological and functional results are good or excellent in most of cases, the incidence of complications and need for reintervention still remains noticeable. Re-operations were more frequent in younger patients, complete articular fractures and high energy injuries, and it worsened functional outcomes.

Does a Hand Strength-Focused Exercise Program Improve Grip Strength in Older Patients With Wrist Fractures Managed Nonoperatively?: A Randomized Controlled Trial

OBJECTIVE

Distal radius fractures in the older population significantly impair grip strength. The aim of the study was to investigate whether a hand strength focused exercise program during the period of immobilization for nonoperatively managed distal radius fractures in this population improved grip strength and quality of life.

DESIGN

This is a single-center randomized controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis. Fifty-two patients older than 60 yrs who experienced distal radius fractures managed nonoperatively with cast immobilization. The intervention group (n = 26) received a home hand strength-focused exercise program from 2 and 6 wks after injury while immobilized in a full short arm cast. The control group (n = 26) performed finger range of motion exercises as per protocol. Primary outcome was grip strength ratio of injured arm compared with uninjured arm. Secondary outcome included functional scores of the 11-item shortened version of the Disabilities of the Arm, Shoulder and Hand. Outcomes were measured at 2, 6, and 12 wks after injury.

RESULTS

The intervention group significantly improved grip strength ratio at both 6 and 12 wks (6 wks: 40% vs 25%, P = 0.0044, and 12 wks: 81% vs 51%, P = 0.0035). The intervention group improved the 11-item Disabilities of the Arm, Shoulder and Hand score at 12 wks; however, this was not statistically significant (25 vs 40, P = 0.066).

CONCLUSIONS

A hand strength-focused exercise program for elderly patients with distal radius fractures while immobilized significantly improved grip strength.

Wrist deformity, bother and function following wrist fracture in the elderly

Objective

Wrist deformity in older people is common following treatment for a wrist fracture, particularly after non-surgical treatment. A cohort of older wrist fracture patients were surveyed by telephone regarding perceived deformity, bother with deformity and patient-reported wrist function. The objectives were to: (1) determine whether older patients with wrist fractures perceived a deformity of their wrist and if they were bothered by it; (2) test if there were associations between deformity and treatment-type and between deformity and function; (3) test for associations between bother and treatment-type and between bother and function; (4) measure the test–retest reliability of the ‘bother’ question.

Results

Of 98 eligible patients who were invited to participate, 41 responded. Out of 41, 14 (34%) believed they had a deformity and 4 (10%) reported that they were bothered by the appearance of their wrist. Deformity was associated with non-surgical treatment (RR = 3.85, p = 0.006) but was not significantly associated with functional outcomes (p = 0.15). All those who were bothered belonged to the non-surgical treatment group. Bother was significantly associated with poorer functional outcomes (p = 0.006) and this association was clinically significant (MD = 35 points). The deformity and bother questions were found to have excellent test–retest reliability; κ = 1.00 and κ = 0.92, respectively.