Epidemiological and Treatment Trends of Distal Radius Fractures across Multiple Age Groups

Incidence and Outcomes of Tree Stand Injuries in Rural Pennsylvania

IntroductionIn the United States, more than 11.5 million people participate in hunting. Deer hunters commonly use tree stands as tall as 8 m. Falls from tree stands can cause injury and even death. Previous studies have investigated the types of injuries sustained from tree stand falls, but few have investigated patient outcomes. This study investigated patient outcomes related to tree stand falls and analyzed injury types resulting from tree stand falls, and this paper discusses factors that may lead to tree stand falls.MethodsThis study used a retrospective chart review of patients at the same institution between January 1, 2012, and August 31, 2022. Patient information, injury type, fall height, and interventions were collected.ResultsA total of 38 patients were included in the study, 36 males (94.70%) and 2 females (5.30%). The average fall height from a tree stand was 4.22±1.62 m (13.86±5.30 ft). Of the 38 patients, 19 had sustained orthopedic injuries to their upper extremity, lower extremity, spine/pelvis, or multiple areas; the average fall height of this subgroup was 4.51±1.76 m (14.79±5.76 ft). Nonoperative management was the highest used intervention because 12 patients did not require surgery. Orthopedic surgery was used to treat 6 patients, and 1 patient had nonorthopedic surgery.ConclusionsAlthough tree stand falls are rare, the injuries they cause can be fatal. Injury severity and outcome are determined by a multitude of factors. This study highlights the significance of these injuries and the importance of practicing safe guidelines while hunting.

Locking pegs versus locking screws in volar plating of distal radius fractures

PURPOSE

The aim of this study was to compare the radiological outcome of patients with distal radius fractures stabilized with a volar plate using either locking screws or pegs.

MATERIAL & METHODS

For this retrospective study all adult patients that received volar plating of a distal radius fracture at a trauma center between 06/2019 and 06/2022 were eligible for inclusion. Only patients who received an implant allowing both locking pegs and screws were included. Primary outcome was radiological loss of reduction at the 6-week and at the 12-month follow-up. Secondary outcomes were duration of surgery, implant removal, fracture union and complications.

RESULTS

Fourty-nine patients treated with pegs and 39 with screws were included. Patient demographics were comparable, however there were more complex fractures in the peg group. There was no significant difference in the occurrence of radiological loss of reduction between the groups at 6 weeks or 12 months (p = 1). Patients treated with pegs were more frequently operated upon by experienced surgeons while screws were more often used by more junior staff. The duration of surgery was longer for patients who received screws (p = 0.003). Union was achieved in all fractures for which a 12-month x-ray was available. There was no significant difference in implant removal rate or other complications.

CONCLUSIONS

Regarding secondary loss of reduction both locking pegs and screws show similar results. Considering the potential benefits of pegs, such as the smooth surface which may reduce the risk of joint penetration, pegs are a viable alternative to screws.

Digitally Enhanced Plaster of Paris Imaging of Distal Radial Fractures Is Preferred by Orthopaedic Surgeons and Radiologists: A Single Site Survey

INTRODUCTION

X-rays of bone fractures immobilised with Plaster of Paris (POP) produce images of reduced diagnostic quality due to the increased density and irregular pattern of the POP overlying the anatomy of interest. Post-processing parameters in digital radiography (DR) can be applied to POP images to increase diagnostic quality without increasing radiation dose. The aim of this study was to evaluate the preferred image quality of POP immobilised distal radius fractures using optimised digital image manipulation algorithms.

METHODS

A cross-sectional, quantitative survey study was conducted between November 2021 and December 2023 at a large metropolitan health network. The manufacturer standard algorithm and three new image post-processing algorithms were applied to pre-selected image sets. Orthopaedic surgeons (n = 34) and radiologists (n = 35) were surveyed to rank image quality of 10 random image sets (80 images in total). Data were described and analysed using median rankings, Mann-Whitney U tests and Friedman rank tests with post hoc Wilcoxin rank tests.

RESULTS

A total of 13 orthopaedic surgeons and 14 radiologists participated. A highly enhanced algorithm using contrast boost (Algorithm D) was the most preferred set (n = 18/27) due to better visibility of bony detail and fracture sites. There was no difference in rankings between clinician groups.

CONCLUSION

In this single site survey, both orthopaedic surgeons and radiologists preferred the highly enhanced post-processing algorithm (D) indicating that image quality can be improved using optimised digital manipulation. POP post-processing parameters with contrast boosting could be implemented to potentially increase diagnostic accuracy without increasing radiation dose for x-ray imaging of the wrist with POP.

Are Routine Post-Cast Removal Radiographs and a Second Follow-up Appointment Necessary in the Management of Nondisplaced or Minimally Displaced Distal Radius Fractures?

Background

The effectiveness of routine follow-up radiographs and appointments after cast removal when managing minimally displaced pediatric distal radius fractures has not been conclusively proven. This study aims to assess how often follow-up appointments and radiographs taken after cast removal alter management of patients with minimally displaced distal radius fractures.

Methods

A single-center retrospective chart review was conducted on patients under 18 years of age with minimally displaced distal radius fractures between 2017 and 2023. Demographic information, fracture characteristics, time to follow-up, and each appointment outcome were recorded. A change in patient management following post-cast removal radiographs was defined as a need for closed reduction, operative intervention, or prolonged immobilization. The second follow-up appointment was considered to modify management if it necessitated a physical therapy referral or an additional office visit. Unscheduled appointments and any changes in fracture alignment during follow-up visits were also noted.

Results

Ninety-three patients met the inclusion criteria; 1.1% (1 of 93) of patients had their management changed following their post-cast removal radiographs according to our criteria. One patient was indicated for prolonged immobilization for a visible fracture line; no patients were indicated for surgery or closed reduction. Thirty-eight patients who underwent cast removal attended their 2nd follow-up appointment; 2.6% (1 of 38) of patients had their management changed according to our criteria. One patient required an additional follow-up appointment for a physeal check; no patient required a physical therapy referral. Two patients had an unscheduled appointment after discharge of care, due to parental desire of recovery confirmation before returning to gym play. No changes in fracture alignment were observed during any follow-up radiographs.

Conclusions

This study suggests that post-cast removal radiographs and second follow-up appointments rarely alter management of minimally displaced distal radius fractures. Limiting unnecessary visits and imaging could reduce costs and ease the burden on patients and families.

Key Concepts

1) Post-cast removal radiographs rarely altered management for minimally displaced pediatric distal radius fractures.2) Only 1.1% of patients required prolonged immobilization, with no cases needing surgery or closed reduction.3) Second follow-up appointments infrequently changed management, with only 2.6% of patients requiring an additional visit.4) Unscheduled visits were primarily driven by parental concerns rather than clinical necessity.5) No changes in fracture alignment were observed in any follow-up radiographs.

Level of Evidence

Level IV - case series.

Arthroscopic-Assisted vs. Fluoroscopic-Only ORIF of Distal Radius Fractures: Clinical and Economic Perspectives

Background and Objectives: Distal radius fractures (DRFs) are among the most common fractures globally, with a lifetime incidence of around 9%. They typically present in two age peaks: high-impact trauma in patients under 40 and low-energy trauma in those over 40. Intra-articular DRFs are classified according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification, influencing the treatment approach. Surgical management, particularly open reduction and internal fixation (ORIF) using volar plate osteosynthesis, is considered the gold standard. This study aims to compare the treatment costs of fluoroscopy-assisted ORIF and arthroscopy-assisted ORIF for intra-articular DRF. The analysis includes surgical procedure costs, material expenses, and operating time to evaluate the cost-effectiveness of both methods, considering reimbursement within the German healthcare system. Materials and Methods: A retrospective, monocentric study was conducted at Ludwig-Maximilians-University (LMU) Hospital, a supraregional hand trauma center in southern Germany. Patients with DRFs requiring ORIF were treated either with fluoroscopy or arthroscopic assistance. Group 1 included patients treated by the Department of Hand Surgery (Plastic Surgery), subdivided into Group 1a (arthroscopy-assisted) and Group 1b (fluoroscopy-only). Group 2 comprised patients treated by Orthopaedics and Trauma Surgery (fluoroscopy-only). Costs associated with surgical procedures, including materials, operating time, and postoperative care, were analyzed. Results: A total of 43 DRFs were treated. Group 1 consisted of 17 cases, with an average age of 49.6 years (SD = 19.4) and a 64% majority of female patients. Of these, 10 cases were treated with arthroscopy-assisted ORIF (Group 1a) and 7 with fluoroscopy-only ORIF (Group 1b). In Group 1a, the average age was 53.9 years (SD = 16.3) with 60% female and 40% male patients, while in Group 1b, the average age was 43.6 years (SD = 23.1) with 71.4% female patients. Group 2 included 25 cases, with an average age of 54.2 years (SD = 21.0) and a distribution of 64% female and 36% male patients. There was no significant difference in age and gender distribution within the groups and subgroups (p > 0.05). The mean procedure time was longer for arthroscopically assisted ORIF (111.5 min) compared to fluoroscopy-only ORIF (80.1 min), and even longer compared to Group 2 (65.0 min). Material costs were slightly higher in Group 1. Total costs for Group 1 averaged EUR 4906.58, with subgroup costs of EUR 5448.24 for arthroscopy-assisted and EUR 4132.80 for fluoroscopy-only. In comparison, Group 2 costs averaged EUR 3344.08. Conclusions: Intra-articular DRFs with severely displaced fragments or concomitant injuries benefit from arthroscopically assisted fracture treatment. While material costs do not significantly differ between arthroscopically assisted and fluoroscopy-only treatments, the significantly longer procedure time for arthroscopy-assisted ORIF results in the largest cost component. Despite this, reimbursement through the DRG system remains fixed and does not account for the increased operative duration or complexity of arthroscopic procedures. Our findings demonstrate that DRF treatment, regardless of the method used, is either not or only marginally cost-covering under the current German reimbursement structure. In the context of the ongoing shift towards outpatient hand surgery, including the management of DRF, adequate reimbursement rates are necessary to ensure the economic viability of DRF management, particularly for complex intra-articular fractures requiring arthroscopic assistance.

Hypertensive status redicts 30-day postoperative complications following open reduction internal fixation of distal radius fractures

BACKGROUND

The primary objective of this study was to investigate the association between preoperative hypertension and postoperative complications following open reduction internal fixation of distal radius fractures.

METHODS

All patients who underwent open reduction internal fixation (ORIF) for distal radius fractures (DRF) between 2015 and 2021 were queried from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Postoperative complications were reported within 30 days of procedure. We identified a total of 26,138 patients, and 31.5% (n = 8,225) of patients had hypertension. Hypertension was defined as blood pressure greater than 140/90 as documented in the medical record, requiring the use of an antihypertensive medication within 30 days of the operation. Multivariate logistic regression adjusted for all significantly associated variables was used to identify postoperative complications associated with preoperative systemic hypertension.

RESULTS

Characteristics of patients significantly associated with systemic hypertension were age ≥ 65 (p < 0.001), female gender (p < 0.001), body mass index (BMI) ≥ 30 (p < 0.001), American Society of Anesthesiologist (ASA) ≥ 3 (p < 0.001), dependent functional status (p < 0.001), smoking (p < 0.001), non-insulin-dependent diabetes (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), congestive heart failure (p < 0.001), chronic steroid use (p < 0.001), and bleeding disorder (p < 0.001). After controlling for significantly associated variables, postoperative complications significantly associated with systemic hypertensive status were major complication (OR 1.83, 95% CI 1.10-3.05; p = 0.020), urinary tract infection (OR 2.02, 95% CI 1.04-3.90; p = 0.037), and non-home discharge (OR 3.48, 95% CI 2.95-4.10; p < 0.001).

CLINICAL RELEVANCE

Preoperative hypertension requiring medication is an independent predictor for major complication, urinary tract infection, and non-home discharge following ORIF for distal radius fractures. A better understanding of preoperative risk factors, such as a patient's hypertensive status, may aid physicians to identify patients at increased risk for postoperative complications and to better counsel patients prior to management of DRF.

Racial Disparities in Surgical Versus Nonsurgical Management of Distal Radius Fractures in a Medicare Population

BACKGROUND

As racial/ethnic disparities in management of distal radius fractures (DRFs) have not been well elucidated in the literature, this study sought to evaluate the correlation of race/ethnicity on surgical versus nonsurgical management of DRFs in a Medicare population.

METHODS

The PearlDiver Standard Analytical Files Medicare claims database was used to identify patients ≥65 years old with isolated DRF. Patients with polytrauma or surgery performed for upper extremity neoplasm were excluded. Surgical versus nonsurgical management was compared based on demographics, comorbidity (Elixhauser Comorbidity Index, ECI), race/ethnicity, and whether the fracture was open or closed. Univariate and multivariable analyses were used to assess for independent predictors.

RESULTS

Of 54 564 isolated DRFs identified, surgery was performed for 20 663 (37.9%). On multivariable analysis, patients were independently less likely to receive surgical management if they were: older (relative to 65- to 69-year-olds, incrementally decreasing by age bracket up to >85 years where odds ratio [OR] was 0.27, P < .001), higher ECI (per 2 increase OR: 0.96, P < .001), and closed fractures (OR: 0.35, P < .001). For race/ethnicity: black (OR: 0.64, P < .001), Hispanic (OR: 0.71, P < .001), and Asian (OR: 0.60, P < .001) patients were less likely to undergo surgery.

CONCLUSIONS

While age, comorbidities, and fracture type are known to affect surgical decision-making for DRF, race/ethnicity has not previously been reported, and its independent prediction of nonsurgical management for several groups points to a disparity in surgical decision-making/access to care. This highlights the need for increased attention to initiatives that seek to provide equitable care to all patients.

LEVEL OF EVIDENCE

Level III-Retrospective review of national database.

External validation and revision of the Lafontaine criteria for unstable distal radius fractures: a retrospective study

BACKGROUND

The Lafontaine criteria are the most commonly cited criteria for predicting unstable distal radius fractures. However, formal validation of the performance of these criteria remains limited. Therefore, we aimed to evaluate the Lafontaine criteria as a diagnostic prediction rule for distal radius fractures, assess the inter-rater reliability and predictive ability of various parameters for distal radius instability, and develop new criteria for fracture instability using reliable and highly predictive factors.

METHODS

This retrospective study included 274 adult patients with acute distal radius fractures treated with closed reduction and immobilisation between January 2019 and December 2022. Patients who underwent immediate surgery, were lost to follow-up before 4 weeks, or had unacceptable alignment after reduction were excluded. The Lafontaine criteria were validated using the area under the receiver operating characteristic curve (AUROC). Criteria with an AUROC > 0.7 were considered acceptable. The criteria were updated using risk factors with stronger associations in the multivariable logistic regression analysis, and the inter-rater reliability of potential predictors was evaluated.

RESULTS

The median age of the patients was 63 years; 78% were female. Redisplacement occurred in 39% of the cases. The AUROC for the Lafontaine criteria was 0.65 (95% confidence interval [CI] 0.57-0.74). Multivariable logistic regression showed that age 56-74 years (odds ratio [OR] 3.92, 95% CI 1.82-9.16, p < 0.001) age > 74 years (OR 6.34, 95% CI 2.66-16.2, p < 0.001), associated ulna fracture (OR 1.61, 95% CI 0.92-2.84, p = 0.10), and initial radial shortening > 3 mm (OR 5.78, 95% CI 3.11-11.2, p < 0.001) were the strongest predictive factors of fracture instability. These predictors demonstrated substantial inter-rater reliability, making them suitable for clinical use. Updating the model with these risk factors resulted in an AUROC of 0.74 (95% CI 0.66-0.82).

CONCLUSIONS

The performance of the Lafontaine criteria in discriminating unstable distal radius fractures was unacceptable in our study cohort. The updated criteria using age group (< 56 years, 56-74 years, and > 74 years), associated ulnar fractures, and initial radial shortening > 3 mm was found to have moderate discrimination; however, further research is warranted to improve the prediction and measurement reliability of fracture instability.

Outcomes in Patients with Bilateral Distal Radius Fractures

Background  Fractures of the distal radius that occur bilaterally are comparatively uncommon, with the incidence of these injuries and patient outcomes following different modes of treatment being unknown. Purpose  This article evaluates the demographics, management, and functional outcomes of patients that sustain bilateral distal radius fractures (DRFs). Materials and Methods  We retrospectively identified 85 patients that sustained bilateral DRF and were treated at a single institution from 2016 to 2019. Thirty-four patients were treated operatively, 41 patients were treated nonoperatively, and 10 patients were treated operatively in one extremity and nonoperatively in the other. Fractures were classified by a single fellowship-trained orthopaedic hand surgeon. Range of motion (ROM) data and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores were collected. Differences between the three groups with regards to demographics, mechanism of injury (MOI), and complications were recorded. Results  The pediatric population had significantly higher energy MOIs compared to the adult population. There was no difference between the groups with regard to associated injuries or complications. The pediatric population had significantly more AO type A fractures compared to the adult population, which had a bimodal distribution of AO type A and C fractures. The pediatric population saw significantly more patients undergo nonoperative treatment. Both populations had a higher rate of operative intervention for bilateral DRF than noted in the literature for unilateral. In the adult population there were no significant differences in DASH scores between the operative and nonoperative groups. Conclusion  Bilateral DRFs appear to have a similar bimodal age distribution to unilateral DRF. Younger patients undergo nonoperative management more commonly than operative or mixed management. Postoperative ROM and complications appear to be equivalent across all three groups regardless of age. Level of Evidence  Level IV, Prognostic study.

Hospital-Based Epidemiological Study of Distal Radius Fractures at a Hand and Microsurgery Unit in Malaysia

OBJECTIVE

Distal radius fractures (DRFs) are the most common upper limb fractures in clinical practice. Due to the absence of a formal national registry describing the characteristics of DRFs in Southeast Asia, this study aims to provide hospital-based epidemiological data to bridge this gap in the literature.

METHODS

We conducted a retrospective study in the Hand and Microsurgery Unit of Hospital Selayang, Batu Caves, Malaysia, which included all patients who sustained non-pathological DRFs over 24 months, from 01 January 2022 to 31 December 2023. Medical records were analyzed in terms of detailed demographic data, fracture characteristics, and mode of treatment.

RESULTS

Over the two-year study period, we identified 446 patients with DRF, totaling 450 DRFs (four patients had bilateral injuries). Male patients outnumbered female patients 114 (64%) to 63 (36%) in 2022 and 145 (54%) to 124 (46%) in 2023. The mean age of patients was significantly higher in 2023 compared to 2022 (54.51 ± 22.20 vs. 45.25 ± 23.64 years, respectively; p < 0.0001). The most common fracture type was type A, based on the Orthopaedic Trauma Association(OTA) classification, accounting for 83.6% of cases in 2022 and 87.4% of cases in 2023. In terms of treatment, most DRFs were treated conservatively as opposed to operatively (77.4% vs. 71.3%), with plate fixation being the most common operative intervention, accounting for 57.5% of cases in 2022 and 73.3% of cases in 2023.

CONCLUSION

The incidence of DRF was higher among male patients than among female patients in our study population, with an increasing annual trend. Most cases were the result of low-impact trauma and were closed fractures that were conservatively managed.

Insulin dependence as an independent predictor of complications following surgical treatment of distal radius fracture

PURPOSE

Diabetes mellitus (DM) is a well-established risk factor for postoperative complications. Distal radius fractures (DRFs) are a common orthopedic injury and often require open reduction and internal fixation (ORIF). The rise of ORIF utilization warrants investigation into factors that may expose patients to postoperative complications following DRF ORIF.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for cases of DRF ORIF between 2015 and 2021. Cases were stratified into cohorts based on diabetes mellitus (DM) status. The DM cohort was further stratified into non-insulin-dependent DM (NIDDM) and insulin-dependent DM (IDDM) groups. Bivariate logistic regression was performed to compare patient demographics, comorbidities, and 30-day postoperative complications. Multivariate logistic regressions were performed to identify associations between diabetes mellitus status and postoperative complications.

RESULTS

A total of 27,761 cases of DRF ORIF were identified from 2015 to 2021. After exclusion criteria were applied, 25,971 cases remained, of which 2169 (8.4%) cases had DM and 23,802 (91.6%) cases were free of DM. Within the DM cohort, there were 1392 cases in the NIDDM subgroup and 777 cases in the IDDM subgroup. Relative to the cohort without diabetes, the IDDM cohort was independently associated with sepsis, septic shock, reintubation, myocardial infarction, blood transfusion, failure to wean off mechanical ventilation, readmission, and nonhome discharge.

CONCLUSION

Having IDDM was independently associated with higher rates of postoperative sepsis, septic shock, reintubation, myocardial infarction, blood transfusion, failure to wean off ventilation, readmission, and nonhome discharge when compared to the cohort without diabetes following DRF ORIF.

LEVEL OF EVIDENCE

Level III; Retrospective cohort comparison; Prognosis study.

Employer-Sponsored Medicare Advantage Plans and the 2018 Therapy Cap Repeal: Reduced Overall Spending Does Not Constrain Out-of-Pocket Costs

BACKGROUND

Policy impacting traditional Medicare beneficiaries may have unintended effects for privately insured patients. After the repeal of a longstanding $1500 outpatient therapy cap in 2018, we aimed to evaluate if this policy change was associated with differences in use of cost of postoperative therapy after common hand surgeries, including carpal tunnel release, trigger finger release, ganglion cyst excision, De Quervain tenosynovitis release, carpometacarpal arthroplasty, and distal radius fracture open reduction/internal fixation or percutaneous pinning.

METHODS

The Medicare Supplement and Coordination of Benefits files from Marketscan were used. Frequency of therapy appointments, overall costs, and out-of-pocket costs were obtained. A segmented interrupted time series with Poisson and log-transformed linear regression was performed.

RESULTS

No significant monthly change in odds of therapy use was found in the postpolicy period for patients who underwent trigger finger release, carpal tunnel release, Ganglion cyst excision, De Quervain tenosynovitis release, carpometacarpal arthroplasty, or distal radius fracture, pinning, or open reduction/internal fixation. Overall cost decreased in the postpolicy period by 2% for comprehensive plans (95% confidence interval [CI]: -0.03 to -0.01, P < 0.001), by 7% for those with exclusive provider organizations (95% CI: -0.10 to -0.04, P < 0.001), by 1% for HMOs (95% CI: -0.01 to 0.002, P = 0.01), and by 3% for preferred provider organizations (95% CI: -0.03 to -0.02, P < 0.001). In the postpolicy period, no monthly change in out-of-pocket cost was observed for patients with comprehensive, exclusive provider organization, health maintenance organization, preferred provider organization, or point of service with capitation insurance plans.

CONCLUSIONS

Patients with employer-sponsored Medicare Advantage plans experienced increased out-of-pocket costs for therapy despite lower net costs. These data highlight an urgent need for policy ensuring that patients benefit when overall costs of care decrease.

Is home-based real-time video conferencing telerehabilitation as effective as conventional face-to-face rehabilitation in patients with operated for distal radius fracture? A single-blind, randomized prospective study

Objectives

This study aims to investigate whether telerehabilitation is as effective as face-to-face rehabilitation in terms of joint range of motion (ROM), edema, and functionality in patients operated for distal radius fractures (DRFs).

Patients and methods

Between May 2022 and May 2023, a total of 54 patients (8 males, 46 females; mean age: 56.8±11.6 years; range, 24 to 77 years) who underwent volar plate due to DRF with direct X-ray and computed tomography (CT) were included in this single-blind, randomized study. The patients were randomly divided into the face-to-face rehabilitation group (FFG) and telerehabilitation group (TRG). The same rehabilitation program was applied as face-to-face and Home-Based Real-Time Video Conferencing (HBRVC) telerehabilitation. Demographic data and participation times in rehabilitation sessions were recorded. A perimeter was measured using the Figure of 8 method. The ROM of the joint was measured by goniometry. Hand grip strength was measured with a hand dynamometer, and pinch grip was measured with a pinch meter. The Patient-Rated Wrist Evaluation (PRWE) and Disabilities of the Arm, Shoulder and Hand Questionnaire (Quick-DASH) were used to assess functionality.

Results

In the initial evaluation, no statistically significant difference was found between age, smoking, dominant hand, operated hand, sex, and the number of participants in rehabilitation sessions (p>0.05). Comparing the values at Week 12 and Week 2, the change in pinch meter (p=0.007) and hand grip (p=0.030) values was higher in FFG than TRG. The Quick-DASH change (p<0.001) and PRWE change (p=0.001) values were statistically significantly lower in TRG than in FFG.

Conclusion

The HBRVC telerehabilitation program seems to be as effective as face-to-face rehabilitation on joint ROM and edema in patients undergoing volar plate fixation for DRF. However, the telerehabilitation method on functionality and muscle strength is less effective than face-to-face rehabilitation.

Assessment of Reproducibility and Agreement of the IDEAL Classification for Distal Radius Fractures

Objective  To analyze the reproducibility and intra- and interobserver agreement of the IDEAL classification for distal radius fractures. Methods  This qualitative, analytical study evaluated 50 pairs of radiographs in two views of patients with distal radius fractures. There were ten observers with different levels of orthopedic training who assessed the radiographs in three different evaluations. The results underwent the Cohen and Fleiss Kappa tests to determine intra- and interobserver agreement levels. Statistical calculations used Excel and SPSS, version 26.0. Results  The Cohen Kappa index values for intraobserver evaluation indicated poor to little agreement (-0.177-0.259), with statistical significance in only one instance. The Fleiss Kappa index values revealed little agreement among the resident group (0.277-0.383) with statistical significance, poor to little agreement among the general orthopedists (0.114-0.225) with statistical significance in most instances, and moderate agreement among hand surgeons (0.449-0.533) with statistical significance. Conclusion  The IDEAL classification had interobserver agreement levels ranging from poor to moderate, influenced by the physicians' training level. Other intraobserver agreement levels ranged from poor to little agreement but without statistical significance.

Optimizing Treatment Strategies for Distal Radius Fractures in Osteoporosis: A Comparative Review

Osteoporosis is a common yet underdiagnosed condition that increases the risk of fractures, contributing to substantial morbidity, mortality, and healthcare costs. Distal radius fractures (DRFs) are some of the most common fractures associated with osteoporosis and often precede more severe fractures. Managing DRFs in patients with osteoporosis can be a challenge due to altered bone quality, which can affect healing and surgical fixation. This review examines both operative and nonoperative management strategies for DRFs in osteoporotic patients, emphasizing the importance of individualized treatment. Surgical interventions, like open reduction and internal fixation (ORIF) with plating, can facilitate early mobilization and improved alignment, especially in more active patients. However, osteoporosis poses risks such as hardware failure, infection, and malunion, calling for careful patient selection. Conversely, nonoperative management may be more suitable for patients with lower functional demands or higher surgical risks, despite the increased risk of malunion. By adapting treatment strategies to individual patient characteristics, orthopedic surgeons can optimize outcomes, minimize complications, and potentially prevent future fractures. Both operative and nonoperative treatments can yield positive outcomes when personalized to the patient's needs.

Delayed fixation of distal radial fractures beyond three weeks after initial failed closed reduction increases the odds of reoperation

Aims

We aimed to compare reoperations following distal radial fractures (DRFs) managed with early fixation versus delayed fixation following initial closed reduction (CR).

Methods

We used administrative databases in Ontario, Canada, to identify DRF patients aged 18 years or older from 2003 to 2016. We used procedural and fee codes within 30 days to determine which patients underwent early fixation (≤ seven days) or delayed fixation following CR. We grouped patients in the delayed group by their time to definitive fixation (eight to 14 days, 15 to 21 days, and 22 to 30 days). We used intervention and diagnostic codes to identify reoperations within two years. We used multivariable regression to compare the association between early versus delayed fixation and reoperation for all patients and stratified by age (18 to 60 years and > 60 years).

Results

We identified 14,960 DRF patients, 8,339 (55.7%) of whom underwent early surgical fixation (mean 2.9 days (SD 1.8)). In contrast, 4,042 patients (27.0%) underwent delayed fixation between eight and 14 days (mean 10.2 days (SD 2.2)), 1,892 (12.7%) between 14 and 21 days (mean 17.5 days (SD 1.9)) and 687 (4.6%) > 21 days (mean 24.8 days (SD 2.4)) post-fracture. Patients who underwent delayed fixation > 21 days post-fracture had a higher odds of reoperation (odds ratio (OR) 1.33 (95% CI 1.11 to 1.79) vs early fixation). This worsened for patients aged > 60 years (OR 1.69 (95% CI 1.11 to 2.79)). We found no difference in the odds of reoperation for patients who underwent delayed fixation within eight to 14 or 15 to 21 days post-fracture (vs early fixation).

Conclusion

These data suggest that DRF patients with fractures with unacceptable reduction following CR should be managed within three weeks to avoid detrimental outcomes. Prospective studies are required to confirm these findings.

Considering occupational performance during recovery of distal radius fracture: A scoping review

INTRODUCTION

Distal radius fracture (DRF) is one of the most common upper extremity fractures treated by hand therapists and can lead to chronic physical impairment and reduced occupational performance. This scoping review aimed to reveal what is currently known about occupational performance following DRF and to explore if and how occupational performance is defined and considered in the research.

METHODS

This review was guided by the PRISMA-Scoping review and the Joanna Briggs Institute (JBI) guidelines. Relevant databases were searched, and studies that addressed occupation performance in adult participants following DRF were included. The findings were summarised according to the components of occupational performance (person, occupation, and environment), and quality was measured using the Mixed Methods Appraisal Tool.

RESULTS

Forty-three articles met the eligibility criteria for inclusion. All of the studies discussed at least two components of occupational performance, while 25 recognised all three. The consideration of occupational performance was dominated by biomechanical issues associated with the person component (i.e. range of motion, strength). There was some acknowledgement of the psychosocial aspects of the person and, to a lesser extent, the environment, as well as the impact of both on return to occupational performance.

CONCLUSION

Despite occupational performance being at the core of occupational therapy theory, its consideration within the context of research on DRF appears to be focussed on the person component of occupational performance and on biomechanical issues. Further research is recommended to determine how much this reflects current clinical practice and if a more comprehensive consideration of occupational performance will improve rates of recovery following DRF.

CONSUMER AND COMMUNITY INVOLVEMENT

As part of the protocol development for this review, consumers and stakeholders were consulted. They provided feedback on clarity and importance of the research questions.

PLAIN LANGUAGE SUMMARY

A distal radius fracture happens when you break the bone on the thumb side of your wrist. This type of injury often occurs when you fall and land on an outstretched hand. It is one of the more common injuries that hand therapists see in their practice. For some people, recovering from this fracture can take a long time and come with a lot of pain, difficulty moving, and emotional stress. These problems can make it hard to do everyday things like driving, cooking, or getting dressed. It can also affect both paid and unpaid work as well as leisure and social activities, making life more difficult for everyone involved. The findings from this review suggest that the current research usually focuses on how the body physically heals from this type of injury, but it does not pay as much attention to the emotional and social impact on healing. Also, it does not always discuss the activities that are important to the person, or the environment where they live, work, and socialise. This may show a gap in the research regarding our full comprehension of recovery from distal radius fractures. Taking a broader view and approach to recovery, considering a person's emotions, social life, environment, and daily activities, could help people recover fully and get back to their previous life routines and roles after this type of injury.

Assessing the Impact of Nicotine Dependence on 90-Day Major Complications and 2-Year Hardware Outcomes in Open Reduction and Internal Fixation of the Distal Radius Fracture

BACKGROUND

This study aims to assess the impact of nicotine dependence on both 90-day major postoperative outcomes and 2-year implant-related outcomes in patients undergoing open reduction internal fixation (ORIF) for distal radius fractures.

METHODS

We queried TriNetX, a national research database that provides real-time access to deidentified medical records, for patients of all ages who underwent an ORIF of the distal radius (Current Procedural Technology codes 25607, 25608, 25609) between 2001 and 2021. Patients were categorized by nicotine dependence history (International Classification of Diseases, Tenth Revision code: F17), with groups 1:1 propensity matched for age, sex, race, ethnicity, body mass index, type 2 diabetes, hypertension, cerebrovascular disease, and chronic obstructive pulmonary disease. The primary analysis examined major postoperative complications within 90 days, while the secondary analysis assessed hardware-related issues within 2 years. Risk ratios and 95% confidence intervals were generated for each outcome.

RESULTS

Of 62 137 patients treated with distal radius ORIF, 7764 had nicotine dependence, and 54 373 did not. Each group comprised 7591 patients after 1:1 matching. Nicotine dependence was associated with increased risk of skin infections, sepsis, and wound disruption in the 90-day postoperative period (P < .001). Within the 2-year postoperative period, nicotine dependence was associated with increased risk of mechanical complication of internal fixation device (P < .001), nonunion (P < .01), and surgical intervention for nonunion (P = .009).

CONCLUSIONS

Nicotine dependence is associated with increased risk of infection, sepsis, wound disruption within 90 days, and hardware complication, nonunion, and nonunion repair at 2 years. These data emphasize the importance of nicotine counseling by treating surgeons.

Distal Radius Fracture Rehabilitation

Distal radius fracture (DRF) is arguably the most common upper extremity fracture resulting from a fall accident. These clinical practice guidelines (CPG) were developed to guide all aspects of the management of DRF by physical therapists and other rehabilitation practitioners, such as certified hand therapists. This CPG employed a systematic review methodology to locate, appraise, and synthesize contemporary evidence while developing practice recommendations for determining the prognosis of outcomes, examination, and interventions while managing individuals with DRF. The quality of the primary studies found in the literature search was appraised using standardized tools. The strength of the available evidence for a particular practice domain (e.g., prognosis or intervention) was graded as strong, moderate, weak, or conflicting, where such gradings guided the level of obligation for each practice recommendation. Lastly, the CPG also provided the gaps in the evidence pool for the rehabilitation of DRF that future research efforts can address. J Orthop Sports Phys Ther 2024;54(9):CPG1-CPG78. doi:10.2519/jospt.2024.0301.

[Standardized reduction and palmar plating of dorsally displaced distal radius fractures for safe and atraumatic reconstruction of the anatomy of the radius]

OBJECTIVE

Standardization of palmar plate osteosynthesis in order to consequently achieve physiologic anatomy of the distal radius end.

INDICATIONS

Unstable dorsally displaced distal radius fractures or fractures that should be treated functionally.

CONTRAINDICATIONS

Severe intraarticular joint depression that cannot be reduced with either a palmar or arthroscopic assisted approach.

SURGICAL TECHNIQUE

Patient in supine position with the forearm supinated on arm table. Radiopalmar incision along the radial border of the flexor carpi radialis tendon. Detachment of the pronator quadratus muscle from radial to ulnar. Gross reduction with eventual correction of a dorsal or radial shift. Placement of the angular stable plate and preliminary fixation with a nonangular stable cortical screw in the long hole at the radius shaft. Fluoroscopic control of axial alignment in the anteroposterior view and of correct distal position of the plate in the lateral view under reduction condition. Placement of one or two angular stable screws at the shaft. Under subtle reduction with flexion, ulnar deviation and axial traction placement of two K‑wires via the holes at the distal edge of the plate. These wires mostly keep reduction maintained while reduction maneuver can be paused. Fluoroscopic control in two planes. Replacement of the wires by distal angular stable screws with the help of the wires as an orientation. In case of insufficient reduction, reduction maneuver can be repeated while the first angular stable screw is locked. Final fluoroscopic control in two planes and ulnar deviation, eventually also in tangential view and clinical testing for stability of the distal radioulnar joint. Wound closure only by skin suture. Application of a sterile dressing and a palmar cast.

POSTOPERATIVE MANAGEMENT

Arm consequently in upright position and active and complete movement of fingers. Palmar below-elbow cast for 2 weeks, then movement of wrist without exertion. After regular radiographic control 4-5 weeks postoperatively, increase of axial load to normal and, if needed, physiotherapy. Clinical control for irritation of tendons by plate or screws after 1 year and eventual plate removal.

Do Social Deprivation and Surgical Volume Influence Outcomes Following Distal Radius Fracture Fixation?

BACKGROUND

Distal radius fractures account for nearly 25% of fractures in adults, with a trend toward operative fixation. The objective of this study was to assess the relationship between surgeon and hospital volume with complications following distal radius fixation.

METHODS

A retrospective study was performed using the New York Statewide Planning and Research Cooperative System database from 2009 to 2015. Outpatient claims were identified for distal radius fractures and surgery. The facility and surgeon's identifier were used to calculate annual procedure volume. The risk for infection, carpal tunnel surgery, and revision/hardware removal was analyzed, and Social Deprivation Index (SDI) was linked to each patient. Patient demographics and rate of complications were compared across hospital and physician volume.

RESULTS

A total of 14 748 patients were included, finding Federal and self-pay insurance associated with low-volume (LV) facility care and private insurance with high-volume (HV) facilities. The SDI for patients treated by LV surgeons and hospitals was significantly higher compared with HV providers. Low-volume facilities and surgeons had a higher 3-month risk of infection requiring reoperation. High-volume facilities were less likely to treat Hispanic patients, those with comorbidities, higher SDI, and with Federal or self-pay insurance.

CONCLUSIONS

Patients treated by LV surgeons and facilities had a higher risk of infection requiring surgery within 3 months than those treated by HV providers. Low-volume facilities were more likely to treat patients who were Hispanic, Federally insured, and with comorbidities and higher SDI than HV facilities, increasing their risk for disadvantaged care.

LEVEL OF EVIDENCE

Level III.

Hospitalizations for hip and non-hip osteoporotic fractures in Belgium: nationwide trends between 2010 and 2021

This study aimed to describe the incidence of hospitalizations for osteoporotic fractures in patients aged 50 years and over in Belgium between 2010 and 2021. A declining trend in crude and age-adjusted hospitalization incidence was observed, however, the absolute number of hospitalisations for osteoporotic fractures increased due to demographic changes.

PURPOSE

The secular trends of hospitalizations for hip and other osteoporotic fractures between 2010 and 2021 in patients aged 50 years and over in Belgium are unknown. This study aimed to describe the incidence of hospitalizations for osteoporotic fractures in patients aged 50 years and over in Belgium between 2010 and 2021.

METHODS

Population-based, retrospective study based on hospitalization data extracted by the national database NIHDI and demographical data retrieved from the Belgian Federal Bureau for Statistics. Data were combined to determine the crude and age-standardized hospitalization incidence of fractures of the hip, distal femur, pelvis, humerus, wrist, and spine (2010 as the reference year).

RESULTS

A total of 445,234 hospitalizations for osteoporotic fractures were reported between 2010 and 2021 (excluding 2015). Hospitalizations increased by 5.8% between 2010 and 2021 (p = 0.013) with a higher increase in men (12.1%; p = 0.001) compared to women (4.1%; p = 0.041). The crude incidence of hospitalizations for all fractures per 100,000 persons per year decreased from 990 to 910 between 2010 and 2021 (p = 0.572). The age-standardized incidence for hospitalizations of any osteoporotic fracture in men declined from 5.30/1,000 to 4.42/1,000 (p = 0.010). In women, a similar decrease was observed (13.84/1,000 to 11.62/1,000; p = 0.003). Both age-standardized hospitalizations for hip and non-hip fractures showed a decrease in both sexes.

CONCLUSION

Although a declining trend in the crude incidence per 100,000 and in the age-adjusted incidence of hospitalizations for osteoporotic fractures was observed, the absolute number of hospitalizations for osteoporotic fractures increased due to the demographic change of an ageing population.

Psychostimulants prescribed to children for ADHD following distal radius fractures significantly reduce bone density as a function of duration

Methylphenidate and mixed amphetamine salts (MAS) are psychostimulant medications widely prescribed for various psychiatric disorders. Although these medications are known to adversely impact bone mineral content and density, as well as biomechanical integrity during skeletal development in rats, their effect on bone density in children remains largely unknown. The primary aim of this work was to investigate the effects of methylphenidate and MAS on bone density following distal radius fractures in pediatric populations, and secondarily assess any impact on healing. The retrospective case-control study was designed to assess fracture healing in patients treated with stimulant drugs and matched controls. For the primary outcome, X-rays ( n  = 188) were evaluated using an optical density image analysis technique to compare bone density throughout the bone healing process. Results showed that methylphenidate and MAS significantly reduced bone healing by approximately 20% following distal radius fractures in these children. The data also suggested that duration of psychostimulant use played a role in bone healing; the longer the treatment (1-5 years), the lower the bone density was observed (by approximately 52%) as compared to controls (no medication). However, subjects taking these drugs for longer than 5 years did not show a significant difference. Our results suggested that children taking psychostimulants for up to 5 years had slower bone healing following distal radius fractures. Orthopedic surgeons planning elective surgeries should be cognizant of this as a potential issue in recovery after any elective bone procedures and preoperatively optimize bone health as well as counsel patients and their families.

Understanding Changing Demographic and Treatment Trends of Distal Radius Fractures: A TriNetX Database Contemporary Analysis of 32,912 Patients

Purpose

Distal radius fractures (DRF) are among the most commonly encountered fractures. The population of the United States is rapidly growing, aging, and diversifying. This study was undertaken to better understand current incidences and treatment trends across all ages, gender, and races to inform resource allocation and to potentially address treatment inequities.

Methods

The TriNetX US Collaborative Network was queried for all patients diagnosed with DRFs from 2017 to 2022. Cohorts were defined by inclusion and exclusion of Current Procedural Terminology procedure codes and categorized into operative and nonsurgical groups. Statistical analysis was performed to determine differences in management among demographic groups across the 6-year time period.

Results

Incidence rates of operative intervention for DRF increased from 19.6% in 2017 to 23.6% in 2022. Incidence rates of operative intervention increased from 21.7% to 25.2% for females and from 15.3% to 19.7% for males. A bimodal distribution was observed in females with more fractures occurring in the pediatric and geriatric ages, but this distribution was not observed in males. All demographic groups had an overall higher incidence of nonsurgical intervention. Patients aged 40-64 years were more likely to undergo operative intervention than patients 18-39 years. Females were more likely to undergo operative intervention than males. White patients were more likely to undergo operative intervention than Black patients and Asian patients.

Conclusions

The incidence of DRFs continues to climb, as does their rate of operative management. The classic bimodal distribution was observed in females, but not males. However, differences in management of DRFs were also observed across different demographic groups with ongoing racial disparities. Future consideration should be taken into optimizing treatment disparities relative to demographic status.

Type of Study/Level of Evidence

Prognosis IV.

Is reduction necessary in overriding metaphyseal distal radius fractures in children under 11 years: a systematic review and meta-analysis of comparative studies

OBJECTIVE

To determine the necessity of reduction in the treatment of overriding metaphyseal distal radius fractures (DRF) in children under 11 years.

METHODS

In this systematic review and meta-analysis, PubMed, Embase, and Cochrane databases were searched to retrieve studies published from inception to 2023. Two reviewers independently screened for studies with observational or randomized control design comparing two treatments for overriding metaphyseal DRF in patients under 11 years: simple casting without reduction (SC group) versus closed reduction plus casting or pin fixation (CRC/F group); with varying outcomes reported (CRD471761). The risk of bias was assessed using the ROBINS-I tool.

RESULTS

Out of 3,024 screened studies, three met the inclusion criteria, 180 children (mean age 7.1 ± 0.9 years) with overriding metaphyseal DRF: SC-group (n = 79) versus CRC/F-group (n = 101). Both treatment groups achieved 100% fracture consolidation without requiring further manipulation. The SC-group showed significantly fewer complications (mean difference [MD] 0.08; 95% CI [0.01, 0.53]; I2 = 22%; P < 0.009) and trends towards better sagittal alignment (MD 5.11; 95% CI [11.92, 1.71]; I2 = 94%; P < 0.14), less reinterventions (MD 0.31; 95% CI [0.01, 8.31]; P < 0.48), and fewer patients with motion limitation at the end of follow-up (MD 0.23; 95% CI [0.03,  1.98]; P < 0.18), although these findings were not statistically significant.

CONCLUSIONS

Despite a limited number of studies comparing SC versus CRC/F in overriding DRF in children under 11 years, this study suggests that anatomical reduction is not necessary. Treating these fractures with SC, even when presenting with an overriding position, leads to reduced complications, shows a trend towards fewer reinterventions, improved sagittal alignment, and less limitation in patient motion.

LEVEL OF EVIDENCE

Level III, Systematic review of Level-III studies.

A Comparison of the Rates of Postoperative Infection Following Distal Radius Fixation Between Pediatric and Young Adult Populations: An Analysis of 32 368 Patients

BACKGROUND

Infection following surgical fixation of a distal radius fracture can markedly compromise a patient's functional outcome. This study aimed to compare infection rates in pediatric (5-14 years) and adolescent (15-17 years) patients undergoing fixation of a distal radius fracture to a cohort of young adult (18-30 years) patients.

METHODS

A matched retrospective study was performed using PearlDiver to determine the rates of postoperative infection following distal radius fixation. χ2 and logistic regression were used to assess differences in rates, while linear regression was used to analyze rates of infection over time.

RESULTS

In 32 368 patients, young adults experienced postoperative infection at a significantly increased rate (odds ratio [OR] = 1.81; 95% confidence interval [CI], 1.45-2.27). This trend was consistent among the male (OR = 1.96; 1.49-2.57) and female (OR = 2.11, 1.37-3.27) cohorts. In the multivariate model, the adult cohort remained at increased risk (OR = 1.40; 95% CI, 1.04-1.89), with open fracture (OR = 4.99; 3.55-6.87), smoking (OR = 1.76; 1.22-2.48), hypertension (OR = 1.69; 1.20-2.33), and obesity (OR = 1.37; 1.02, 1.80) identified as other significant risk factors. There was no significant change in the rate of postoperative infections over the 11-year study period.

CONCLUSION

This study demonstrated that although surgical site infections following distal radius fixation are low in patients aged 30 years or younger (0.97%), young adults develop infections at a significantly increased rate. This is important for surgeons to recognize when counseling patients on the risks of surgical fixation.

Trajectory of Recovery following ORIF for Distal Radius Fractures

Background  Distal radius fractures are commonly seen among the elderly, though studies examining their long-term outcomes are limited. Purpose  The aim of this study was to describe the 5-year trajectory of recovery of distal radius fractures treated with open reduction and internal fixation (ORIF). Methods  Patients with distal radius fractures (AO/OTA 23.A-C) treated by ORIF were prospectively studied. Patient-Rated Wrist Evaluation (PRWE) score was measured at baseline (preinjury recall) and postoperatively at 6 months, 1 year, and 5 years. Clinically relevant change in PRWE score was assessed using the minimal clinically important difference (MCID). Results  A total of 390 patients were included, of which 75% completed 5-year follow-up. Mean baseline PRWE score was 1.25 (standard deviation, SD: 2.9). At 6 months, mean PRWE score was at its highest up to 20.2 (SD: 18.4; p  < 0.01). A significant improvement in mean PRWE score was observed at 1 year down to 15.2 (SD: 17.6; p  < 0.01); 44% of patients were still one MCID outside of their baseline PRWE score at 1 year. Further significant improvement in mean PRWE score occurred at 5 years down to 9.4 (SD: 13.4; p  < 0.01); 29% of patients remained one MCID outside of their baseline PRWE score at 5 years. Conclusion  Recovery after ORIF for distal radius fractures showed significant worsening after surgery, followed by significant improvements up to 1 year and between years 1 and 5, albeit to a lesser extent. Statistically and clinically relevant wrist pain and disability persisted at 5 years. Future research should examine different treatment modalities and include a nonoperative treatment arm for comparison. Level of Evidence  Prognostic level II.

Risk Factors for 30-Day Complications and Unplanned Reoperation Following Surgical Treatment of Distal Radius Fractures

BACKGROUND

The purpose of this study was to identify demographic data, medical comorbidities, and perioperative factors that are associated with increased risk of overall surgical complications, wound complications, and reoperation within 30 days of open reduction and internal fixation (ORIF) of distal radius fractures.

METHODS

All adult patients undergoing ORIF of distal radius fractures in the National Surgical Quality Improvement Program database between 2005 and 2020 were identified. Patients were excluded for secondary procedures, open/infected injuries, or inpatient surgical setting. Demographic data, medical comorbidities, and perioperative data were examined for each patient, and patients were grouped by the presence or absence of any surgical complication. Univariate analysis and multivariate logistic regression were used to identify risk factors.

RESULTS

A total of 20 301 patients from between 2005 and 2020 met the inclusion criteria, of which 219 complications (1.1% of cases) were identified. Following multivariate analysis, independent risk factors found to be associated with surgical complications included male sex, smoking, heart failure, longer operative time, and American Society of Anesthesiologists (ASA) classification of 3 or higher.

CONCLUSION

Male sex, smoking, heart failure, prolonged operative time, and ASA status of 3 or higher are associated with an increased risk of surgical complications following ORIF of distal radius fractures. These complications, with the exception of heart failure, were also associated with an increased risk of wound complications. Finally, male sex, nonwhite race, smoking, dialysis, prolonged operative time, and 3 or higher ASA class were associated with reoperations. Understanding these risk factors allows surgeons to better predict and prevent complications in high-risk populations.

The Effect of Social Deprivation on Hospital Utilization Following Distal Radius Fracture Treatment

Purpose

Social determinants of health disparities have been shown to adversely impact outcomes following distal radius fracture (DRF) treatment. Identifying risk factors for increased hospital use following DRF has been historically difficult; however, it is of utmost concern to orthopedic surgeons to improve outcomes and decrease the total cost of care. The effect of social deprivation following DRF has yet to be fully investigated.

Methods

This is a retrospective cohort analysis of a single institution's experience in treating DRF with either an operative or nonsurgical modality between 2005 and 2020. Patient demographic information and health care utilization (hospital readmission, emergency department [ED] visitation, office visits, and telephone use) were collected from within 90 days of treatment. Area Deprivation Index (ADI) national percentiles were recorded. Patients were stratified into terciles based on their relative level of deprivation, and their outcomes were compared. Secondary analyses included stratifying patients based on treatment modality, race, and legal sex.

Results

In total, 2,149 patients were included. The least, intermediate, and most deprived groups consisted of 552, 1,067, and 530 patients, respectively. Risk factors for hospital readmission included higher levels of relative deprivation. Identifying as Black or African American and nonsurgical management were risk factors for increased ED visitation. No differences in rate of hospital readmission, ED visitation, office visitation, or telephone use were seen based on deprivation level.

Conclusions

High levels of social deprivation, treatment modality, race, and legal sex disparities may influence the amount of hospital resource utilization following DRF treatment. Understanding and identifying risk factors for greater resource utilization can help to mitigate inappropriate use and decrease health care costs. We hope to use these findings to guide clinical decision making, educate patient populations, and optimize outcomes following DRF treatment.

Type of Study/Level of Evidence

Therapeutic III.

Volar fixed plating of distal radius fractures: optimizing plate position for enhanced clinical outcomes

BACKGROUND

The precise influence of plate position on clinical outcomes in the context of volar fixed-angle plating for distal radius fractures is not fully understood. This article aims to investigate the influence of plate position on clinical results, and functional outcomes in patients treated with volar fixed plating for distal radius fractures.

METHODS

A total of 58 patients with 64 distal radius fractures were included in the study. Patient demographics, fracture characteristics, surgical details, and radiographic data were collected. Post-operative AP and Lat views of all patients taken on the first day after surgery were evaluated. Volar Tilt, Radial Inclination and Radial Height measurements were used as reduction criteria. In the follow-up, the patients were called for their last control, flexion and extension angles of the wrist and Mayo Wrist Scores, the distance of the plate to the joint line and the angle between the plate and the radial shaft were measured and recorded.

RESULTS

A total of 64 distal radius fractures, with a mean age of 46.9 years, and the mean follow-up period 24.9 months were included in this study. There was a significant relationship between the Radial Inclination and Plate-Shaft Angle variables and the Mayo Wrist Score at a 99% confidence interval. Additionally, a relationship was observed between the Radial Height variable and the Mayo Score at a 90% confidence interval. A significant positive association was observed between radial inclination and achieving a Good-to-Excellent Mayo score (OR = 1.28, 95% CI [1.08-1.51], p = 0.004). Plate distance to joint line demonstrated a marginally significant positive association with a Good-to-Excellent Mayo score (OR = 1.31, 95% CI [0.97-1.77], p = 0.077). Univariate analysis revealed a significant negative association between plate-shaft angle and achieving a Good-to-Excellent Mayo score (OR = 0.71, 95% CI [0.52-0.99], p = 0.045). This negative association remained statistically significant in the multivariate analysis (p = 0.016).

CONCLUSION

Radial inclination, plate distance to joint line, and angle between plate and radius shaft were identified as significant factors associated with improved Mayo Wrist Scores.

Epidemiology and Treatment of Distal Radius Fractures at Four Public Hospitals in Malawi

BACKGROUND

Little is known about the burden or management of distal radius fractures (DRFs) in low- and middle-income countries. The purpose of this study was to describe the care of DRFs in Malawi.

METHODS

We retrospectively reviewed a registry of all patients with fractures who presented to the orthopaedic departments at four public hospitals in Malawi.

RESULTS

Totally, 1,440 patients (14.5%) were with a DRF. Average age was 40, and 888 (62.0%) were male. Surgery was done for 122 patients (9.5%). Patients presenting to Queen Elizabeth Hospital, patients presenting after a fall, and patients initially evaluated by an orthopaedic registrar or orthopaedic clinical officer had lower odds of receiving surgical treatment. Meanwhile, open injuries had the greatest odds of receiving surgery.

CONCLUSION

The most common musculoskeletal injury among patients in the Malawi Fracture Registry was fractures of the distal radius. These most affected young adult male patients may benefit from surgery; however, the majority were managed nonsurgically. Lack of access to surgical fixation and conservative follow-up may have long-term functional consequences in a predominantly agrarian society. Outcomes-based research is needed to help guide management decisions and standardize patient care and referral protocols.

Teardrop Alignment Changes After Volar Locking Plate Fixation of Distal Radius Fractures With Volar Ulnar Fragments

BACKGROUND

We assessed factors associated with change in radiographic teardrop angle following volar locking plate (VLP) fixation of volarly displaced intra-articular distal radius fractures with volar ulnar fragments (VUF) within the ICUC database. The primary outcome was change in radiographic alignment on follow-up imaging, defined as a change in teardrop angle from intra-operative fluoroscopy greater than 5°.

METHODS

Patients with distal radius fractures treated with a VLP within the ICUC database, an international collaborative and publicly available dataset, were identified. The primary outcome was volar rim loss of reduction on follow-up imaging, defined as a change in radiographic alignment from intra-operative fluoroscopy, teardrop angle less than 50°, or loss of normal radiocarpal alignment. Secondary outcomes were final range of motion (ROM) of the affected extremity. Radiographic Soong classification was used to grade plate position. Descriptive statistics were used to assess variables' distributions. A Random Forest supervised machine learning algorithm was used to classify variable importance for predicting the primary outcome. Traditional descriptive statistics were used to compare patient, fracture, and treatment characteristics with volar rim loss of reduction. Volar rim loss of reduction and final ROM in degrees and as compared with contralateral unaffected limb were also assessed.

RESULTS

Fifty patients with volarly displaced, intra-articular distal radius fractures treated with a VLP were identified. Six patients were observed to have a volar rim loss of reduction, but none required reoperation. Volar ulnar fragment size, Soong grade 0, and postfixation axial plate position in relation to the sigmoid notch were significantly associated (P < .05) with volar rim loss of reduction. All cases of volar rim loss of reduction occurred when VUF was 10.8 mm or less.

CONCLUSIONS

The size of the VUF was the most important variable for predicting volar rim loss of reduction followed by postfixation plate position in an axial position to the sigmoid notch and the number of volar fragments in the Random Forest machine learning algorithm. There were no significant differences in ROM between patients with volar ulnar escape and those without.

The Impact of Social Determinants of Health on the Treatment of Distal Radius Fracture

BACKGROUND

Disparities in social determinants of health (SDH) have been shown to play an increasingly important role in the equitable delivery of health care. Distal radius fractures (DRFs) are among the most common upper-extremity injuries encountered. This study aims to examine the influence of economic, educational, social, environmental, and healthcare disparities on management of these injuries.

METHODS

PearlDiver Mariner insurance claims database was analyzed for treatment patterns of DRF in patients aged 18 to 65 years based on the presence or absence of social determinants of health disparities (SDHDs). Outcome variables included the primary mode of management of DRF, including operative versus non-operative, as well as concomitant procedures. Multivariate logistic regression was used to compare fracture management modality in patients with and without SDHDs.

RESULTS

Of 161 704 patients identified with DRF, 38.3% had at least 1 reported SDHD. The majority of SDHDs were economic. Patients identified with 1 or more SDHDs had a higher medical comorbidity index. Patients with environmental SDHD were more likely to receive non-operative management. Within any SDHD and economic subgroups, odds of operative management were higher. No relationship was identified between SDHD and concomitant procedures.

CONCLUSIONS

The presence of environmental disparities in SDH may predispose patients disproportionately to non-operative management. The presence of SDHDs may influence medical decision-making in favor of open reduction and internal fixation in patients with DRF treated operatively. In treating at-risk populations, providers should be aware of the potential for implicit bias associated with SDHDs and prioritize shared decision-making between patients and physicians.

Epidemiology of distal radius fractures: Elucidating mechanisms, comorbidities, and fracture classification using the national trauma data bank

BACKGROUND

An update on the epidemiology of distal radius fractures in the United States is necessary, particularly as the elderly population grows. Additionally, age and frailty have been associated with complications following surgical fixation of DRFs. Herein, we utilize the National Trauma Data Bank, a robust nationwide resource, to investigate the relationship between demographics, comorbidities, injury and fracture characteristics, and admission details.

METHODS

Patients with isolated distal radius fractures were identified from the National Trauma Data Bank (2016-2019) according to ICD-10 codes. Univariate and multivariate regressions were conducted to determine independent risk factors for bilateral fractures, displaced fractures, open fractures, as well as length of hospital stay and adverse discharge disposition for patients undergoing inpatient surgical fixation.

RESULTS

The incidence of DRFs was 3.6/1,000 trauma-related emergency department visits and 10.8/1,000 upper extremity traumas. Trauma mechanism was significantly associated with displaced and open fractures. Age (OR 1.01, 95% CI 1.01-1.01), BMI (OR 1.02, 95% CI 1.01-1.02), smoking (OR 1.34, 95% CI 1.15-1.57), and alcohol level (trace: OR 2.18, 95% CI 1.41-3.29; intoxicated: OR 2.20, 95% CI 1.63-2.95) were significantly associated with open fractures. Machinery (β=2.04, 95% CI 1.00-3.08) and MVT (β=0.39, 95% CI 0.08-0.69) mechanisms were independent risk factors for longer length of stay. mFI-5 was an independent risk factor, in a stepwise fashion, for both length of stay and adverse discharge disposition.

CONCLUSIONS

High-energy mechanisms and risk factors for poor skin quality were significantly associated with open fractures. mFI-5 was an independent risk factor for longer length of stay and non-routine discharges in patients of all ages, despite controlling for other comorbidities, unrelated complications, and mechanism of injury. Trauma mechanism was an independent risk factor for prolonged length of stay only, particularly in patients younger than 65 years of age.

Social Media Posts About Distal Radius Fracture: A Cross-Sectional Analysis of Patient and Provider Perspectives

BACKGROUND

Social media offers a popular, unfiltered source of patient and provider perspectives on health care. This study investigated the characteristics of social media posts referencing distal radius fracture (DRF).

METHODS

Content was queried from Instagram from February 06, 2019, to December 08, 2021, using the hashtags "#distalradiusfracture" and "#wristfracture." The 1500 most-liked posts were analyzed. Poster demographics including age, gender, region, laterality, and treatment type and post characteristics including post type, number, content, timing relative to treatment, tone, and satisfaction were examined. Variables were compared using χ2 tests. Univariate, multivariate, and stepwise regression were performed.

RESULTS

The most popular post formats were single photo (44.5%), multiple photos (32.3%), and single video (13.9%). Patients (40.3%) were the most common poster followed by surgeons (33.4%). Men (48.7%) and women (51.3) were evenly represented. Of the total posts, 87.7% depicted the post-treatment phase of care; 54.8% of posts depicted operative management, while 26.6% depicted non-operative management; and 73.7% of posts were positive in tone, 18.7% neutral, and 7.6% negative. Univariate analysis demonstrated that posters who were patients, friends/family of patients, female, and posts with >100 "likes" were more likely to share negative tones. Multivariate and stepwise regression were consistent with the above.

CONCLUSION

Most posts regarding DRF originate from patients, are post-treatment, and are positive. Negative tone is associated with posts from patients, family/friends of patients, female posters, and posts with >100 likes. With this information, surgeons will be better prepared to address patient concerns, manage expectations, and actively participate in social media themselves.

A Cadaveric Comparison of Approaches for Exposure of the Volar Distal Radius: Is There a Utilitarian Approach?

BACKGROUND

It remains unclear whether exposure for planned fixation of distal radius fractrues is superior with any given approach, and whether a single utilitarian approach exists that permits reliable complete exposure of the volar distal radius.

METHODS

A cadaveric study was performed using 10 matched specimens. Group 1 consisted of 3 radially based approaches (standard flexor carpi radialis [FCR], standard FCR with radial retraction of FCR and flexor pollicis longus [FPL] tendons, extended FCR). Group 2 consisted of 2 ulnarly based approaches (volar ulnar, extended carpal tunnel). The primary outcome was total width of exposed distal radius at the watershed line. Mann-Whitney U and Wilcoxon rank testing was used to identify differences.

RESULTS

The standard FCR approach exposed 29 mm (90%), leaving on average 3 mm (10%) of the ulnar corner unexposed. Retracting the FCR and FPL tendons radially allows for an extra 1 mm of volar ulnar corner exposure. Finally, converting to an extended FCR approach provided 100% exposure in all specimens. The volar ulnar exposure however provided exposure to only 9 mm (37%), leaving 20 mm (62.5%) left unexposed radially. The extended carpal tunnel provided exposure to 21 mm (65%), leaving 11 mm (35%) radially unexposed. Differences between each group were statistically significant (P < .05).

CONCLUSIONS

The extended FCR approach exposed 100% of the volar distal radius in our study and may serve as a utilitarian volar surgical approach for exposure and fixation of distal radius fractures. Additional knowledge of the limitations of alternative approaches can be helpful in surgical planning.

[Distal radius fracture-tactic and approach]

OBJECTIVE

The aim of surgical treatment is fracture healing with restored alignment, rotation, and joint surface. Stable fixation allows for functional postoperative aftercare.

INDICATIONS

Displaced intra- and extra-articular fractures which either could not be adequately reduced or in which a secondary displacement is to expected due to instability criteria. The following factors are considered instability criteria: age > 60 years, female, initial dorsal displacement > 20°, dorsal comminution, radial shortening > 5 mm, palmar displacement.

CONTRAINDICATIONS

The only absolute contraindication is if the patient is deemed unfit for surgery due to concerns regarding anesthesia. Old age is a relative contraindication, as it is currently debated whether older patients benefit from the operation.

SURGICAL TECHNIQUE

The surgical technique is guided by the fracture pattern. Palmar plating is most commonly performed. If the joint surface needs to be visualized, a dorsal approach (in combination with another approach or alone) or arthroscopically assisted fixation should be chosen.

POSTOPERATIVE MANAGEMENT

In general, a functional postoperative regime can be carried out after plate fixation with mobilization without weightbearing. Short-term splinting can provide pain relief. Concomitant ligamentous injuries and fixations, which are not stable enough for functional aftercare (such as k‑wires) require a longer period of immobilization.

RESULTS

Provided the fracture is reduced correctly, osteosynthesis improves functional outcome. The complication rate ranges between 9 and 15% with the most common complication being tendon irritation/rupture and plate removal. Whether surgical treatment holds the same benefits for patients > 65 years as for younger patients is currently under debate.

Medicare Eligibility and Racial and Ethnic Disparities in Operative Fixation for Distal Radius Fracture

Importance

Medicare provides near-universal health insurance to US residents aged 65 years or older. How eligibility for Medicare coverage affects racial and ethnic disparities in operative management after orthopedic trauma is poorly understood.

Objective

To assess the association of Medicare eligibility with racial and ethnic disparities in open reduction and internal fixation (ORIF) after distal radius fracture (DRF).

Design, Setting, and Participants

This retrospective cohort study with a regression discontinuity design obtained data from the Healthcare Cost and Utilization Project all-payer statewide databases for Florida, Maryland, and New York. These databases contain encounter-level data and unique patient identifiers for longitudinal follow-up across emergency departments, outpatient surgical centers, and hospitals. The cohort included patients aged 57 to 72 years who sustained DRFs between January 1, 2016, and November 30, 2019. Data analysis was performed between March 1 and October 15, 2023.

Exposure

Eligibility for Medicare coverage at age 65 years.

Main Outcomes and Measures

Type of management for DRF (closed treatment, external fixation, percutaneous pinning, and ORIF). Time to surgery was ascertained in patients undergoing ORIF. Multivariable logistic regression and regression discontinuity design were used to compare racial and ethnic disparities in patients who underwent ORIF before or after age 65 years.

Results

A total of 26 874 patients with DRF were included (mean [SD] age, 64.6 [4.6] years; 22 359 were females [83.2%]). Of these patients, 2805 were Hispanic or Latino (10.4%; hereafter, Hispanic), 1492 were non-Hispanic Black (5.6%; hereafter, Black), and 20 548 were non-Hispanic White (76.5%; hereafter, White) and 2029 (7.6%) were individuals of other races and ethnicities (including Asian or Pacific Islander, Native American, and other races). Overall, 32.6% of patients received ORIF but significantly lower use was observed in Black (20.2% vs 35.4%; P < .001) and Hispanic (25.8% vs 35.4%; P < .001) patients compared with White individuals. After adjusting for potential confounders, multivariable logistic regression analysis confirmed the disparity in ORIF use in Black (odds ratio [OR], 0.60; 95% CI, 0.50-0.72) and Hispanic patients (OR, 0.82; 95% CI, 0.72-0.94) compared with White patients. No significant difference in ORIF use was found among racial and ethnic groups at age 65 years. The expected disparity in ORIF use between White and Black patients at age 65 years without Medicare coverage was 12.6 percentage points; however, the actual disparity was 22.0 percentage points, 9.4 percentage points (95% CI, 0.3-18.4 percentage points) greater than expected, a 75% increase (P = .04). In the absence of Medicare coverage, the expected disparity in ORIF use between White and Hispanic patients was 8.3 percentage points, and this result persisted without significant change in the presence of Medicare coverage.

Conclusions and Relevance

Results of this study showed that surgical management for DRF was popular in adults aged 57 to 72 years, but there was lower ORIF use in racial or ethnic minority patients. Medicare eligibility at age 65 years did not attenuate race and ethnicity-based disparities in surgical management of DRFs.

Elastic stable intramedullary nailing versus Kirschner wire in the treatment of pediatric metaphyseal-diaphyseal junction fractures of the distal radius: a case-control study

BACKGROUND

Several methods have been used for the treatment of pediatric distal radius fractures, such as the elastic stable intramedullary nail (ESIN), Kirschner wire (K-wire), and plate, but there has been no consensus about the optimum method. The purpose of this study was to compare ESIN and K-wire techniques used in metaphyseal-diaphyseal junction (MDJ) fractures of the pediatric distal radius.

METHODS

The data of patients who were treated at a children's hospital affiliated with Shandong University between August 2018 and January 2022 were analyzed retrospectively. The children were divided into the ESIN and K-wire groups. Clinical outcomes were measured by the Gartland and Werley scoring system. Variables were analyzed using a statistical approach between the two groups.

RESULTS

The study included 26 patients, of whom 11 were treated with K-wire and 15 with ESIN. At the final follow-up, all of the fractures were healed. There were no differences in terms of age, sex, fracture location, or wrist function score. However, the ESIN was superior to K-wire in operative time, fluoroscopic exposure, and estimated blood loss (EBL).

CONCLUSIONS

K-wire and ESIN are both effective methods in the treatment of MDJ fractures of the pediatric distal radius. The use of the ESIN technique represents less EBL, fluoroscopy exposure, and operation time compared with K-wire. We recommend osteosynthesis by ESIN rather than K-wires in patients with MDJ fractures of the distal radius.

LEVEL OF EVIDENCE

III, a case-control study.

Chronic Steroid Use, Complications, and Readmission Following Open Reduction Internal Fixation of Distal Radius Fracture

Purpose

The increasing incidence of both distal radius fractures (DRFs) and chronic conditions that necessitate long-term steroid use has resulted in a growing intersection between the patient populations of the two. Chronic steroid use is known to increase bone frailty and the likelihood of fractures but may also contribute to poorer outcomes following the repair of DRF. The purpose of this study was to investigate the association between preoperative chronic steroid use, postoperative complications, and readmission after open reduction internal fixation (ORIF) of DRF.

Methods

The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent DRF ORIF between 2015 and 2021. However, 30-day postoperative complications after DRF ORIF were collected. Multivariate logistic regression analysis was conducted to investigate the relationship among preoperative chronic steroid use, postoperative complications, and patient factors associated with readmission.

Results

The postoperative complications associated with the steroid cohort were categorized as major, minor, and overall complications. Additionally, pneumonia, stroke, myocardial infarction, bleeding transfusions, deep vein thrombosis, pulmonary embolism, readmission, non-home discharge, and mortality were recorded. Chronic steroid use was found to be independently associated with major , minor, and overall complications, deep vein thrombosis, and readmission. Further investigation of readmission showed that male sex and comorbid chronic obstructive pulmonary disease were the only two patient factors independently associated with a greater likelihood of readmission after DRF ORIF.

Conclusions

Preoperative chronic steroid use was associated with an increasing rate of postoperative complications after DRF ORIF. Male sex and comorbid chronic obstructive pulmonary disease were characteristics of chronic steroid-use patients independently associated with increased risk of readmission after DRF ORIF. A better understanding of preoperative chronic steroid use as a risk factor for postoperative complications may allow surgeons to improve preoperative risk stratification and patient counseling in the management of DRF.

Type of study/level of evidence

Prognostic III.

Biomechanical analysis of a novel screw system with a variable locking angle in mandible angle fractures

Locking plates nowadays represent an important treatment in bone trauma and bone healing due to its strong biomechanical properties. The purpose of this study was to both computationally and experimentally validate a novel screw locking system by comparing it to another locking system from state-of-the-art and to apply it in an environment of a fractured mandible. FEA was used to test both systems prior to experimental tests. The systems were locked in the plate holes at 0°, 10°, 15°, and 20°. Cyclic bending tests and push-out tests were performed in order to determine the stiffness and push-out forces of both locking systems. Finally, newly designed locking system was implemented in mandibular angle fracture. Control locking system was biomechanically superior in push-out test, but with no greater significance. In contrast, the new locking system showed greater stiffness by 17.3% at the deflection angle of 20° in cyclic tests, with lower values for other deflection angles. Similar values were displayed in fractured mandible angle environment. Greater stiffness of the new locking system in cyclic loading tests, together with polyaxiallity of the new locking screw, could lead to easier application and improved biomechanical stability of the mandible angle fractures.

Preoperative Anemia as a Risk Factor for Postoperative Complications After Open Reduction Internal Fixation of Distal Radius Fractures

Purpose

The incidence of distal radius fractures (DRFs) in the United States is more than 640,000 cases per year and is projected to increase. The overall prevalence of anemia in the United States increased from 5.71% in 2005 to 6.86% in 2018. Therefore, preoperative anemia may be an important risk factor to consider before surgical fixation of a distal radius fracture. The purpose of this study was to investigate preoperative anemia and its association with short-term complications after surgical treatment of DRFs.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent open reduction internal fixation (ORIF) of DRFs between 2015 and 2020. The initial pool of patients was divided into cohorts based on preoperative hematocrit. Multivariate logistic regression, adjusted for all significantly associated patient demographics and comorbidities, was used to identify associations between preoperative anemia and postoperative complications after ORIF of DRFs.

Results

A total of 22,923 patients who underwent ORIF of DRFs were identified in National Surgical Quality Improvement Program from 2015 to 2020. Of the 12,068 patients remaining after exclusion criteria, 9,616 (79.7%) patients were included in the normal cohort, 2,238 (18.5%) patients were included in the mild anemia cohort, and 214 (1.8%) patients were included in the severe anemia cohort. Compared with the reference cohort, patients with any anemia were independently associated with higher rates of reintubation (odds ratio [OR], 6.51; 95% confidence interval [CI], 1.29-32.80; P = .023), blood transfusion (OR, 11.83; 95% CI, 3.95-35.45; P < .001), septic shock (OR, 10.76; 95% CI, 1.19-97.02; P = .034), readmission (OR, 2.10; 95% CI, 1.60-2.76; P < .001), nonhome discharge (OR, 2.22; 95% CI, 1.84-2.68; P < .001), and mortality (OR, 2.70; 1.03-7.07; P = .043).

Conclusions

Preoperative anemia, both mild and severe, were clinically significant predictors for postoperative complications within 30-day after ORIF of DRFs. Severe anemia was associated with higher rates of blood transfusion, nonhome discharge, and mortality compared with mild anemia.

Type of study/level of evidence

Prognostic III.

Intramedullary Kirschner wire fixation of displaced distal forearm fractures in children

AIM OF THE WORK

This study was designed to highlight internal fixation by intramedullary K-wires for displaced distal forearm fractures among children and analyze the results of this technique. We hypothesize that physis-sparing intramedullary fixation prevents displacement with a lower complication rate.

METHODS

This prospective case series involving 47 patients was conducted between February 2018 and December 2019. All patients with open physis presented with recent displaced distal forearm fractures were included, and all of them were treated with an intramedullary k-wire fixation for both bones with the assessment of the union rate, union time, suspected complication, radiographic evaluation, and functional outcome.

RESULTS

The study population consisted of 31 boys (66%) and 16 girls (34%). The mean age of the patients was 10.68 ± 2.728 years (range, 7-15 years). All fractures were united in a median of 6 weeks (range, 4-8 weeks), The functional outcome after 12 months was normal in 42 patients (89.4%), whereas, in five patients (10.6%), the functional parameters were minimally reduced. The median preoperative angulation improved from 36° (range, 24°-52°) preoperatively to 4° (range, 0°-10°) on immediate postoperative radiographs. After 12 months, the median angulation was 2° (range, 0°-7°) (p < 0.001). The angulation of the distal radius immediately after surgery and at the final follow-up was statistically correlated with the functional outcome (p < 0.001 and 0.002, respectively).

CONCLUSION

This technique provides a good result with less susceptibility to re-displacement and low complication rates.

LEVEL OF EVIDENCE

Level IV.

Trends in the Utilization of Computed Tomography in Operative Treatment of Distal Radius Fractures

Purpose

To identify patient, surgeon, and injury characteristics associated with preoperative computed tomography (CT) scan utilization for operative distal radius fractures (DRF). In addition, we aimed to determine if preoperative CT was associated with treatment methods other than isolated volar-locked plating (VLP).

Methods

We retrospectively reviewed all operatively treated adult DRFs within our health care system from 2016 to 2020. Baseline demographics, injury, treatment characteristics, and the fellowship training of the 44 included surgeons were recorded. We compared cases with and without a preoperative CT, and an adjusted logistic regression model was generated to determine the odds of having a preoperative CT.

Results

A total of 1,204 operatively treated DRFs performed by 44 surgeons were included. CT utilization increased during the study period. Intra-articular fractures accounted for 76% of cases, and preoperative CT scans were ordered in 243 of 1240 cases (20%). Overall, isolated VLP was used in 83% of cases. Cases with a preoperative CT were more likely to be treated with an alternative method of fixation (such as dorsal plating). The adjusted logistic regression model demonstrated that male sex (OR 1.62; 95% CI: 1.16, 2.26), intra-articular fractures (OR 3.11; 95% CI: 1.87, 5.81), and associated fractures (OR 2.69; 95% CI: 1.82, 3.98) had a significantly increased odds of having a preoperative CT. Fellowship training was not associated with increased CT utilization overall, but hand surgeons were more likely to use a CT in Orthopaedic Trauma Association-C3 fractures.

Conclusions

Patient and injury characteristics are associated with CT utilization in operative DRFs. Preoperative CTs are associated with alternative fixation approaches, as cases with a CT were more likely to use fixation methods other than isolated VLP. The costs and benefits of CT scans must be carefully weighed against whether this modality adds value or improves outcomes in treating DRFs.

Level of evidence

Prognostic II.

Questions, answers and challenges: Summarising the guidance for distal radius fractures

This article summarises the current recommendations from the American Academy of Orthopaedic Surgeons (AAOS), the British Orthopaedic Association (BOA), the British Society for Surgery of the Hand (BSSH) and the National Institute of Health and Care Excellence (NICE) for the management of distal radius fractures (DRF). We performed an audit of DRF management at our local emergency hospital. Results and conclusion: Despite DRF representing a large portion of our workload, there remains a paucity of evidence to base recommendations on. Recommendations can be conflicting, and some seem aspirational rather than achievable. Our local audit highlights the challenges of putting guidelines into practice. Treatment plans should incorporate best practice guidance but ultimately be individualised to each patient.

Distal radius fractures in children aged 5-12 years: a Swedish nationwide register-based study of 25 777 patients

BACKGROUND

Distal radius fracture (DRF) is the most common type of fracture in children. There is no clear consensus on primary treatment for complete DRFs. Kirschner wire (K-wire) fixation has been recommended, to avoid the risk of redislocation. However, recent studies have indicated that casting can be sufficient, at least for children with two or more years left to grow. There is no recent study regarding pediatric DRFs and the extent of K-wire fixations in the Swedish population. The purpose of this study was to investigate epidemiology and treatment of pediatric DRFs registered in the Swedish Fracture Register (SFR).

METHODS

In this retrospective study, based on data from SFR for children aged 5-12 years with DRF between January 2015 and October 2022, we investigated epidemiology and choice of treatment. Sex, age, type of DRF, treatment, cause and mechanism of injury, were analyzed.

RESULTS

In total, 25,777 patients were included, 7,173 (27%) with complete fractures. Number and peak age of girls vs. boys with fractures were 11,742 (46%), 10 years, and 14,035 (54%), 12 years, respectively. Odds ratio (OR) for a K-wire fixation in girls vs. boys was 0.81 (95% confidence interval (CI) 0.74-0.89, p < .001). With age 5 -7 years as reference, OR for age group 8-10 years was 0.88 (95% CI 0.80-0.98 p = .019) and OR for age group 11-12 years was 0.81 (95% CI 0.73-0.91 p =  < .001.

CONCLUSION

Casting only was the preferred treatment for all fractures (76%). Boys acquired DRFs more often than girls, with a peak age of 12 years. Younger children and boys with a complete fracture were more likely than older children and girls to receive a K-wire. Further research regarding indications for K-wiring of DRFs in the pediatric population is needed.

Validation of a Novel Smartphone-Based Electronic Data Capture System Following Surgical Fixation of Distal Radial Fractures

BACKGROUND

Large prospective institutional data provide the opportunity to conduct level II and III studies using robust methodologies and adequately powered sample-sizes, while circumventing limitations of retrospective databases. We aimed to validate a prospective data collection tool, the Orthopaedic Minimal Data Set Episode of Care (OME), implemented at a tertiary North American health care system for distal radial fracture (DRF) open reduction and internal fixation (ORIF).

METHODS

The first 100 DRF ORIFs performed after OME inception (February 2015) were selected for this validation study. A blinded review of the operative notes and charts was performed, and extracted data of 75 perioperative DRF ORIF procedure variables were compared with OME collected data for agreement. Outcomes included completion rates and agreement measures in OME versus electronic medical record (EMR)-based control datasets. Data counts were evaluated using raw percentages and McNemar tests. Cohen (κ) and concordance correlation coefficient analyzed categorical and numerical variable agreement, respectively.

RESULTS

Overall, OME demonstrated superior completion and agreement parameters versus EMR-based retrospective review. Nine data points (12.0%) demonstrated significantly higher completion rates within the OME dataset (P < .05, each), and 88% (66/75) of captured variables demonstrated similar completion rates. Up to 80.0% (60/75) of variables either demonstrated an agreement proportion of ≥0.90 or were solely reported in the OME. Of 33 variables eligible for agreement analyses, 36.4% (12/33) demonstrated almost perfect agreement (κ > 0.80), and 63.6% (21/33) exhibited almost perfect or substantial agreement (κ > 0.60).

CONCLUSIONS

The OME is a valid and accurate prospective data collection tool for DRF ORIF that is reliably able to match or supersede traditional retrospective chart review. Future investigations could use this tool for large-scale analyses investigating peri/intraoperative DRF ORIF variables.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level I randomized controlled study.

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

Introduction

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

Patients and methods

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

Results

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

Discussion

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