Bone density and geometric properties of the distal radius in displaced and undisplaced Colles' fractures: quantitative CT in 70 women

Fracture Severity and Triangular Fibrocartilage Complex Injury in Distal Radius Fractures with or without Osteoporosis

The purpose of this study was to investigate the fracture morphology of distal radius fractures (DRFs) with the status of triangular fibrocartilage complex (TFCC) foveal insertion in patients with or without osteoporosis and to identify the relationship between osteoporosis and foveal tear. Seventy-five patients who underwent surgery for DRF from January 2021 to September 2023 were included. All patients were evaluated by standard radiography and dual-energy X-ray absorptiometry and underwent a 3.0 T magnetic-resonance imaging examination of the involved wrist to identify TFCC foveal tear. Patients were allocated into two groups according to the presence of osteoporosis: patients with osteoporosis (group I) and those without osteoporosis (group II). Group I showed a significantly larger displacement of fractures compared to group II (radial inclination; 13.7 ± 5.4 vs. 17.9 ± 4.2; p < 0.001, dorsal angulation; 22.2 ± 12.1 vs. 16.5 ± 9.4; p = 0.024, ulnar variance; 4.15 ± 2.1 vs. 2.2 ± 1.9; p < 0.001). Dorsal angulation and ulnar variance were found to be independent prognostic factors for TFCC foveal tear in logistic regression analysis. Displacement of fractures was related to osteoporosis, and dorsal angulation and ulnar variance were independent prognostic factors for TFCC foveal tear. However, osteoporosis was not identified as a factor associated with TFCC foveal tears.

No association between osteoporosis and AO classification of distal radius fractures: an observational study of 289 patients

Background

It is mechanically plausible that osteoporosis leads to more severe peripheral fractures, but studies investigating associations between BMD and radiographically verified complexity of distal radius fractures are scarce. This study aims to study the association between osteoporosis, as well as other risk factors for fracture, and the AO classification of distal radius fractures.

Methods

In this observational study, 289 consecutive patients aged ≥40 years with a distal radius fracture were included. Bone mineral density (BMD) of the hips and spine was measured by dual-energy x-ray absorptiometry (DXA), and comorbidities, medication, physical activity, smoking habits, body mass index (BMI), and history of previous fracture were registered. The distal radius fractures were classified according to the Müller AO system (AO) (type B and C regarded as most complex).

Results

Patients with osteoporosis (n = 130) did not have increased odds of a more complex distal radius fracture (type B + C, n = 192)) (n = vs type A (n = 92) (OR 1.1 [95% CI 0.5 to 2.3]) compared to those with osteopenia /normal BMD (n = 159). Patients with AO fracture types A or C had a higher prevalence of osteoporosis than patients with type B fracture.

Conclusions

Distal radius fracture patients with osteoporosis did not sustain more complex fractures than those with osteopenia/normal BMD according to the AO classification system. The AO classification of distal radius fracture cannot be used to decide which patients should be referred to DXA scan and considered for secondary fracture prevention.

Smaller Radius Width in Women With Distal Radius Fractures Compared to Women Without Fractures

Introduction

Bone mineral density (BMD) measured using dual-energy x-ray absorptiometry (DXA) is typically used to assess fracture risk. However, other factors such as bone size and the forward momentum of a fall (a function of body size) can also potentially influence fracture risk, but are understudied. This report describes the characteristics of a cohort of Caucasian pre- and postmenopausal women with distal radius fractures (DRF) after falling onto an outstretched hand.

Methods

The fracture cohort comprised entries in an institutional review board-approved registry of study patients who had had DXA scans. For patients with DRF, the contralateral radius was scanned and BMD, T-scores (used to define bone status as normal, osteopenic, or osteoporotic), and radius width were recorded. Generally, side-to-side (left-right) differences in bone size and BMD are small and, hence, the contralateral radius was considered a surrogate for bone status of the fractured radius. Apparently healthy women without fractures were used as race-, age-, and BMI-matched controls.  

Results

Premenopausal women < 49 years of age (mean age, 38 years) with DRF had significanty smaller radii width compared to matched controls. Mean radius BMD was in the normal range. As a group, the cohort was overweight based on mean BMI. Postmenopausal women > 50 years (mean age, 64 years) with DRF also had low radius width, but in contrast to the first group, this group had low peripheral and central BMD.

Conclusions

Women with DRF had contralateral and presumably fractured radii of bone width smaller than matched controls. As a group, these women were also overweight based on BMI. The smaller radius width may increase the risk for fracture irrespective of BMD, especially since larger body size would result in greater inertial force when falling while ambulating.  

Relationship Between Ulnar Variance, Cortical Bone Density, and Load to Failure in the Distal Radius at the Typical Site of Fracture Initiation

PURPOSE

Increased ulnar variance has been shown to lead to diminished load borne by the distal radius. The purpose of this study was to determine the correlations among ulnar variance, bone mineral density, and load to failure at the distal radius.

METHODS

Posteroanterior radiographs and computed tomographic scans were taken of 12 cadaveric forearms in neutral rotation. Ulnar variance was measured for each wrist by the method of perpendiculars. Measurements of cortical, trabecular, and combined bone density were made at the distal radius. We performed linear regression analysis and correlation analysis to determine the relationship between bone densities and ulnar variance measurements. Next, we loaded the 12 cadaveric radii to failure under axial compression. Linear regression analysis and correlation analysis were then performed to determine the relationship between load to failure and both ulnar variance and cortical density.

RESULTS

Increased ulnar variance was significantly correlated with decreased cortical bone density at the distal radius and both were correlated with decreased load to failure. We found no correlation between ulnar variance and trabecular density or combined trabecular and cortical bone density at the distal radius.

CONCLUSIONS

Our study found that increased ulnar variance and decreased cortical bone mineral density correlates with decreased load to failure under axial compression.

CLINICAL RELEVANCE

Ulnar variance is linked to both bone quality and load to failure at the distal radius.

Evaluation of trabecular bone score in patients with a distal radius fracture

We compared bone mineral density (BMD) and trabecular bone score (TBS) in postmenopausal women with a distal radius fracture older than 50 years with controls. Total hip BMD was significantly different, but TBS was not different between two groups, suggesting TBS does not reflect microarchitectural changes of the distal radius.

INTRODUCTION

The purpose of this study was to determine whether trabecular bone score (TBS) has additive value for discriminating distal radius fracture (DRF) independent of BMD.

METHODS

We compared BMD and TBS in 258 postmenopausal women with a DRF older than 50 years of age with age- and body mass index (BMI)-matched controls who had no history of osteoporotic fracture. BMD was measured at the lumbar spine and hip using dual energy X-ray absorptiometry scans (GE Lunar Prodigy). TBS was calculated on the same spine image. A multivariate logistic regression analysis was used to analyze the odds ratio (OR) for the occurrence of DRF using age, BMI, lumbar spine BMD, total hip BMD, and TBS.

RESULTS

Patients with a DRF had significantly lower BMDs at hip (neck, trochanter and total) than those of controls: 0.752 ± 0.097, 0.622 ± 0.089, and 0.801 ± 0.099 in patients and 0.779 ± 0.092, 0.648 ± 0.089, 0.826 ± 0.101 in controls. However, lumbar spine BMD and TBS were not significantly different between the groups (p = 0.400 and 0.864, respectively). The multivariate analysis indicated that only total hip BMD was significantly associated with the occurrence of DRF (OR, 10.231; 95 % confidence interval, 1.724-60.702; p = 0.010).

CONCLUSIONS

TBS was not different between women with a DRF and those without a history of osteoporotic fracture, suggesting that TBS measured at the lumbar spine does not reflect early microarchitectural changes of the distal radius. Only total hip BMD is associated with the risk of DRF in Korean women.

Recent Update in the Diagnosis and Treatment of Bone Frailty in Patients with a Distal Radius Fracture

Distal radius fracture (DRF) is the most common upper extremity fracture in the elderly. Patients with a DRF have a two to fourfold higher risk of a subsequent fracture than those with no history of fractures, and DRFs occur on average 15 years earlier than hip fractures. Therefore, patients with a DRF offer physicians an important opportunity to diagnose and treat osteoporosis to prevent a secondary fracture. In this review, we provide recent update in the diagnosis and treatment of bone frailty in patients with a DRF.

External fixation in the elderly

Orthopaedic trauma is an increasingly common problem in geriatric patients. As demands of daily life and recreational activities are increasing in these patients, surgeons need to be able to manage geriatric fractures to achieve good functional results. Reduced bone quality in the elderly presents a considerable challenge and may preclude the use of established surgical stabilisation techniques that are performed in younger trauma patients. Furthermore, pre-existing medical conditions and considerable comorbidities in the elderly could complicate standard surgical procedures that younger patients would be offered. In this respect, application of external fixators represents a validated, minimally-invasive treatment opportunity. This review article summarises the use of external fixation in geriatric trauma patients for wrist fractures, proximal femoral fractures, pelvic fractures, and ankle fractures. Modern modifications, like pin coating with hydroxyapatite, and aspects of pin care will be discussed.

Cast-treated distal radius fractures: a prospective cohort study of radiological outcomes and their association with impaired calcaneal bone mineral density

INTRODUCTION

We hypothesized that treating distal radius fractures with cast only or closed reduction and cast is associated with high malunion risk and that the risk is higher in patients with low bone mineral density (BMD).

MATERIALS AND METHODS

We prospectively studied 130 patients aged 40 years or older with distal radius fractures treated with cast only (87 patients) or closed reduction and cast (43 patients). Radiographs were obtained before treatment, after reduction (in the closed reduction group), and at 1 year. We measured calcaneal BMD with DXA scanner and calculated T scores. We calculated radiological changes from baseline (initial radiographs in cast only and post-reduction radiographs in closed reduction patients) to 1 year. We assessed the relationship between BMD status (normal, osteopenia or osteoporosis) and baseline-to-1-year worsening in volar tilt, ulnar variance, and radial inclination with analysis of covariance adjusting for baseline radiological values. We used receiver operating characteristic (ROC) analysis to determine the ability of T scores to distinguish patients with severe malunion (dorsal tilt >25° and/or ulnar variance ≥5 mm) from those with less severe or no malunion.

RESULTS

In both treatment groups, baseline radiological variables had deteriorated at 1 year, more in the closed reduction group. Compared to patients with normal BMD, those with osteoporosis had significantly greater worsening in volar tilt and radial inclination but did not differ in ulnar variance worsening. Severe malunion was found in 34 fractures (26 %, 15 in cast only group); T scores had a modest ability in distinguishing severe malunion (area under ROC curve 0.67, 95 % CI 0.56-0.78, p = 0.003).

CONCLUSIONS

Closed reduction and cast is not an effective treatment for distal radius fractures if radiological graphic outcomes are considered. There is a higher risk of malunion involving dorsal and radial tilt in patients with osteoporosis. Calcaneal BMD measurement may have some benefit in predicting the risk of severe malunion.

Exploring the relationship between bone density and severity of distal radius fragility fracture in women

Background

Bone mineral density (BMD) has been shown to be a consistent and independent risk factor for distal radius fracture. Inconsistent data have been reported on the association between BMD and severity of distal radius fracture. Our primary aim was to explore if there is an association between cortical BMD at the hand and the severity of fragility distal radius fracture.

Methods

Consecutively recruited females aged ≥50 years with fragility fracture at the distal radius (n = 110) from a county hospital were included. Cortical hand BMD was assessed by the digital X-ray radiogrammetry (DXR) method. X-rays of the fracture were scored by experienced orthopedic surgeons for fracture severity according to the Müller AO classification of long bones and radiographic parameters such as ulnar variance and dorsal angle.

Results

A weak association between lower DXR BMD and increased ulnar variance and dorsal angle was found but not with the AO scoring system for fracture type. A history of glucocorticoid (GC) use but not DXR-BMD was found to be significantly associated with the presence of having an intra- or extra-articular fracture.

Conclusion

Our data indicate that bone material properties which are impaired by GC use are more important for fracture severity than BMD.

Where is the distal fracture line location of dorsally displaced distal radius fractures?

No consensus currently exists on the facture location of dorsally displaced distal radius fractures (DRFs). We present a systematic evaluation of the distal fracture line (DFL) location of DRFs and possible influencing factors. Determining the average location of DRFs provides a basis for developing more sensitive tests to determine bone strength using a variety of imaging techniques and for developing improved biomechanical models to test fracture characteristics and surgical implants. Initial radiographs of 157 DRFs dorsally displaced DRFs in patients aged 40-74 years were identified, patient and trauma specific data were collected, and standard radiographic measurements and (AO) fracture classification were performed. The dorsal and palmar DFL locations relative to the corresponding apex of the lunate facet were measured. The DFL was located dorsally 7.9 ± 2.7 mm and palmarly 11.7 ± 3.9 mm proximal to the corresponding lunate fossa apex. The dorsal DFL was significantly distal to the palmar one (p  < 0.001), but the two did not correlate (r² = 0.018, p = 0.095). DFL location was independent of age, energy of the fall, and fracture complexity.

Distal radius fractures

Distal radius fractures are a common injury, particularly in the elderly population. Severity of these fractures is directly related to the bone mineral density of the patient, and clinical results are dependent on this parameter as well. In terms of treatment, several options exist. Nonoperative management consists of closed treatment with casting. Operative treatment options include intrafocal pinning, nonbridging and bridging external fixation, arthroscopic-assisted external fixation, and various methods of open reduction internal fixation. When operative intervention is indicated, considerations include the characteristics of the fracture and the experience of the surgeon with the treatment modalities.

Do We need to include osteoporosis in today's classification of distal radius fractures?

Although the correlation between decreased bone mineral density and increased incidence of distal radius fractures is widely acknowledged, the effect of osteoporosis on specific fracture types is seldom addressed. No classification system has been established for clinical use that has been validated for osteoporotic fractures or that includes parameters of the bone density or bone quality. So far, only one experimental study could report a clear correlation between bone properties and fracture patterns, and an additional clinical study assesses bone density in relation to displacement in Colles fractures. Further studies are needed to analyze the intra- and interobserver reproducibility of more simplified but nonetheless comprehensive classification systems that recognize the impact of osteoporosis on distal radius fracture and that specifically incorporate bone mineral density.

Association of bone mineral density with deformity of the distal radius in low-energy Colles' fractures in Japanese women above 50 years of age

PURPOSE

To investigate whether the degree of radiographically observed pretreatment radius deformity of low-energy Colles' type distal radius fractures resulting from falls is associated with the degree of bone fragility as measured by bone mineral density (BMD) of the lumbar spine in Japanese women above 50 years of age.

METHODS

The study subjects were 125 consecutive Japanese women older than 50 years of age with Colles' type (AO type A and C) dorsally angulated distal radius fractures caused by falls. Fractures due to high-energy injuries such as traffic accidents were excluded. Radius deformity was assessed on anteroposterior and lateral radiographs by measuring ulnar variance, radial inclination, and dorsal angulation at initial examination before manual repositioning of the bone. Bone mineral density of the lumbar spine was also measured by dual energy x-ray absorptiometry at the follow-up visit.

RESULTS

There were significant differences in the respective values of ulnar variance, radial inclination, and dorsal angulation between patients with BMD values < 70% of the mean value of young adults and those with BMD values > or = 70%. Radius deformity was significantly greater for all parameters in the former group relative to the latter. The respective values of increased ulnar variance, decreased radial inclination, and increased dorsal angulation significantly correlated with lower BMD. Stepwise regression analysis of data of all subjects identified that ulnar variance was significantly associated with dorsal angulation, BMD, and radial inclination. The addition of body height, body weight, body mass index, and urinary type I collagen cross-linked N-telopeptides (bone resorption marker) to the regression analysis of data of a subset of patients confirmed that ulnar variance was significantly associated with BMD and radial inclination.

CONCLUSIONS

There is a significant association between BMD of the lumbar spine and radiographic radius deformity seen in low-energy Colles' type distal radius fractures resulting from falls in Japanese women above 50 years of age.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

Anterior fracture displacement in Colles' fractures after Kapandji wiring in women over 59 years

The aim of this study was to assess the radiological results of Colles' fractures treated with Kapandji wiring and to determine the frequency of postoperative anterior fracture displacement. The X-rays of 89 fractures in women over 59 years of age were evaluated. Five weeks after injury, palmar shift of the distal fracture fragments and/or palmar tilt of more than 20 degrees were observed in 26 patients. In ten wrists dorsal tilt was not sufficiently corrected and measured more than 10 degrees . Increase in ulnar variance was more than 2 mm in 37 wrists and more than 5 mm in six wrists; this was more pronounced when the palmar tilt was not corrected properly or when anterior fracture displacement was present. We conclude that Kapandji wiring may not be able to prevent anterior fracture displacement in almost one-third of Colles' fractures in osteoporotic elderly patients.

Low BMD is a risk factor for low-energy Colles' fractures in women before and after menopause

Until now, it was unclear if low volumetric bone mineral density at the distal radius was also a risk factor for Colles' fracture, especially in patients with low-energy trauma. In our study, we used peripheral quantitative computed tomography to measure volumetric bone mineral density of a nonfractured distal radius and dual-energy x ray absorptiometry to measure areal bone mineral density at the spine and hip in patients with Colles' fractures, including 45 women who were premenopausal (age range, 40-50 years) and 39 women who were postmenopausal (age range, 51-65 years). In each group, the patients were subdivided into low-energy and high-energy fracture groups. Ninety-five age-matched healthy women who were premenopausal and 90 age-matched healthy women who were postmenopausal without fracture history served as controls. The results showed that patients with low-energy fractures had a lower bone mineral density at all measurement sites, compared with either patients with high-energy fractures or control subjects. More patients were found with a bone mineral density less than -2.5 standard deviations (Z-score) in the premenopausal group (12.5% measured by dual-energy x ray absorptiometry and 41.2% measured by peripheral quantitative computed tomography) than in the postmenopausal group (6.0% measured by dual-energy x ray absorptiometry and 4.8% measured by peripheral quantitative computed tomography). These results suggest that low bone mineral density, particularly measured using peripheral quantitative computed tomography at the distal radius of women who were premenopausal, was an important risk factor for low-energy Colles' fractures.

LEVEL OF EVIDENCE

Prognostic study, Level I-1 (prospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Impact of bone density on distal radius fracture patterns and comparison between five different fracture classifications

OBJECTIVE

To investigate the impact of bone mineral density (BMD) and bone geometry on failure loads and fracture patterns of the distal radius and to compare 5 different fracture classifications.

DESIGN

Biomechanical and radiologic in vitro study.

SETTING

Research laboratory.

MAIN OUTCOME MEASUREMENTS

A total of 118 intact human forearms from elderly donors were examined by means of conventional radiography and peripheral quantitative computed tomography (PQCT) to determine BMD and geometry. The forearms were subjected to a standardized biomechanical test simulating a fall on the outstretched hand. The distal radius fractures were classified from x-rays using the AO ( 33), Cooney ( 9), Fernandez ( 15), Frykman ( 17), and Melone ( 31) classifications. The grading was repeated after preparation and direct visual inspection of the fracture site and was correlated with radiographic results. Fracture patterns also were correlated with BMD and geometry.

RESULTS

Correlations between bone properties and fracture patterns (r = 0.09-0.70) suggested an increase in the severity of fractures with decreasing bone quality. The highest correlation between failure load and bone properties was found for the cortical area (r = 0.70) and trabecular density (r = 0.60). Good correlations between radiographic and direct visual classification were obtained for the Cooney ( 9) (r = 0.70), the AO ( 33) (r = 0.68), and the Fernandez ( 15) (r = 0.65) classifications. Smaller values were found for the Frykman ( 17) (r = 0.44) and the Melone ( 31) (r = 0.27) classifications.

CONCLUSIONS

With increasing osteopenia, the load to failure decreases, and the severity of fractures increases. Fracture patterns in this patient population can be adequately graded with the AO ( 33) and Cooney ( 9) classifications. The severity of distal radius fractures tends to be underestimated by conventional x-ray examination, which needs to be taken into account when a fracture treatment plan is selected.