Aspects of current management of distal radius fractures in the elderly individuals

The Effect of Age and Sex on Early Postoperative Outcomes after Surgical Treatment of Distal Radius Fractures

Background: We aim to evaluate the impact of advanced age and sex on postoperative complications and radiographic outcomes after open reduction with internal fixation of distal radius fractures (DRF). Methods: We conducted a retrospective chart review, including all patients who underwent open reduction with internal fixation of a DRF between 2012 and 2018 at a single level 1 trauma centre. We recorded patient age, sex, fracture classification (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association [AO/OTA]), time from injury to surgical date, surgical duration, diabetes status, tobacco use, illicit drug use, history of osteoporosis, use of adjuvants, fixation type, postoperative radiographic restoration of normal parameters and early complications including loss of reduction within 30 days postoperatively. Advanced age was defined as age greater than 60 years. Results: A total of 521 patients underwent operative treatment - 264 males and 257 females. Males were twice as likely (23.5% vs. 10.1%; p < 0.0001) to sustain a type C3 fracture and be treated with a wrist spanning plate (5.3% vs. 0; p < 0.0001). A larger percentage of elderly patients undergoing operative treatment of DRF were female (20.2% vs. 5.7%; p < 0.0001) and females were more likely to carry a pre-injury diagnosis of osteoporosis (9.3% vs. 0%; p < 0.0001). And 100% of the elderly patients received were treated with a volar plate. The overall early loss of reduction was 7.5%. The overall complication rate was 8.2%. No differences in early postoperative complications were identified between sexes or age groups. Neither female sex nor advanced age was found to have increased risk of postoperative complications or early loss of reduction. Similar postoperative radiographic parameter measurements were obtained across groups as well. Conclusions: Our results support the idea that operative treatment of unstable DRF in elderly patients and women is a reasonable treatment option without significant increases in early postoperative complications. Level of Evidence: Level III (Therapeutic III).

Comparison of Short-Arm Immobilization and Long-Arm Immobilization in Conservatively Managed Distal Radius Fractures: A Meta-Analysis and Systematic Review

Distal radius fractures are often treated conservatively with immobilization. Immobilizing above the elbow limits forearm rotation, though recent literature has suggested the effects on radiographic or functional outcomes may be negligible. This systematic review and meta-analysis aimed to analyze the radiographic and functional outcome scores of distal radius fractures managed with short-arm (SA) immobilization and long-arm (LA) immobilization. An electronic systematic search was performed of the PubMed and EMBASE databases from inception to October 5, 2022. All randomized controlled trials (RCTs) involving patients with acute distal radius fractures undergoing nonoperative treatment (involving application/maintenance of immobilization) comparing above-elbow versus below-elbow constructs were included. The outcomes of interest were changes in radiographic parameters (loss of volar tilt [VT], radial height [RH], and radial inclination [RI]), loss of reduction, requirement for surgery, and patient-reported functional outcomes (Disabilities of the Arm, Shoulder, or Hand [DASH] or Quick DASH survey). The Cochrane Risk of Bias Tool 2.0 was used for study quality assessment. The effect size of the interventions was assessed using random effect models to calculate mean differences (MDs) for continuous variables and odds ratios (ORs) for categorical variables. Standardized mean difference (SMD) was calculated for patient-reported functional outcome scores. Nine studies involving 983 cases were included, including 497 SA and 486 LA. No statistically significant differences were observed with regards to VT (P = 0.83), RH (P = 0.81), RI (P = 0.35), loss of reduction (P = 0.33), requirement for surgery (P = 0.33), or patient-reported functional outcomes (P = 0.10). There was no difference in radiographic outcomes, need for surgery, or functional scores among patients treated with SA and LA immobilization. Utilizing SA immobilization is a safe option for conservative management of distal radius fractures and the benefits of mitigating complications associated with LA immobilization may supersede the theoretical limited forearm rotational stability observed with SA immobilization. Further study is required to determine the optimal method of SA immobilization.

Clinical Outcomes of a Novel Unidirectional Porous β-Tricalcium Phosphate Filling in Distal Radius Fracture with Volar Locking Plate Fixation: Secondary Publication of the Japanese Version

Postoperative loss of correction is a concern in cases of distal radius fracture with bone loss after surgery. The purpose of this study was to evaluate the usefulness of a β-tricalcium phosphate (β-TCP) with unidirectional pore structure (Affinos®: Kuraray Co., Ltd, Tokyo, Japan) with internal fixation in patients with bone defects during the correction of distal radius fractures. Thirty-nine patients (40 radii) treated between 2016 and August 2020 were included in the study. There were 8 males and 31 females; the mean age was 70.9 (32-88). The mean postoperative observation period was 14.6 (3.4-24) months. The bone defect that occurred in the surgery was filled with Affinos® and fixed with a locking plate. Radial inclination (RI), volar tilt (VT), and ulnar variance (UV) were evaluated after the operation and at the final observation. The start of absorption and the completion of replacement to the host bone of Affinos® were also evaluated. There were no complications associated with grafts of Affinos®. The mean time of translucent findings around artificial bone was 1.85 (0.5-6) months, and that of complete resorption was 10.6 (1.5-16.5) months after surgery. The mean RI was 21.82° after surgery and 21.16° at final observation. The mean VT was 8.54° after surgery and 8.50° at final observation. The mean UV was -0.3 mm after surgery and 0.5 mm at final observation. Affinos® was resorbed relatively early, and host bone formation was observed. Filling of unidirectional pore structure β-TCP with internal fixation showed favorable outcomes in the surgery of distal radius fractures with bone defects.

Peri-Implant Distal Radius Fracture: Proposal of a New Classification

A peri-implant fracture near the volar plate of the distal radius represents a rarity and can be associated with a mechanical failure of the devices. A literature review was conducted including all fractures that occurred around a volar wrist plate, which could be associated with an ulna fracture. All articles published until December 2021 were considered according to the guidelines presented in the PRISMA Statement. The search was conducted with the PubMed electronic database, Cochrane Database of Systematic Reviews, Medline, Embase, and Google Scholar. Only nine cases of these fractures were reported in the literature. The causes could be due to delayed union/non-union of the old fracture after low energy traumas, high energy trauma in patients with poor bone quality, or hardware mechanical failure. Furthermore, the literature review of peri-implant radius fracture shows different level of radius fracture and types of implant failure. In accordance with these different cases, a new classification of peri-implant fracture of the distal radius is proposed.

Surgical treatment is not cost-effective compared to nonoperative treatment for displaced distal radius fractures in patients 65 years and over

Aims

The purpose was to compare operative treatment with a volar plate and nonoperative treatment of displaced distal radius fractures in patients aged 65 years and over in a cost-effectiveness analysis.

Methods

A cost-utility analysis was performed alongside a randomized controlled trial. A total of 50 patients were randomized to each group. We prospectively collected data on resource use during the first year post-fracture, and estimated costs of initial treatment, further operations, physiotherapy, home nursing, and production loss. Health-related quality of life was based on the Euro-QoL five-dimension, five-level (EQ-5D-5L) utility index, and quality-adjusted life-years (QALYs) were calculated.

Results

The mean QALYs were 0.05 higher in the operative group during the first 12 months (p = 0.260). The healthcare provider costs were €1,533 higher per patient in the operative group: €3,589 in the operative group and 2,056 in the nonoperative group. With a suggested willingness to pay of €27,500 per QALY there was a 45% chance for operative treatment to be cost-effective. For both groups, the main costs were related to the primary treatment. The primary surgery was the main driver of the difference between the groups. The costs related to loss of production were high in both groups, despite high rates of retirement. Retirement rate was unevenly distributed between the groups and was not included in the analysis.

Conclusion

Surgical treatment was not cost-effective in patients aged 65 years and older compared to nonoperative treatment of displaced distal radius fractures in a healthcare perspective. Costs related to loss of production might change this in the future if the retirement age increases.

Level of evidence: II

Cite this article: Bone Jt Open 2021;2(12):1027–1034.

Learning a MIPO technique for distal radius fractures: Mentoring versus simple experience versus deliberate practice

BACKGROUND

Performance skills of a surgeon for a specific surgical technique range from 1 (novice) to 5 (expert). Mentoring can bring the surgeon to level 3. Simple experience rarely allows achievement of level 5, in contrast to deliberate practice, in which performance skills are improved by setting learning goals based on feedback about the trainee's previous performance.

HYPOTHESIS

When learning a technique for the internal fixation of distal radius fractures, the level of performance skills achieved is higher with deliberate practice than with mentoring or simple experience.

MATERIAL AND METHODS

Four surgeons each performed minimally invasive plate osteosynthesis (MIPO) of 15 distal radius fractures. The procedures were recorded by an HD camera. The first five fractures (step 1) were treated after mentoring, the next 5 fractures after reading an article and viewing a reference video (step 2), and the last 5 fractures after viewing and commenting 20 short videos highlighting possible errors (step 3). Each recording of the procedures performed by the surgeons was scored using the Objective Structured Assessment of Technical Skills (OSATS, 10 items on basic skills [B] and 10 on MIPO-specific skills [S]).

RESULTS

For the basic skills, the mean OSATS scores (on 50) were 31 for step 1, 31 for step 2, and 43 for step 3. For the specific skills, the mean OSATS scores (on 50) were 25 for step 1, 29 for step 2, and 48 for step 3. For overall skills (B+S), the mean OSATS score (on 100) was 56 for step 1, 60 for step 2, and 91 for step 3.

DISCUSSION

Our study confirms that the deliberate practice teaching method is more efficient in improving surgeon skills than simple experience. Deliberate practice consists of four essential steps: (i) setting a well-defined goal; (ii) being motivated to improve one's performance; (iii) receiving immediate feedback; and (iv) having multiple opportunities to repeat and gradually perfect one's performance. Our main hypothesis was verified, since the results of learning a MIPO technique, as assessed using the OSATS scale, were significantly better with a video-assisted deliberate practice technique than with mentoring or simple experience.

CONCLUSION

Video-assisted deliberate practice deserves to be widely used in order to optimise learning curves and to improve risk management in surgery.

LEVEL OF EVIDENCE

III.

Comparison of rehabilitation interventions in nonoperatively treated distal radius fractures: a randomized controlled trial of effectiveness

AIMS

Following cast removal for nonoperatively treated distal radius fractures, rehabilitation facilitated by advice leaflet and advice video were compared to a course of face-to-face therapy.

METHODS

Adults with an isolated, nonoperatively treated distal radius fracture were included at six weeks post-cast removal. Participants were randomized to delivery of rehabilitation interventions in one of three ways: an advice leaflet; an advice video; or face-to-face therapy session(s). The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at six weeks post intervention and secondary outcome measures included DASH at one year, DASH work subscale, grip strength, and range of motion at six weeks and one year.

RESULTS

A total of 116 (97%) of 120 enrolled participants commenced treatment. Of those, 21 were lost to follow-up, resulting in 30 participants in the advice leaflet, 32 in the advice video, and 33 face-to-face therapy arms, respectively at six weeks of follow-up. There was no significant difference between the treatment groups in the DASH at six weeks (advice leaflet vs face-to-face therapy, p = 0.69; advice video vs face-to-face therapy, p = 0.56; advice leaflet vs advice video, p = 0.37; advice leaflet vs advice video vs face-to-face therapy, p = 0.63). At six weeks, there were no differences in any secondary outcome measures except for the DASH work subscale, where face-to-face therapy conferred benefit over advice leaflet (p = 0.01).

CONCLUSION

Following cast removal for nonoperatively treated distal radius fractures, offering an advice leaflet or advice video for rehabilitation gives equivalent patient-reported outcomes to a course of face-to-face therapy. Cite this article: Bone Joint J 2021;103-B(6):1033-1039.

Approaching "Elective" Surgery in the Era of COVID-19

The coronavirus disease 2019 pandemic created unprecedented challenges for the health care system. To meet capacity demands, hospitals around the world suspended surgeries deemed to be elective. In hand surgery, numerous pathologies are treated on an elective basis, but a delay or absence of care may result in poorer outcomes. Here, we present an ethical framework for prioritizing elective surgery during a period of resource scarcity. Instead of using the term "elective," we define procedures that can be safely delayed on the basis of 3 considerations. First, a safe delay is possible only if deferral will not result in permanent injury. Second, a delay in care will come with tolerable costs and impositions that can be appropriately managed in the future. Third, a safe delay will preserve the bioethical principle of patient autonomy. In considering these criteria, 3 case examples are discussed considering individual patient characteristics and the pathophysiology of the condition. This framework design is applicable to ambulatory surgery in any period of crisis that may strain resources, but further considerations may be important if an operation requires hospital admission.

A rare case of peri-implant distal radius fracture

A peri-implant fracture near the volar plate of distal radius represent a very rare injury. The main factor of this lesion is high energy trauma on the wrist. We report a case of a 61-year-old woman with a peri-implant fracture located just proximally to the plate and a fracture of the ulnar head that occurred after a simple fall. The patient was surgically treated by plate and screws removal. The fracture was fixed using a longer volar plate for the radial fracture and a plate for the head ulnar fracture. Different factors such as osteoporosis, BMI and screw position could influence the fracture pattern. However, considering growing use of plates for distal radius fracture fixation, the frequency of these kind of fracture will probably increase.

Practice Variation Among Hispanic American Orthopedic Surgeons in the Management of Geriatric Distal Radius Fracture

Introduction

There is a controversy in the management of distal radius fractures (DRF) and its criteria for surgical intervention on geriatric patients. The American Academy of Orthopedic Surgeons (AAOS) developed evidence-based guidelines for treatment of DRF. The aim of this study was to evaluate the current practice of Hispanic orthopedic surgeons in the management of geriatric DRF and examine their adherence to AAOS guidelines based on years of surgical experience.

Material & Methods

A survey was emailed to all orthopedic surgeons who live in Puerto Rico and treated DRF in their daily practice. Responses concerning demographic, management and clinical scenarios were evaluated. For each clinical scenario, treatment of choice was selected with the same fracture in a geriatric and young adult patient. Comparison between years of surgical experience and adherence to the AAOS guidelines was performed.

Results

A total of 65 surgeons responded the survey with 65% having >15 years in practice. A high consensus with AAOS guidelines for DRF was found. Use of preoperative radiographs was reported in all respondents, with an additional 12% routine use of preoperative computed tomography scans. Seventy-seven percent of respondents did not allow any range of motion (ROM) at immediate postoperative period, while 23% allowed active or passive ROM. Use of postoperative therapy was reported in 72.3%. Correlation between years of surgical experience showed a higher use of Vitamin C postoperatively for prophylaxis of Complex Regional Pain Syndrome among surgeons <15 years (P = 0.01). A general consensus trend toward operative fixation was noted among geriatric and young adult patients with the same fracture type in all clinical scenarios.

Discussion and Conclusions

This survey demonstrates a practice variation toward surgical management of geriatric DRF among Hispanic orthopedic surgeons; despite their compliance with the AAOS AUC guidelines. The geriatric DRF management does not vary significantly among years of surgical experience.

Analysis of low-dose estrogen on callus BMD as measured by pQCT in postmenopausal women

Background

Osteoporosis affects elderly patients of both sexes. It is characterized by an increased fracture risk due to defective remodeling of the bone microarchitecture. It affects in particular postmenopausal women due to their decreased levels of estrogen. Preclinical studies with animals demonstrated that loss of estrogen had a negative effect on bone healing and that increasing the estrogen level led to a better bone healing. We asked whether increasing the estrogen level in menopausal patients has a beneficial effect on bone mineral density (BMD) during callus formation after a bone fracture.

Methods

To investigate whether estrogen has a beneficial effect on callus BMD of postmenopausal patients, we performed a prospective double-blinded randomized study with 76 patients suffering from distal radius fractures. A total of 31 patients (71.13 years ±11.99) were treated with estrogen and 45 patients (75.62 years ±10.47) served as untreated controls. Calculated bone density as well as cortical bone density were determined by peripheral quantitative computed tomography (pQCT) prior to and 6 weeks after the surgery. Comparative measurements were performed at the fractured site and at the corresponding position of the non-fractured arm.

Results

We found that unlike with preclinical models, bone fracture healing of human patients was not improved in response to estrogen treatment. Furthermore, we observed no dependence between age-dependent bone tissue loss and constant callus formation in the patients.

Conclusions

Transdermally applied estrogen to postmenopausal women, which results in estrogen levels similar to the systemic level of premenopausal women, has no significant beneficial effect on callus BMD as measured by pQCT, as recently shown in preclinical animal models.

Trial registration

Low dose estrogen has no significant effect on bone fracture healing measured by pQCT in postmenopausal women, DRKS00019858. Registered 25th November 2019 - Retrospectively registered. Trial registration number DRKS00019858.

Supplementary information

The online version contains supplementary material available at 10.1186/s12891-020-03713-4.

The Impact of Malnutrition on 30-Day Postoperative Complications following Surgical Fixation of Distal Radius Fractures

Introduction  Distal radius fractures (DRFs) are increasingly managed surgically among fragility fractures due to prolonged life expectancy and surgical advancements. Yet, malnutrition can impact postoperative outcomes and complications. We sought to determine the impact of malnutrition on open reduction and internal fixation (ORIF) of DRFs during the perioperative and 30-day postoperative periods. Materials and Methods  Using the National Surgical Quality Improvement Program database, all patients who underwent ORIF of a DRF between January 1, 2008, and December 31, 2016, were identified and stratified by preoperative serum albumin levels: normal (≥3.5 g/dL; n = 2,546) or hypoalbuminemia (<3.5 g/dL; n = 439). Demographical and perioperative data were compared. Operative complications were stratified into major and minor complications, and data were analyzed using descriptive statistics and multivariate regression models. Results  Compared with patients with normal levels, a higher proportion of hypoalbuminemia patients had ASA scores > 3 (9.1 vs. 2%) and a longer mean length of stay (3.16 vs. 0.83 days). Hypoalbuminemia patients also had 625% greater odds for developing major complications during the 30-day postoperative period (odds ratio = 7.25; 95% confidence interval: 1.91-27.49). Conclusion  Malnutrition significantly affected outcomes and complications of distal radius ORIF. This study highlights the importance of prevention and treatment of malnutrition in the setting of fragility fractures.

Laser Ablated Periodic Nanostructures on Titanium and Steel Implants Influence Adhesion and Osteogenic Differentiation of Mesenchymal Stem Cells

Metal implants used in trauma surgeries are sometimes difficult to remove after the completion of the healing process due to the strong integration with the bone tissue. Periodic surface micro- and nanostructures can directly influence cell adhesion and differentiation on metallic implant materials. However, the fabrication of such structures with classical lithographic methods is too slow and cost-intensive to be of practical relevance. Therefore, we used laser beam interference ablation structuring to systematically generate periodic nanostructures on titanium and steel plates. The newly developed laser process uses a special grating interferometer in combination with an industrial laser scanner and ultrashort pulse laser source, allowing for fast, precise, and cost-effective modification of metal surfaces in a single step process. A total of 30 different periodic topologies reaching from linear over crossed to complex crossed nanostructures with varying depths were generated on steel and titanium plates and tested in bone cell culture. Reduced cell adhesion was found for four different structure types, while cell morphology was influenced by two different structures. Furthermore, we observed impaired osteogenic differentiation for three structures, indicating reduced bone formation around the implant. This efficient way of surface structuring in combination with new insights about its influence on bone cells could lead to newly designed implant surfaces for trauma surgeries with reduced adhesion, resulting in faster removal times, reduced operation times, and reduced complication rates.

Distal radius fractures: an evidence-based approach to assessment and management

Distal radius fractures account for one in five bony injuries in both primary and secondary care. These are commonly the result of a fall on outstretched hands or high-energy trauma. On assessment, clinicians should determine the mechanism of injury, associated bony or soft tissue injuries, and neurovascular symptoms. Investigations should always include radiographs to evaluate for intra-articular involvement and fracture displacement. Owing to the heterogeneous injury patterns and patient profiles, the preferred management should consider the severity of the fracture, desired functional outcome and patient comorbidities. Non-operative management in select patients can give good results, especially in older adults. Immobilisation with or without reduction forms the mainstay of non-operative treatment. Surgical management options include closed reduction and application of a cast, percutaneous K-wires, open reduction and internal fixation with plates, or external fixation. Patients should be encouraged to mobilise as soon as it is safe to do so, to prevent stiffness. Median nerve compression is the most common complication followed by tendon rupture, arthrosis and malunion. This article outlines the British Orthopaedic Association Standards for Trauma and Orthopaedics for the management of distal radius fractures.

Comparative results of radius distal AO type C1 fractures of elderly women by two different techniques

ackgrounds: We evaluated clinical and radiographic outcomes of volar locking plates and close reduction with percutaneous pinning treatment approaches for elderly female patients with AO type C1 simple intra-articular distal radius fractures.

PATIENTS AND METHODS

We conducted retrospective studies of 72 elderly female patients with AO type C1 simple intra-articular DRFs treated with VLPs or CRPP, from 2012 to 2018. The patients were divided into two groups: There were 38 patients in VLP group and 34 patients in CRPP group. Periodic clinical and radiological evaluation was performed at 2nd, 4th, 6th, 8th weeks and in 6 and 12 months intervals for all patients. We recorded the patient-rated wrist evaluation scores, flexion, extension, supination and pronation degrees and radiographic outcome scores at the end of 6th and 12 months after surgery.

RESULTS

A total number of 72 patients were studied. 38 patients were treated with VLP and 34 patients were treated with CRPP .The mean age of the patients was 70,5 years. Comparing the PRWE scores, the VAS scores and the ROM degrees between the 2 groups yielded no significant difference at any time point between 6 months and 1 year. There were no differences in radiographic outcomes at the latest reported follow up between the two interventions and there was no significant difference in the complication between the 2 groups (VLP 6 and CRPP 6) complications.

CONCLUSIONS

Complicated surgeries should be avoided because of specific problems in women aged 60 years or older. Our study show that VLP and CRPP techniques had little differences and similar clinical and radiographic results.

The Declining Use of Wrist-Spanning External Fixators

Background: External fixation has been traditionally used to treat comminuted or open distal radius fractures that are not amenable to open reduction internal fixation. This procedure is associated with a relatively high complication rate and has been used with decreasing frequency in recent years. However, trends in external fixation utilization for the treatment of distal radius fractures have not been described. Methods: Using the Nationwide Inpatient Sample, patients with a distal radius fracture treated with external fixation from 2003 to 2014 were identified. The annual incidence was reported, and hospital and demographic variables associated with external fixation use were determined. Results: During the study period, 593 929 patients with a distal radius fracture were identified, of which 51 766 (8.7%) were treated with a wrist-spanning external fixator. Wrist external fixation for the treatment of distal radius fractures declined steadily from 2003 to 2014. In 2003, external fixation use was highest, accounting for 17.4% of distal radius fractures. By 2014, only 4.9% of distal radius fracture were treated with external fixation. During this period, the incidence of distal radius fractures declined by 6.9% while external fixator utilization decreased by 73.7%. Patients receiving an external fixator were more likely to be male, low-income, and treated in a rural, nonteaching, privately owned hospital. Conclusions: External fixator use for the treatment of distal radius fractures steadily declined during the study period. Males and those with lower incomes treated in rural, nonteaching, and privately owned hospitals are more likely to receive external fixation.

Evaluation and Management of Osteoporosis and Sarcopenia in Patients with Distal Radius Fractures

Distal radius fractures (DRFs) are one of the most common fractures seen in elderly people. Patients with DRFs have a high incidence of osteoporosis and an increased risk of subsequent fractures, subtle early physical performance changes, and a high prevalence of sarcopenia. Since DRFs typically occur earlier than vertebral or hip fractures, they reflect early changes of the bone and muscle frailty and provide physicians with an opportunity to prevent progression of frailty and secondary fractures. In this review, we will discuss the concept of DRFs as a medical condition that is at the start of the fragility fracture cascade, recent advances in the diagnosis of bone fragility including emerging importance of cortical porosity, fracture healing with osteoporosis medications, and recent progress in research on sarcopenia in patients with DRFs.

International Survey: Factors Associated With Operative Treatment of Distal Radius Fractures and Implications for the American Academy of Orthopaedic Surgeons' Appropriate Use Criteria

OBJECTIVES

Through an international survey, we assessed whether deciding to operatively treat an intra-articular distal radius fracture (DRF) is guided by identifiable patient and surgeon factors. In addition, we compared surgeons' treatment decisions with the American Academy of Orthopaedic Surgeons' Appropriate Use Criteria (AUC) treatment recommendations.

METHODS

This cross-sectional survey asked 224 surgeons to operatively or nonoperatively treat 28 hypothetical patients with radiographs of an intra-articular DRF. We randomized patient age (50/70 years), gender, mechanism of injury, activity level, and OTA/AO fracture type. We classified 6 fractures as "nonclinically significant displacement" and 22 as "potentially clinically significant displacement." Multilevel logistic regression analysis was performed. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported. Statistical significance was P < 0.05.

RESULTS

Patient factors independently associated with surgery included younger age (OR 6.7, P = 0.003), clinically significant fracture displacement (type B: OR 122, CI, 20-739, P < 0.001; type C: OR 59, CI, 12-300, P < 0.001), normal activity level (OR 5.0, P < 0.001), and high-energy mechanisms (OR 1.3, P = 0.002). Surgeon factors associated with recommending surgery included practicing outside the United States (Europe: OR 2.6, P < 0.001; "other": OR 4.8, P < 0.001). Hand surgeons most often selected surgery, as compared to orthopaedic trauma surgeons (OR 2.3, P = 0.001) and "other orthopaedists" (OR 2.2, P = 0.022). Thirty-seven percent of treatment decisions for patients with normal activity levels were rated by AUC recommendations as "rarely appropriate," which included 91% disagreement for 70-year-olds with nonclinically significant displacement.

CONCLUSIONS

Surgeons use patient age and fracture displacement to make treatment recommendations for intra-articular DRF. We recommend that the AUC be updated to include these clinical factors as essential components in its algorithm.

LEVEL OF EVIDENCE

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

The Effect of Malnutrition on Postoperative Complications Following Surgery for Distal Radius Fractures

PURPOSE

Malnutrition is known to negatively affect outcomes after arthroplasty, hip fracture, and spine surgery. Although distal radius fracture surgery may be considered in a similar patient cohort, the effect of malnutrition in this scenario is unknown. We hypothesized that admission serum albumin level, as a marker for malnutrition, would correlate with the rate of postoperative complications following surgery for distal radius fracture.

METHODS

We performed a retrospective cohort study of the American College of Surgeons National Surgery Quality Improvement database. Patients undergoing open reduction and internal fixation of a distal radius fracture were identified using Current Procedural Terminology codes. We excluded patients who were septic at presentation, were multiply injured, or had open fractures. We collected patient demographics, length of stay, 30-day complications, reoperation, and readmission rates. We performed multivariable linear regression analysis controlling for age, sex, body mass index, operative time, discharge destination, and modified Frailty Index score.

RESULTS

We identified 1,989 patients (mean age, 56 years; range, 18-90 years) with available albumin levels, and 14.7% had hypoalbuminemia (albumin, < 3.5 g/dL). Multivariable regression revealed that malnourished patients had higher rates of postoperative complications (6.5% vs 1.3%; odds ratio [OR] 4.88; 95% confidence interval [95% CI], 2.47-9.66). Specifically, these patients had increased rates of Clavien-Dindo IV (life-threatening) complications (2.4% vs 0%), readmission (7.2% vs 2%; OR, 3.37; 95% CI, 1.88-6.03), and mortality (1.7% vs 0.1%; OR, 9.23; 95% CI, 1.55-54.87). Malnourished patients had significantly longer length of stay (3.55 vs 0.73 days). Albumin concentration was inversely associated with risk of death (OR, 0.12; 95% CI, 0.03-0.52).

CONCLUSIONS

Malnutrition, indicated by albumin less than 3.5 g/dL, is a powerful predictor of uncommon, but important, postoperative complications, including mortality, following surgery for distal radius fracture. Evaluation of preoperative albumin level may, therefore, help surgeons provide individualized counseling and more accurately stratify the risk of patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Considerations in the Treatment of Osteoporotic Distal Radius Fractures in Elderly Patients

PURPOSE OF REVIEW

With the incidence of distal radius fractures increasing in the elderly population, we sought to summarize the current orthopedic and medical management of these fractures in the elderly osteoporotic population.

RECENT FINDINGS

The number of osteoporotic patients undergoing surgical fixation for distal radius fractures has increased in recent years. This is likely due to the improved outcomes seen with volar locking plates, as well as an increase in the number of fellowship-trained hand surgeons. Despite this potential improvement in acute fracture management, a majority of these patients are underdiagnosed and undertreated for their underlying osteoporosis or endocrinopathies. The implementation of fracture liaison services and the ability of the treating orthopedist to recognize this gap in patient care result in a higher number of patients initiating appropriate treatment. It is vital that when discussing acute fracture management, a thorough discussion is had with patients regarding functional outcome and the benefits of both surgical and non-operative management. As these fractures become more prevalent and a greater percentage undergo surgical intervention, the economic burden of distal radius fractures will continue to rise. It is imperative that the treating surgeon view these fractures as sentinel events that are predictive of future hip and vertebral fractures. While relatively new, the use of fracture liaison services to help aide in proper screening and treatment of osteoporotic patients is of great value. Non-pharmacologic therapy such as physical therapy, smoking and alcohol cessation programs, and dietary modifications are crucial in treating patients with osteoporosis. While bisphosphonates remain the first-line treatment in patients with osteoporosis, novel therapies show promise for future use.

Plating of Distal Radius Fracture Using the Wide-Awake Anesthesia Technique

Fractures of the distal radius are one of the most common types of injuries encountered in hand surgery. Plate osteosynthesis is recommended for unstable fractures. Because distal radius fracture fixation is usually performed under general or regional anesthesia with the use of a tourniquet, this exposes patients, especially elderly people with extensive comorbidities, to adverse effects commonly associated with these forms of anesthesia. As such, many of these patients are unable to undergo surgery in a timely manner until they are deemed medically fit for surgery or anesthesia, and some may still be treated nonsurgically. Injecting local anesthetic of lidocaine and epinephrine into the surgical field and without using a tourniquet is known to be advantageous for various surgical procedures of the hand. However, this approach, also known as wide-awake local anesthesia no tourniquet (WALANT), has not been used in the fixation of fractures beyond the wrist. Using the WALANT approach as an alternative anesthetic for plating of distal radius fractures may enable patients who are normally denied surgery owing to their age or medical comorbidities to undergo plate fixation for the fractures. This article outlines the WALANT approach used for a single case of fixation of distal end radius fracture with a detailed description of the technique of administering local anesthesia.

"Island-shape" Fractures of Lister's tubercle have an increased risk of delayed extensor pollicis longus rupture in distal radial fractures: After surgical treatment by volar locking plate

PURPOSE

Weperformed a retrospective case-control study to explore the hypothesis that conditions adjacent to Lister's tubercle (LT) in patients with distal radial fractures (DRFs) exhibiting dorsal comminution would influence the extent of the delayed extensor pollicis longus (EPL) rupture.

METHODS

Among patients treated by volar locking plates (VLPs) were placed between March 2011 and December 2015, 314 met inclusion/exclusion criteria and were analyzed. We designated group 1 as the "EPL rupture" and group 2 as the "no EPL rupture". Basic demographic data, radiological findings, and operative variables were evaluated. The fracture patterns around LT were classified as follows: type I, no fracture line/fragment in LT or the EPL groove (third compartment); type IIA, a fracture of LT or the EPL groove with displacement <2 mm; type IIB, a fracture of LT or the EPL groove with displacement >2 mm; and type III, the presence of an island-shaped fracture fragment of LT (isolated free fragment of LT).

RESULTS

EPL ruptures were found in 18 patients (5.7%). The basic demographic parameters did not differ significantly among the groups. Clinically, neither the time to surgery nor the type of VLP used (of three different types) was not significantly associated with EPL rupture, nor was arthroscopically assisted reduction. In terms of radiological variables, the overall ratio of intra-to-extra-articular fractures did not differ among the groups. However, the fracture type significantly affected the extent of the rupture (P < 0.001), the odds ratio of which increased significantly in the fracture order IIA, IIB, and III, compared to type I (91.9, 220.1, and 342.06, respectively).

CONCLUSIONS

The extent of delayed EPL rupture after treatment of DRFs by VLPs was associated with the fracture pattern around the LT. Especially, an island-shaped LT fracture was associated with a high rupture risk because callus formation narrowed the EPL groove.

LEVEL OF EVIDENCE

Therapeutic Level III.

Use of a 5-Item Modified Frailty Index for Risk Stratification in Patients Undergoing Surgical Management of Distal Radius Fractures

PURPOSE

Compared with cast treatment, surgery may expose patients with distal radius fractures to undue risk. Surgical intervention in this cohort may offer less benefit than previously thought and appropriate patient selection is imperative. The modified Frailty Index (mFI) predicts complications after other orthopedic surgeries. We hypothesized that this index would predict, and might ultimately prevent, complications in patients older than 50 years with distal radius fractures.

METHODS

We retrospectively reviewed the American College of Surgeons-National Surgery Quality Improvement Program (ACS-NSQIP) database, including patients older than 50 years who underwent open reduction and internal fixation of a distal radius fracture. A 5-item mFI score was then calculated for each patient. Postoperative complications, readmission and reoperation rates, as well as length of stay (LOS) were recorded. Bivariate and multivariable statistical analysis was then performed.

RESULTS

We identified 6,494 patients (mean age, 65 years). Compared with patients with mFI of 0, patients with mFI of 2 or greater were nearly 2.5 times as likely to incur a postoperative complication (1.7% vs 7.4%). Specifically, the rates of Clavien-Dindo IV, wound, cardiac, and renal complications were increased significantly in patients with mFI of 2 or greater. In addition, as mFI increased from 0 to 2 or greater, 30-day reoperation rate increased from 0.8% to 2.4%, 30-day readmission from 0.8% to 4.6%, and LOS from 0.5 days to 1.44 days. Frailty was associated with increased complications as well as rates of readmission and reoperation even when controlling for demographic data, LOS, and operative time. Age alone was not significantly associated with postoperative complications, readmission, reoperation, or LOS.

CONCLUSIONS

A state of frailty is highly predictive of postoperative complications, readmission, reoperation, and increased LOS following open reduction and internal fixation of distal radius fractures. Our data suggest that a simple frailty evaluation can help inform surgical decision making in patients older than 50 years with distal radius fractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

The Effect of Osteoporosis on the Outcomes After Volar Locking Plate Fixation in Female Patients Older than 50 Years With Unstable Distal Radius Fractures

PURPOSE

The aim of this study was to investigate the effect of osteoporosis on radiological and clinical outcomes after volar locking plate (VLP) fixation in women older than 50 years with unstable distal radius fractures (DRFs).

METHODS

We retrospectively reviewed data of 79 women older than 50 years with DRFs treated by VLP fixation. We collected patients' baseline data, including age and bone mineral density. We also measured the cortical thickness of the distal radius on plain radiographs and computed tomography to assess local bone density. Radiological outcomes included late displacement at 1 year after surgery, which was defined as a change in radiological parameters (radial inclination, volar tilt, and ulnar variance). Clinical outcomes were assessed with the Disabilities of the Arm, Shoulder, and Hand (DASH) and modified Mayo wrist score at 1 year after surgery. We compared mean values between the nonosteoporotic (group 1, T score > -2.5) and the osteoporotic groups (group 2, T score ≤ -2.5). We conducted linear and logistic regression analysis to investigate factors associated with poor outcomes.

RESULTS

There were 49 patients in group 1 and 30 patients in group 2. Radiological outcomes were similar in both groups. The mean DASH score was 14.9 (SD, 16.4) for group 1 and 12.5 (SD, 13.5) for group 2, and the mean modified Mayo wrist score was 87.6 (SD, 8.8) for group 1 and 88.2 (SD, 11.4) for group 2. There were no significant differences in clinical outcomes between groups. Simple and multivariable linear regression analysis showed only older age was associated with the change in volar tilt. Osteoporosis and cortical thickness were not associated with poor clinical outcomes on simple logistic regression analysis.

CONCLUSIONS

Osteoporosis and cortical thickness of the distal radius did not affect clinical outcomes after VLP fixation in women older than 50 years with unstable DRFs.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Evidence-Based Review of Distal Radius Fractures

Distal radius fractures are one of the most commonly treated fractures in the United States. The highest rates are seen among the elderly, second only to hip fractures. With the increasing aging population these numbers are projected to continue to increase. Distal radius fractures include a spectrum of injury patterns encountered by general practitioners and orthopedists alike. This evidence-based review of distal radius fractures incorporates current and available literature on the diagnosis, management, and treatment of fractures of the distal radius.

Re-fracture of Distal Radius and Hardware Repair in the Setting of Trauma

Distal radius fractures are one of the most common fractures in the elderly. Falls and motor vehicle collisions lead to increased risk for this type of fracture. A seventy-three year-old female had a previous history of distal radius fracture with repair by open reduction and internal fixation. She was involved in a motor vehicle collision that re-fractured the distal radius. The plate was bent and required removal, which is a very rare but potentially serious complication. Surgery was done to fix the open reduction and internal fixation with volar locking plates while removing damaged hardware. Only a select few cases have reported hardware failure as a cause of complications. Among those cases, high-energy activities and maintained stress on the hardware were likely causes. Distal radius fractures are the most common upper extremity fracture in the elderly. We highlight a unique case of re-fracture in the setting of trauma with prior hardware failure and describe the strategy for hardware repair.

National Surgical Trends for Distal Radius Fractures in Korea

The objective of this study was to investigate national surgical trends for distal radius fractures (DRFs) in Korea and analyze healthcare institution type-specific surgical trends. We analyzed a nationwide database acquired from the Korean Health Insurance Review and Assessment Service (HIRA) from 2011 to 2015. International Classification of Diseases, 10th revision (ICD-10) codes and procedure codes were used to identify patients aged ≥ 20 years with newly diagnosed DRFs. A total of 459,388 DRFs occurred from 2011 to 2015. The proportion of DRF cases treated by surgery tended to increase over time, from 32.6% in 2011 to 38.3% in 2015 (P < 0.001). Open reduction with internal fixation (ORIF) using a plate steadily gained in popularity each year, increasing from 39.2% of overall surgeries in 2011 to 60.9% in 2015. The type of surgery for DRFs differed depending on the type of healthcare institution. ORIF (91%) was the most popular procedure in tertiary hospitals, whereas percutaneous pinning (58%) was most popular in clinics. In addition, general hospitals and hospitals with 30-100 beds used external fixation more frequently than tertiary hospitals and clinics did. Overall, our findings indicate that surgical treatment of DRF, particularly ORIF, continues to increase, and that the component ratio of operation codes differed according to the healthcare institution type.

Core curriculum illustration: "Colles," dorsally angulated fracture of the distal radius

This is the 41st installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.erad.org/page/CCIP_TOC .

Distal Radius Fractures in the Elderly

Distal radius fractures are common in elderly patients, and the incidence continues to increase as the population ages. The goal of treatment is to provide a painless extremity with good function. In surgical decision making, special attention should be given to the patient's bone quality and functional activity level. Most of these fractures can be treated nonsurgically, and careful closed reduction should aim for maintenance of anatomic alignment with a focus on protecting fragile soft tissues. Locked plating is typically used for fracture management when surgical fixation is appropriate. Surgical treatment improves alignment, but improvement in radiographic parameters may not lead to better clinical outcomes. Treatment principles, strategies, and clinical outcomes vary for these injuries, with elderly patients warranting special consideration.

Early Complications Following Osteosynthesis of Distal Radius Fractures: A Comparison of Geriatric and Nongeriatric Cohorts

BACKGROUND

Distal radius fractures (DRFs) are common geriatric fractures with the overall incidence expected to increase as the population continues to age. The purpose of this investigation was to compare the short-term complication rates in geriatric versus nongeriatric cohorts following osteosynthesis of DRFs.

METHODS

The American Board of Orthopaedic Surgery (ABOS) part II database was queried for adult DRF cases performed from 2007 to 2013. Current Procedural Terminology codes were used to identify cases treated via osteosynthesis. Patient demographic information and reported complication data were analyzed. Comparisons between geriatric (age ≥65 years) and nongeriatric (age <65 years) patients were performed.

RESULTS

From 2007 to 2013, a total of 9867 adult DRFs were treated via osteosynthesis by ABOS part II candidates. Geriatric patients comprised 28% of the study cohort. Mean age of the geriatric and nongeriatric cohorts was 74 ± 7 and 46 ± 13 years, respectively. There was a greater proportion of female patients (P < .001) in the geriatric cohort as compared with the nongeriatric cohort. The geriatric cohort demonstrated higher rates of anesthetic complications (P = .021), iatrogenic bone fracture (P = .021), implant failure (P = .031), loss of reduction (P = .001), unspecified medical complications (P = .007), and death (P = .017) than the nongeriatric cohort. The geriatric cohort also showed lower rates of nerve palsy (P = .028) when compared with the nongeriatric cohort, though no differences in rates of secondary surgery were noted between the two cohorts.

CONCLUSION

Increased rates of complications related to poor bone quality and poor health status may be expected among geriatric patients following osteosynthesis of DRFs. However, geriatric and nongeriatric patients have similarly low rates of secondary surgery. Future studies are needed to delineate the economic, functional, and societal impact of geriatric DRFs treated via osteosynthesis.

Volar locking plate fixation for distal radius fractures: Does age affect outcome?

BACKGROUND

The AAOS guidelines are unable to recommend for or against operative treatment of distal radius fractures in older patients.

AIMS

This study compares the outcomes of older patients (≥60 years) against a cohort of younger patients treated with volar locking plate (VLP) fixation.

METHODS

We assessed 78 patients, comparing range of movement (ROM), grip and pinch strength, subjective Visual Analogue Score (VAS) for pain and function and composite outcome scores.

RESULTS

There was no difference in clinical outcomes between the two groups at six months.

CONCLUSION

Open reduction and VLP for distal radius fractures gives comparable outcomes in the older population.

Clinical trial and in-vitro study comparing the efficacy of treating bony lesions with allografts versus synthetic or highly-processed xenogeneic bone grafts

Background

Our study aim was to compare allogeneic cancellous bone (ACB) and synthetic or highly-processed xenogeneic bone substitutes (SBS) in the treatment of skeletal defects in orthopedic surgery.

Methods

232 patients treated for bony lesions with ACB (n = 116) or SBS (n = 116) within a 10-year time period were included in this case–control study. Furthermore, both materials were seeded with human osteoblasts (hOB, n = 10) and analyzed by histology, for viability (AlamarBlue®) and protein expression activity (Luminex®).

Results

The complication rate was 14.2 %, proportion of defects without bony healing 3.6 %; neither outcome parameter differed comparing the intervention groups. Failed consolidation correlated with an increase in complications (p < 0.03). The rate of complications was further highly significant in association with the location of use (p < 0.001), but did not depend on age, ASA risk classification, BMI, smoking behavior or type of insurance. However, those factors did significantly influence the bony healing rate (p < 0.02). Complication and consolidation rates were independent of gender and the filling substances employed within the different locations. Histological examination revealed similar bone structures, whereas cell remnants were apparent only in the allografts. Both materials were biocompatible in-vitro, and seeded with human osteoblasts. The cells remained vital over the 3-week culture period and produced microscopically typical bone matrix. We observed initially increased expression of osteocalcin, osteopontin, and osteoprotegerin as well as leptin and adiponectin secretion declining after 1 week, especially in the ACB group.

Conclusion

Although both investigated materials appeared to be similarly suitable for the treatment of skeletal lesions in-vivo and in-vitro, outcome was decisively influenced by other factors such as the site of use or epidemiological parameters.

Comparing the effect of volar plate fixators and external fixators on outcome of patients with intra-articular distal radius fractures: A clinical trial

BACKGROUND

Distal radius fractures (DRFs) are much more prone to malunion than unstable extra-articular fractures. There is no clear consensus concerning what the proper treatment should be, and the best approach to use for displaced DRFs remains challenging.

OBJECTIVE

To compare the effect of two different therapeutic surgical methods, i.e., volar plate fixators and external fixators, on outcomes of patients with intra-articular distal radius fractures.

METHODS

From May 2010 to November 2014, 76 subjects who had experienced intra-articular fractures of the distal radius were enrolled in this double-blind, randomized, controlled trial in Imam Ali Hospital in Bojnourd, Iran. The patients were divided into two groups, i.e., 1) patients who were treated with internal fixation using the volar plate (group A) and 2) patients who were treated with external fixators (group B). The primary outcome was a composite measure of the patient's quality of life using three different scores, i.e., 1) the MAYO score, 2) Disabilities of the Arm, Shoulder, and Hand (DASH (score, and 3) the Short Form (36) (SF-36) Health Survey score.

RESULTS

A total of 76 patients were allocated randomly to groups A and B. The mean ages for external fixator cases and volar plate cases were 51.7 and 46.3, respectively. No significant age distribution was seen between the two groups (p=0.348). Gender distribution between the two groups was not significantly different (p=0.022). Grip power was significantly different between the two groups, but no significant differences were detected in range of motion (p=0.008, p=0.367, respectively). The MAYO score was significantly higher in the open reduction and internal fixation (ORIF) group, and, according to the SF-36 test, the ORIF group also a higher level of general mental and physical health, social functioning, and personal physical functioning than the other group. However, postoperatively, the mental discomfort and physical discomfort were more prevalent in the external fixator group. The DASH score was not significantly different between the two groups (p=0.124).

CONCLUSIONS

ORIF and its subtitle, volar plate fixation, is a more preferred surgical procedure than the external fixator for the treatment of intra-articular distal radius fractures. This conclusion is important when one considers cost-effectiveness and an earlier return to work.

TRIAL REGISTRATION

The trial is registered at the Thai Clinical Trial Registry (clinicaltrials.in.th) with the TCR identification number TCTR20150609002.

FUNDING

The authors received no financial support for the research, authorship, and/or publication of this article.

External fixation versus open reduction with locked volar plating for geriatric distal radius fractures

The optimal management of displaced dorsal radius fractures (DRFs) in older patients remains an issue of debate. Bridging external fixation is a well-accepted treatment modality for severely comminuted DRFs, while open reduction and internal fixation with locked volar plating has emerged as a promising alternative in recent years. The current body of randomized trials supports the trend toward locked volar plating, as it allows for quicker improvement in subjective and functional outcomes. There is no clear evidence to suggest that one technique carries significantly less complications than the other. Locked volar plating should be considered in patients for whom an accelerated functional recovery would be advantageous. Otherwise, both external fixation and locked volar plating provide good long-term clinical outcomes.