In adults, early mobilization may be beneficial for distal radius fractures treated with open reduction and internal fixation: a systematic review and meta-analysis

Systematic review and meta-analysis of mobilisation following open reduction and internal fixation of hand fractures

Delayed mobilisation following open reduction and internal fixation (ORIF) of hand fractures may contribute to stiffness and poor functional recovery. The aim of this systematic review and meta-analysis was to evaluate whether timing of mobilisation post-ORIF impacts patient-reported and clinical post-operative outcomes. The review was conducted according to the Cochrane Handbook and was reported in concordance with PRISMA guidelines. All studies reporting mobilisation regimens following ORIF performed within two weeks of metacarpal or phalangeal fractures were included. Of 794 abstracts screened, 53 studies were included, evaluating 1822 hand fractures treated with ORIF. We found differences between mobilisation timing in patient-reported outcome measures (PROMs), adverse events and time to radiological fracture union. Immediate mobilisation (≤1 day of ORIF) had the shortest mean bone healing time of 38.7 days (95% CI 34.3, 42.3) compared to early mobilisation (≤7 days) (49.6 days [95% CI 42.8, 56.5]). Delayed mobilisation (>7 days) had the lowest rate of adverse events at 9.3% [95% CI 5.6, 15.2] compared to early mobilisation at 25.0% [95% CI 17.1, 35.0]. However, variable outcome reporting and inconsistent diagnostic criteria limited definitive conclusions. The current literature on post-ORIF mobilisation is heterogeneous. Our meta-analysis demonstrated wide variability in outcomes across different regimens, with overlapping confidence intervals across most summary estimates. A definitive, multi-centre RCT comparing time to mobilisation post-ORIF, including comprehensive outcome reporting and cost-effectiveness analysis, is warranted to inform clinical practice.

Literature Review of Postoperative Distal Radius Fracture Immobilization Recommendations

Distal radius fractures (DRFs) are a commonly treated injury in orthopedics. DRFs have a high incidence across patient demographics, including pediatrics, young patients in high-energy trauma, and geriatric patients in low-energy trauma. While DRFs occur across a large range of age groups, they are especially consequential in geriatric patients with osteoporosis. Management of DRFs has extensive variability, ranging from conservative casting to surgical interventions, such as open reduction and internal fixation surgical procedures. The diversity of treatment options for DRFs is due to a consideration of factors, such as fracture characteristics, time to presentation with an orthopedic surgeon, age of the patient, and medical comorbidities of the patient. Despite being a common fracture type, there remain discrepancies in the non-pediatric literature regarding postoperative recommendations, such as the timing and methods of immobilization. There is also debate regarding whether postoperative immobilization in adult DRFs has clinical benefit. Some of this variability depends on the type of fixation utilized, such as a volar locking plate, dorsal locking plate, and dorsal wrist-spanning fixation. This literature review examines recommendations and outcomes of postoperative splinting (supination, pronation, or neutral rotation of the forearm) versus removable wrist brace versus soft dressings only for DRFs with both intra-articular and extra-articular fracture patterns with operative fixation. Postoperative care is imperative to study as it carries long-term effects on patients' quality of life, as their range of motion and strength can be dictated by the methodology of this care. Studies have been conducted comparing the outcomes of early mobilization versus prolonged immobilization after surgical intervention. This literature review analyzes these studies to understand which methods carry better outcomes with respect to the range of motion and quality of life of patients for operatively treated DRFs in non-pediatric patients.

Clinical value of rehabilitation nursing after internal fixation of distal radius fractures

OBJECTIVE

To evaluate the clinical value of rehabilitation nursing following internal fixation of distal radius fractures (DRFs).

METHODS

This retrospective study analyzed the medical records of 114 patients who underwent internal fixation for DRFs between July 2019 and May 2023. Among them, 54 patients received routine nursing care (control group) and 60 patients received rehabilitation nursing (observation group). Comparative analyses were conducted on postoperative pain (Visual Analogue Scale [VAS]), swelling, rehabilitation indicators (healing time, time to regain limb mobility, and hospital stays), wrist joint functional recovery (grip strength, Gartland-Werley Scale, rate of excellent and good reduction), quality of life (Short-Form 36 [SF-36]), adverse emotions (Self-Rating Depression Scale [SDS] and Self-Rating Anxiety Scale [SAS]), and nursing satisfaction.

RESULTS

The observation group exhibited a significant stepwise decrease in VAS and swelling scores on postoperative days 3 and 7 compared to preoperative levels (all P<0.05), and these scores were lower than those of the control group (all P<0.05). The observation group also showed significantly shorter healing time, faster recovery of limb mobility, and reduced hospital stays (all P<0.05). Additionally, patients in the observation group demonstrated higher grip strength, a greater rate of excellent and good reduction, and significantly lower Gartland-Werley, SDS, and SAS scores compared to the control group (all P<0.05). Higher SF-36 scores and greater nursing satisfaction were also observed in the observation group (both P<0.05).

CONCLUSIONS

Rehabilitation nursing after internal fixation of DRFs has significant clinical value, evidenced by substantial relief of postoperative pain and swelling, reduction in adverse emotions, enhanced rehabilitation, improved wrist joint function, and higher quality of life and nursing satisfaction.

The osteocutaneous radial forearm free flap: A multidisciplinary review of the evidence

The osteocutaneous radial forearm (OCRFF) is a versatile free flap option for bony defects of the head and neck, given the thinness and pliability of the forearm cutaneous paddle, pedicle length, reliability, lack of atherosclerosis, and functional concerns common to other osseous donor sites. The OCRFF was once associated with a high risk of radial fracture, in addition to concerns about the quality and durability of bone stock for osseous reconstruction, particularly for the mandible. Following the introduction of prophylactic plating of the radius, the incidence of symptomatic radial fracture has drastically decreased. Furthermore, modifications of the bony osteotomies and other evolutions of this flap harvest have increased the use of the OCRFF throughout the head and neck. Despite these advantages, the OCRFF is not widely utilized by microvascular reconstructive surgeons due to perceived limitations and risks. Herein, we present a multidisciplinary, contemporary review of the harvest technique, outcomes, and perioperative management for the OCRFF.

Early Daily Activity: Development and description of an occupation-based intervention for surgically repaired distal radius Fractures

OBJECTIVE

To describe the theoretical development and structure of an occupation-based intervention for people with a surgically repaired distal radius fracture.

INTERVENTION DEVELOPMENT AND RATIONALE

The Early Daily Activity (EDA) intervention uses the performance of strategically selected daily activities as the primary rehabilitative strategy. Occupation-based interventions are recommended for hand injury rehabilitation but are often poorly described and lack explicit theoretical underpinnings. The EDA-intervention was developed from exploratory research that informed the theory and structure. The theoretical principles are that daily activity performance is (i) safe within defined parameters (ii) appropriately self-determined (iii) produces high ranges and amounts of therapeutic movement, and (iv) builds psychosocial competencies.

INTERVENTION DESCRIPTION

The EDA-intervention is designed to be commenced within 2 weeks of surgery. There are three key components. The first is activity-specific education to emphasise the safety, benefits, and therapeutic actions of activity performance. A set of parameters for defining safe activities is described to support education. The second component is patient-therapist collaboration to select a range of daily activities that provide a 'just-right' challenge. Collaboration occurs at regular intervals throughout the rehabilitation period to incrementally increase the challenge of activities. The third component is performance of activities at-home targeted at improving range of movement and function.

NEXT STEPS

The EDA-intervention can be used by hand therapists, but it has not yet undergone effectiveness evaluation. A planned study will explore clinician readiness to adopt the EDA-intervention, inform iterative changes to the protocol and the design of feasibility and effectiveness studies.

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.

Cast immobilization duration for distal radius fractures, a systematic review

PURPOSE

The optimal duration of immobilization for the conservative treatment of non- or minimally displaced and displaced distal radius fractures remains under debate. This research aims to review studies of these treatments to add evidence regarding the optimal immobilization period.

METHODS

A comprehensive database search was conducted. Studies investigating and comparing short (< 3 weeks) versus long (> 3 weeks) immobilizations for the conservative treatment of distal radius fractures were included. The studies were evaluated for radiological and functional outcomes, including pain, grip strength, and range of motion. Two reviewers independently reviewed all studies and performed the data extraction.

RESULTS

The initial database search identified 11.981 studies, of which 16 (involving 1.118 patients) were ultimately included. Patient-reported outcome measurements, grip strength, range of motion, and radiological outcomes were often better after shorter immobilization treatments. Radiological outcomes were better with longer immobilization in two studies and shorter immobilization in one study. Fourteen studies concluded that early mobilization is preferred, while the remaining two studies observed better outcomes with longer immobilization. The data were unsuitable for meta-analysis due to their heterogeneous nature.

CONCLUSION

Shorter immobilization for conservatively treated distal radius fractures often yield equal or better outcomes than longer immobilizations. The immobilization for non- or minimally displaced distal radius fractures could therefore be shortened to 3 weeks or less. Displaced and reduced distal radius fractures cannot be immobilized shorter than 4 weeks due to the risk of complications. Future research with homogeneous groups could elucidate the optimal duration of immobilization.

3D Printed Orthopaedic External Fixation Devices: A Systematic Review

BACKGROUND

External fixators are complex, expensive orthopaedic devices used to stabilize high-energy and complex fractures of the extremities. Although the technology has advanced dramatically over the last several decades, the mechanical goals for fracture stabilization of these devices have remained unchanged. Three-dimensional (3D) printing technology has the potential to advance the practice and access to external fixation devices in orthopaedics. This publication aims to systematically review and synthesize the current literature on 3D printed external fixation devices for managing orthopaedic trauma fractures.

METHODS

The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocols were followed for this manuscript with minor exceptions. PubMed, Embase, Cochrane Review, Google Scholar, and Scopus online databases were systematically searched. Two independent reviewers screened the search results based on predetermined inclusion and exclusion criteria related to 3D printing and external fixation of fractures.

RESULTS

Nine studies met the inclusion criteria. These included one mechanical testing study, two computational simulation studies, three feasibility studies, and three clinical case studies. Fixator designs and materials varied significantly between authors. Mechanical testing revealed similar strength to traditional metal external fixators. Across all clinical studies, five patients underwent definitive treatment with 3D printed external fixators. They all had satisfactory reduction and healing with no reported complications.

CONCLUSIONS

The current literature on this topic is heterogeneous, with highly variable external fixator designs and testing techniques. A small and limited number of studies in the scientific literature have analyzed the use of 3D printing in this area of orthopaedic surgery. 3D printed external fixation design advancements have yielded promising results in several small clinical case studies. However, additional studies on a larger scale with standardized testing and reporting techniques are needed.

Anterior locking plate versus non-operative treatment in different age groups with distal radial fractures: a systematic review and meta-analysis

This meta-analysis compared anterior locking plate and non-operative treatment for distal radial fractures and assessed if the age of the patients is associated with the treatment effect. We searched the MEDLINE, Embase and CENTRAL databases and included 12 studies with 1366 patients. Compared with non-operative care, anterior locking plate treatment does not seem to provide clinically important benefits in mean DASH score, mean pain or their mean quality of life at 12 to 24 months if the patients' ages are not considered (moderate to low certainty evidence). However, the younger the patients, the larger the benefit for surgery. Meta-regression with the DASH score suggested that while people over 70 likely experience no clinically relevant benefit from surgery, the mean effects cannot be generalized to people under 60. The evidence regarding the risk of adverse events is too uncertain to make firm conclusions.

Enhanced recovery after surgery for major orthopedic surgery: a narrative review

Background

With increasing interest in enhanced recovery after surgery (ERAS), the literature on ERAS in orthopedic surgery is also rapidly accumulating. This review article aims to (1) summarize the components of the ERAS protocol applied to orthopedic surgery, (2) evaluate the outcomes of ERAS in orthopedic surgery, and (3) suggest practical strategies to implement the ERAS protocol successfully.

Main body

Overall, 17 components constituting the highly recommended ERAS protocol in orthopedic surgery were identified. In the preadmission period, preadmission counseling and the optimization of medical conditions were identified. In the preoperative period, avoidance of prolonged fasting, multimodal analgesia, and prevention of postoperative nausea and vomiting were identified. During the intraoperative period, anesthetic protocols, prevention of hypothermia, and fluid management, urinary catheterization, antimicrobial prophylaxis, blood conservation, local infiltration analgesia and local nerve block, and surgical factors were identified. In the postoperative period, early oral nutrition, thromboembolism prophylaxis, early mobilization, and discharge planning were identified. ERAS in orthopedic surgery reduced postoperative complications, hospital stay, and cost, and improved the patient outcomes and satisfaction with accelerated recovery. For successful implementation of the ERAS protocol, various strategies including the standardization of care system, multidisciplinary communication and collaboration, ERAS education, and continuous audit system are necessary.

Conclusion

The ERAS pathway enhanced patient recovery with a shortened length of stay, reduced postoperative complications, and improved patient outcomes and satisfaction. However, despite the significant progress in ERAS implementation in recent years, it has mainly focused on major surgeries such as arthroplasty. Therefore, further efforts to apply, audit, and optimize ERAS in various orthopedic surgeries are necessary.

Application Value of the Workshop Practice Teaching Method Based on Target-Oriented Study Modules on the Internet in Orthopedic Rehabilitation

Objective

To explore the application value of the workshop practice teaching method based on target-oriented study modules on the internet in orthopedic rehabilitation.

Methods

Thirty interns (2019-2020) in the rehabilitation department of our hospital were selected as the control group, another thirty interns (2021) in the rehabilitation department of our hospital were selected as the experimental group, and their materials were retrospectively reviewed. Both groups were given the three-month practice teaching. Besides, the conventional practice teaching method was applied to the control group, and the workshop practice teaching method based on target-oriented study modules on the internet was applied to the experimental group. After the practice teaching, the united examination paper and assessment table of the rehabilitation operation process were used to evaluate the interns' scores of theoretical knowledge about orthopedic rehabilitation, scores of practical skills, and comprehensive scores of clinical practice in the two groups. The evaluation team consisting of 5 guiding experts in the scientific research office assessed the teaching quality of the two methods.

Results

Compared with the control group, the experimental group had a notably higher score of theoretical knowledge about orthopedic rehabilitation, higher score of practical skills, and higher comprehensive score of clinical practice (92.47 ± 4.81 vs. 86.43 ± 5.12, 91.30 ± 5.68 vs. 81.53 ± 7.21, and 91.88 ± 2.45 vs. 83.98 ± 4.42, P < 0.001). According to the evaluation team, the teaching quality of the experimental group was observably higher than that in the control group (P < 0.05), and there was no remarkable difference in the scores of teachers' performance between the two groups (P > 0.05).

Conclusion

The workshop practice teaching method based on target-oriented study modules on the internet, as a high-quality “Internet+” practice teaching mode, can improve the orthopedic interns' scores of theoretical knowledge and practical operation ability and enhance their comprehensive qualities of orthopedic rehabilitation in all respects.