Outcomes and Complications in the Management of Distal Radial Fractures in the Elderly

Outcomes in Patients with Bilateral Distal Radius Fractures

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

Comparative Analysis of Radial Corrective Osteotomy and Sauvé-Kapandji Procedure for Malunited Distal Radius Fractures in Older Adults

PURPOSE

Malunited distal radius fractures frequently occur in the older population, posing a dilemma in selecting ideal management for symptomatic patients. Radial corrective osteotomy (RCO) and the Sauvé-Kapandji procedure (SK) have been used to treat this challenging condition. However, it remains unknown which approach is better for the older population. The objective of this study was to compare the outcomes of RCO with those of SK for the treatment of symptomatic distal radius malunion in older adults.

METHODS

Thirty-three patients aged ≥60 years, with malunited distal radius fractures, were randomized to be treated with either RCO or SK and followed for a minimum of 2 years. The primary evaluation parameter was grip strength, and secondary outcome parameters were surgical time, range of motion of the wrist, exercise-related wrist pain assessment using visual analog scale scores, radiographic results, patient-reported outcomes evaluated using the Disability of the Arm, Shoulder, and Hand (DASH), and Patient-Related Wrist Evaluation (PRWE) scores.

RESULTS

The average follow-up duration was 36.7 ± 10.2 months. The grip strength was significantly higher in the RCO group. The surgical time was shorter in the SK group than in the RCO group. The postoperative wrist range of motion and visual analog scale scores for exercise-related pain alleviation were similar in both groups. The ulnar variance decreased in both groups and was similar when compared with the postoperative images. The DASH and PRWE scores were similar between the RCO and SK groups.

CONCLUSIONS

Radial corrective osteotomy and SK surgeries have similar clinical and functional outcomes in patients aged ≥60 years. Grip strength is higher in the RCO group than in the SK group. However, the operating time to accomplish SK is shorter than RCO.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Surgical Treatment of Periarticular Distal Radius Fracture in Elderly: A Systematic Review

Background/Objectives: The treatment of periarticular distal radius fractures remains challenging. Different surgical treatment options have been proposed as alternatives to conservative treatment. This systematic review aims to compare the functional outcomes, radiological outcomes, and complications among volar locking plates (VLPs), Kirschner-wire fixations, and external fixations (EFs) for distal radius fractures in patients aged 60 years and older. Methods: We conducted a comprehensive search of PubMed, Cochrane, and Science Direct databases assessing the effects of VLP, EF, and K-wire treatments for distal radius fractures in patients aged 60 years and over. The primary outcome was the evaluation of the range of motion (ROM) degrees after three surgical procedures, trying to assess the best treatment option. The secondary outcome included evaluation of the Disabilities of the Arm, Shoulder, and Hand (DASH) score, quick-DASH score, Patient-Rated Wrist Evaluation (PRWE) score, Visual Analog Scale (VAS) score, grip strength, radiographic assessment, and complications comparing VLPs, EFs and K-wires. Results: A total of 23 studies were included, comparing VLP, EF, and K-wire fixation. The overall population comprised 5618 patients, with 4690 females and 1015 males, of which 4468 patients were treated with VLP, 503 with EF, and 647 with K-wire. The most common complications among the VLP group were complex regional pain syndrome (7.5%) and carpal tunnel syndrome (6.8%); for the EF group, infections (9.8%) and carpal tunnel syndrome (6.8%); and for the K-wire group, carpal tunnel syndrome (7.5%) and infections (6.9%). Conclusions: VLP showed better clinical outcomes in the first few months after treatment. However, these differences decreased over time and became similar after one year. EF and K-wire fixations remain easier to manage during surgery.

Outcomes Following Surgical Fixation of Distal Radius Fractures in Patients With Chronic Kidney Disease

Purpose

Moderate-to-severe chronic kidney disease (CKD, stages III-IV) and end-stage renal disease (ESRD or CKD stage V) are known to be independent risk factors for fragility fracture. Altered bone and mineral metabolism contributes to greater complications and mortality rates in the setting of fractures, although most existing literature is limited to hip fractures. We hypothesized that patients with moderate-to-severe CKD or ESRD would have greater complication rates after surgical treatment of distal radius fractures compared with those without CKD.

Methods

We retrospectively identified all patients at a level 1 trauma center between 2008 and 2018 who had a diagnosis of stage III-IV CKD or ESRD at the time of operative fixation of a distal radius fracture. We recorded demographic data, comorbidities, and surgical complications. Data for readmissions within 90 days and 1-year mortality were collected. A 2:1 sex-matched control group without CKD who underwent distal radius fixation was selected for comparison, with age-adjusted analysis.

Results

A total of 32 patients with CKD (78.1% CKD stage III/IV, 21.9% ESRD) and 62 without CKD were identified. The mean age was 67 ± 12 years in the CKD group and 55 ± 15 years in the control group. The CKD group had a higher Charlson Comorbidity Index (5.7 vs 2.0). Surgical complication rate in the CKD group was 12.5% (12.0% CKD III/IV; 14.3% ESRD). Neither early nor late surgical complication rates were statistically different from those in patients without CKD. Reoperation rate as well as 30- and 90-day readmission rates were similar between groups. Overall, 1-year mortality was greater in the CKD group (9.4% vs 0%).

Conclusions

Surgical complications and readmission rates are similar in patients with and without CKD after distal radius fracture fixation. However, 1-year mortality rate is significantly higher after distal radius fixation in patients with moderate-to-severe CKD or ESRD.

Type of study/level of evidence

Prognostic IIIa.

Complications After Open Reduction and Internal Fixation for Distal Radius Fractures in Patients With and Without Rheumatoid Arthritis

PURPOSE

Rheumatoid arthritis (RA) can have severe impact on patients' functional abilities and increase the risk of fragility fractures. Little is known about how patients with RA fare after operative management of distal radius fractures. The purpose of this study was to compare postoperative complications after surgical fixation in patients with RA and controls, hypothesizing that patients with RA would have higher levels of postoperative complications.

METHODS

Patients were identified using Current Procedural Terminology and International Classification of Diseases, Ninth and Tenth Revision, codes for open treatment of distal radius fractures and RA at 3 level 1 trauma centers over a 5-year period (2015-2019). Chart abstraction provided details regarding injuries and treatment. Age- and sex-matched controls were identified in a 2:1 ratio. Postoperative complications were classified according to the Clavien-Dindo-Sink classification system and divided into early (less than 90 days) and late groups.

RESULTS

Sixty-four patients (21 with RA and 43 controls) were included. The patients were predominantly women, with a mean age of 62 years and a mean Charlson comorbidity index of 2.1. The RA medications at the time of injury included conventional synthetic disease-modifying antirheumatic drugs (5/21), biologic disease-modifying antirheumatic drugs (5/21), or chronic oral prednisone (6/21). Rheumatoid medications, except hydroxychloroquine, were withheld for 2-3 weeks after surgery. Rheumatoid patients were significantly more likely to sustain a complication compared with the control group, although this was no longer significant on adjusted analysis. Class I complications were the most common. The incidence of early versus late complications was similar between the groups. A high rate of early return to surgery for fixation failure occurred in the RA group compared with none in the control group.

CONCLUSIONS

Patients with RA undergoing operative management of distal radius fractures are at risk of postoperative complications, particularly fracture fixation failure, necessitating return to the operative room. High levels of pain, stiffness, and mechanical symptoms were noted in the RA group.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Comparison of DN4 and DN4 Interview Tests in the Identification of Neuropathic Pain after Fracture Surgery

Objective:  This study aimed to compare results obtained with the DN4 (in-person interview) and DN4i (telephone interview) questionnaires in identifying neuropathic pain after fracture surgery. Methods:  This study was methodological, using questionnaires administered in person (DN4) or via telephone (DN4i). The participants were at least 18 years old, underwent fracture surgery at a university hospital between January 2017 and July 2020, signed the Informed Consent Form (ICF), and could go to the Orthopedics and Traumatology Hospital. Pearson's correlation coefficient determined the agreement between the total score obtained during in-person and telephone interviews. The kappa coefficient evaluated the agreement between individual questionnaire items. Results:  Of the 53 participants, 50 presented the same result for neuropathic pain screening in DN4 and DN4i, including 41 with a positive score for neuropathic pain and 12 with a negative score. The Pearson's correlation coefficient and kappa coefficient were r = 0.84. Conclusion:  DN4 and DN4i presented a strong agreement between individual items of the questionnaires and the total scores obtained.

Aspartate Aminotransferase-to-Platelet Ratio Index Suggestive of Liver Dysfunction Predicts Early Complications After Open Reduction Internal Fixation of Distal Radius Fractures

Purpose

Aspartate aminotransferase-to-platelet ratio index (APRI) is a cost-effective and noninvasive measure of liver function, an alternative to the gold standard liver biopsy, which is resource-intensive and invasive. The purpose of this study was to investigate the association between preoperative APRI and 30-day postoperative complications after isolated open reduction internal fixation (ORIF) of distal radius fractures (DRFs).

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent isolated ORIF of DRFs between 2015 and 2021. The study population was divided into two groups on the basis of preoperative APRI: normal/reference (APRI, <0.5) and liver dysfunction (APRI, ≥0.5). Information on patient demographics, comorbidities, and 30-day postoperative complications after isolated ORIF of DRFs was collected. Multivariate logistic regression analysis was performed to investigate the relationship between preoperative APRI and postoperative complications.

Results

Compared to patients with normal APRI, patients with preoperative APRI associated with liver dysfunction were significant for male sex (P < .001), younger age (P < .001), American Society of Anesthesiologists classification grade ≥3 (P < .001), being smokers (P < .001), and having comorbid diabetes (P = .002) and bleeding disorders (P < .001). Preoperative APRI associated with liver dysfunction was independently associated with a greater likelihood of any complications (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.19-1.87; P < .001), nonhome discharge (OR, 1.62; 95% CI, 1.15-2.27; P = .005), and a length of stay of >2 days (OR, 1.70; 95% CI, 1.32-2.20; P < .001).

Conclusions

Aspartate aminotransferase-to-platelet ratio index values associated with liver dysfunction were associated with an increased rate of early postoperative complications after DRF ORIF.

Clinical relevance

This study suggests APRI's utility as a cost-effective, noninvasive measure of liver function that physicians can use before surgery to better identify surgical candidates with DRFs and suspicion of liver dysfunction.

Type of study/level of evidence

Prognostic III.

Variations in Treatment and Costs for Distal Radius Fractures in Patients Over 55 Years of Age: A Population-Based Study

Objective  To evaluate the rate of surgery for symptomatic malunion after nonoperatively treated distal radius fractures in patients aged 55 and above, and to secondarily report differences in demographics, geographical variation, and utilization costs of patients requiring subsequent malunion correction. Methods  We identified patients aged 55 and above who underwent nonoperative treatment for a distal radius fracture between 2007 and 2016 using the IBM MarketScan database. In the nonoperative cohort, we identified patients who underwent malunion correction between 3 months and 1 year after distal radius fracture. The primary outcome was rate of malunion correction. Multivariable logistic regression controlling for sex, region, and Elixhauser Comorbidity Index (ECI) was used. We also report patient demographics, geographical variation, and utilization cost. Results  The rate of subsequent malunion surgery after nonoperative treatment was 0.58%. The cohort undergoing malunion surgery was younger and had a lower ECI. For every 1-year increase in age, there was a 6.4% decrease in odds of undergoing surgery for malunion, controlling for sex, region, and ECI (odds ratio = 0.94 [0.93-0.95]; p  < 0.01). The southern United States had the highest percentage of patients initially managed operatively (30.7%), the Northeast had the lowest (22.0%). Patients who required a malunion procedure incurred higher costs compared with patients who did not ($7,272 ± 8,090 vs. $2,209 ± 5,940; p  < 0.01). Conclusion  The rate of surgery for symptomatic malunion after initial nonoperative treatment for distal radius fractures in patients aged 55 and above is low. As younger and healthier patients are more likely to undergo malunion correction with higher associated costs, surgeons may consider offering this cohort surgical treatment initially.

Risk Factors and Outcomes in Carpal Tunnel Syndrome Following Distal Radius Open Reduction Internal Fixation

PURPOSE

Carpal tunnel syndrome (CTS) is a common complication following the operative repair of distal radius fractures. It is unclear who is at risk of developing this complication in the postoperative period. This study sought to identify risk factors for developing CTS and to evaluate patient-reported outcomes in patients who develop postoperative CTS.

METHODS

A retrospective review of all distal radius fractures treated surgically at a single private academic center was performed from January 2007 to October 2019. Of the 4,487 patients, 68 were identified to have an ipsilateral carpal tunnel release within 6 months of the distal radius injury. Collected data comprised patient demographics, medical history, and functional outcome scores.

RESULTS

Carpal tunnel syndrome was more likely to develop in older patients (62.9 years vs 57.4 years). Sex, body mass index, smoking history, and the type of insurance were not found to be significantly different between the groups. Medical history of kidney disease, psychiatric conditions, and peripheral vascular disease were found to be associated with developing CTS. Patients who developed CTS had higher average Disabilities of the Arm, Shoulder, and Hand scores than patients without CTS (28.1 vs 20.0) at the final follow-up. In a multivariable analysis, patients who developed CTS were found to be older (Odds ratio, 1.03) and less likely to be smokers (Odds ratio, 0.46).

CONCLUSIONS

In our cohort, we observed that older patients were more likely to require carpal tunnel release following distal radius fracture. In addition, nonsmokers were more likely to require subsequent carpal tunnel release, probably as a result of confounding effects. Special care should be taken to monitor these patients for CTS in the postoperative period following a distal radius open reduction and internal fixation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

The hidden impact of neuropathic pain after surgical fixation of wrist, hip, and ankle fractures: A cross-sectional retrospective study evaluating its prevalence and risk factors

BACKGROUND

Dysesthesia, electrical and burning sensations, in addition to allodynia are frequent symptoms of neuropathic pain. Despite the high frequency, scientific data on the development of neuropathic pain after surgery for fracture fixation are scarce. The goal of the present study was to determine the prevalence, risk factors, and evaluate potential associations among neuropathic pain, pain intensity, sociodemographic, and clinical variables after wrist, hip, and ankle fracture fixation.

METHODS

A cross-sectional retrospective study involving a cohort of 166 patients who underwent surgery for distal radius, proximal femur, malleolar fracture fixation was performed. Neuropathic pain was assessed one year after fracture fixation using the Doleur Neuropathique Questionnaire (DN4).

RESULTS

The incidence of neuropathic pain in our sample was 49 (29.5%). Predictors for the development of neuropathic pain included patients with a high body mass index (BMI), female gender, diabetes mellitus, long-term use of analgesics (especially using pain-modulating medication), patients who presented some fracture-related complication during the course of the treatment, who had limitations for daily activity, and who were away from work due to chronic pain.

CONCLUSION

In our study, neuropathic pain after wrist, hip, and ankle fracture fixation was prevalent and associated with higher BMI values and amount of medication, in addition to higher proportions of female sex, absence from work, DM, limitation for daily activities, postoperative complications, and use of pain modulating medications.

Current Management and Volar Locking Plate Fixation with Bone Cement Augmentation for Elderly Distal Radius Fractures-An Updated Narrative Review

Distal radius fractures (DRFs) are the most common among all kinds of fractures with an increase in incidence due to the rapidly expanded size of the elderly population in the past decades. Both non-surgical and surgical treatments can be applied for this common injury. Nowadays, more and more elderly patients with DRFs undergo surgical treatments to restore pre-injury activity levels faster. However, optimal treatment for geriatric DRFs is still debated, and careful evaluation and selection of patients are warranted considering clinical and functional outcomes, and complications following surgical treatments. Furthermore, osteoporosis is a predominant factor in elderly DRFs mostly deriving from a low-energy trauma, so many treatment modalities are developed to enhance better bone healing. Among various options for bone augmentation, bone cement is one of the most widely used measures. Bone cement such as calcium phosphate theoretically improves fracture stability and healing, but whether the elderly patients with DRFs can significantly benefit from surgical fixation with bone cement augmentation (BCA) remains controversial. Hence, in the present review, the latest literature regarding current concepts of management and evidence about volar locking plate fixation (VLPF) with BCA for elderly DRFs was searched in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science; out of >1000 articles, full texts of 48 and 6 articles were then examined and analyzed separately for management and VLPF with BCA for elderly DRFs. We aim to provide the readers with updates concerning the above issues.

Controversies in the Management of Bicolumnar Fractures of the Distal Humerus

Bicolumnar fractures of the distal humerus pose numerous treatment challenges for upper-extremity surgeons. Although open reduction and internal fixation demonstrates advantages compared with nonsurgical treatment, restoration of osseous anatomy can be difficult, particularly for comminuted, intra-articular fractures. Despite well-recognized complications, total elbow arthroplasty remains an option for elderly patients with fractures not amenable to fixation. Although indications remain controversial, distal humerus hemiarthroplasty has emerged as a potential alternative to total elbow arthroplasty in carefully selected patients with nonreconstructable fractures. Numerous controversies remain with respect to the management decisions for these complex injuries, including the optimal surgical approach, management of the ulnar nerve, and ideal fixation constructs for open reduction internal fixation. Our purpose is to review the management of bicolumnar distal humerus fractures in adult patients and discuss current controversies related to treatment.

Volar locking plate fixation for distal radius fractures: did variable-angle plates make difference?

Purpose

Two different locking plate designs are now being used for volar plating of the distal radius fractures based on the freedom of screw direction; the fixed-angle, and the variable-angle (polyaxial) plates. We investigated the clinical and radiographic outcomes of both designs.

Methods

We reviewed 96 patients with 113 unstable distal radius fractures that were operated on with volar locking plates. The patients’ mean age was 41 years. Fixed-angle volar locking plates were utilized in 65 fractures and variable-angle volar locking plates in 48 fractures through modified Henry approach or extended carpal tunnel approach. Full clinical and radiographic evaluation was done for all patients with a mean follow-up of 14 months.

Results

All patients had acceptable clinical and radiographic parameters. The overall functional results (Mayo score, Quick Disability of Arm, Shoulder, and Hand (Q-DASH) score, Range of motion (ROM), and grip strength) were in favor of the variable-angle plate. The radiographic parameters were better with the variable-angle group. The variable-angle group recorded less operative time but more mean image intensifier exposure time. There were two cases of flexor tendon rupture with the fixed-angle group. Fixation with the fixed-angle system needed K-wire augmentation more than the variable-angle group. There was a positive correlation between hand dominance and the final score.

Conclusion

Distal radius volar locking plates yield satisfactory results comparable among different designs. In our series, the variable-angle system showed slightly better function and radiographic outcomes. Supplementary K-wires were needed more frequently with the fixed-angle system.

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

PURPOSE

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

METHODS

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

RESULTS

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

CLINICAL RELEVANCE

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

Trends in the Incidence and Treatment of Distal Radius Fractures in the United States in Privately Insured and Medicare Advantage Enrollees

Background: This study aims to determine the trends in the treatment of distal radius fractures (DRFs) in patients aged 18 years and older. Methods: An administrative claims database of more than 100 million patients was used to identify patients aged 18 years and older with a DRF between 2005 and 2014. A total of 137 130 DRFs were identified in 135 128 patients. Results: The proportion and rate of fractures were more predominant in those aged 55 years and older compared with a decreasing incidence in patients younger than 55 years. Age-adjusted rates of surgical treatment have significantly increased in both women and men by 15.9% (absolute change, 4.8%) and 5.0% (absolute change, 1.7%) change over time, respectively. Conversely, age-adjusted rates of nonsurgical treatment have significantly decreased overtime in both women and men by 6.9% and 2.6%, respectively. Conclusions: These data provide better understanding of the epidemiology of DRF, which is important to develop preventive strategies targeting high-risk populations and to develop effective treatment strategies.

Epidemiology and Factors Affecting Functional Outcome of Distal Radial Fracture in an Urban Tertiary Medical Centre in Malaysia

Introduction

Distal radial fracture is a commonly encountered fracture. This study aims to study the epidemiology of distal radial fracture and factors affecting the patients' functional outcome one to two years after the injury.

Materials and methods

This is a retrospective cohort study. The records of patients, fulfilling the radiographical diagnosis of distal radial fracture, and aged 18 and above, who presented to our Emergency Department from 1st January 2018 to 31st December 2018 were retrieved. According to AO classification, we grouped our patients into A (extra-articular), B (partial articular) and C (complete articular). Patients with congenital abnormalities were excluded. Epidemiological data and relevant medical history were obtained and tabulated. A Malaysian language translation of Disability of the Arm, Shoulder and Hand (DASH) questionnaire was used to assess the functional outcome.

Results

Out of 168 patients' data retrieved, only 110 patients' data were found complete for purposes of this study. The mean DASH score was 13.7 ± 7.87 approximately one to two years post-injury regardless of treatment method. Increasing age was associated with higher DASH score with r=0.407(p<0.001). Several variables had significantly better functional outcome: male gender (p=0.01), Type A fracture configuration (p=0.007) and non-operational treatment (p=0.03). There was no significant difference between treatment modalities in Type A fracture (p=0.094), but Type B (p=0.043) and Type C (p=0.007) had better outcome without surgery. There was no significant difference between different ethnic groups, open or closed fracture and mechanism of injury.

Conclusion

Better functional outcome after sustaining distal radial fracture was associated with young age, male gender, type A fracture and treated non-operatively. Interestingly, more complex fracture pattern had better functionality were observed without surgery.

Adult Distal Radius Fracture Management

Distal radius fractures (DRFs) are some of the most commonly encountered fractures, and the incidence is increasing. Optimal treatment remains controversial. Critical evaluation of the initial imaging is necessary to recognize fracture characteristics and stability. The fracture pattern, injury mechanism, soft-tissue injury, patient characteristics, and surgeon preference are generally taken into consideration when choosing the most appropriate modality. Volar plating has become the workhorse of surgical DRF management but is not without complications. The surgeon should be comfortable using a wide variety of techniques to customize the fixation to the fracture pattern. Recognition of potential dangers and use of intraoperative imaging techniques can mitigate complications. Goals of rehabilitation after the initial treatment of DRF include regaining motion, strength, and ultimately function while managing pain.

Successful Closed Reduction of Distal Radius Volar Locking Plate Plastic Deformation with Associated Fracture: A Case Report

CASE

Distal radius fractures are among the most common orthopaedic injuries. The volar locking plate is now the most utilized internal fixation method for these fractures. There are few reports of mechanical failure of volar locking plates within the literature. In this case report, we describe successful closed reduction of traumatic volar locking plate plastic deformation with associated fracture. In addition, we discuss existing literature regarding plastic deformation of distal radius plates.

CONCLUSION

Traumatic, plastic deformation of distal radius volar locking plates with associated fracture may be managed nonoperatively with closed reduction.

Outcomes and complications of operative versus non-operative management of distal radius fractures in adults under 65 years of age

To compare the outcomes of non-operative versus operative treatment for distal radius fractures in patients aged from 18 to 64 years, we performed a retrospective analysis using the OptumLabs® Data Warehouse using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes of distal radius fracture. Of the 34,184 distal radius fractures analysed, 11,731 (34%) underwent operative management. Short-term complications within 90 days of fracture identified an overall complication rate of 16.6 per 1000 fractures and the 1-year upper extremity-specific complication rate was 287 per 1000 fractures. Overall, post-injury stiffness was the most common 1-year upper extremity-specific complication and was associated with operative management (202.8 vs. 123.4 per 1000 fractures, operative vs. non-operative, p < 0.01). Secondary procedures were significantly more common following non-operative management (8.7% vs. 43%, operative vs. non-operative, p < 0.01) with carpal tunnel release representing the most common secondary procedure. Operative management of distal radius fractures resulted in significantly fewer secondary procedures at the expense of increased overall 1-year complication rates, specifically stiffness.Level of evidence: III.

Management of Comminuted Distal Radius Fractures: A Critical Analysis Review

Distal radius fractures occur in a bimodal age and sex distribution. Their incidence continues to rise with an increasingly active aging population. The current American Academy of Orthopaedic Surgeons guidelines for operative intervention are radial shortening of >3 mm, dorsal tilt of >10[degrees], or intra-articular displacement or step-off of >2 mm. The method of reduction and fixation should be selected on a case-by-case basis with a focus on patient factors, fracture behavior, surgical proficiency, and functional outcomes.

Diagnosis of dorsal screw penetration after volar plating of a distal radial fracture

Aims

The aim of this study was to investigate whether intraoperative 3D fluoroscopic imaging outperforms dorsal tangential views in the detection of dorsal cortex screw penetration after volar plating of an intra-articular distal radial fracture, as identified on postoperative CT imaging.

Methods

A total of 165 prospectively enrolled patients who underwent volar plating for an intra-articular distal radial fracture were retrospectively evaluated to study three intraoperative imaging protocols: 1) standard 2D fluoroscopic imaging with anteroposterior (AP) and elevated lateral images (n = 55); 2) 2D fluoroscopic imaging with AP, lateral, and dorsal tangential views images (n = 50); and 3) 3D fluoroscopy (n = 60). Multiplanar reconstructions of postoperative CT scans served as the reference standard.

Results

In order to detect dorsal screw penetration, the sensitivity of dorsal tangential views was 39% with a negative predictive value (NPV) of 91% and an accuracy of 91%; compared with a sensitivity of 25% for 3D fluoroscopy with a NPV of 93% and an accuracy of 93%. On the postoperative CT scans, we found penetrating screws in: 1) 40% of patients in the 2D fluoroscopy group; 2) in 32% of those in the 2D fluoroscopy group with AP, lateral, and dorsal tangential views; and 3) in 25% of patients in the 3D fluoroscopy group. In all three groups, the second compartment was prone to penetration, while the postoperative incidence decreased when more advanced imaging was used. There were no penetrating screws in the third compartment (extensor pollicis longus groove) in the 3D fluoroscopy groups, and one in the dorsal tangential views group.

Conclusion

Advanced intraoperative imaging helps to identify screws which have penetrated the dorsal compartments of the wrist. However, based on diagnostic performance characteristics, one cannot conclude that 3D fluoroscopy outperforms dorsal tangential views when used for this purpose. Dorsal tangential views are sufficiently accurate to detect dorsal screw penetration, and arguably more efficacious than 3D fluoroscopy. Cite this article: Bone Joint J 2020;102-B(7):874–880.