Prediction of instability in distal radial fractures

Incidence and predictors of dorsal comminution in older adults with low-energy distal radius fracture

PURPOSE

To identify the incidence of dorsal comminution using computed tomography (CT) images and identify predictors of this phenomenon in older adults with low-energy distal radius fractures (DRFs).

METHODS

A total of 150 patients aged > 50 years with fall-induced dorsally angulated DRFs were enrolled in this study. Patients were divided into two groups based on the presence of dorsal comminution, defined as a metaphyseal void of greater than one-third of the maximum posterior to anterior depth of the bone on at least three cuts in the sagittal plane on post-reduction CT images. Data on participants' basic demographics, including age, sex, body mass index (BMI), and AO classification of DRFs, were collected. Bone mineral density (BMD) was assessed using T-scores of the femoral neck, and cortical thickness of the distal radius was determined from plain post-reduction radiographs. Radiological parameters and combined ulnar fractures were measured on plain pre-reduction radiographs.

RESULTS

Among study participants, 91 (61%) had dorsal comminution, whereas 59 (39%) had no dorsal comminution on CT images. Both patient groups were compared based on presence of dorsal comminution, and showed no significant differences in age, sex, BMI, BMD, or cortical thickness on radiographs. However, all radiological parameters were better in the no dorsal comminution group than in the dorsal comminution group, and the proportion of patients with combined ulnar fractures was higher in the dorsal comminution group. In the multivariate analysis, the presence of combined ulnar fractures was the only significant predictor of dorsal comminution (p = 0.029, odds ratio = 2.267, 95% confidence interval: 1.085-4.736).

CONCLUSION

The incidence of dorsal comminution is relatively high in patients with low-energy DRFs aged > 50 years. In particular, the presence of combined ulnar fractures is closely associated with dorsal comminution of DRFs. Thus, surgeons should exercise caution when evaluating this phenomenon.

A prospective randomized control trial comparing outcomes of casting, pinning, and plating for distal end of radius fractures (AO type A2, A3, C1, or C2) in the elderly population

PURPOSE

With this prospective randomized control trial (RCT), we aim to provide the outcome analyses of the three most used treatment modalities for distal end of radius (DER) fracture management in the elderly.

METHODS

A prospective randomized control trial was performed. Fifty-two patients with DER fractures (AO A2, A3, C1, or C2) were randomized to the casting (n = 17), percutaneous pinning (n = 18), and the volar plating group (n = 17). Radiological measurements measured were radial inclination (RI), radial height (RH), volar tilt (VT), and ulnar variance (UV). The outcome was measured based on range-of-motion, grip strength, Patient-Related-Wrist-Evaluation (PRWE) score, and the Quick-Disabilities-of-the-Arm-Shoulder-Hand (QDASH) score.

RESULTS

Immediate post-operative and 1-year-follow-up X-rays showed a significant difference measurement between the groups (p < 0.05). Pairwise comparisons of the casting and pinning groups (p < 0.05) and the casting and plating groups (p < 0.05) revealed significant differences at the 1-year follow-up, but not the pinning and plating groups (p > 0.05). The analysis found significant differences in clinical outcomes after 1 month of follow-up, with the plating group outperforming the other two (p > 0.05). However, after a year of follow-up, all groups had comparable outcomes; however, the plating group showed improved palmar flexion (p < 0.001), radial deviation (p < 0.001), and a lower PRWE score (p < 0.05), indicating better wrist function. Complications were more in casting group.

CONCLUSION

The study found a radiologically significant difference between groups throughout the follow-up, but it did not affect functional results. Clinical outcomes were similar across the groups, with plating showing better palmar flexion and radial deviation. Grip strength was also better in the plating group, but statistically insignificant. The study suggests plating should be chosen over other treatments for high-demand patients.

Understanding Variations in the Management of Displaced Distal Radius Fractures With Satisfactory Reduction

BACKGROUND

The American Academy of Orthopaedic Surgeons has set forth Clinical Practice Guidelines (CPGs) to help guide management of closed, displaced distal radius fractures (DRFs). There still exists variation in practice regarding operative vs nonoperative decision-making. This study aims to identify which factors influence the decision to treat DRFs not indicated for surgery by the CPGs after initial closed reduction.

METHODS

Fifteen sets of DRFs and clinical vignettes were distributed via email to over 75 orthopedic residency programs, Orthopaedic Trauma Association, and New York Society for Surgery of the Hand membership. A Qualtrics survey collected respondent demographics, choice of treatment, and rationale.

RESULTS

Responses were received from 106 surgeons and resident trainees. The odds of selecting operative management for fractures with 5 or more radiographic instability signs versus 3 or 4 was 3.11 (P < .05). Age over 65, higher patient activity level, and dominant-hand injury were associated with greater odds of operative management (3.4, 30.28, and 2.54, respectively). In addition, surgeons with more years in practice and high-volume surgeons had greater odds of selecting operative management (2.43 and 2.11, respectively).

CONCLUSIONS

Assessment of instability at the time of injury, patient age and activity level, as well as surgeon volume and time in practice independently affect the decision to manage well-reduced DRF with surgical or nonsurgical treatment. The source of heterogeneity in the treatment of these fractures is borne at least in part from a lack of formal direction on the importance of prereduction instability from the CPGs.

Four weeks versus six weeks of immobilization in a cast following closed reduction for displaced distal radial fractures in adult patients: a multicentre randomized controlled trial

Aims

There is no level I evidence dealing with the optimal period of immobilization for patients with a displaced distal radial fracture following closed reduction. A shorter period might lead to a better functional outcome due to less stiffness and pain. The aim of this study was to investigate whether this period could be safely reduced from six to four weeks.

Methods

This multicentre randomized controlled trial (RCT) included adult patients with a displaced distal radial fracture, who were randomized to be treated with immobilization in a cast for four or six weeks following closed reduction. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE) score after follow-up at one year. Secondary outcomes were the abbreviated version of the Disability of Arm, Shoulder and Hand (QuickDASH) score after one year, the functional outcome at six weeks, 12 weeks, and six months, range of motion (ROM), the level of pain after removal of the cast, and complications.

Results

A total of 100 patients (15 male, 85 female) were randomized, with 49 being treated with four weeks of immobilization in a cast. A total of 93 completed follow-up. The mean PRWE score after one year was 6.9 (SD 8.3) in the four-week group compared with 11.6 (SD 14.3) in the six-week group. However, this difference of -4.7 (95% confidence interval -9.29 to 0.14) was not clinically relevant as the minimal clinically important difference of 11.5 was not reached. There was no significant difference in the ROM, radiological outcome, level of pain, or complications.

Conclusion

In adult patients with a displaced and adequately reduced distal radial fracture, immobilization in a cast for four weeks is safe, and the results are similar to those after a period of immobilization of six weeks.

Is Capitate Shift Reliable as a Single Indicator for Failure of Non-operative Management in Distal Radius Fractures?

Background Distal radius fractures (DRFs) are the most commonly treated fracture; however, their treatment remains controversial. There is significant variation in the rate of surgical intervention related to a lack of consensus regarding the displacement threshold for surgery. Although studies have advocated that carpal malalignment is the most important radiographic parameter for surgical correction, it is rarely considered in general clinical practice and remains poorly studied. Recently, capitate shift was identified as the most useful measure of carpal malalignment, and a capitate shift threshold of -5.98 mm was proposed to indicate surgical intervention. This study aimed to investigate if this threshold is associated with the failure of non-operatively managed DRFs and should be used as a threshold for primary surgical intervention. Methodology A retrospective analysis was performed of all adult patients who underwent closed manipulation and cast immobilisation for DRFs in a UK district general hospital between September 2021 and February 2022. Capitate shift was measured on initial post-casting radiographs using the validated capitate-to-axis-of-radius distance (CARD) by a junior surgeon. The outcome measure was the failure of conservative management, which was defined as the need for repeat intervention (i.e., cast reapplication or surgical fixation) following closed reduction and cast immobilisation. Results A total of 64 patients with 65 DRFs (16 (25%) male, 49 (75%) female) were included in the study. The mean age was 66.6 years (SD = 17.9, 95% CI = 62.2 to 70.9). The mean capitate shift was -1.51 mm (SD = 5.05, 95% CI = -0.28 to -2.73) in all cases (n = 65). The failure rate of DRFs with an 'unacceptable' capitate shift (i.e., equal or less than -5.98 mm) compared to those with an 'acceptable' capitate shift (i.e., greater than -5.98 mm) was 16.7% versus 3.8% (p = 0.09). Conclusions The study concluded that there was no significant association between a capitate shift threshold of -5.98 mm and failure of non-operatively managed DRFs. Given the ease of use and reliability of capitate shift, we advocate for multicentre large cohort studies to identify a threshold for surgical intervention and establish its association with functional outcomes.

If at first you don't succeed, should you try again? The efficacy of repeated closed reductions of distal radius fractures

INTRODUCTION

A repeated closed reduction ("re-reduction") of a displaced distal radius fracture is a common procedure performed to obtain satisfactory alignment and avoid surgery when the initial reduction is deemed unsatisfactory. However, the efficacy of re-reduction is unclear. Compared to a single closed reduction, does a re-reduction of a displaced distal radius fracture: (1) improve radiographic alignment at the time of fracture union and, (2) decrease the rate of operative intervention?

MATERIALS AND METHODS

Retrospective cohort analysis of 99 adults aged 20-99 years with extra-articular or minimally displaced intra-articular, dorsally angulated, displaced distal radius fracture with or without an associated ulnar styloid fracture who underwent a re-reduction, compared against 99 adults matched for age and sex who were managed with a single reduction. Exclusion criteria were skeletal immaturity, fracture-dislocation and articular displacement greater than 2 mm. Outcome measures included radiographic alignment at fracture union and rate of surgical intervention.

RESULTS

At 6-8 weeks follow-up, the single reduction group had greater radial height (p = 0.045, CI 0.04 to 3.57), and less ulnar variance (p < 0.001, CI - 3.08 to - 1.00) compared to the re-reduction group. Immediately following re-reduction, 49.5% of patients met radiographic non-operative criteria, but by 6-8 weeks follow-up, only 17.5% of patients continued to meet these criteria. Patients in the re-reduction group were treated with surgery 34.3% of the time, compared to 14.1% of the time for patients in the single reduction group (p = 0.001). In patients aged under 65 years, 49.0% of those who underwent a re-reduction were managed with surgery, compared to 21.0% of those who had a single reduction (p = 0.004).

CONCLUSION

A re-reduction performed to improve radiographic alignment and avoid surgical management in this subset of distal radius fractures had minimal value. Alternative treatment options should be considered before attempting a re-reduction.

Rising incidence of stair-related upper extremity fractures among older adults in the United States: a 10-year nationwide analysis

Upper extremity (UE) fractures are prevalent age-related fractures, and stair-associated falls are a common mechanism for these injuries. Our study has identified an increasing incidence of stair-related UE fractures and associated hospitalization rates among the older United States population between 2012-2021. Targeted prevention efforts should be implemented by health systems.

INTRODUCTION

To analyze United States (US) emergency department trends in upper extremity stair-related fractures among older adults and investigate risk factors associated with hospitalization.

METHODS

We queried the National Electronic Injury Surveillance System (NEISS) for all stair-related fracture injuries between 2012 and 2021 among adults 65 years or older. The US Census Bureau International Database (IDB) was analyzed to calculate incidence rates. Descriptive analysis, linear regression analysis, and multivariate regression analysis were used to interpret the collected data.

RESULTS

Our analysis estimated 251,041 (95% CI: 211,678-290,404) upper extremity stair-related fractures among older adults occurred between 2012 and 2021. The primary anatomical locations were the humeral shaft (27%), wrist (26%), and proximal humerus (18%). We found a 56% increase in injuries (R² = 0.77, p < 0.001), 7% increase in incidence per 100,000 persons (R² = 0.42, p < 0.05), and an 38% increase in hospitalization rate (R² = 0.61, p < 0.01) during the 10-year study period. Women sustained the majority of fractures (76%) and most injuries occurred in homes (89%). Advanced age (p < 0.0001), males (p < 0.0001), proximal humerus fractures (p < 0.0001), humeral shaft fractures (p < 0.0001), and elbow fractures (p < 0.0001) were associated with increased odds of hospitalization after injury.

CONCLUSION

Stair-related UE fracture injuries, incidence, and hospitalization rates among older adults are increasing significantly, particularly among older females. Improving bone health, optimizing functional muscle mass, and "fall-proofing" homes of older age groups may help mitigate the rising incidence of these injuries.

Predictors of Management of Distal Radius Fractures in Patients Aged >65 Years

BACKGROUND

Treatment of distal radius fractures (DRFs) in patients aged >65 years is controversial. The purpose of this study was to identify what patient and fracture characteristics may influence the decision to pursue surgical versus nonsurgical treatment in patients aged >65 years sustaining a DRF.

METHODS

We queried our institutional DRF database for patients aged >65 years who presented to a single academic, tertiary center hand clinic over a 5-year period. In all, 164 patients treated operatively were identified, and 162 patients treated nonoperatively during the same time period were selected for comparison (total N = 326). Demographic variables and fracture-specific variables were recorded. Patient and fracture characteristics between the groups were compared to determine which variables were associated with each treatment modality (operative or nonoperative).

RESULTS

The average age in our cohort was 72 (SD: 11) years, and 274 patients (67%) were women. The average Charlson Comorbidity Index (CCI) was 4.1 (SD: 2.1). The CCI is a validated tool that predicts 1-year mortality based on patient age and a list of 22 weighted comorbidities. Factors associated with operative treatment in our population were largely related to the severity of the injury and included increasing dorsal tilt (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.05-1.12; P < .001) and AO Classification type C fractures (OR, 5.42; 95% CI, 2.35-11.61; P < .001). Increasing CCI was the only factor independently associated with nonoperative management (OR, 0.84; 95% CI, 0.72-0.997; P = .046).

CONCLUSION

Fracture severity is a strong driver in the decision to pursue operative management in patients aged >65 years, whereas increasing CCI predicts nonoperative treatment.

Forearm bone mineral density as a predictor of reduction loss in distal radius fractures treated with cast immobilization

Objective

Many potential predictors have been identified and proposed for predicting late reduction loss in distal radius fractures. However, no report exists on whether the bone mineral density (BMD) of the forearm correlates with the loss of reduction in distal radius fractures. This study aimed to investigate whether forearm BMD can be used as a predictor of reduction loss in distal radius fractures treated with cast immobilization.

Methods

Ninety patients with distal radius fractures were divided into two groups according to the maintenance or loss of reduction evaluated from radiographs taken at least 6 weeks after their injury. Lumbar and forearm BMD (total and metaphysis) T-scores were measured and compared between the maintenance of reduction (MOR) group and the loss of reduction (LOR) group. Additionally, serologic markers (C-terminal telopeptide, osteocalcin, vitamin D) and radiologic risk factors (intra-articular fracture, ulnar fracture, dorsal comminuted fracture, volar hook) were evaluated and a logistic multiple regression analysis was performed to know the main risk factors of reduction loss.

Results

Reduction loss was observed in 38 patients (42.2%). The total and metaphyseal BMD of the forearm was less in the LOR group than in the MOR group. However, the difference was not statistically significant [−2.9 vs. −2.5 for total (p = 0.18), −2.3 vs. −2.0 for metaphysis (p = 0.17)]. Multiple logistic regression analysis showed initial dorsal comminution (p = 0.008) and ulnar variance (p = 0.01) were the main risk factors for reduction loss.

Conclusions

Forearm BMD was not a valuable prognostic factor for reduction loss in distal radius fractures. Initial dorsal comminution and ulnar variance rather than forearm BMD should be considered preferentially when predicting which patients are at high risk of reduction loss in distal radius fractures.

LIMPER trials: immediate mobilisation versus 2-week cast immobilisation after distal radius fracture treated with volar locking plate - a study protocol for a prospective, randomised, controlled trial

INTRODUCTION

Open reduction and internal fixation with volar locking plate has become the most common fixation method in the treatment of unstable distal radius fracture (DRF). There is, however, no consensus as to whether or for how long a wrist should be immobilised after operative treatment. To date, there have been relatively few studies that have evaluated the effect of immediate postoperative mobilisation on functional outcomes. The aim of postoperative rehabilitation is to obtain a good function and to reduce impairment, recovery time, socioeconomical costs and absence from work. Therefore, there is a need for studies that evaluate the optimal method of postoperative rehabilitation to optimise wrist function and return to work.

METHODS AND ANALYSIS

This study is a prospective, randomised, controlled trial in which a total of 240 working-age patients who undergo volar plating for DRF will be randomly assigned to either an early mobilisation group or a postoperative 2-week casting group. The aim of the study will be to compare early postoperative outcomes between the study groups. The primary outcome will be patient-rated wrist evaluation at 2 months after operation. A coprimary outcome will be the total length of sick leave. Our follow-up period will be 1 year, and secondary outcomes will include pain, patient satisfaction, perceived ability to work and complications identified at different time points. We expect those patients who undergo immediate mobilisation will have at least as rapid a return to work and function as those patients who undergo postoperative immobilisation, indicating/meaning that there will be no need for postoperative casting.

ETHICS AND DISSEMINATION

This study will be conducted according to the Standard Protocol Items: Recommendations for Interventional Trials statement. The Ethics committee of Tampere University Hospital has approved the protocol. Ethics committee approval number is R21111, and it is accepted on 7 September 2021. The results of this study will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05150925.

Short arm cast is as effective as long arm cast in maintaining distal radius fracture reduction: Results of the SLA-VER noninferiority trial

BACKGROUND

Distal radius fractures (DRFs) are a common challenge in orthopaedic trauma care, yet for those fractures that are treated nonoperatively, strong evidence to guide cast treatment is still lacking.

AIM

To compare the efficacy of below elbow cast (BEC) and above elbow cast (AEC) in maintaining reduction of manipulated DRFs.

METHODS

We conducted a prospective, monocentric, randomized, parallel-group, open label, blinded, noninferiority trial comparing the efficacy of BEC and AEC in the nonoperative treatment of DRFs. Two hundred and eighty patients > 18 years of age diagnosed with DRFs were successfully randomized and included for analysis over a 3-year period. Noninferiority thresholds were defined as a 2 mm difference for radial length (RL), a 3° difference for radial inclination (RI), and volar tilt (VT). The trial is registered at Clinicaltrials.gov (NCT03468023).

RESULTS

One hundred and forty-three patients were treated with BEC, and 137 were treated with AEC. The mean time of immobilization was 33 d. The mean loss of RL, RI, and VT was 1.59 mm, 2.83°, and 4.11° for BEC and 1.63 mm, 2.54°, and 3.52° for AEC, respectively. The end treatment differences between BEC and AEC in RL, RI, and VT loss were respectively 0.04 mm (95%CI: -0.36-0.44), -0.29° (95%CI: -1.03-0.45), and 0.59° (95%CI: -1.39-2.57), and they were all below the prefixed noninferiority thresholds. The rate of loss of reduction was similar.

CONCLUSION

BEC performs as well as AEC in maintaining the reduction of a manipulated DRF. Being more comfortable to patients, BEC may be preferable for nonoperative treatment of DRFs.

Forecasting effects of "fast-tracks" for surgery in the Swedish national guidelines for distal radius fractures

BACKGROUND AND PURPOSE

National guidelines for treatment of distal radius fractures (DRFs) were presented in Sweden in 2021. In the guidelines, a fast-track is recommended for 4 subgroups of highly unstable DRFs. Regardless of the results of the closed reduction these are recommended for surgery within 1 week of injury. This study aims to evaluate the potential consequences of the newly presented national guidelines on incidence of surgical interventions.

PATIENTS AND METHODS

In all, 1,609 patients (1,635 DRFs) with primary radiographs after a DRF between 2014 and 2017 at two Swedish hospitals were included in a retrospective cohort study. An estimation was made of the percentage of patients in the historical pre-guidelines cohort, that would have been recommended early primary surgery according to the new national guidelines compared to treatment implemented without the support of these guidelines.

RESULTS

On a strict radiological basis, 32% (516 out of 1635) of DRFs were classified into one of the 4 defined subgroups. At 9-13 days follow-up, cast treatment was converted into delayed primary surgery in 201 cases. Out of these, 56% (112 out of 201) fulfilled the fast-track criteria and would with the new guidelines have been subject to early primary surgery.

INTERPRETATION

The fast-track regimen in the new guidelines, has a high likelihood of identifying the unstable fractures benefitting from early primary surgery. If the proposed Swedish national guidelines for DRF treatment are implemented, a greater proportion of fractures would be treated with early primary surgery, and a delayed surgery avoided in the majority of cases. The potential benefits in relation to possible costs when using the fast-track criteria in every day practice are still unknown.

Does circumferential casting prevent fracture redisplacement in reduced distal radius fractures? A retrospective multicentre study

Background

This study evaluates whether a circumferential cast compared to a plaster splint leads to less fracture redisplacement in reduced extra-articular distal radius fractures (DRFs).

Methods

This retrospective multicentre study was performed in four hospitals (two teaching hospitals and two academic hospitals). Adult patients with a displaced extra-articular DRF, treated with closed reduction, were included. Patients were included from a 5-year period (January 2012–January 2017). According to the hospital protocol, fractures were immobilized with a below elbow circumferential cast (CC) or a plaster splint (PS). The primary outcome concerned the difference in the occurrence of fracture redisplacement at one-week follow-up.

Results

A total of 500 patients were included in this study (PS n = 184, CC n = 316). At one-week follow-up, fracture redisplacement occurred in 52 patients (17%) treated with a CC compared to 53 patients (29%) treated with a PS. This difference was statistically significant (p = 0.001).

Conclusion

This study suggests that treatment of reduced DRFs with a circumferential cast might cause less fracture redisplacement at 1-week follow-up compared to treatment with a plaster splint.

Level of Evidence Level III, Retrospective study.

Volar Locking Plate Versus Dorsal Locking Nail-Plate Fixation for Dorsally Displaced Unstable Extra-Articular Distal Radial Fractures: Functional and Radiographic Results from a Randomized Controlled Trial

The use of low-profile dorsal and volar locking plates for distal radial fracture surgery has improved results and lowered the complication rate compared with older plate designs. The purpose of the present randomized controlled trial was to compare patient-reported outcomes as well as radiographic and functional results between patients who underwent stabilization with a volar locking plate or a dorsal locking nail-plate for the treatment of dorsally displaced unstable extra-articular distal radial fractures.

Influence of volar margin of the lunate fossa fragment fixation on distal radius fracture outcomes: A retrospective series

BACKGROUND

Distal radius fractures accompanied by the volar margin of the lunate fossa (VMLF) lesions are often overlooked or inadequately reduced in clinical practice.

AIM

To investigate the impact of VMLF fragment in distal radius fractures on the stability and function of the wrist joint.

METHODS

This was a retrospective study of patients with distal radius fractures who underwent surgical treatment between January 2013 and December 2017. The patients were divided into two groups according to whether the VMLF fragments were fixed or not. X-rays and computed tomography were performed before surgery, immediately postoperatively, and at 1, 3, and 6 mo to measure the scapholunate angle, radiolunate angle, capitolunate angle, and effective radiolunate flexion (ERLF). The Mayo wrist score and disabilities of the arm, shoulder, and hand (DASH) score were determined at 1 year.

RESULTS

Thirty-five patients were included. There were 15 males and 20 females. Their mean age was 52.5 ± 14.3 (range: 19-70) years. There were 38 wrists (17 on the left side, 15 on the right, and three bilateral; 16 in the fixed group, and 22 in the unfixed group). The interval between trauma and surgery was from 1 h to 1 mo. The incidence of postoperative wrist instability in the unfixed group (86.4%) was higher than in the fixed group (25.0%) (P ≤ 0.001). Ten patients had ERLF > 25° in the unfixed group and none in the fixed group (P = 0.019). The Mayo wrist score was 94 ± 5.7 in the fixed group and 68 ± 15.1 in the unfixed group (P < 0.001). The DASH score was 4.6 ± 2.5 in the fixed group and 28.5 ± 19.5 in the unfixed group (P < 0.001).

CONCLUSION

Injuries of VMLF, even small fractures, might damage the radial-lunar ligament, leading to postoperative wrist instability, sagittal force line imbalance, and poor recovery of wrist joint function.

Single volar locking plating for the intra- and extra-articular distal radius fractures with dorsal metaphyseal comminution

BACKGROUND

Volar locking plating remains a popular method for the surgical management of distal radius fractures. Dorsal metaphyseal comminution (DMC) is a common fracture pattern which weakens the stability during fracture fixation. In this study, we aimed to compare the radiographic and functional outcome of the intra- and extra-articular distal radius fractures with DMC following single volar locking plate fixation.

MATERIALS AND METHODS

Patients suffered from a distal radius fracture with DMC were reviewed in the clinical database of the authors' institution between Jan 2016 and Jan 2020. The included patients were classified into the extra-articular (A3) group or the intra-articular (C2 and C3) group according to the AO/OTA system. The radiological parameters, wrist range of motion, and functional outcomes were evaluated following open reduction and volar locking plate fixation.

RESULTS

A total of 130 patients were included in this study with a mean follow-up length of 17.2 months. Compared with the A3 fracture group, no significant fracture re-displacement or reduced wrist ROMs was observed in the C2 fractures after 12-month's follow-up. However, significantly decreased volar tilt (P = 0.003) as well as the extension/flexion ROMs were observed in the C3 fractures comparing to the A3 fractures. Most of the patients achieved an excellent (n = 75) or good (n = 51) Gartland and Werley wrist score. Four patients with C3 fractures resulted in a fair functional outcome due to a significant loss of volar tilt during follow-up.

CONCLUSIONS

The single volar locking plate fixation provided sufficient stability for distal radius fractures with DMC, and resulted in similar radiological and functional outcomes in the intra-articular distal radius fractures with a simple articular component (C2 fractures) as those in the extra-articular fractures. Considering the intra-articular fractures with multifragmentary articular component (C3 fracture), despite of the subsequent loss of volar tilt, the majority of the patients achieved good to excellent wrist function following single volar locking plating.

TRIAL REGISTRATION

This study has been registered on the ClinicalTrials.gov.

The CAST study protocol: a cluster randomized trial assessing the effect of circumferential casting versus plaster splinting on fracture redisplacement in reduced distal radius fractures in adults

BACKGROUND

There is no consensus concerning the optimal casting technique for displaced distal radius fractures (DRFs) following closed reduction. This study evaluates whether a splint or a circumferential cast is most optimal to prevent fracture redisplacement in adult patients with a reduced DRF. Additionally, the cost-effectiveness of both cast types will be calculated.

METHODS/DESIGN

This multicenter cluster randomized controlled trial will compare initial immobilization with a circumferential below-elbow cast versus a below-elbow plaster splint in reduced DRFs. Randomization will take place on hospital-level (cluster, n = 10) with a cross-over point halfway the inclusion of the needed number of patients per hospital. Inclusion criteria comprise adult patients (≥ 18 years) with a primary displaced DRF which is treated conservatively after closed reduction. Multiple trauma patients (Injury Severity Score ≥ 16), concomitant ulnar fractures (except styloid process fractures) and patients with concomitant injury on the ipsilateral arm or inability to complete study forms will be excluded. Primary study outcome is fracture redisplacement of the initial reduced DRF. Secondary outcomes are patient-reported outcomes assessed with the Disability Arm Shoulder Hand score (DASH) and Patient-Rated Wrist Evaluation score (PRWE), comfort of the cast, quality of life assessed with the EQ-5D-5L questionnaire, analgesics use, cost-effectiveness and (serious) adverse events occurence. In total, 560 patients will be included and followed for 1 year. The estimated time required for inclusion will be 18 months.

DISCUSSION

The CAST study will provide evidence whether the type of cast immobilization is of influence on fracture redisplacement in distal radius fractures. Extensive follow-up during one year concerning radiographic, functional and patient reported outcomes will give a broad view on DRF recovery.

TRIAL REGISTRATION

Registered in the Dutch Trial Registry on January 14th 2020. Registration number: NL8311 .

Reliability of recommendations to reduce a fracture of the distal radius

Background and purpose - It is unclear what degree of malalignment of a fracture of the distal radius benefits from reduction. This study addressed the following questions: (1) What is the interobserver reliability of surgeons concerning the recommendation for a reduction for dorsally displaced distal radius fractures? (2) Do expert-based criteria for reduction improve reliability or not?Methods - We sent out 2 surveys to a group of international hand and fracture surgeons. On the first survey, 80 surgeons viewed radiographs of 95 dorsally displaced (0° to 25°) fractures of the distal radius. The second survey randomized 68 participants to either receive or not receive expert-based criteria for when to reduce a fracture and then viewed 20 radiographs of fractures with dorsal angulation between 5° and 15°. All participants needed to indicate whether they would advise a reduction or not.Results - In the 1st study, the interrater reliability of advising a reduction was fair (kappa 0.31). Multivariable linear regression analyses indicated that each additional degree of dorsal angulation increased the chance of recommending a reduction by 3%. In the 2nd study, reading criteria for reduction did not increase interobserver reliability for recommending a reduction.Interpretation - There is notable variation in recommendations for reduction that is not accounted for by surgeon or patient factors and is not diminished by exposure to expert criteria. Surgeons should be aware of their biases and develop strategies to inform patients and share the decision regarding whether to reduce a fracture of the distal radius.

The Effect of Providing Audiovisual Surgical Information on Decisional Conflict in Patients Undergoing Plate Fixation for Distal Radius Fractures

Backgroud

Patients experiencing acute trauma have limited time for their involvement in shared decision making, which may lead to decisional conflict. The purpose of this study was to evaluate whether providing audiovisual surgical information can reduce decisional conflict when deciding between surgical and nonsurgical treatment in patients with distal radius fractures (DRFs) and to evaluate factors that may affect decisional conflict.

Methods

We prospectively enrolled 50 consecutive patients who presented with acute DRFs and chose to undergo surgery, for which volar plate fixation was recommended. We randomized these patients into 2 groups. The test group was given a video clip of audiovisual surgical information in addition to regular information while the control group was only given regular information. The video clip consisted of the purpose, procedure, and effect of the surgery, precautions and complications after the operation, and other treatment options that could be performed if operation was not performed. At 2 weeks after the surgery, we evaluated patients' decisional conflict using a decisional conflict scale (DCS). In addition, we evaluated factors that might affect decisional conflict, such as age, dominant hand, comorbidities, history of previous operations, perceived disability, and provision of the video clip.

Results

The test group showed significantly lower DCS scores than the control group (19.6 vs. 32.1, p = 0.001). In multivariate analysis, younger age and provision of the video clip were associated with lower DCS scores.

Conclusions

This study has demonstrated that providing information through audiovisual media such as video clips could reduce decisional conflict in patients who chose to undergo plate fixation for DRFs. This study also suggests that older patients may need more careful doctor-patient communication as they have more decisional conflict than younger patients.

Association of secondary displacement of distal radius fractures with cortical bone quality at the distal radius

INTRODUCTION

The aim of this study was to investigate the associations of patient characteristics, bone mineral density (BMD), bone microarchitecture and calculated bone strength with secondary displacement of a DRF based on radiographic alignment parameters.

MATERIALS AND METHODS

Dorsal angulation, radial inclination and ulnar variance were assessed on conventional radiographs of a cohort of 251 patients, 38 men and 213 women, to determine the anatomic position of the DRF at presentation (primary position) and during follow-up. Secondary fracture displacement was assessed in the non-operatively treated patients (N = 154) with an acceptable position, preceded (N = 97) or not preceded (N = 57) by primary reduction (baseline position). Additionally, bone microarchitecture and calculated bone strength at the contralateral distal radius and tibia were assessed by HR-pQCT in a subset of, respectively, 63 and 71 patients.

OUTCOME

Characteristics of patients with and without secondary fracture displacement did not differ. In the model with adjustment for primary reduction [OR 22.00 (2.27-212.86), p = 0.008], total [OR 0.16 (95% CI 0.04-0.68), p = 0.013] and cortical [OR 0.19 (95% CI 0.05-0.80], p = 0.024] volumetric BMD (vBMD) and cortical thickness [OR 0.13 (95% CI 0.02-0.74), p = 0.021] at the distal radius were associated with secondary DRF displacement. No associations were found for other patient characteristics, such as age gender, BMD or prevalent vertebral fractures.

CONCLUSIONS

In conclusion, our study indicates that besides primary reduction, cortical bone quality may be important for the risk of secondary displacement of DRFs.

Compilation and Analysis of Web-Based Orthopedic Personalized Predictive Tools: A Scoping Review

Web-based personalized predictive tools in orthopedic surgery are becoming more widely available. Despite rising numbers of these tools, many orthopedic surgeons may not know what tools are available, how these tools were developed, and how they can be utilized. The aim of this scoping review is to compile and synthesize the profile of existing web-based orthopedic tools. We conducted two separate PubMed searches-one a broad search and the second a more targeted one involving high impact journals-with the aim of comprehensively identifying all existing tools. These articles were then screened for functional tool URLs, methods regarding the tool's creation, and general inputs and outputs required for the tool to function. We identified 57 articles, which yielded 31 unique web-based tools. These tools involved various orthopedic conditions (e.g., fractures, osteoarthritis, musculoskeletal neoplasias); interventions (e.g., fracture fixation, total joint arthroplasty); outcomes (e.g., mortality, clinical outcomes). This scoping review highlights the availability and utility of a vast array of web-based personalized predictive tools for orthopedic surgeons. Increased awareness and access to these tools may allow for better decision support, surgical planning, post-operative expectation management, and improved shared decision-making.

Geometric semi-automatic analysis of radiographs of Colles' fractures

Fractures of the wrist are common in Emergency Departments, where some patients are treated with a procedure called Manipulation under Anaesthesia. In some cases, this procedure is unsuccessful and patients need to revisit the hospital where they undergo surgery to treat the fracture. This work describes a geometric semi-automatic image analysis algorithm to analyse and compare the x-rays of healthy controls and patients with dorsally displaced wrist fractures (Colles' fractures) who were treated with Manipulation under Anaesthesia. A series of 161 posterior-anterior radiographs from healthy controls and patients with Colles' fractures were acquired and analysed. The patients' group was further subdivided according to the outcome of the procedure (successful/unsuccessful) and pre- or post-intervention creating five groups in total (healthy, pre-successful, pre-unsuccessful, post-successful, post-unsuccessful). The semi-automatic analysis consisted of manual location of three landmarks (finger, lunate and radial styloid) and automatic processing to generate 32 geometric and texture measurements, which may be related to conditions such as osteoporosis and swelling of the wrist. Statistical differences were found between patients and controls, as well as between pre- and post-intervention, but not between the procedures. The most distinct measurements were those of texture. Although the study includes a relatively low number of cases and measurements, the statistical differences are encouraging.

A comparison of sugar-tong and volar-dorsal splints for provisional immobilization of distal radius fractures in the adult population

INTRODUCTION

Distal radius fractures are extremely common injuries affecting a wide range of patient demographics. The purpose of this study was to evaluate the outcomes of distal radius fractures managed initially with closed reduction and immobilization in either a below elbow volar-dorsal splint versus sugar-tong splint prior to conversion into a short arm cast.

METHODS

We performed a retrospective study of patients with distal radius fractures placed in a sugar-tong (n = 45) and volar-dorsal splint (n = 36). Anteroposterior and lateral radiographs were evaluated immediately after closed reduction and placement into either a sugar-tong or volar-dorsal splint. The radial inclination, radial length, volar tilt, and intra-articular displacement were measured.

RESULTS

The average age was not significantly different between groups (Diff: 1.1 years, P = 0.8766). Initial clinic follow-up radiographs illustrated significantly lower radial inclination in the sugar-tong group than volar-dorsal group (17.1 vs. 19, P = 0.0443). Follow-up mean radial length was not significantly lower in the sugar-tong than volar-dorsal group (8.4 vs. 9.2, P = 0.0858). Palmar tilt and articular step-off was not significantly different between splint types. The loss of reduction was 28.8% for the sugar-tong and 25.0% for the volar-dorsal group (P = 0.696).

CONCLUSION

Our results did not demonstrate a significant difference in loss of reduction rates between the two splint groups. There was no significant difference between the sugar-tong and volar-dorsal groups in terms of loss of radial length and volar tilt. Loss of reduction was similar between groups suggesting no advantage of a volar-dorsal splint compared to a sugar-tong splint.

LEVEL OF EVIDENCE

Therapeutic level III.

Reoperation Rate and Indication for Reoperation after Free Functional Muscle Transfers in Traumatic Brachial Plexus Injury

Background

Free functional gracilis muscle transfers (FFGT) are an option for reconstruction after traumatic brachial plexus injury. Few studies report the rate of revision surgeries following free functional muscle transfers. We examined the reoperation rate and indication for reoperation after primary reconstruction of upper extremity function with a free gracilis transfer after brachial plexus injury.

Methods

From 2003-2016, we identified 25 patients who underwent a free functional gracilis muscle transfer for restoration of upper extremity function. We reviewed their medical charts to record patient, injury, and treatment characteristics. Indication for reoperation and reoperative procedure were also identified.

Results

Fourteen out of 25 patients (56%) had a reoperation after FFGT. Four flaps were re-explored for vascular compromise, but there were no flap failures. The majority of reoperations involved adjustment of tendon excursion (8/14) which demonstrated that tenolysis was the main procedure.

Conclusion

Despite promising results of free functional gracilis transfers, reoperation is relatively common and should be discussed with the patient as a preoperative strategy. Early exploration of vascular compromise may decrease the flap failure. Poor tendon excursion is a common unpredicted consequence after FFMT and is the main indication for reoperation.

Distal radius fractures in the elderly population

We found no clear evidence of the clinical superiority of distal radius fracture surgery among older adults at one year.

Surgical treatment, however, may yield a faster recovery to previous level of activity in elderly patients.

With operative treatment, hardware-based problems may warrant secondary operations and implant removal, whereas in non-operative treatment, symptomatic loss of alignment and malunion can occur.

In elderly patients, non-operative treatment can be considered to be the gold standard.

Cite this article: EFORT Open Rev 2020;5:361-370. DOI: 10.1302/2058-5241.5.190060

The Impact of Coronavirus Disease 2019 (COVID-19) on the Practice of Hand Surgery in Singapore

The coronavirus disease 2019 (COVID-19) pandemic is rapidly evolving. Tan Tock Seng Hospital and the National Centre for Infectious Disease see the majority of confirmed and suspected cases in Singapore. This article describes the impact of COVID-19 on the practice of hand and reconstructive microsurgery (HRM) in our institution. It details our department's response as the situation escalated and the impact on the HRM elective and emergency workload, including the use of personal protective equipment on the surgical practice of HRM, as well as the effects of the condition on social and academic life.

Functional outcome after corrective osteotomy for malunion of the distal radius: a randomised, controlled, double-blind trial

Purpose

The purpose of this randomised, controlled, double-blind trial was to evaluate functional outcome during the first year after corrective osteotomy for malunited distal radius fractures, with or without filling the osteotomy void.

Method

Patients were randomised to receive a HydroSet bone substitute or no graft. Cortical contact was maintained and stabilisation of the osteotomy was carried out with a DiPhos R- or RM Plate. To evaluate subjective functional outcome, the Patient-Rated Wrist Evaluation (PRWE), the Quick Disabilities of the Arm, Shoulder and Hand Questionnaire (Q-DASH), the Canadian Occupational Performance Measure (COPM) and the RAND-36 were used. Moreover, range of motion and grip strength were measured by blinded evaluators. Evaluations were made pre-operatively and three, six and 12 months post-operatively.

Results

There were no significant differences between the groups at any time point post-operatively with respect to any of the PROMs that were used or range of motion or grip strength (p > 0.05). In both groups, there was a significant improvement at the 12-month follow-up compared with pre-operatively for the PRWE, the Q-DASH and the COPM satisfaction scores. The RAND-36 revealed no significant differences except for two domains, in which there was an improvement in the treatment group (p < 0.05). For grip strength and for range of motion in all movement directions, except dorsal extension, there was a significant improvement in both groups (p < 0.05).

Conclusion

There is no significant difference in functional outcome during the first year after corrective open-wedge distal radius osteotomy, where cortical contact is maintained, regardless of whether or not bone substitute to fill the void is used.

Analysis and Review of Automated Risk Calculators Used to Predict Postoperative Complications After Orthopedic Surgery

PURPOSE OF REVIEW

To discuss the automated risk calculators that have been developed and evaluated in orthopedic surgery.

RECENT FINDINGS

Identifying predictors of adverse outcomes following orthopedic surgery is vital in the decision-making process for surgeons and patients. Recently, automated risk calculators have been developed to quantify patient-specific preoperative risk associated with certain orthopedic procedures. Automated risk calculators may provide the orthopedic surgeon with a valuable tool for clinical decision-making, informed consent, and the shared decision-making process with the patient. Understanding how an automated risk calculator was developed is arguably as important as the performance of the calculator. Additionally, conveying and interpreting the results of these risk calculators with the patient and its influence on surgical decision-making are paramount. The most abundant research on automated risk calculators has been conducted in the spine, total hip and knee arthroplasty, and trauma literature. Currently, many risk calculators show promise, but much research is still needed to improve them. We recommend they be used only as adjuncts to clinical decision-making. Understanding how a calculator was developed, and accurate communication of results to the patient, is paramount.

Indications, surgical approach, reduction, and stabilization techniques of distal radius fractures

Distal Radius fractures (DRF) are one of the most common injuries in the upper extremity and incidence is expected to rise due to a growing elderly population. The complex decision to treat patients operatively or conservatively depends on a large variety of parameters which have to be considered. No unanimous consensus has been reached yet, which operative approach and fixation technique would produce the best postoperative functional results with lowest complication rates. This article addresses the available evidence for indications, approaches, reduction, and fixation techniques in treating DRF.

Deterioration of initially accepted radiological alignment of conservatively treated AO type-C distal radius fractures: mid-term outcome

BACKGROUND AND AIMS

It still remains controversial how often the once-accepted radiological alignment of an AO type-C distal radius fracture deteriorates after conservative treatment, and to what extent this deterioration is perhaps associated with patient-rated outcome measures (PROms). Thus, we aimed to evaluate this radiological deterioration and its association with mid-term functional follow-up.

PATIENTS AND METHODS

We retrospectively reviewed 66 patients (mean age at fracture 53 years, SD 14.1, range 18-73, female 65%) with 68 C-type distal radius fractures at a mean of 6.7 years (SD 0.5 years, range 5.8-7.7 years) after primary closed reduction and cast immobilization. Radiographs of the wrists were taken and analysed for any radial shortening, dorsal tilt or step-off at the joint surface. Range of motion and grip strength were measured. In addition to the radiological result, primary outcome measures included Quick Disabilities of the Arm, Shoulder and Hand (QDash) and Patient-Rated Wrist Evaluation (PRWE).

RESULTS

At mid-term follow-up, an acceptable anatomical radiological result was seen in only 22 wrists (32%). Deterioration of the once-achieved and accepted primary alignment was seen in a majority of cases (68%). Radial shortening of ≥ 2 mm was found in 34 wrists (51%, mean 4 mm, range 2-8 mm), with no association with QDash (12.8 vs. 5.5, p = 0.22) or PRWE (9.1 vs. 5.7, p = 0.40). Only four patients (6%) showed step-off at the joint surface (mean 1.1 mm, range 0.5-2 mm). Twenty-two wrists (32%) showed dorsal tilt of ≥ 10° (five with volar tilt of 15°-25°), with no effect on QDash or PRWE (14.7 vs. 6.5, p = 0.241 and 10.1 vs. 5.8, p = 0.226). Altogether, patients with dorsal tilt, step-off or shortening did not show significantly worse QDash (10.3 vs. 5.7, p = 0.213) or PRWE (8.1 vs. 5.1, p = 0.126) versus those with none. Twenty-nine (43%) of the patients had deficits in range of motion (ROM), either in extension (39%), flexion (43%), supination (16%) or pronation (4%), or combinations of these. Worse extension was associated with worse QDash (15.9 vs. 5.0, p = 0.037), flexion deficit with worse PRWE (11.5 vs. 4.4, p = 0.005) and supination deficit with both QDash (21.7 vs. 6.8, p = 0.025) and PRWE (18.9 vs. 5.2, p = 0.007).

CONCLUSIONS

The initially accepted radiological alignment of AO type-C radius fractures deteriorated in a majority of cases during conservative treatment. However, this deterioration was fairly mild and showed no significant association with functional outcome. Restricted ROM showed some association with PROms.

LEVEL OF EVIDENCE

IV.

Necessity of acceptable radiologic alignment by preoperative closed reduction for unstable distal radius fractures treated with volar locking plates

PURPOSE

The purpose of this study was to demonstrate the necessity of achieving acceptable radiographic alignment by preoperative closed reduction in unstable distal radius fractures (DRFs) to improve preoperative pain and obtain satisfactory outcomes after surgery.

METHODS

From 2013 to 2016, patients who received volar locking plates for DRFs were retrospectively reviewed. Patients were classified into acceptable and non-acceptable reduction groups based on immediate post-reduction radiographs. To avoid potential bias, a matched-pair analysis was performed, and paired patients were categorized into non-acceptable reduction (group A) and acceptable reduction (group B) groups. Preoperative pain level, mean length of stay, operation time, postoperative complications, and surgical outcomes were analysed. The preoperative pain level and functional results were assessed by the visual analogue scale (VAS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores.

RESULTS

Of the 239 patients, 80 had non-acceptable and 159 had acceptable reductions. Among these patients, 201 (66 in group A vs. 135 in group B) were matched in a 1:2 matched ratio. Although the radiological parameters after closed reduction were better in group B, there were no significant differences in the preoperative pain VAS score, mean length of stay, operation time, and postoperative complications between the groups. In addition, radiologic parameters and the DASH score at a 1-year follow-up were also not significantly different between the groups.

CONCLUSION

Our results suggest that obtaining acceptable radiologic alignment by closed reduction is not necessary for patients who make an informed decision to undergo volar plating for unstable DRFs.

How Many Screws Are Needed for Reliable Stability of Extra-articular Nonosteoporotic Distal Radius Fractures Fixed with Volar Locking Plates?

Background

We hypothesized that volar locking pate fixation using a minimum number of screws-four in the distal row and two in the shaft of the plate-will provide sufficient stability for unstable extra-articular fractures of the distal radius. We aimed to compare the biomechanical properties of different numbers and locations of screws in volar locking plate fixation and describe the clinical and radiological outcome of plate fixation using a minimum number of screws for distal radius fractures.

Methods

We divided 48 artificial radius fracture bones into four groups (group A-D) based on the number and location of screws used for fixation with volar locking plates. The artificial bone models were subjected to axial compression and volar bending load with a force of 250 N and 80 N, respectively, for 1,000 cycles at a frequency of 1 Hz. We also retrospectively reviewed 42 patients with unstable, extra-articular, distal radius fractures who were treated with volar locking plate fixation using a minimum number of screws.

Results

Group A (seven distal screws and three proximal screws) had the highest mean stiffness: 303.7 N/mm under axial compression and 61.1 N/mm under volar bending. Compared with group A, group D (four screws in the distal part and two screws in the shaft) showed significantly lower stiffness; therefore, group D was considered inferior in terms of stability. However, in the fatigue test, neither deformation of the metal plate nor detachment or breakage of the metal screws was observed in all groups. In the clinical study, all fractures united without displacement and satisfactory clinical outcome was obtained.

Conclusions

In the dorsally comminuted, extra-articular, nonosteoporotic distal radius fractures, the minimum number of screws-four in the distal row and two in the shaft-in volar locking plate fixation can provide sufficient stability. Further biomechanical studies involving osteoporotic bone will be necessary to confirm the results because volar plate fixation is most commonly used in patients with osteoporosis.

Percutaneous pinning for treating distal radial fractures in adults

BACKGROUND

Fracture of the distal radius is a common clinical problem. A key method of surgical fixation is percutaneous pinning, involving the insertion of wires through the skin to stabilise the fracture. This is an update of a Cochrane Review published in 2007.

OBJECTIVES

To assess the effects (benefits and harms) of percutaneous pinning versus cast immobilisation alone and of different methods and techniques of percutaneous pinning, modalities or duration of immobilisation after pinning, and methods or timing of pin or wire removal for treating fractures of the distal radius in adults. Our primary focus was on dorsally displaced fractures.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, trial registers, conference proceedings and reference lists of articles up to June 2019.

SELECTION CRITERIA

Randomised or quasi-randomised controlled clinical trials involving adults with a fracture of the distal radius, which compared percutaneous pinning with non-surgical treatment or different aspects of percutaneous pinning. Our main outcomes were patient-reported function at the short term (up to three months), medium term (three up to 12 months) and long term (greater than 12 months); overall numbers of participants with complications requiring secondary treatment and any complication; grip strength and health-related quality of life at 12 months.

DATA COLLECTION AND ANALYSIS

At least two review authors independently performed study screening and selection, 'Risk of bias' assessment and data extraction. We pooled data where appropriate and used GRADE for assessing the quality of evidence for each outcome.

MAIN RESULTS

We included 21 randomised controlled trials (RCTs) and five quasi-RCTs, involving 1946 generally older and female adults with dorsally displaced and potentially or evidently unstable distal radial fractures. Trial populations varied but the majority of studies reported mean ages in the sixth decade or older. All trials were at high risk of bias, invariably performance bias - which for most trials reflected the impracticality of blinding care providers or participants to treatment allocation - and often detection bias and selective reporting bias. Allocation concealment was secure in one trial only. All trials reported outcomes incompletely. The studies tested one of 10 comparisons. In the following, we report on those of the main outcomes for which evidence was available. No subgroup analysis, such as by pinning methods, was viable. Eleven heterogeneous trials involving 917 participants compared percutaneous pinning with plaster cast immobilisation after closed reduction of the fracture. The quality of the evidence was very low for all reported outcomes. Thus, we are uncertain if percutaneous pinning compared with plaster cast alone makes any difference to patient-reported function, measured using the DASH questionnaire, at six weeks or six months (incomplete data from one trial). Overall numbers of participants with complications were not reported. Redisplacement resulting in secondary treatment occurred on average in 12% (range 3.3% to 75%) of participants treated by cast alone (six trials) whereas pin tract infection requiring antibiotics and, often, early wire removal, occurred on average in 7.7% (range 0% to 15%) of pinning group participants (seven trials). We are uncertain whether pinning makes a difference to the incidence of complex regional pain syndrome, reported in four studies. Although two studies found finger stiffness after cast removal was less common after pinning (20% versus 36%), the treatment implications were not reported. Other reported complications were mainly surgery-related. Based on incomplete data or qualitative statements from only four studies, we are uncertain of the effects of pinning on grip strength at 12 months. We are uncertain if percutaneous pinning compared with plaster cast alone makes any difference to patient-reported quality of life at four months (one study). Five comparisons of different pinning methods were made by six trials in all. One of these trials, which reported results for 96 participants, compared Kapandji intrafocal pinning (2 or 3 wires) with early mobilisation versus trans-styloid fixation (2 wires) with six weeks cast immobilisation. We are uncertain whether Kapandji pinning slightly increases the risk of superficial radial nerve symptoms or complex regional pain syndrome, or whether it makes a difference in grip strength at 12 months (very low-quality evidence). Two small trials using two distinct pinning techniques compared biodegradable pins versus metal pins in 70 participants. Although very low-quality evidence, the extra demands at surgery of insertion of biodegradable pins and excess of serious complications (e.g. severe osteolytic reactions) associated with biodegradable material are important findings. Three poorly-reported trials involving 168 participants compared burying of wire ends versus leaving them exposed. We are uncertain whether burying of wires reduces the incidence of superficial infection (very low-quality evidence). There is low-quality evidence that burying of wires may be associated with a higher risk of requiring more invasive treatment for wire removal. Four small trials compared different types or duration of postoperative immobilisation. Very low-quality evidence of small between-group differences in individual complications and grip strength at 17 weeks, means we are uncertain of the effects of positioning the wrist in dorsiflexion versus palmar flexion during cast immobilisation following pinning of redisplaced fractures (one trial; 60 participants). Three small heterogeneous trials compared cast immobilisation for one week (early mobilisation) versus four or six weeks after percutaneous pinning in 170 people. Although we note one trial using Kapandji pinning reported more complications in the early group, the very low-quality evidence means there is uncertainty of the effects of early mobilisation on overall and individual complications, or grip strength at 12 months. No trials tested different methods for, or timing of, pin/wire removal.

AUTHORS' CONCLUSIONS

Overall, there is insufficient RCT evidence to inform on the role of percutaneous pinning versus cast immobilisation alone or associated treatment decisions such as method of pinning, burying or not of wire ends, wrist position and duration of immobilisation after pinning. Although very low-quality evidence, the serious complications associated with biodegradable materials is noteworthy. We advise waiting on the results of a large ongoing study comparing pinning with plaster cast treatment as these could help inform future research.

Correlation Between Radiological Parameters and Functional Outcomes in Patients Older Than 60 Years of Age With Distal Radius Fracture

Background: The relationship between radiographic and functional outcomes is controversial in the elderly. The objective of this study is to determine whether there is a correlation between functional outcome and acceptable distal radius fracture (DRF) alignment in patients older than 60 years of age. Methods: This correlation study was carried out at the Central Metropolitan Health Service of Chile. A total of 180 patients diagnosed with extra-articular DRF, according to the AO classification, were prospectively recruited. Radiological parameters, including radial inclination, residual dorsal angulation, ulnar variance, and articular step-off, were evaluated to assess the results of orthopedic reduction. Functional outcome was assessed immediately following cast removal and again at the 6-month follow-up. The Disabilities of the Arm, Shoulder and Hand (DASH) and Patient-Rated Wrist Evaluation (PRWE) questionnaires were administered to assess upper extremity function, and the visual analog scale (VAS) was used to assess pain intensity. Results: Only 68 patients (37.8%) showed acceptable DRF alignment. After cast removal, the correlations between alignment and the functional outcome measures were as follows: DASH 0.071 (P = .546), PRWE 0.03 (P = .823), and VAS 0.12 (P = .631). At the 6-month follow-up, the correlations between alignment and the functional outcome measures were as follows: DASH 0.029 (P = .768), PRWE 0.014 (P = .895), and VAS 0.09 (P = .614). Conclusions: There was no significant correlation between acceptable alignment according to radiological parameters and short- or medium-term functional outcome in patients older than 60 years with extra-articular DRF treated conservatively.

Factors associated with the decision for operative versus conservative treatment of displaced distal radius fractures in the elderly

BACKGROUND

The treatment of senile distal radius fractures had not been clearly defined. The objective of this study was to identify the factors associated with the decision for operative treatment of displaced distal radius fractures in patients aged over 55 years.

METHODS

Data of 318 patients with displaced distal radius fractures were collected on patient-, fracture- and surgeon-related characteristics that were plausibly related to the decision for operation. Mean comparisons or chi-squared test were used for univariate analysis of the above-mentioned factors, and then multiple logistic regression was used to identify factors associated with the decision for operation.

RESULTS

Univariate analysis showed that age, osteoporosis, Charlson score, associated orthopaedic injuries requiring surgery, Orthopaedic Trauma Association (AO) and Fernandez classification, radial height, volar tilt, volar/dorsal comminution, ulnar variance, intra-articular displacement/step-off, associated distal radioulnar joint instability or radiocarpal joint dislocation and subspecialty of treating surgeons had statistically significant association with operative intervention. In the multivariate analysis, the predictors of operative intervention were younger patient age (P = 0.028), associated orthopaedic injuries requiring surgery (P = 0.020), higher AO classification (P = 0.037), higher Fernandez classification (P = 0.041), radial shortening >5 mm (P = 0.020), volar tilt > -10° (P = 0.020), volar/dorsal comminution (P = 0.020), ulnar variance >5 mm (P = 0.023), intra-articular displacement/step-off >2 mm (P = 0.004), associated distal radioulnar joint instability or radiocarpal joint dislocation (P = 0.047) and treatment by an upper extremity specialist (P = 0.038).

CONCLUSION

The decision for surgery was predominantly influenced by the characteristics and severity of the fracture. Patients' age and treatment by an upper extremity specialist were also significant factors associated with a higher likelihood of operative intervention.

Impact of Design on Force between Flexor Tendons and Distal Radius Volar Plates

Background  Flexor tendon injury is a rare but serious complication of distal radius volar plating. Purpose  This study aims to determine whether the design of distal radius volar plates impacts the amount of force exerted on the flexor digitorum profundus (FDP) and flexor pollicis longus (FPL) tendons when the plates are placed proximal and distal to the watershed line. Methods  Three commercially available plates were applied to 10 fresh, matched-pair upper extremity specimens. Cyclical loading was applied to the tendons, and the force generated between tendon and plate was measured. Linear mixed effect models were used to evaluate differences in maximum and mean forces by plate position, plate design, and the interaction between position and design. Results  Forces on the tendons differed significantly by position but not plate design. For the FPL tendon, the average maximum force with a plate in Soong's grade 2 was 4.50 (95% confidence interval [CI]: 2.8-7.3) times higher than when the plate was in a Soong's grade 0 placement, and 4.63 (95% CI: 2.82-7.61) times higher for the FDP tendon. While not statistically significant, lower observed force values with thinner plates when plates were placed distal to the watershed line suggest that that plate thickness could also be a critical plate characteristic for distally placed plates. Conclusion  Despite differences in plate design, the main determinant of plate prominence and therefore flexor tendon injury potential is placement in relation to the watershed line. Clinical Relevance  This study may help to guide surgeon implant selection and volar plate design.

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

Background  The purpose of this study is to assess the epidemiology, population-specific treatment trends, and complications of distal radius fractures in the United States. Methods  The PearlDiver database (Humana [2007-2014], Medicare [2005-2014]) was used to access US inpatient and outpatient data for all patients who had undergone operative and nonoperative treatment for a distal radius fracture in the United States. Epidemiologic analysis was performed followed by age-based stratification, to assess prevalence, treatment trends, and rates of complications. Results  A total of 1,124,060 distal radius treatment claims were captured. The incidence of distal radius fractures follows a bimodal distribution with distinct peaks in the pediatric and elderly population. Fractures in the pediatric population occurred predominately in males, whereas fractures in the elderly population occurred more frequently in females. The most commonly used modality of treatment was nonoperative; however, the use of internal fixation increased significantly during the study period, from 8.75 to 20.02%, with a corresponding decrease in percutaneous fixation. The overall complication rate was 8.3%, with mechanical symptoms most frequently reported. Conclusions  The last decade has seen a significant increase in the use of internal fixation as treatment modality for distal radius fractures. The impetus for this change is likely multifactorial and partly related to recent innovations including volar locking plates and an increasingly active elderly population. The implicated financial cost must be weighed against the productivity cost of maintaining independent living to determine the true burden to the healthcare system.

Early palmar plate fixation of distal radius fractures may benefit patients aged 50 years or older: a randomized trial comparing 2 different treatment protocols

Background and purpose - There is no consensus regarding optimal treatment of displaced distal radius fractures (DRFs). We compared the results of 2 treatment protocols: early palmar plating vs. primary nonoperative treatment of displaced DRFs. Patients and methods - We performed a prospective randomized controlled study including 80 patients aged ≥ 50 years with dorsally displaced DRFs, excluding AO type C3 fractures. Patients were randomized to undergo either immediate surgery with palmar plating (n = 38), or initial nonoperative treatment (n = 42) after successful closed reduction in both groups. Delayed surgery was performed in nonoperatively treated patients showing early loss of alignment (n = 16). The primary outcome measure was Disabilities of the Arm, Shoulder, and Hand (DASH) score. Results - Mean DASH scores at 24 months in the early surgery group were 7.9 vs. 14 in the initial nonoperative group (difference between means 6, 95% CI 0.1-11, p = 0.05). Delayed operation was performed on 16/42 of patients due to secondary displacement in the initial nonoperative group. In "as treated" analysis, DASH scores were 7 in the early surgery group, 13 in the nonoperative group, and 17 after delayed surgery (p = 0.02). The difference in DASH scores between early and delayed surgery was 9 points (CI 0.3-19, p = 0.02) Interpretation - Treatment of DRFs with early palmar plating resulted in better 2-year functional outcomes for ≥50-year-old patients compared with a primary nonoperative treatment protocol. Delayed surgery in case of secondary displacement was not beneficial in terms of function.

Carpal Alignment: A New Method for Assessment

Background  Carpal alignment may be used as a tool to evaluate fracture reduction in patients with distal radius fractures. However, there is little consensus on how to measure and quantify carpal alignment. Purpose  The aim of this study was to compare the inter- and intraobserver variability of a new perpendicular method with the existing method in fractured and unfractured wrists. Additionally, the normal distribution of carpal alignment in unfractured wrists was investigated. Patients and Methods  Carpal alignment was assessed on lateral plain radiographs using two different methods, one described by Ng and McQueen and another newly proposed method, the perpendicular method. Using the perpendicular method, the observer draws one line along the inner rim of the volar cortex of the radius and one perpendicular line to the center of the capitate. The carpus is aligned when the line along the inner rim transects the center of the capitate. Three examiners measured the carpal alignment in 50 patients with nonfractured and 50 patients with fractured distal radius. Intra- and interobserver variability for both methods were determined. Results  The interobserver coefficient for the perpendicular method was 0.98 and that for the Ng method was 0.86. The intraobserver coefficients for three examiners were 0.89, 0.62, and 0.63, respectively, for the Ng method. For the perpendicular method, the intraobserver variability was 0.96, 0.89, and 0.72, respectively. In patients with unfractured wrists, the mean perpendicular to the center of the capitate was 0.25 mm dorsally. Conclusion  The new proposed method is a reproducible method for measuring carpal alignment with a high inter- and intraclass coefficient. Clinical Relevance  This method of measurement allows for a reproducible technique for measuring carpal alignment.

Complications in the Management of Distal Radius Fractures: How Do We Avoid them?

PURPOSE OF THIS REVIEW

Distal radius fractures are one of the most common fractures in the upper extremity. The purpose of this review is to outline common complications that may arise when caring for distal radius fractures and to describe the treatment strategies when faced with such complications.

RECENT FINDINGS

Tendon complications are not uncommon after distal radius fractures. Recent literature highlights new plating technology for dorsal plating techniques. Moreover, new literature has outlined parameters for flexor tendon complications when using volar locking plates in an effort to avoid flexor tendon irritation and rupture. In summary, it is important to understand the various complications that can arise when treating distal radius fractures in an effort to avoid suboptimal outcomes.

The severity of ulnar variance compared with contralateral hand: its significance on postoperative wrist function in patients with distal radius fracture

The aim of this study was to detect the severity of ulnar variance (UV) compared with contralateral hand on postoperative wrist function in patients with distal radius fracture. 116 cases with unilateral distal radius fracture were retrospectively analyzed and divided into high or low UV severity groups (Dividing value = 2.5 mm). The following parameters were used to evaluate the effect: palmar tilt, radial inclination, VAS score, DASH score and wrist function. The severity of UV existed widely, accounting for 93.1% (108 cases). The severity of UV correlated with palmar tilt, radial inclination, grip strength, VAS score, DASH score and the wrist function (P < 0.05). Log-rank analysis showed that the severity of UV, palmar tilt, radial inclination were important factors influencing the joint function postoperatively (P < 0.0 5). Multivariate analysis confirmed that the severity of UV was an independent and significant factor on wrist function (P = 0.010). And the palmar tilt was also an important factor influencing wrist function (P = 0.047). The severity of ulnar variance compared with contralateral hand is an independent and significant factor on wrist function, which should be considered as an important step during preoperative plan.

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.

Computed Tomography vs Standard Radiograph in Preoperative Planning of Distal Radius Fractures with Articular Involvement

Introduction

Distal radius fractures with articular involvement are more likely to require surgical management. Treatment decisions are based on parameters which are obtained from plain radiographs. This study aims to determine the differences between computed tomography and standard radiographs in the preoperative planning of distal radius fractures with articular involvement. This was performed by measuring the intraobserver and interobserver reliability between three systems used to interpret the main fracture characteristics and two treatment decisions.

Materials and methods

Forty-three cases of distal radius fractures with articular involvement were included. Fracture displacement was measured using plain radiographic and computed tomography. Five orthopedic surgeons evaluate the images to determine the AO/OTA classification, the articular fragments, the biomechanical columns involved, and recommend a surgical approach and implant for fracture fixation.

Results

An articular step-off was identified in 13 cases (30%) with the standard radiographs and in 22 (51%) cases with the computed tomography (p = 0.00). Interobserver variation for preoperative planning was slight when evaluated using the standard radiographs. Computed tomography improves reliability for AO/OTA classification and articular fragments but not for the biomechanical columns. Intraobserver variation for preoperative planning was slight to moderate for AO/OTA classification and slight to fair for identification of articular fragments and biomechanical columns. With regard to selection of the surgical approach, there was slight to moderate variation and, finally, for fracture fixation it was slight to fair.

Conclusion

Information provided by conventional radiography and computed tomography are sufficiently different as to induce the surgeon to select different treatments for the same fracture.

How to cite this article

Azi ML, Teixeira MB, de Carvalho SF, et al. Computed Tomography vs Standard Radiograph in Preoperative Planning of Distal Radius Fractures with Articular Involvement. Strategies Trauma Limb Reconstr 2019;14(1):15–19.

Distal Radius Fractures: Evaluation of Closed Reduction and Percutaneous Kirschner Wire Pinning

Objective Closed reduction and percutaneous pinning (CRPP) is losing popularity as a treatment modality for distal radius fractures. However, in select cases, CRPP may have advantages relative to open reduction and internal reduction. We aimed to retrospectively assess the outcomes after CRPP for the treatment of distal radius fractures. Study Design This is a retrospective cohort study. Methods We used billing records to identify all skeletally mature patients with a distal radius fracture who were treated with CRPP by a single surgeon at a level I trauma center in an urban city in the United States. We assessed the medical charts and recorded demographics, trauma and treatment characteristics, radiographic characteristics, and outcomes. Results All patients had a good or excellent range of motion regarding forearm rotation, and almost 80% had good or excellent range of motion regarding flexion or extension of their wrist. One patient had a concern for pin tract infection, and one had subcutaneous migration of a pin, which were both treated by pin removal. Conclusion CRPP is a good option in patients with few and sizeable fracture fragments in patients with a distal radius fracture, and it should be considered as an effective tool to restore radiographic parameters and functional outcomes.

Below- vs above-elbow cast for distal radius fractures: is elbow immobilization really effective for reduction maintenance?

PURPOSE

The choice of the cast length in conservative management of distal radius fractures still represents a debated controversy. Historically, the elbow is immobilized to reduce the risk of secondary displacement; however, short-arm casts are currently felt to be equally effective with less complications and better patient comfort. This paper investigates whether immobilization of the elbow is actually effective in reducing the risk of loss of reduction in conservatively manipulated distal radius fractures.

METHODS

We retrospectively studied 297 consecutive patients with distal radius fractures requiring manipulation and subsequently immobilized with above-elbow cast or below-elbow cast. Maintenance of reduction, radial height, radial inclination, and volar tilt were assessed after the reduction and at 35 days. Appropriate statistical analysis was performed to correct data selection bias and to assess any difference in the effectiveness among the two treatments.

RESULTS

The mean difference of loss of radial height, inclination, and volar tilt between the two groups was 0.8 mm, 0.4°, and 0.9° respectively, being not statistically significant. Average difference in reduction maintenance probability between the two groups stratified with a statistical propensity score was 1.2%.

CONCLUSIONS

Above- and below-elbow casts had comparable performance in maintaining reduction of manipulated distal radius fractures.

Radiographic Diagnosis of Scapholunate Diastasis in Distal Radius Fractures: Implications for Surgical Practice

Background  Radiographic diagnosis of scapholunate ligament injury (SLI) in the setting of distal radius fractures (DRFs) is challenging. It remains unclear to what extent radiographic diagnosis of SLI by a radiologist influences surgical decision-making regarding treatment of SLI. Purpose  We aimed to (1) identify the number of times that concerns for the possibility of concurrent SLI in the setting of a DRF had been raised by the radiologists, (2) identify how often the radiologist's diagnosis was confirmed by the treating surgeon, and (3) how many of the patients with a radiographic concern for SLI by the radiologist received operative treatment for the SLI. Patients and Methods  Based on Current Procedural Terminology codes, we identified 2,923 patients that were operatively treated for their DRF in 1 of 3 participating institutions in an urban city in the United States. We reviewed the medical charts of 654 patients who had a mention of scapholunate ligament (SL) distance in their radiography, surgery, or clinical notes. We then measured the SL distance and recorded patient, diagnosis, and treatment characteristics of all these patients. Results  A total of 200 out of 2,923 patients (6.8%) received a radiological diagnosis of SLI. In seven of these patients (3.5%), the surgeon confirmed the diagnosis of the radiologist. Four patients (2%) had operative repair of their SLI. Conclusion  Radiologists demonstrate a low threshold to identify SLI in the setting of DRFs, while the number of SLIs identified by the treating surgeon is a remarkably smaller number. Level of Evidence  Level II, prognostic study.

Nordic Innovative Trial to Evaluate OsteoPorotic Fractures (NITEP-group): non-operative treatment versus surgery with volar locking plate in the treatment of distal radius fracture in patients aged 65 and over - a study protocol for a prospective, randomized controlled trial

BACKGROUND

In the literature, there are numerous studies that compare different surgical procedures in the treatment of distal radius fractures (DRF). It is, however, unknown whether operative treatment and better restoration of anatomy with volar locking plate yields a better functional outcome in the elderly population when compared with non-operative treatment.

METHODS AND DESIGN

This study is a prospective, randomized, controlled, multi-center trial. The purpose will be to compare the non-operative and operative treatment of initially or early malaligned distal radius fractures in patients aged 65 and older. The primary outcome in this study will be the patient rated wrist evaluation (PRWE) score measured after 1 and 2 years.

DISCUSSION

We expect that initial operative treatment of a DRF with volar locking plate will not yield superior results when compared with non-operative treatment with cast immobilization in terms of functional outcome, pain, disability, quality of life, grip strength, and number of complications.

TRIAL REGISTRATION

This trial is registered on clinicaltrials.gov , identifier NCT02879656 , registration date 08/17/2016.

Repeated closed reduction attempts of distal radius fractures in the emergency department

INTRODUCTION

Repeated attempts of closed reduction of distal radius fractures (DRF) are performed in the emergency department setting to optimize fracture alignment and avoid surgery. The additional manipulation of the fracture may, however, increase dorsal comminution and lead to loss of reduction in the cast. This retrospective cohort study has investigated the effect of second reduction attempt on fracture alignment and comminution.

MATERIALS AND METHODS

Six-hundred-eighteen patients with DRF were treated in the medical center in 2007-2010. Seventy-six (12.3%) DRF who underwent two reductions were included in the study. Radiographs taken after the first and second reduction attempts were reviewed for changes in fracture alignment parameters (radial height, radial inclination, volar tilt) and dorsal comminution length. Patients were also followed retrospectively to determine the rates of secondary displacement in a cast.

RESULTS

A second closed reduction attempt improved mean radial height by 1.43 mm, mean radial inclination by 1.62° and mean volar tilt by 8.75°. Mean dorsal comminution length increased by 1.6 mm. Of the 19 (25%) patients with acceptable alignments after two reduction attempts, follow-up radiographs were available for 12, which showed successful reduction in four cases (33.3 or 5.2% of total 76 patients).

CONCLUSIONS

A second closed reduction attempt improved immediate fracture alignment, but also worsened dorsal comminution. Only 5.2% of patients who underwent two reduction attempts had an acceptable final alignment and did not require surgery. Increased dorsal comminution may further compromise fracture stability, complicate surgery and have negative effect on the postoperative course.

Ulnar Neck Fractures Associated with Distal Radius Fractures

Background  There is little published data to guide management of ulnar neck fractures associated with fractures of the distal radius. Purpose  As unplanned surgery usually reflects adverse events and this injury combination is relatively uncommon, we used a large database to study the incidence of unplanned surgeries after surgical and nonsurgical treatment of distal metaphyseal ulna fractures associated with a distal radius fracture and identify factors associated with these unplanned surgeries. Patients and Methods  We identified 277 patients with an ulnar neck fracture associated with a distal radius fracture. Fifty-six (20%) ulnar neck fractures were initially treated operatively and six of them (11%) had a second, unplanned surgery. Of the 221 initially nonoperatively treated fractures, only one (0.45%) had a subsequent unplanned surgery that seemed unrelated to the fracture (ulnar nerve neurolysis). Results  Bivariate analysis showed that younger age, open fracture, multifragmentary fractures, and initial operative treatment of the ulnar neck fracture were significantly associated with unplanned surgery. A multivariable analysis was not feasible due to the small number of unplanned surgeries. Conclusion  Eighty percent of ulnar neck fractures associated with a fracture of the distal radius was treated nonoperatively in our region, and subsequent surgery for problems was very uncommon. Operative treatment and fracture complexity were associated with unplanned surgery, which reflected some measure of injury severity, technical inadequacy, and inherent problems associated with surgery. Level of Evidence  Level II, prognostic study.