Percutaneous fixation with Kirschner wires versus volar locking-plate fixation in adults with dorsally displaced fracture of distal radius: five-year follow-up of a randomized controlled trial

The Choice of Osteosynthesis for Distal Radius Fractures: A Matter of Taste, Fracture Instability, or Patient-Related Factors? A Retrospective Study of Functional Outcome in 346 Distal Radius Fractures Operated With Percutaneous Wires or Volar Plate Fixation

BACKGROUND

Surgery with volar locking plate (VLP) for distal radius fractures (DRFs) has become dominant over percutaneous Kirschner wire (K-wire) (PKW) fixation. Not many studies have proved advantages of the VLP and the increasing dominance of the VLP is thus not derived from evidence of superiority but influenced by other factors.

METHODS

By retrospectively classifying 346 DRFs treated with either PKW or VLP fixation, according to the Buttazzoni classification system, we aimed to investigate the determining factors for choice of surgical method, and by review of the patients' medical records, the functional outcome, duration, and frequentness of the rehabilitation period were correlated to Buttazzoni type and surgical method.

RESULTS

The odds ratio of having volar plate fixation was negatively correlated to age and positively correlated to a higher Buttazzoni type. We found no clinically significant differences in the functional outcome for different Buttazzoni type of fractures within the VLP and PKW groups, respectively, nor between the 2 methods of surgery for any Buttazzoni type of fracture.

CONCLUSION

Younger patients and fractures with higher grade of instability were more likely to be treated with VLP than PKW; however, neither fracture instability nor surgical method had any impact on functional outcome.

Functional outcomes are restored a decade after a distal radius fracture: a prospective long-term follow-up study

We performed an 11-13-year prospective follow-up of patients after a distal radial fracture (DRF) to investigate the association between fracture malunion, radiocarpal osteoarthritis and clinical outcome. In total, 292 patients responded to patient-reported outcome measures; of them, 242 underwent clinical examination. Clinical outcomes improved with time. A decade after fracture, median Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was 5, EuroQol Five-dimensions score was 1.0, and range of motion and grip strength were 96% of the contralateral side. Neither osteoarthritis (6%) nor pseudoarthrosis of the ulnar styloid (30%) affected the outcomes. Dorsal tilt, radial inclination, ulnar variance and intra-articular extension did not affect long-term clinical outcomes or the risk of osteoarthritis. Recovery after a DRF is an ongoing process that lasts years. A decade after the injury event, range of motion, grip strength and QuickDASH were recovered to population normal, regardless of radiological outcomes.Level of evidence: II.

The Impact of Social Determinants of Health on the Treatment of Distal Radius Fracture

BACKGROUND

Disparities in social determinants of health (SDH) have been shown to play an increasingly important role in the equitable delivery of health care. Distal radius fractures (DRFs) are among the most common upper-extremity injuries encountered. This study aims to examine the influence of economic, educational, social, environmental, and healthcare disparities on management of these injuries.

METHODS

PearlDiver Mariner insurance claims database was analyzed for treatment patterns of DRF in patients aged 18 to 65 years based on the presence or absence of social determinants of health disparities (SDHDs). Outcome variables included the primary mode of management of DRF, including operative versus non-operative, as well as concomitant procedures. Multivariate logistic regression was used to compare fracture management modality in patients with and without SDHDs.

RESULTS

Of 161 704 patients identified with DRF, 38.3% had at least 1 reported SDHD. The majority of SDHDs were economic. Patients identified with 1 or more SDHDs had a higher medical comorbidity index. Patients with environmental SDHD were more likely to receive non-operative management. Within any SDHD and economic subgroups, odds of operative management were higher. No relationship was identified between SDHD and concomitant procedures.

CONCLUSIONS

The presence of environmental disparities in SDH may predispose patients disproportionately to non-operative management. The presence of SDHDs may influence medical decision-making in favor of open reduction and internal fixation in patients with DRF treated operatively. In treating at-risk populations, providers should be aware of the potential for implicit bias associated with SDHDs and prioritize shared decision-making between patients and physicians.

QuickDASH and PRWE Are Not Optimal Patient-Reported Outcome Measures After Distal Radial Fracture Due to Ceiling Effect: Potential Implications for Future Research

BACKGROUND

The aim of this study was to determine the floor and ceiling effects for both the QuickDASH (shortened version of the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire) and the PRWE (Patient-Rated Wrist Evaluation) following a distal radial fracture (DRF). Secondary aims were to determine the degree to which patients with a floor or ceiling effect felt that their wrist was "normal" according to the Normal Wrist Score (NWS) and if there were patient factors associated with achieving a floor or ceiling effect.

METHODS

A retrospective cohort study of patients in whom a DRF was managed at the study center during a single year was undertaken. Outcome measures included the QuickDASH, PRWE, EuroQol-5 Dimensions-3 Levels (EQ-5D-3L), and NWS.

RESULTS

There were 526 patients with a mean age of 65 years (range, 20 to 95 years), and 421 (80%) were female. Most patients were managed nonsurgically (73%, n = 385). The mean follow-up was 4.8 years (range, 4.3 to 5.5 years). A ceiling effect was observed for both the QuickDASH (22.3% of patients with the best possible score) and the PRWE (28.5%). When defined as a score that differed from the best available score by less than the minimum clinically important difference (MCID) for the scoring system, the ceiling effect increased to 62.8% for the QuickDASH and 60% for the PRWE. Patients who had a ceiling score on the QuickDASH and the PWRE had a median NWS of 96 and 98, respectively, and those who had a score within 1 MCID of the ceiling score reported a median NWS of 91 and 92, respectively. On logistic regression analysis, a dominant-hand injury and better health-related quality of life were the factors associated with both QuickDASH and PRWE ceiling scores (all p < 0.05).

CONCLUSIONS

The QuickDASH and PRWE demonstrate ceiling effects when used to assess the outcome of DRF management. Some patients achieving ceiling scores did not consider their wrist to be "normal." Future research on patient-reported outcome assessment tools for DRFs should aim to limit the ceiling effect, especially for individuals or groups that are more likely to achieve a ceiling score.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Five-year outcomes for patients with a displaced fracture of the distal tibia

Aims

To report the outcomes of patients with a fracture of the distal tibia who were treated with intramedullary nail versus locking plate in the five years after participating in the Fixation of Distal Tibia fracture (FixDT) trial.

Methods

The FixDT trial reported the results for 321 patients randomized to nail or locking plate fixation in the first 12 months after their injury. In this follow-up study, we report the results of 170 of the original participants who agreed to be followed up until five years. Participants reported their Disability Rating Index (DRI) and health-related quality of life (EuroQol five-dimension three-level questionnaire) annually by self-reported questionnaire. Further surgical interventions related to the fracture were also recorded.

Results

There was no evidence of a difference in patient-reported disability, health-related quality of life, or the need for further surgery between participants treated with either type of fixation at five years. Considering the combined results for all participants, there was no significant change in DRI scores after the first 12 months of follow-up (difference between 12 and 24 months, 3.3 (95% confidence interval -1.8 to 8.5); p = 0.203), with patients reporting around 20% disability at five years.

Conclusion

This study shows that the moderate levels of disability and reduced quality of life reported by participants 12 months after a fracture of the distal tibia persist in the medium term, with little evidence of improvement after the first year.

Conservative management versus volar plating for dorsally displaced distal radius fractures in the elderly: A randomized control trial

Objective

This randomized trial aims to compare the clinical, and radiological outcomes between plaster cast and volar plating for distal radius fractures (DRF) in the elderly at six months, and one-year.

Methods

A randomized trial was performed at Jinnah Postgraduate Medical Centre between February 2015 and April 2020. The study included patients that were above 60 years but under 75 with an isolated, closed, unilateral, dorsally displaced DRF. Randomization into two groups (casting or plating) was based on a computer-generated algorithm stratified by age group and AO/OTA fracture type. The primary outcome was Patient Rated Wrist Evaluation score. Secondary clinical outcomes were active range of motion, grip strength, the Mayo's wrist score and the quick Disability Arm, Shoulder, Hands scale. Patient's satisfaction was evaluated with use of a SF-12 questionnaire and finally complications were recorded.

Results

This trial has shown that there is no significant difference in clinical outcomes of DRF at six and twelve months follow up when treated by cast immobilization or plating. Although, the radiological parameters and the number of complications were significantly higher in the immobilization group.

Conclusion

The results of the trial have shown that plating and casting are equally effective in achieving satisfactory patient reported and clinical outcomes at intermediate and final follow-up restoring patient satisfaction.Trial registration: The trial is registered in the Chinese Clinical Trial Registry. The trial registration number is ChiCTR2000032843, and the URL is: http://www.chictr.org.cn/searchprojen.aspx.

Outcomes of the Management of Distal Radius Fractures in the Last 5 Years: A Meta-analysis of Randomized Controlled Trials

Objective  Over the last decades, volar locking plates (VLPs) have been the mainstay treatment for distal radius fractures (DRFs). With the growing body of evidence, we systematically reviewed studies on recent VLP modifications. Methods  A systematic search was performed in the PubMed/MEDLINE database for studies published in English in the past five years. The inclusion criteria were randomized controlled trials (RCTs) on the operative treatment of DRFs. We excluded ongoing trials and studies not directly addressing DRF. The primary outcomes assessed were subjective (such as the scores on the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire, the Patient-rated Wrist Evaluation [PRWE], the European Quality of Life-5 Dimensions [EQ-5D], the 36-item Short Form Health Survey [SF-36], and the Visual Analog Scale [VAS]) and objective clinical outcomes (the complication rate). Results  We identified 29 articles published from 2016 to 2020 with high quality of evidence, except for one, which had evidence of moderate quality. In total, 3,079 DRFs were analyzed in the present study. All studies except one had a greater proportion of female participants, and only in 1 study the mean age of the sample was < 40 years old. There were no significant differences between the VLP and external fixation (EF) in terms of the scores on the DASH ( p  = 0.18) and PRWE ( p  = 0.77). The VLP alone without pronator quadratus (PQ) repair yielded significantly better outcomes. Conclusion  In unstable fractures, the VLP and EF yielded comparable long-term results. There is no clear benefit of adding PQ repair to current the VLP surgical technique. Level of Evidence  Level I.

Non-operative treatment or volar locking plate fixation for dorsally displaced distal radius fractures in patients over 70 years - a three year follow-up of a randomized controlled trial

Background

Surgical treatment of displaced distal radius fractures (DRF) in older patients has increased, despite lacking evidence of its superiority over non-operative treatment. How treatment choice affects these patients after the initial 12-month period remains unknown. This study presents a clinical and radiographic follow up at an average of 3 years after treatment in the context of a randomized clinical trial comparing outcomes in patients aged ≥70 years, with a dorsally displaced distal radius fracture treated either surgically with volar locking plate or non-operatively.

Methods

Between 2009 and 2017, 140 patients aged ≥70 years with dorsally displaced DRF were randomized to surgery with volar locking plate (VLP) or non-operative treatment. At an average of 3 years after inclusion the participants were invited to an additional follow-up. The primary outcome was Patient Rated Wrist Evaluation (PRWE). Secondary outcomes included additional Patient Reported Outcome Measures (PROM), grip strength, range of motion, complications and radiological results.

Results

Sixty six patients were available for a 3 year follow-up, 33 in the non-operatively treated group and 33 in the VLP-group. The mean age at injury was 77 years. At 3 years the median PRWE was better (0 points) in the VLP-group than in the non-operative treatment group (9 points) p-value: 0.027. No statistically significant difference was found in Disabilities of the Arm, Hand, and Shoulder (DASH), EuroQol 5 Dimensions (EQ-5D) or grip strength. Total arc of range of motion was larger in the operatively treated group. No significant difference in osteoarthritis was found. Both groups had regained grip strength. The complication rate was similar. Outcomes improved from the 1 year to the 3 year follow-up.

Conclusions

Surgery with volar locking plate gave less long-term disability compared to non-operative treatment for severely displaced distal radius fractures in patients aged ≥70 years. Our findings were statistically significant but in the lower range of clinical importance.

Trial registration

The study was registered at : NCT02154620 03/06/2014 and NCT01268397 30/12/2010. Ethical approval was obtained from Ethical Committee in Stockholm, Sweden (2009/37–31/3, 2013/105–31/2, 2014/1041–32, 2017/611–32).

Five-year outcomes for patients sustaining severe fractures of the lower limb : mid-term results from the Wound management for Open Lower Limb Fracture (WOLLF) trial

AIMS

The aim of this study was to report the outcomes of patients with severe open fractures of the lower limb in the five years after they took part in the Wound management for Open Lower Limb Fracture (WOLLF) trial.

METHODS

The WOLLF trial compared standard dressings to negative pressure wound therapy (NPWT) applied at the end of the first surgical wound debridement, and patients were followed-up for 12 months. At 12 months, 170 of the original 460 participants agreed to take part in this medium-term follow-up study. Patients reported their Disability Rating Index (DRI) (0 to 100, where 100 is total disability) and health-related quality of life (HRQoL) using the EuroQol five-dimension three-level health questionnaire (EQ-5D-3L) annually by self-reported questionnaire. Further surgical interventions related to the open fracture were also recorded.

RESULTS

There was no evidence of a difference in patient-reported disability, HRQoL, or the need for further surgery between patients treated with NPWT versus standard dressings at five years. Considering the combined results for all participants, there was a small but statistically significant change in DRI scores over time (1.6 units per year; p = 0.005), but no evidence that EQ-5D-3L scores changed significantly during years two to five (p = 0.551).

CONCLUSION

This study shows that the high levels of disability and reduced HRQoL reported by patients 12 months after severe open fractures of the lower limb persist in the medium term, with little evidence of improvement between years two and five. Cite this article: Bone Joint J 2022;104-B(5):633-639.

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.

Different approach to charcot neuroarthropathy: A case report

Introduction and importance

Charcot neuroarthropathy (CN) is a degenerative, progressive disease affecting the ankle and foot and it is usually a disabling factor in diabetic patients. Surgical management of CN aims to obtain a painless stable plantigrade foot which can be achieved through fusion. Achieving joint arthrodesis in CN usually carries a high failure rate.

Cases presentation

We presented two patients with late-stage CN foot deformity. The first case is a 52-year-old female with CN on her left ankle and presented without any infection or prior correction. The second case reported a 47-year-old man with complaints of deformity on his right ankle, he had undergone surgical treatment with an external fixator before, and now presented with infection in the surgical site.

Clinical discussion

Ankle arthrodesis has been considered by many as the treatment of choice for severe and late-stage CN foot. This treatment aims to give a rigid enough fixation which will maintain the stability of the ankle joint and prevents further destruction of surrounding tissue. Multiple modalities of treatment are available and must be chosen accordingly to each clinical case. Minimal implants and the use of multiple bone grafts could be considered as a plan of treatment. Both patients have promising and positive results from the two procedures.

Conclusion

Treatment of CN Foot with internal plate fixation combined with fibular strut graft seemed to give promising results, both radiographically and functionally. Furthermore, a slight modification of treatment with a minimal implant or iliac graft may be considered.

•

We present case reports consist of 2 patients with CN and diabetes mellitus condition.

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The management for this varied condition has not described in many published literatures.

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We performed minimal implant and multiple bone grafts technique surgery in different kind of patient's condition, both in non-infected and infected patient.

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The follow up of clinical and radiograph imaging shows satisfiying outcome, and both patients now progresses to a partially weight bearing and continue to give promising results.

Is early mobilization after volar locking plate fixation in distal radius fractures really beneficial? A meta-analysis of prospective randomized studies

STUDY DESIGN

This was a systematic review with a meta-analysis.

INTRODUCTION

Despite rising trends toward surgical treatment of distal radius fractures (DRF) with volar locking plate (VLP) fixation, there is a lack of consensus on when to start vigorous wrist range of motion (ROM) exercises after surgery.

PURPOSE

We performed a meta-analysis to compare early and late mobilization after VLP fixation in patients with DRF.

METHODS

Four prospective randomized controlled trials with a minimum of 6 months of follow-up were retrieved through MEDLINE (PubMed), EMBASE, Web of Science, the Cochrane Library, and the KoreaMed databases in March 2021. We divided patients into an early group (patients who started ROM exercises of the wrist within 2 weeks after surgery), and a late group (patients who started ROM exercises 5 or 6 weeks after surgery). The primary outcome was treatment efficacy which was measured through improvement in pain score, function score, ROM, and grip power. The secondary outcome was the incidence of postoperative complications.

RESULTS

This meta-analysis included 127 patients in the early group and 131 patients in the late group. The outcomes were compared at 6 weeks, 3 months, and 6 months postoperatively. There was no significant difference in pain score, though the early group had a lower average visual analog scale score. The early group had a lower arm, shoulder, and hand disability score than the late group (95 % CI, -16.25 to -8.35 points; P < .001) at 6 weeks postoperatively, suggesting significantly superior outcomes. A similar trend persisted at 3 (n = 74 in the early group and n = 77 in the late group; 95% CI, -5.45 to -0.30; P = .029) and 6 months (n = 102 in the early group and n = 100 in the late group; 95% CI, -4.81 to 0.21; P = .073), but the differences were smaller. The early group had a higher grip power at all follow-up periods, but the difference was only significant at 6 months postoperatively (n = 88 in the early group and n = 83 in the late group; 95% CI, 0.50 to 6.99; P = 0.024). The early group also had more favorable ROM in all directions at 6 weeks, but only in supination at 6 months. The complication rate was not significantly different between the 2 groups. There were no differences in the rates of secondary operation and reduction loss.

CONCLUSION

Early ROM exercise after VLP in DRF resulted in superior functional scores and grip power until 6 months postoperatively. The dominance of the joint ROM, which was seen at 6 weeks after surgery in the early exercise group, decreased with time and ultimately showed little difference at 6 months. Early exercise is safe and did not increase complication rates.

Long-term subjective results and radiologic prognosis of a distal radius fracture in working-aged patients - a prognostic cohort study of 201 patients

OBJECTIVE

To investigate long-term outcomes associated with distal radius fracture (DRF) in working-aged patients. The authors hypothesized that the majority of patients experience no permanent loss of function when measured with patient-rated wrist evaluation (PRWE).

METHODS

This was a retrospective cohort study of patients with a DRF aged between 18 and 65 years. The primary outcome measure was PRWE score at a minimum of 4 years after DRF. Secondary outcome measures were pain catastrophizing scale (PCS) and radiographic measurements.

RESULTS

Of 201 patients included, 179 were primarily treated non-operatively with a 5-week cast treatment and 22 were primarily operated. The mean follow-up duration was 5 years. The mean PRWE score was 10.9 (95% confidence interval 8.4, 13.4) and median PRWE was 3.5 (interquartile range, 0.0-13.0). There was minor correlation between PCS and PRWE score (correlation coefficient [CC] 0.3), and between PRWE score and dorsal angulation of the fracture measured after closed reduction (CC 0.2) and in one-week follow-up radiographs (CC 0.2).

CONCLUSIONS

Working-aged patients seem to gain nearly normal wrist function after DRF in longer follow-up. Pain catastrophizing appears to correlate with long-term treatment outcome.

Impact of the COVID-19 pandemic on the trauma and orthopaedic department at level one Major Trauma Centre in the republic of Ireland

The Coronavirus Disease (COVID-19) has been identified as the cause of a rapidly spreading respira- tory illness in Wuhan, Hubei Province, China in early December 2019. Since then, the free movement of people has decreased. The trauma-related injuries and the demand on the trauma and orthopaedic service would be expected to fall. The aim of this study to examine the impact of the COVID-19 pandemic on a level 1 Trauma Centre in the Republic of Ireland (ROI). Patients admitted to the Trauma & Orthopaedic (T&O) Department at Cork University Hospital (CUH) and the South Infirmary Victoria University Hospital (SIVUH), and their associated fracture patterns and management, between 01/03/20 and the 15/04/20 were documented and compared to the patient admissions from the same time period one year earlier in 2019. The total number of T&O operations performed decreased by 10.15% (P= 0.03)between the two time periods. The number of paediatric procedures fell by 40.32% (P= 0.15). Adult Distal radius and paediatric elbow fractures (excluding supracondylar fracture) increased by 88% and 13% (P= 0.19), (P= 0.04) respectively. Hip fractures remained the most common fracture-type admitted for surgery. The COVID-19 crisis has to lead to a decrease in the total numbers of trauma surgeries in a major trauma centre in the ROI. This decline is most evident in the number of paediatric and male adult patients presenting with fractures requiring operative management. Interestingly, fractures directly related to solo outdoor activities, such as running or cycling, as well as simple mechanical falls like ankle, distal radius, elbow, and hand fractures all increased. Irish males were more compliant with outdoors restrictions than females.

An Analysis of the Impact of Timing and Technique on Outcomes after Surgery for Distal Radius Fractures: The Wrist and Radius Injury Surgical Trial Collaborative Study

BACKGROUND

Surgical treatment of closed distal radius fractures varies based on treatment, surgeon schedule, and patient preferences. The authors examined how timing and technique impact surgeon-perceived procedural difficulty and quality of reduction, outcomes, and complications.

METHODS

This was a retrospective study of participants in the randomized, multicenter Wrist and Radius Injury Surgical Trial with isolated unstable distal radius fractures. Participants were randomized to treatment with a volar locking plate system, closed reduction and percutaneous pinning, or external fixation. The authors analyzed surgeon-perceived procedural difficulty and reduction quality based on time to operation.

RESULTS

Of 184 participants, 88 underwent surgery less than 7 days after fracture (mean, 4.6 days) and 96 underwent surgery at more than 7 days after fracture (mean, 12.3 days). Surgery performed at more than 7 days was rated more difficult versus surgery at less than 7 days [4.6 versus 3.8 of 10 (1 = easiest); p = 0.05]. When the volar locking plate technique was performed, there was no difference in surgeon-perceived difficulty or reduction quality between the groups; however, surgeons performing closed reduction and percutaneous pinning more than 7 days after injury reported greater procedure difficulty (4.1 versus 2.9; p = 0.05) and poorer reduction quality compared to less than 7 days (7.2 versus 8.1; p = 0.03). Participants who underwent surgery at less than 7 days scored 8 and 7 points greater on the Michigan Hand Outcomes Questionnaire Satisfaction (p = 0.05) and Activities of Daily Living (p = 0.03) domains, respectively.

CONCLUSIONS

Surgery performed less than 7 days after fracture leads to better surgeon-perceived reduction quality and less procedural difficulty. If surgery cannot be performed before 7 days, the authors recommend patients undergo treatment with the volar locking plate system, given the comparable level of surgeon-perceived procedural difficulty and reduction quality when surgery was performed less than 7 days after injury.

CLINICAL QUERSTION/LEVEL OF EVIDENCE

Therapeutic, III.

Predicting fracture outcomes from clinical registry data using artificial intelligence supplemented models for evidence-informed treatment (PRAISE) study protocol

Background

Distal radius (wrist) fractures are the second most common fracture admitted to hospital. The anatomical pattern of these types of injuries is diverse, with variation in clinical management, guidelines for management remain inconclusive, and the uptake of findings from clinical trials into routine practice limited. Robust predictive modelling, which considers both the characteristics of the fracture and patient, provides the best opportunity to reduce variation in care and improve patient outcomes. This type of data is housed in unstructured data sources with no particular format or schema. The “Predicting fracture outcomes from clinical Registry data using Artificial Intelligence (AI) Supplemented models for Evidence-informed treatment (PRAISE)” study aims to use AI methods on unstructured data to describe the fracture characteristics and test if using this information improves identification of key fracture characteristics and prediction of patient-reported outcome measures and clinical outcomes following wrist fractures compared to prediction models based on standard registry data.

Methods and design

Adult (16+ years) patients presenting to the emergency department, treated in a short stay unit, or admitted to hospital for >24h for management of a wrist fracture in four Victorian hospitals will be included in this study. The study will use routine registry data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), and electronic medical record (EMR) information (e.g. X-rays, surgical reports, radiology reports, images). A multimodal deep learning fracture reasoning system (DLFRS) will be developed that reasons on EMR information. Machine learning prediction models will test the performance with/without output from the DLFRS.

Discussion

The PRAISE study will establish the use of AI techniques to provide enhanced information about fracture characteristics in people with wrist fractures. Prediction models using AI derived characteristics are expected to provide better prediction of clinical and patient-reported outcomes following distal radius fracture.

Management of Distal Radius Fractures in Adolescent Patients

BACKGROUND

While management recommendations for distal radius fractures in both young and skeletally mature patients have been generally well-established, controversy still exists regarding optimal management in adolescent patients approaching skeletal maturity. Thus, the goal of this review is to analyze relevant literature and provide expert recommendations regarding the management of distal radius fractures in this patient population.

METHODS

A PubMed search was performed to identify literature pertaining to distal radius fractures in adolescent patients, defined as 11 to 14 years in girls and 13 to 15 years in boys. Relevant articles were selected and summarized.

RESULTS

Distal radius fractures demonstrate significant potential for remodeling of angular deformity and bayonet apposition, even in patients older than 12 years of age. Rotational forearm range of motion and functional outcomes are acceptable with up to 15 degrees of residual angulation. Closed reduction and percutaneous pinning reduces fracture redisplacement but has a high associated complication rate. There is no literature comparing plate versus pin fixation of distal radius fractures in the pediatric population, but in adults plate fixation is associated with higher cost with no improvement in long-term functional outcomes.

CONCLUSIONS

Remodeling can still be expected to occur in adolescent patients, and even with residual deformity functional outcomes after distal radius fractures are excellent. Up to 15 degrees of residual angulation can be accepted before considering operative management. Smooth pins should be considered over plates as first-line operative management for unstable fractures that fail nonoperative treatment.

Impact of percutaneous poking reduction combined with minimally invasive plate internal fixation on foot function and complications of patients with Sanders type II and III calcaneal fractures

OBJECTIVE

To investigate the impact of percutaneous poking reduction (PPR) combined with minimally invasive plate internal fixation on foot function and complications of Sanders type II and III calcaneal fractures (CFs).

METHODS

In this prospective study, 76 patients with Sanders type II and III CFs were randomly divided into the control group (n=38, "L" incision open reduction and plate internal fixation) and the study group (n=38, PPR combined with minimally invasive plate internal fixation (MIPIF)). The operation related indexes, skin necrosis rate, Gissane angle, Bohler angle, calcaneal height and ankle-hindfoot score before and after the operation were compared between the two groups. Complications of the two groups were recorded.

RESULTS

Compared with the control group, the operation time of the study group was significantly prolonged, but the intraoperative blood loss was significantly reduced, and the fracture healing time and hospitalization time were significantly shortened (P<0.05). The skin necrosis rate of the study group was slightly lower than that of the control group without statistical significance (P>0.05). The Gissane angle, Bohler angle and calcaneal height of the two groups increased 6 months after the operation, and the changes in the study group were more obvious than those in the control group (P<0.05). Six months after the operation, the ankle-hindfoot scores of the two groups significantly increased, and the changes of the study group were more significant than that of the control group (P<0.05). The total incidence of postoperative complications in the study group was significantly lower than that in the control group (P<0.05).

CONCLUSION

PPR combined with MIPIF can significantly promote the healing of Sanders type II and III CFs and the recovery of the Gissane angle and Bohler angle, effectively improve the foot function of patients and induce fewer complications, which is worthy of clinical promotion.

Displaced distal radius fracture: reduction, follow-up, and clinical outcomes : learning from a pragmatic approach during the 2020 COVID-19 lockdown transition

Aims

Displaced distal radius fractures were investigated at a level 1 major trauma centre during the COVID-19 2020 lockdown due to the implementation of temporary changes in practice. The primary aim was to establish if follow-up at one week in place of the 72-hour British Orthopaedic Association Standards for Trauma & Orthopaedics (BOAST) guidance was safe following manipulation under anaesthetic. A parallel adaptation during lockdown was the non-expectation of Bier’s block. The secondary aim was to compare clinical outcomes with respect to block type.

Methods

Overall, 90 patients were assessed in a cross-sectional cohort study using a mixed, retrospective-prospective approach. Consecutive sampling of 30 patients pre-lockdown (P1), 30 during lockdown (P2), and 30 during post-lockdown (P3) was applied. Type of block, operative status, follow-up, and complications were extracted. Primary endpoints were early complications (≤ one week). Secondary endpoints were later complications including malunion, delayed union or osteotomy.

Results

In P1, 86.6% of patients were seen between days one to three, 26.7% in P2, and 56.7% in P3. There were no documented complications from days one to three. Operative rate was 35.5%, which did not vary significantly (p= 0.712). Primary endpoints occurred between day four to seven, and included one patient each period treated for plaster cast pain. Secondary endpoints in P1 included delayed union (one patient). During P2, this included malunion (one patient), a pressure sore (one patient) and ulnar cutaneous nerve symptoms (two patients). In P3, malunion was identified in one patient. Mean follow-up was six months (4 to 9) with union rate 96%. Change in block practice varied significantly (p =＜0.05). The risk ratio of complications using regional block (Bier’s) over haematoma block was 0.65.

Conclusion

Follow-up adaptations during lockdown did not adversely affect patient outcomes. Regional anaesthesia is gold standard for manipulation of displaced distal radial fractures.

Cite this article: Bone Jt Open 2021;2(5):338–343.

Kirschner Wire Fixation of Distal Radius Fractures, Indication, Technique and Outcomes

Distal radius fractures are the most common upper extremity fracture that present to US emergency departments. Given the variable presentation, including age and fracture pattern, there are many techniques that have been utilized to treat them. Closed reduction and percutaneous pin (CRPP) fixation remains a viable option in extra-articular and simple intra-articular fracture patterns. CRPP techniques flourished in the mid-twentieth century until the treatment patterns shifted to primarily volar-locked plating in the twenty-first century. Although several meta-analyses have been performed comparing outcomes and complications of CRPP versus alternative methods, controversy remains over which treatments are superior.

Hot Topics in Hand and Wrist Surgery

The field of hand surgery continues to evolve in new and exciting directions. Advances in diagnosis and management for common complaints and complex injuries allow higher-level care, while still being cognizant of the cost of health care delivery. Indications and protocols for past paradigm shifts, such as volar locked plating for distal radial fractures, continue to be honed, and the outcomes seen for modern flexor tendon repairs are impressive. Open questions remain, but promising results for scaphoid nonunion surgery and peripheral nerve reconstruction with processed allograft will continue to shed light on these unsolved problems.

Cast immobilization is non-inferior to volar locking plates in relation to QuickDASH after one year in patients aged 65 years and older: a randomized controlled trial of displaced distal radius fractures

AIMS

To compare operative and nonoperative treatment for displaced distal radius fractures in patients aged over 65 years.

METHODS

A total of 100 patients were randomized in this non-inferiority trial, comparing cast immobilization with operation with a volar locking plate. Patients with displaced AO/OTA A and C fractures were eligible if one of the following were found after initial closed reduction: 1) dorsal angulation > 10°; 2) ulnar variance > 3 mm; or 3) intra-articular step-off > 2 mm. Primary outcome measure was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) after 12 months. Secondary outcome measures were the Patient-Rated Wrist and Hand Evaluation (PRWHE), EuroQol-5 dimensions 5-level questionnaire (EQ-5D-5L), range of motion (ROM), grip strength, "satisfaction with wrist function" (score 0 to 10), and complications.

RESULTS

In all, 89 women and 11 men were included. Mean age was 74 years (65 to 91). Nonoperative treatment was non-inferior to operation with a five-point difference in median QuickDASH after 12 months (p = 0.206). After three and six months QuickDASH favoured the operative group (p = 0.010 and 0.030). Median values for PRWHE were 19 (interquartile range (IRQ) 10 to 32) in the operative group versus ten (IQR 1 to 31) in the nonoperative group at three months (p = 0.064), nine (IQR 2 to 20) versus five (IQR 0 to 13) (p = 0.020) at six months, and two (IQR 0 to 12) versus zero (IQR 0 to 8) (p = 0.019) after 12 months. Range of motion was similar between the groups. The EQ-5D-5L index score was better (mean difference 0.07) in the operative group at three and 12 months (p = 0.008 and 0.020). The complication rate was similar (p = 0.220). The operated patients were more satisfied with wrist function (median 8 (IQR 6 to 9) vs 6 (IQR 5 to 7) at three months, p = 0.002; 9 (IQR 7 to 9) vs 8 (IQR 6 to 8) at six months, p = 0.002; and 10 (IQR 8 to 10) vs 8 (IQR 7 to 9) at 12 months, p < 0.001).

CONCLUSION

Nonoperative treatment was non-inferior to operative treatment based on QuickDASH after one year. Patients in the operative group had a faster recovery and were more satisfied with wrist function. Results from previous trials comparing operative and nonoperative treatment for displaced distal radius fractures in the elderly vary between favouring the operative group and showing similar results between the treatments. This randomized trial suggests that most elderly patients may be treated nonoperatively. Cite this article: Bone Joint J 2021;103-B(2):247-255.

Infection after buried or exposed K-wire fixation of distal radial fractures: a randomized clinical trial

We treated 220 extra-articular distal radial fractures with closed reduction and percutaneous K-wire fixation and randomized K-wire placement to buried or exposed. We analysed the incidence and severity of infection and the mobility of the metacarpophalangeal joints. At 6 weeks postoperatively, 12 patients in the exposed group had infections versus two in the buried group, which was a statistically significant difference. Mobility was statistically but not clinically better in the buried group. One patient in each group had wires removed before fracture healing due to infection, which resulted in malunion. From this study we conclude that, in the treatment of distal radial fractures, it is better to bury the K-wires under the skin, especially when geographical conditions make it difficult to control the patients' adherence to hygiene and postoperative care despite the higher costs incurred with removal of buried K-wires.Level of evidence: II.

Management of Comminuted Distal Radius Fractures: A Critical Analysis Review

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

Surgical comfort and clinical outcomes of MIPO with an extra-short plate designed for distal radius fractures

OBJECTIVES

Volar locking plates (VLPs) are increasingly used for distal radius fractures (DRFs) with minimally invasive plate osteosynthesis (MIPO), but surgery learning curves could be long. The purpose of this study was to assess a new extra-short plate with two locking diaphyseal divergent screws, specifically designed for MIPO, preserving the pronator quadratus muscle.

MATERIALS AND METHODS

This retrospective study consisted of three phases: (i) the evaluation of surgical comfort with the incision size and the duration of 59 consecutive surgeries using the extra-short plate in DRFs; (ii) the verification of the implant ability to maintain radiographic indices compared immediately postoperatively and at consolidation. They included radial inclination (RI), volar tilt (VT) and ulnar variance (UV); (iii) the assessment of clinical outcomes at last follow-up through: pain measured on the visual analogue scale (VAS), QuickDASH score, patient-rated wrist evaluation (PRWE) score, grip strength, range of motion and complications.

RESULTS

In the first phase: mean incision size was 32 mm, and mean operative time was 28.5 min. In the second phase, there was no statistical difference between the two measures of the indices studied. In the third phase, mean follow-up time was 14.2 months, VAS score was 1.1, QuickDASH score was 11.4/100, and PRWE score was 9.5/100. Flexion was 91%, extension was 94%, and grip strength was 86% compared to the contralateral side.

CONCLUSION

The surgical comfort may be related to short operative time and incision. The implant allowed maintaining the radiographic indices without secondary displacement. Functional clinical outcomes were satisfactory. This extra-short plate design belongs to a novel generation of VLPs.

Management of Distal Radius Fractures: Comparison of Three Methods

Introduction

Distal radius fractures are the most common type of all extremity fractures. It is generally accepted that fractures with more than 2 mm step-off in the radiocarpal joint and greater than 10 degrees dorsal tilt should be treated surgically. However, the ideal technique for surgical management is still a point of debate. We performed cross-sectional data analysis to compare the results of three treatments methods - volar locking plate (VLP), external fixation (EF), Kirschner wire (K-wire) - in patients with distal radius fractures, and compared the clinical, functional, and radiological results

Materials and methods

Forty-four patients with distal radius fractures who underwent fixation with VLP, K-wire or EF between 2011 and 2013 were included in the study. All fractures were classified according to the Müller’s Arbeitsgemeinschaft für Osteosynthesefragen (AO) and Frykman's classifications. Routine radiographs were taken at the postoperative three weeks, six weeks, and three months. Radial inclination, volar tilt, radial length and ulnar variance were assessed on the follow-up visits and additionally at the follow -up for the study. The patient-based Disabilities of the Arm, Shoulder and Hand (DASH) score system and the physician-based MAYO scale were used to evaluate functional outcomes. Radiological and functional outcomes between three surgical modalities were compared and statistically analyzed.

Results

The average age at the time of surgery was 52 years (range = 35-69 years). Of a total of 44 patients, 28 were operated with VLP, 11 were with K-wire and five with EF. Satisfactory reduction was achieved in all fractures, and all of the fractures healed. DASH and MAYO scores were similar in all groups. Regarding radiographic parameters, there was no significant difference in radial inclination, volar tilt, radial length and ulnar variance between the treatment modality groups. When evaluated based on fracture geometry, the DASH score was significantly higher in the patients with AO23A type fracture compared to the patients with AO23B and AO23C type fractures. As for MAYO score, all AO23 groups had similar outcomes.

Conclusions

Surgical treatment options VLP, EF, and K-wire provide adequate fixation, satisfactory radiological, and functional results for the management of distal radius fractures of various severities. The optimal treatment approach depends on individual features, and the choice for an internal fixation or closed reduction method for the restoration of wrist function should be evaluated thoroughly by the operating surgeon considering the patient-related variations.

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

Aims

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

Methods

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

Results

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

Conclusion

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

Correlation between patient-reported outcome measures and Single Assessment Numerical Evaluation score in patients treated with a volar locking plate for a distal radial fracture

AIMS

The aim of this study was to compare patient-reported outcome measures (PROMs) and the Single Assessment Numerical Evaluation (SANE) score in patients treated with a volar locking plate for a distal radial fracture.

METHODS

This study was a retrospective review of a prospective database of 155 patients who underwent internal fixation with a volar locking plate for a distal radial fracture between August 2014 and April 2017. Data which were collected included postoperative PROMs (Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) and Patient-Rated Wrist Evaluation (PRWE)), and SANE scores at one month (n = 153), two months (n = 155), three months (n = 144), six months (n = 128), and one year (n = 73) after operation. Patients with incomplete data were excluded from this study. Correlation and agreement between PROMs and SANE scores were evaluated. Subgroup analyses were carried out to identify correlations according to variables such as age, the length of follow-up, and subcategories of the PRWE score.

RESULTS

The Pearson correlation coefficient (r) between PROMs and SANE scores was -0.76 (p < 0.001) for DASH and -0.72 (p < 0.001) for PRWE, respectively. Limits of agreement between PROMs and '100-SANE' scores were met for at least 93% of the data points. In subgroup analysis, there were significant negative correlations between PROMs and SANE scores for all age groups and for follow-up of more than six months. The correlation coefficient between PRWE subcategories and SANE score was -0.67 (p < 0.001) for PRWE pain score and -0.69 (p < 0.001) for PRWE function score, respectively.

CONCLUSION

We found a significant correlation between postoperative SANE and PROMs in patients treated with a volar locking plate for a distal radial fracture. The SANE score is thus a reliable indicator of outcome for patients who undergo surgical treatment for a radial fracture. Cite this article: Bone Joint J 2020;102-B(6):744-748.

Trends in the management of fractures of the distal radius in Ireland

Aims

The aim of this study was to examine trends in the management of fractures of the distal radius in Ireland over a ten-year period, and to determine if there were any changes in response to the English Distal Radius Acute Fracture Fixation Trial (DRAFFT).

Patients and Methods

Data was grouped into annual intervals from 2008 to 2017. All adult inpatient episodes that involved emergency surgery for fractures of the distal radius were included

Results

In 2008 Kirschner-wire (K-wire) fixation accounted for 59% of operations for fractures of the distal radius, and plate fixation for 21%. In 2017, the rate of K-wire fixation had fallen to 30%, and the proportion of patients who underwent plate fixation had risen to 62%.

Conclusion

There is an increasing trend towards open reduction and internal fixation for fractures of the distal radius in Ireland. This has been accompanied by a decrease in popularity for K-wire fixation. DRAFFT did not appear to influence trends in the management of fractures of the distal radius in Ireland. Cite this article: Bone Joint J 2019;101-B:1550–1556