Volar fixed plating of distal radius fractures: optimizing plate position for enhanced clinical outcomes

BACKGROUND

The precise influence of plate position on clinical outcomes in the context of volar fixed-angle plating for distal radius fractures is not fully understood. This article aims to investigate the influence of plate position on clinical results, and functional outcomes in patients treated with volar fixed plating for distal radius fractures.

METHODS

A total of 58 patients with 64 distal radius fractures were included in the study. Patient demographics, fracture characteristics, surgical details, and radiographic data were collected. Post-operative AP and Lat views of all patients taken on the first day after surgery were evaluated. Volar Tilt, Radial Inclination and Radial Height measurements were used as reduction criteria. In the follow-up, the patients were called for their last control, flexion and extension angles of the wrist and Mayo Wrist Scores, the distance of the plate to the joint line and the angle between the plate and the radial shaft were measured and recorded.

RESULTS

A total of 64 distal radius fractures, with a mean age of 46.9 years, and the mean follow-up period 24.9 months were included in this study. There was a significant relationship between the Radial Inclination and Plate-Shaft Angle variables and the Mayo Wrist Score at a 99% confidence interval. Additionally, a relationship was observed between the Radial Height variable and the Mayo Score at a 90% confidence interval. A significant positive association was observed between radial inclination and achieving a Good-to-Excellent Mayo score (OR = 1.28, 95% CI [1.08-1.51], p = 0.004). Plate distance to joint line demonstrated a marginally significant positive association with a Good-to-Excellent Mayo score (OR = 1.31, 95% CI [0.97-1.77], p = 0.077). Univariate analysis revealed a significant negative association between plate-shaft angle and achieving a Good-to-Excellent Mayo score (OR = 0.71, 95% CI [0.52-0.99], p = 0.045). This negative association remained statistically significant in the multivariate analysis (p = 0.016).

CONCLUSION

Radial inclination, plate distance to joint line, and angle between plate and radius shaft were identified as significant factors associated with improved Mayo Wrist Scores.

Gait characteristics in patients with distal radius fracture using an in-shoe inertial measurement system at various gait speeds

BACKGROUND

Distal radius fractures (DRF) commonly occur in early postmenopausal females as the first fragility fracture. Although the incidence of DRF in this set of patients may be related to a lower ability to control their balance and gait, the detailed gait characteristics of DRF patients have not been examined.

RESEARCH QUESTION

Is it possible to identify the physical and gait features of DRF patients using in-shoe inertial measurement unit (IMU) sensors at various gait speeds and to develop a machine learning (ML) algorithm to estimate patients with DRF using gait?

METHODS

In this cross-sectional case control study, we recruited 28 postmenopausal females with DRF as their first fragility fracture and 32 age-matched females without a history of fragility fractures. The participants underwent several physical and gait tests. In the gait performance test, the participants walked 16 m with the in-shoe IMU sensor at slower, preferred, and faster speeds. The gait parameters were calculated by the IMU, and we applied the ML technique using the extreme gradient boosting (XGBoost) algorithm to predict the presence of DRF.

RESULTS

The fracture group showed lower hand grip strength and lower ability to change gait speed. The difference in gait parameters was mainly observed at faster speeds. The amplitude of the change in the parameters was small in the fracture group. The XGBoost model demonstrated reasonable accuracy in predicting DRFs (area under the curve: 0.740), and the most relevant variable was the stance time at a faster speed.

SIGNIFICANCE

Gait analysis using in-shoe IMU sensors at different speeds is useful for evaluating the characteristics of DRFs. The obtained gait parameters allow the prediction of fractures using the XGBoost algorithm.

Distal radius fractures: Classifications concordance among orthopedic residents on a teaching hospital

BACKGROUND

Several classification systems have been developed to support orthopedic surgeons regarding diagnostic, treatment, or prognostic outcomes of distal radius fracture (DRF). However, the best classification system for this fracture remains controversial. We aimed to identify the reliability of three different DRF classifications among orthopedists in training (medical residents).

METHODS

Orthopedic residents (n = 22) evaluated thirty cases of DRF in anteroposterior and lateral projections in three different periods (0, 6, 12 months). Each radiography was sorted with three different classifications: Frykman, AO/OTA, and Jupiter-Fernandez. All assessments were blinded to the investigators. The inter- and intra-observer reliability was evaluated using the Cohen's kappa coefficient. An additional analysis was performed for a simpler sub-classification of the AO/OTA (27, 9, or 3 groups).

RESULTS

Inter-observer agreement for AO/OTA, Frykman, and Jupiter-Fernandez classifications was slight (k = 0.15), fair (k = 0.31), and fair (k = 0.30), respectively. Intra-observer agreement showed similar results: AO/OTA, k = 0.14; Frykman, k = 0.28; and Jupiter-Fernandez, k = 0.28. When the AO/OTA classification was simplified (9 or 3 descriptions), the inter-observer agreement improved from slight (k = 0.16) to fair (k = 0.21 and k = 0.30, respectively). A similar improvement from slight (k = 0.14) to fair (k = 0.32 and k = 0.21) was detected for intra-observer agreement.

CONCLUSIONS

The more complex the DRF classification system, the more complex is to reach reliable inter- and intra-observer agreements between orthopedic trainees. Senior residents did not necessarily show greater kappa values in DRF classifications.

Elastic stable intramedullary nailing versus Kirschner wire in the treatment of pediatric metaphyseal-diaphyseal junction fractures of the distal radius: a case-control study

BACKGROUND

Several methods have been used for the treatment of pediatric distal radius fractures, such as the elastic stable intramedullary nail (ESIN), Kirschner wire (K-wire), and plate, but there has been no consensus about the optimum method. The purpose of this study was to compare ESIN and K-wire techniques used in metaphyseal-diaphyseal junction (MDJ) fractures of the pediatric distal radius.

METHODS

The data of patients who were treated at a children's hospital affiliated with Shandong University between August 2018 and January 2022 were analyzed retrospectively. The children were divided into the ESIN and K-wire groups. Clinical outcomes were measured by the Gartland and Werley scoring system. Variables were analyzed using a statistical approach between the two groups.

RESULTS

The study included 26 patients, of whom 11 were treated with K-wire and 15 with ESIN. At the final follow-up, all of the fractures were healed. There were no differences in terms of age, sex, fracture location, or wrist function score. However, the ESIN was superior to K-wire in operative time, fluoroscopic exposure, and estimated blood loss (EBL).

CONCLUSIONS

K-wire and ESIN are both effective methods in the treatment of MDJ fractures of the pediatric distal radius. The use of the ESIN technique represents less EBL, fluoroscopy exposure, and operation time compared with K-wire. We recommend osteosynthesis by ESIN rather than K-wires in patients with MDJ fractures of the distal radius.

LEVEL OF EVIDENCE

III, a case-control study.

Silicone radial head prostheses revisited: do they have a role in today's practice? A systematic review of literature on clinical outcomes

BACKGROUND

Silicone radial head prostheses (SRHP) are considered obsolete due to reports of frequent failure and destructive silicone-induced synovitis. Considering the good outcomes of modern non-radial silicone joint implants, the extent of scientific evidence for this negative view is unclear. The aim of this research was to systematically analyze the clinical evidence on complications and outcomes of SRHP and how SRHP compare to both non-SRHP and silicone prostheses of other joints.

METHODS

A systematic literature review was conducted through the Cochrane, PubMed, and Embase databases.

RESULTS

Eight cohort studies were included, consisting of 142 patients and follow-up periods ranging from 23 months to 8 years. Average patient satisfaction was 86%, range of 71%-100%, and 58 complications were seen, but no cases of synovitis. These outcomes were in line with non-SRHP. Four case series with 11 cases of synovitis were found, all due to implant fractures years to decades after implantation. Six systematic reviews of currently used non-radial silicone joint implants showed excellent outcomes with low complication rates.

CONCLUSIONS

Since SRHP have satisfactory clinical results and an acceptable complication rate when selecting a patient group in suitable condition for surgical indications, it is considered that SRHP can still be chosen as a potential surgical treatment method in current clinical practice.

Evaluation of overgrowth in pediatric radius fractures

PURPOSE

Forearm fractures are the most frequent long bone fractures in children. There have been many reports of differences in leg length due to overgrowth in lower extremity fractures. However, reports of such overgrowth in fractures of the upper extremity are rare. The purpose of this study was to investigate the relationship between angulation and overgrowth in pediatric radius fractures. We hypothesized that more angular deformation of the fracture would result in a periosteal transection and more overgrowth.

METHODS

Retrospectively, between 2013 and 2022, 14 patients under 16 years of age (mean age 9.43 years; 10 boys, four girls) with unilateral radius shaft or metaphyseal fracture without physeal injury, and a minimum follow-up of 12 months, were included. Demographic factors were analyzed; age, sex, body mass index (BMI), right or left. We evaluated the radiologic parameters; ulnar variances, degree of angularity before intervention, fracture gap and treatment options. The patients underwent conservative or surgical treatment.

RESULTS

The mean follow-up period was 27.9 months (range, 13-53 months). Eight patients underwent cast treatment, and six patients underwent surgical treatment. The difference in ulnar variances between the unaffected side and fracture side were statistically significant (P < 0.001). Sex, age, left or right, height, weight, and BMI were not statistically significant. The surgical treatment group (P = 0.013) and the sum of the maximum angularity (P = 0.017) were statistically significant. When the sum of the maximum angularity(SMA) was 30° or more, the ulnar variances were statistically significant, compared with the case where the SMA was less than 30°. The clinical results evaluated at the last outpatient follow-up were good in all patients.

CONCLUSIONS

First, this study implies that the degree of angulation of the fracture may affect the overgrowth of the radius in case of radius shaft or metaphyseal fracture, without physeal injury. Second, it implies that the degree of overgrowth may increase with surgical treatment, as opposed to that with conservative treatment.

LEVEL OF EVIDENCE

Level IV, Retrospective study.

The clinical necessity of a distal forearm DEXA scan for predicting distal radius fracture in elderly females: a retrospective case-control study

BACKGROUND

Recent studies have demonstrated that the distal forearm dual-energy X-ray absorptiometry (DEXA) scan might be a better method for screening bone mineral density (BMD) and the risk of a distal forearm fracture, compared with a central DEXA scan. Therefore, the purpose of this study was to determine the effectiveness of a distal forearm DEXA scan for predicting the occurrence of a distal radius fracture (DRF) in elderly females who were not initially diagnosed with osteoporosis after a central DEXA scan.

METHODS

Among the female patients who visited our institutes and who were over 50 years old and underwent DEXA scans at 3 sites (lumbar spine, proximal femur, and distal forearm), 228 patients with DRF (group 1) and 228 propensity score-matched patients without fractures (group 2) were included in this study. The patients' general characteristics, BMD, and T-scores were compared. The odds ratios (OR) of each measurement and correlation ratio among BMD values of the different sites were evaluated.

RESULTS

The distal forearm T-score of the elderly females with DRF (group 1) was significantly lower than that of the control group (group 2) (p < 0.001 for the one-third radius and ultradistal radius measurements). BMD measured during the distal forearm DEXA scan was a better predictor of DRF risk than BMD measured during the central DEXA (OR = 2.33; p = 0.031 for the one-third radius, and OR = 3.98; p < 0.001 for the ultradistal radius). The distal one-third radius BMD was correlated with hip BMD, rather than lumbar BMD (p < 0.05 in each group).

CONCLUSION

Performing a distal forearm DEXA scan in addition to a central DEXA scan appears to be clinically significant for detecting the low BMD in the distal radius, which is associated with osteoporotic DRF in elderly females.

LEVEL OF EVIDENCE

III; case-control study.

Radiocarpal fracture-dislocation: Review of the literature, new classification and decision algorithm

BACKGROUND

Radiocarpal fractures and dislocations are rarely described in the literature. However, the consequences at the functional level are severe, with the loss of almost half of the articular amplitude. The most widespread classification is that of Dumontier, which divides the injury into two categories according to the presence or absence of a fracture. Currently, no classification considers fracture-dislocations in a global and multi-tissue manner; therefore, no therapeutic strategy has been reported.

METHODS

We conducted an exhaustive bibliographic search for cohort or case report articles concerning radiocarpal fracture-dislocations published between 1990 and the present. Only descriptions of the injury were identified (noting the type of fracture, direction of displacement and carpal injuries).

RESULTS

In all, data were collected from 14 retrospective series and 16 case reports involving 218 patients. Thirty-five and 183 cases involved anterior and posterior displacement, respectively. A fracture of the distal radius was found in 183 cases and 35 cases had a dislocation only, with no significant fracture. Among the posterior displacements, 44 isolated styloid fractures, 62 styloid and posterior marginal fractures, 29 bimarginal fractures (large anterior fragment and small posterior fragment) and 31 fractures of all the fragments described by Medoff with impaction of the central pavement were found. Anterior displacement fractures were found in 17 cases (styloid and/or anterior marginal fracture). We were able to group the different traumatic clinical forms according to a six-category classification.

DISCUSSION

A review of the literature highlighted three major components in the management of radiocarpal fracture-dislocations: the bone component, the ligament component and the associated intracarpal lesions. These three components were included in our classification and allowed us to accurately describe all types of radiocarpal fracture-dislocations published in the literature. Authors currently agree on management of the bone component but disagree on that of the ligament component. Particular attention should be paid to intracarpal lesions, which lead to poor outcomes if ignored. Based on our biographical research, we propose a management plan for these complex injuries.

LEVEL OF EVIDENCE

VI.

Ultrasonography: an interesting imaging method for ligament assessment during the acute phase of closed elbow injuries

PURPOSE

To evaluate whether ultrasonography can be used to explore the medial and lateral ligament structures during the acute phase of a closed elbow injury.

METHODS

A single-center, prospective study performed between December 2019 and June 2020, including patients who suffered a radial head fracture or elbow dislocation. Two radiologists did a blinded analysis using ultrasonography of visibility, injury grade, and presence of bone avulsion for the radial collateral ligament (RCL), lateral ulnar collateral ligament (LUCL), annular ligament (AL), and anterior (MCLant) and posterior bundles (MCLpost) of the medial collateral ligament. The inter-rater agreement was calculated. The ultrasonography findings were compared with the intraoperative findings in the patients who subsequently underwent surgery.

RESULTS

Forty patients were included (28 radial head fractures and 12 elbow dislocations). The inter-rater agreement was strong for all the study parameters (kappa between 0.65 and 1), except for the visibility of the LUCL (kappa 0.52) and the visibility and appearance of the MCLpost (kappa 0.54 and 0.47, respectively). The injured ligaments were thicker than their contralateral counterparts (p < 0.05). In the 10 patients who underwent surgery, the radiological-surgical correlation was 100% for the RCL and medial ligaments and 70% for the LUCL.

CONCLUSION

Ultrasonography is a reproducible examination that can be used to assess the damage to elbow ligaments during the acute phase following an injury. This examination could be incorporated into the exploration protocol for elbow injuries during the preoperative assessment and to adapt the treatment.

Ulnar Nerve Injury Following Distal Radius Fracture Assessed by Ultrasonography: Management of an Ulnar Nerve Lesion

A fracture of the distal radius with an associated injury to the ulnar nerve is rare. The management of the ulnar nerve lesion is unclear. We present a patient with a closed distal radius fracture related to an injury to the ulnar nerve associated with diminished sensation and a claw deformity. This was assessed by ultrasonography (US) that showed the nerve to be in continuity without any evidence of compression. The nerve was deviated towards the volar side at the distal end of the ulna and was enlarged at the same point. Open reduction and internal fixation was performed for the fracture. Emergent nerve exploration was not performed. The function of the ulnar nerve was completely restored at 16 weeks after injury. In cases presenting with ulnar nerve injury, we recommend US to evaluate the condition of the ulnar nerve. Nerve exploration should be performed when neurological deficits were found on US or symptoms did not recover over 4 months observation. Level of Evidence: Level V (Therapeutic).

[Comparison of surgical effects between extension and flexion type of distal radius fracture]

OBJECTIVE

To compare therapeutic effects of internal fixation with volar locking plate in treating extension and flexion type of distal radius fracture (DRF).

METHODS

From January 2015 to June 2018, 103 patients with DRF were retrospectively analyzed. According to original fracture displacement direction, patients were divided into extension fracture(Colles) group and flexion fracture (Smith) group. In Colles fracture group, there were 24 males and 44 females aged from 20 to 79 years old with an average of (59.0±13.4) years old;according to AO classification, 9 patients of type A2, 13 patients of type A3, 16 patientsof type C1, 17 patients of type C2 and 13 patients of type C3;the time from injury to operation ranged from 2 to 9 days with an average of (3.9±0.8) days. In Smith fracture group, there were 15 males and 20 females, aged from 27 to 87 years old with an average of (60.1±15.3) years old;according to AO classification, 4 patienst of A2, 7 patients of A3, 14 patients of C1, 5 patients of C2 and 5 patients of C3;the time from injury to operation ranged from 2 to 6 days with an average of (4.1±0.9) days. Operation time, fracture healing time and postoperative complications were recorded between two groups. Disabilities of arm, shoulder and hand (DASH) score at 6 and 8 weeks, 6 and 8 months were used to evaluate functional recovery of affected limbs during each follow up. Volar tilt, radial inclination and radius height were measured at 8 months after operation. Mayo score was measured at 8 months after operation to evaluate recovery of limb function.

RESULTS

All patients were followed up for 8 to 30 months with an average of (14.8±4.3) months, and no difference in follow up between two groups (P> 0.05). There were no statistical differences in operation time, fracture healing time and postoperative complications between two groups(P>0.05). DASH score at 6 and 12 weeks in Colles fracture group were (37.24±5.08) and (19.68±4.55), while in Smith fracture group were (39.05±4.79) and (23.44±4.21);Colles fracture group was better than that of Smith fracture group (P<0.001);while there were no differences in DASH score at 6 and 8 months between two groups (P>0.05). Volar tilt of Smith fracture group (11.1±3.1)° was better than that of Colles fracture group (8.6±4.1) °, and there were no significant difference in radial inclination and radius height between two groups(P>0.05). Also there was no significant difference in Mayo score between two group(P>0.05).

CONCLUSION

Patients with Colles fracture and Smith fracture could receive good reduction and fixation through volar locking plate. The radiographic parameters of both groups recovered satisfactorily after operation. Recovery of volar tilt of Smith fracture group is better than that of Colles fracture group, and early recovery function of Colles fracture group is better than that of Smith group, but there is no significant difference in long-term wrist joint function and incidence of postoperative complications between two groups.

Is pronator quadratus repair necessary to improve outcomes after volar plate fixation of distal radius fractures? A systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis was conducted to compare functional outcomes with or without pronator quadratus (PQ) repair after volar plate fixation of distal radius fractures.

METHODS

An electronic search was conducted for PubMed, Embase, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials) and Google Scholar databases up to 15th January 2020. Both retrospective case-control and randomised control trials (RCTs) were included.

RESULTS

A total of 6 studies met the inclusion criteria. 4 were RCTs and 2 were retrospective studies. The primary outcome was the difference in the Disabilities of the Arm, Shoulder, and Hand (DASH) scores between the two groups. On analysis of 203 patients with PQ repair and 180 patients with no repair, our results indicated no statistical significant difference in DASH scores between the two groups (SMD: 0.43, 95% CI: -0.12 to 0.98, I²=85%, p=0.12). Also, meta-analysis did not demonstrate any difference in grip strength (SMD: -0.10, 95% CI: -0.53 to 0.33, I²=64%, p=0.64) and pronation strength (SMD: -0.02, 95% CI: -0.82 to 0.78, I²=82%, p=0.96) with or without PQ repair. The pooled analysis did not demonstrate any benefit of PQ repair in improving postoperative ROM.

CONCLUSION

Our results indicate that repair of PQ muscle may not be necessary after volar plate fixation of distal radius fractures. Further large scale RCTs shall validate our conclusions.

LEVEL OF EVIDENCE

II, systematic review and meta-analysis.

Short- to mid-term outcomes of radial head replacement for complex radial head fractures

Background

The purpose of the current study was to investigate short- to mid-term outcomes and complications following radial head replacement (RHR) for complex radial head fractures and to identify factors associated with clinical outcomes.

Methods

Twenty-four patients with complex radial head fractures were treated by RHR. The mean age of the patients was 49.8 years (range, 19–73 years). Clinical and radiographic outcomes were evaluated for a mean follow-up period of 58.9 months (range, 27–163 months) using the visual analog scale (VAS) score for pain, the Mayo elbow performance score (MEPS), the quick disabilities of the arm, shoulder and hand (Quick-DASH) score, and serial plain radiographs. Complications were also evaluated.

Results

At the final follow-up, the mean VAS score, MEPS, and Quick-DASH score were 0.6±1.1, 88.7±11.5, and 19.4±7.8, respectively. The mean range of motion was 132.7° of flexion, 4.7° of extension, 76.2° of pronation, and 77.5° of supination. Periprosthetic lucency was observed in six patients (25%). Heterotopic ossification was observed in four patients (16.7%). Arthritic change of the elbow joint developed in seven patients (29.2%). Capitellar wear was found in five patients (20.8%). Arthritic change of the elbow joint was significantly correlated with MEPS (P=0.047). Four cases of complications (16.6%) were observed, including two cases of major complications (one stiffness with heterotopic ossification and progressive ulnar neuropathy and one stiffness) and two cases of minor complications (two transient ulnar neuropathy).

Conclusions

RHR for the treatment of complex radial head fractures yielded satisfactory short- to mid-term clinical outcomes, though radiographic complications were relatively high.

Prognostic factors for intramedullary nailing in radial neck fracture in children

INTRODUCTION

Radial fracture accounts for 1% of fractures in children. It is potentially serious, and treatment is controversial. Several studies assessed prognostic factors, only one of which used exclusive intramedullary nailing, despite this being the gold standard.

HYPOTHESIS

Open surgery provides poor functional results in radial neck fracture.

MATERIAL AND METHOD

All patients undergoing reduction and internal fixation of radial neck fracture between 2005 and 2015 were analysed. Inclusion criteria comprised Jeffery type 1 fracture with open growth plate, complete file, and ≥1 year's follow-up. Treatment systematically comprised Métaizeau intramedullary nailing, with crossover to open reduction only in case of failure. Good results were defined as full range of motion and pain-free elbow.

RESULTS

Fifty-six patients were included: 33 girls, 23 boys; mean age, 9 years. On the Judet classification modified by Métaizeau, 4 fractures were grade 2, 29 grade 3, 15 grade 4A and 8 grade 4B. Closed reduction was performed in 48 cases, including 8 with the help of percutaneous leverage effect. Eight required a surgical approach. Twenty-three showed postoperative reduction defect. At a mean 74 months' follow-up, at a mean age of 15 years, 37 patients had reached full skeletal maturity. Sixteen had poor results. Open reduction was associated with poor outcome (p<0.01). Age, initial epiphyseal tilt, associated lesions, immobilisation time, time to nail removal and residual tilt after reduction did not significantly affect outcome (p-values>0.05). Percutaneous leverage effect had no impact on the quality of results (p=1).

DISCUSSION

Open reduction is to be avoided in radial neck fracture. A prospective study is needed to assess remodelling potential according to age.

LEVEL OF EVIDENCE

IV, retrospective study.

Finite Element Analysis of Insertion Angle of Absorbable Screws for the Fixation of Radial Head Fractures

Objective

To investigate the biomechanical effects of different insertion angles of absorbable screws for the fixation of radial head fractures.

Methods

The finite element models used to simulate the fractures were created based on CT scans. Two absorbable screws were used to fix and maintain the stability of the fracture, and the angles between the screws were set to 0°, 15°, 30°, 45°, 60°, 75°, and 90°. A downward force of 100 N was applied at the stress point, which was coupled with the surface, and the distal radius was limited to six degrees of freedom. The direction and location of the applied force were the same in each model. The values of the von Mises stress and peak displacements were calculated.

Results

Under the applied load and different screw angles, the maximum von Mises stress in the screws was concentrated on the surface contacting the fracture surfaces. The maximum von Mises equivalent stress in the screw decreased when the angle increased from 0° (19.54 MPa) to 45° (13.11 MPa) and increased when the angle further increased to 90° (24.63 MPa). The peak displacement decreased as the angle increased from 0° (0.19 mm) to 45° (0.15 mm) and increased when the angle further increased to 90° (0.25 mm).

Conclusion

The computational stress distribution showed that fixation with absorbable screws is safe for patients. Moreover, the minimum von Mises stress and displacements were generated when the angle between the screws was 45°; hence, this setting should be recommended for Mason type II radial fractures.

Prevention of secondary displacement and reoperation of distal metaphyseal forearm fractures in children

BACKGROUND

Metaphyseal distal forearm fractures are common in paediatric patients and treating these fractures by reduction and cast immobilization alone is under debate, since secondary displacement is a frequent complication that often warrants re-intervention. This study was conducted to invest the incidence of secondary displacement and re-intervention for non-displaced and displaced fractures, with or without fixation.

MATERIAL AND METHODS

A retrospective cohort study was conducted analysing all consecutive paediatric patients under the age of 16 with distal metaphyseal forearm fractures throughout a 2-year period. Data were recorded on radiographic characteristics, OTC/AO-classification, type of treatment, reduction technique, surgical interventions and removal of hardware and complications.

RESULTS

200 Patients with displaced metaphyseal forearm fractures were included of which 139 were primarily treated in the emergency room, the other 61 patients were primarily treated in the operating room. 83% Of the patients had a satisfactory reduction in the emergency room and 94% of these patients were treated successfully with casting alone. A total of 84 patients were treated in the operating room of whom 30% underwent reduction and K-wire fixation, and 70% underwent reduction and casting only. 47% Of the patients treated with closed reduction without K-wire fixation in the operating room suffered from secondary displacement, of which 80% needed re-intervention.

CONCLUSION

Metaphyseal forearm fractures can be treated with a very high success rate by closed reduction and casting alone in the emergency room. Reduction and casting of displaced metaphyseal forearm fractures in children that needed treatment in the operating room however, resulted in unacceptable high rate of secondary displacement and commonly required re-intervention. Those patients should therefore be treated by reduction and K-wire fixation.

Efficacy of non-bridging external fixation in treating distal radius fractures

Objective

To investigate the efficacy of non‐bridging external fixation in treating distal radius fractures (DRF) and its effect on wrist joint function.

Methods

The medical records of 207 patients who were treated for DRF between May 2008 and April 2017 in our hospital (age, 18.0–70.0 years; 99 males and 108 females) were retrospectively analyzed. All patients had evident wrist trauma and the diagnosis of DRF was confirmed by imaging tests. A total of 101 patients received bridging external fixation (control group), whereas another 106 received non‐bridging external fixation (study group). At 12 weeks after the procedure, the treatment effect was measured using the Dienst scoring system (rating scale: ≤3 points, excellent; 4–7 points, good; 8–11 points, fair; >12 points, poor), and the wrist joint function was evaluated by Gartland and Werley classification (rating scale: 0–2 points, excellent; 3–8 points, good; 9–20 points, fair; >21 points, poor); meanwhile, the radial length, radial inclination, and palmar tilt were examined by X‐ray. Follow‐up visits were conducted once every 2 weeks for 6 months, and the incidences of complications in the two groups within 6 months after operation were recorded, including incision infection, Kirschner wire loosening, delayed fracture healing, and arthritis.

Results

There were no differences in the sex ratio, mean age, mean injury period, Arbeitsgemeinschaft fur osteosynthesefragen classification, and cause of fracture between the two groups (all P > 0.05). In terms of the treatment effects, the study group had a higher percentage of excellent results (P < 0.001) and lower percentages of fair and poor results (P = 0.002, P = 0.001) than the control group 12 weeks after treatment, while both groups had similar percentages of good results (P = 0.109). In terms of the score of the wrist joint function, the study group had a higher proportion of excellent result than the control group 12 weeks after treatment (P = 0.029), whereas no intergroup differences in the proportion of good, fair, and poor results were observed (all P > 0.05). After follow‐up for 6 months, the incidences of incision infection, Kirschner wire loosening, delayed fracture healing, and arthritis, as well as the total complication rate were found to be similar between the two groups (all P > 0.05).

Conclusions

Using non‐bridging external fixation for treating DRF allows some level of wrist movement during the early stage of fixation, effectively maintains the radial length, radial inclination, and palmar tilt, and achieves better outcomes than bridging external fixation.

Perception of quality of intraoperative fluoroscopy and the influence on postoperative management: an international survey

PURPOSE

Intraoperative precise visualization of fractures and assessment of the quality of reduction is essential in orthopedic trauma surgery. Fluoroscopic skills will lead to an increased detection rate of minimal abnormalities needing revision intraoperatively. The definition of fluoroscopic skills and the interpretation of acceptable "minimal abnormalities" remains somehow unclear. The purpose of this study was to analyze the subjective quality assessment of intraoperative radiographs (IR) and whether they are influenced by cultural and demographic factors. Furthermore, we aimed to answer the question whether the indication for revision surgery is international comparable or rather influenceable by cultural aspects.

METHODS

Intraoperative radiographs of 30 patients operated for an ankle or radius fracture were selected for an international survey. In total, 22 patients were randomly selected from an already existing database and eligible for inclusion if reduction was accomplished during initial operation without planed revision. Eight patients of this group had undergone an unplanned revision surgery (26.6%). Fifteen orthopedic trauma surgeons from three different countries answered this survey. All raters were senior consultants.

RESULTS

The quality of reduction was rated as good in both the AP (7.95 of 10) and lateral (7.84 of 10) views. The inter-observer reliability was substantially weaker in Country B (kappa of 0.23) compared to Countries A (p value < 0.05) and C (range 0.33-0.43). In only 33% of the cases the raters requested a postoperative radiograph. This was significantly fewer (p value < 0.001) in Country A. The frequency of postoperative requested CT's was comparable between the countries.

CONCLUSION

This study showed acceptable IR assessment in terms of quality rating. Furthermore, it revealed substantial differences in the postoperative decision-making process in different countries, especially regarding the necessity for postoperative radiographs. This suggests that definition for indication of revision surgery is culturally influenced.

Risk factors for fracture redisplacement after reduction and cast immobilization of displaced distal radius fractures in children: a meta-analysis

PURPOSE

Displaced distal radius fractures in children are common and often reduced if necessary and immobilized in cast. Still, fracture redisplacement frequently occurs. This can be prevented by fixation of fracture fragments with K-wires, but until now, there are no clear guidelines for treatment with primary K-wire fixation. This meta-analysis aimed to identify risk factors for redisplacement after reduction and cast immobilization of displaced distal radius fractures in children, and thereby determine which children will benefit most of primary additional K-wire fixation.

METHODS

Eight databases were searched to identify studies and extract data on the incidence of and risk factors for redisplacement of distal radius fractures after initial reduction and cast immobilization in children.

RESULTS

Twelve studies, including 1256 patients, showed that initial complete displacement (odds ratio [OR] 4.69, 95% confidence interval [CI] 2.98-7.39) and presence of a both-bone fracture (OR 1.95, 95% CI 1.34-2.85) were independent risk factors for redisplacement. Anatomical reduction reduced the redisplacement risk (OR 0.14, 95% CI 0.05-0.40). No significant influence on redisplacement risk could be established for female sex, experience level of the attending surgeon, Cast Index < 0.8, Three-Point Index < 0.8 and patient's age.

CONCLUSIONS

For children with a displaced distal radius fracture, the presence of a both-bone fracture, complete displacement of the distal radius and non-anatomical reduction are risk factors for redisplacement after reduction of their initially displaced distal radius fracture. Children with one or more of these risk factors probably benefit most of reduction combined with primary K-wire fixation.

Effect of different multiplanar reformation algorithms on image quality of intraoperative three-dimensional fluoroscopy

Different multiplanar reformation (MPR-512 and -256) algorithms of intraoperative acquired 3-D-fluoroscopy data exist without recommendations for use in the literature. To compare algorithms, 3-D-fluoroscopic data sets of 46 radius fractures were blinded and processed using MPR-256 and -512 (Ziehm, Vision-Vario 3D). Each reformatted data set was analysed to evaluate image quality, fracture reduction quality and screw misplacements. Overall image quality was higher rated in the MPR-512 compared with the MPR-256 (3.2 vs. 2.2 points, scale 1-5 points), accompanied by a reduced number of scans that could not be analysed (10 vs. 19%). Interobserver evaluation of fracture reduction quality was fair to moderate (independent of the algorithm). In contrast, for screw misplacements MPR-depended ratings were found (MPR-256: fair to moderate; MPR-512: moderate to substantial). Optimization of post-processing algorithms, rather than modifications of image acquisition, may increase the image quality for assessing implant positioning, but limitations in evaluating fracture reduction quality still exist.

Rates of neurovascular injury, compartment syndrome, and early infection in operatively treated civilian ballistic forearm fractures

PURPOSE

The purpose of this study is to evaluate the incidence of neurovascular injuries, compartment syndrome, early postoperative infection as well as the injury factors predictive of neurovascular injury following ballistic fractures of the radius and ulna.

METHODS

A retrospective review was performed to identify all ballistic fractures of the radius and ulna in skeletally mature patients over a 5-year period at a single level-1 trauma center. Chart and radiographic review was performed to identify patient and injury demographics, associated neurologic or vascular injuries, and fracture characteristics. Fracture location was measured on computerized imaging software and fractures were grouped into bone(s) segments involved. Proximal, mid-diaphyseal, and distal locations were used for statistical analysis.

RESULTS

Fifty-six extremities in fifty-five patients were identified (mean age 32 years; male to female ratio 9:1). Overall incidence of neurologic injury was 50%, arterial injury 32%, and compartment syndrome 7.1%. Presence of a proximal third forearm fracture was associated with an increased risk for neurologic injury (p < 0.01), with an odds ratio of 5.7 (95% confidence interval, 1.7-18.4). Furthermore, all high velocity/energy ballistic injuries had associated neurologic injuries (p = 0.02).

CONCLUSION

Ballistic forearm fractures result in high rates of neurovascular injury. Fractures caused by high velocity/energy firearms have extremely high rates of neurologic injury when compared with low velocity ballistic injuries. Ballistic fractures involving the proximal third of the radius or ulna are five times more likely to be associated with neurologic injury after a ballistic injury and should be assessed carefully on initial evaluation.

Association of Insulin-like Growth Factor-1, Bone Mass and Inflammation to Low-energy Distal Radius Fractures and Fracture Healing in Elderly Women Attending Emergency Care

OBJECTIVE

Elderly patients suffer fractures through low-energy mechanisms. The distal radius is the most frequent fracture localization. Insulin-like growth factor-1 (IGF1) plays an important role in the maintenance of bone mass and its levels decline with advancing age and in states of malnutrition. Our aim was to investigate the association of IGF1 levels, bone mass, nutritional status, and inflammation to low-energy distal radius fractures and also study if fracture healing is influenced by IGF1, nutritional status, and inflammation.

METHODS

Postmenopausal women, 55 years or older, with low-energy distal radius fractures occurring due to falling on slippery ground, indoors or outdoors, were recruited in the emergency department (ED) and followed 1 and 5 weeks after the initial trauma with biomarkers for nutritional status and inflammation. Fractures were diagnosed according to standard procedure by physical examination and X-ray. All patients were conservatively treated with plaster casts in the ED. Patients who needed interventions were excluded from our study. Fracture healing was evaluated from radiographs. Fracture healing assessment was made with a five-point scale where the radiological assessment included callus formation, fracture line, and stage of union. Blood samples were taken within 24 h after fracture and analyzed in the routine laboratory. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DXA).

RESULTS

Thirty-eight Caucasian women, aged 70.5 ± 8.9 years (mean ± SD) old, were recruited. Nutritional status, as evaluated by albumin (40.3 ± 3.1 g/L), IGF1 (125.3 ± 39.9 μg/L), body mass index (26.9 ± 3.6 kg/m² ), arm diameter (28.9 ± 8.9 cm), and arm skinfold (2.5 ± 0.7 cm), was normal. A positive correlation was found between IGF1 at visit 1 and the lowest BMD for hip, spine, or radius (r = 0.39, P = 0.04). High sensitive C-reactive protein (hsCRP) and leukocytes were higher at the fracture event compared to 5 weeks later (P = 0.07 and P < 0.001, respectively). Fracture healing parameters (i.e. callus formation, fracture line, and stage of union) were positively correlated with the initial leukocyte count and to difference in thrombocyte count between visit 1 and 3.

CONCLUSIONS

In elderly women with low-energy distal radius fractures, an association between IGF1 and lowest measures of BMD was found, indicating that low IGF1 could be an indirect risk factor for fractures. Fracture healing was associated with initial leukocytosis and a lower thrombocyte count, suggesting that inflammation and thrombocytes are important components in fracture healing.

Is there a need for standardized postoperative radiographs after operative treatment of wrist or ankle fractures?

PURPOSE

The purpose of this study was to evaluate the frequency of changes in treatment plan due to standardized postoperative radiographs. A secondary aim was to compare our results with a national benchmark.

METHODS

This is a single-center retrospective case series of 167 consecutive patients, operated with open reduction and internal fixation (ORIF) for distal radius or ankle fractures in 2014. Changes in the treatment protocol were defined as additional CT-imaging, reoperation or other changes as stated in the postoperative instructions. In addition, a national survey was conducted assessing differences between surgeons in different hospitals concerning revision rates.

RESULTS

In 7.2% (12/167) of the patients, a change in the treatment plan was recorded after the standardized postoperative radiographs. 10 patients (6%) were reoperated (three without additional imaging, seven after additional imaging with CT). The results from our survey showed a good assessment concerning the quality of intraoperative imaging (7.85 on a scale from 0 to 10). Concerning the revision rate, there was a trend to lower revision rate of 8.1% in the six observers.

CONCLUSIONS

Standard postoperative radiographs could improve quality of care. Intraoperative standardized radiographic documentation is needed and the perception and acceptance of quality may vary between hospitals.

Intramedullary nails in the treatment of the distal radius fractures

The distal radius fracture is a common injury in old persons. Its treatment remains a critical challenge because of number of cases, the final cost of the procedure, the level of X-ray irradiation, and the demand of technique of fixation in osteoporotic bone. The entire closed procedure requires a strict percutaneous nailing. This offers advantages in terms of postoperative pain, per-operative irradiation, and cost. The main problem was so far the ability to insure a stable reduction in time. This point is discussed with the introduction of the "Nail-o-Flex^®" nail. A continuous series of 83 patients is introduced.

Treatment goals for distal radius fractures in 2018: recommendations and practical advice

The goals of distal radius fracture treatment in patients above 65 years of age would not change over time if the fracture were the only factor to consider. However, people change, and fixation methods also change. Since this fracture heals in nearly every case and volar plates have eliminated the worry of malunion, we are left with two main goals. In active patients with weakened bones, the aim is to help them regain their quality of life as quickly as possible while avoiding iatrogenic conditions. This compromise is possible because of new tools-but at what price?

Hematoma block or procedural sedation and analgesia, which is the most effective method of anesthesia in reduction of displaced distal radius fracture?

Background

Procedure sedation and analgesia (PSA) is often used to alleviate discomfort and to facilitate fracture reduction for patients with distal radius fracture in emergency departments and clinics, but risks of respiratory distress and needs for different levels of monitoring under PSA are still under concern. Hematoma block (HB) is a simple alternative method of providing rapid pain relief during reduction of distal radius fracture. However, there is still in lack of strong evidence to promote HB over PSA in clinical practice. The aim of this study was to compare HB and PSA for adult and pediatric patients during reduction of displaced distal radius fracture to identify the level of pain relief, frequency of adverse effects (AEs), and reduction failure.

Methods

The PubMed, ScienceDirect, Cochrane Library, and ClinicalTrials.gov were searched for studies comparing HB or PSA in distal radius fracture reduction. The search revealed four randomized controlled trials and one non-randomized trial, which included two studies of pediatric subjects and three studies of adult subjects. Subgroup meta-analysis for adult and pediatric groups were specifically performed according to age difference to avoid potential bias.

Results

In the adult group, the effect of HB on post-reduction pain severity was better than that of PSA with significant heterogeneity (Hedges’ g − 0.600, 95% confidence interval (CI) − 1.170 to − 0.029, p = 0.039), although there was no difference on the pain severity during reduction between these two groups with significant heterogeneity (Hedges’ g 0.356, 95% CI − 1.101 to 1.812, p = 0.632). In the pediatric group, the treatment effect on pain severity was significantly better by HB than that by PSA but without significant heterogeneity (Hedges’ g − 0.402, 95% CI − 0.718 to − 0.085, p = 0.013, I² < 0.001%). Most of the reported adverse effects (AEs) include nausea, vomiting, and respiratory distress developed in adult patients treated by PSA. The rates of reported AEs did not significantly differ between HB and PSA in the pediatric group. Additionally, final outcomes of reduction failure did not significantly differ between HB and PSA in both adult and pediatric groups.

Conclusion

Hematoma block is a safe and effective alternative of anesthesia in reduction of distal radius fracture without inferior pain relief compared with PSA among adult and pediatric patients.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-0772-7) contains supplementary material, which is available to authorized users.

Chemical characterization of wound ointment (WO) and its effects on fracture repair: a rabbit model

Background

Wound ointment (WO), a kind of Chinese medicine, can significantly promote fracture healing. The study aimed at analyzing the chemical composition and the effects of WO on fracture of rabbits and tried to explore the corresponding molecular mechanism in cytokine.

Methods

The qualitative and quantitative analysis of WO was conducted by liquid chromatography-mass spectrometry (LC–MS). Fifty-four Zealand mature male rabbits were randomly divided into 3 groups: Control group, Yunnan Baiyao (YB) group and WO group. All the rabbits suffered a fracture of right radius and were then stabilized with an external fixator. Treated with different methods, fracture healing was observed. The bone specimens were subjected to radiograph, immunohistochemistry (IHC) analysis, hematoxylin–eosin staining (HE), western blot and enzyme linked immunosorbent assay (ELISA).

Results

A total of 12 active compositions were detected by LC–MS. Radiographs showed a considerably better bone healing and remodeling of the fracture in WO group. HE experiments showed that a large number of osteoclasts appeared in the early stage when treated with WO. In immunohistochemistry (IHC), western blot and ELISA test, significant increases in vascular endothelial growth factor (VEGF) expression were observed in WO group compared with other two groups.

Conclusions

Wound ointment contained active compositions which efficiently promoted fracture healing through increasing the expression of VEGF.

Trial Registration Not applicable

Electronic supplementary material

The online version of this article (doi:10.1186/s13020-017-0152-y) contains supplementary material, which is available to authorized users.

A 12-case series

Fractures of the head or neck of the radius account for 5% of elbow fractures in adults. Treatment varies between authors. We report a retrospective series of 12 cases of percutaneous reduction of Mason II radial head fracture, without internal fixation. All fractures consolidated, without secondary displacement. There were no postoperative complications. Mean ranges of motion were 136° flexion-extension and 175° pronation-supination. Mean QuickDASH score was 11. Results in the present series were at least comparable to those for other techniques, validating percutaneous treatment as a solution for radial head fracture.

TYPE OF STUDY

Case series.

LEVEL OF EVIDENCE

IV.

[Nerve injuries associated with distal radius fractures]

Nerve damage is a common complication of distal radius fractures. It may be a result of the injury event or be iatrogenic. It is the source of disability and potential handicap. There is little published data on this topic and no study has validated the strategies needed to prevent or manage these nerve-related complications. There is no consensus on treatment. Prevention requires a good knowledge of the various surgical approaches and rigorous fracture fixation technique. The objective of this article is to take stock of recent data from the scientific literature.

The Optimal Rehabilitation Period for Patients with Distal Radius Fractures According to the MCID in DASH Scores; A Preliminary Study

BACKGROUND

The statistical concept of minimal clinically important difference (MCID) enables the interpretation of small but meaningful changes that result from an intervention. This retrospective study aimed to examine the factors that influence the achievement of MCID after a distal radius fracture.

METHODS

A total of 45 patients (mean age: 54.2 ± 16 years) were included. Of these, 27 patients started rehabilitation within 3 days of surgery (Early group), and 18 patients underwent immobilization for 2 weeks after surgery, before starting rehabilitation (Non-early group). Functional outcomes and DASH scores at 4 weeks (baseline) were compared with those measured at 8 and 12 weeks for both groups, to determine whether the MCID had been achieved.

RESULTS

Our results showed that at 8 weeks after surgery in the early group, the grip strength, ulnar flexion, and baseline DASH score were significantly different between the groups that did and did not show an MCID ([Formula: see text]). There was also a significant difference in the baseline DASH score at 12 weeks after surgery ([Formula: see text]). None of these factors were significant in the non-early group. Logistic regression analysis revealed that the DASH score at 4 weeks (baseline) was an independent predictor for achieving a DASH MCID at 8 weeks postoperatively in the early group (odds ratio: 1.193). Those achieving a DASH MCID at 12 weeks postoperatively were completely separated by the baseline DASH score (≥ 29 points).

CONCLUSIONS

If it is assumed that the effectiveness of rehabilitation depends upon achieving the DASH MCID by promoting functional recovery, early initiation might be recommended.

A retrospective, semi-quantitative image quality analysis of cone beam computed tomography (CBCT) and MSCT in the diagnosis of distal radius fractures

OBJECTIVE

To compare image quality and diagnostic validity of CBCT and MSCT for distal radius fractures.

METHODS

35 CBCT and 33 MSCT scans were retrospectively reviewed with a visual grading scale regarding the depiction of cortical bone, trabecular bone, articular surfaces, and soft tissue. The extent and type of artefacts was analyzed. Agreement on AO classification and measurement of cortical disruption and length of the fracture gap was determined. Fracture reduction was evaluated in post-treatment x-rays. Statistical analysis was performed with visual grading characteristics (VGC), chi square tests, and Kendall's coefficient of concordance.

RESULTS

CBCT performed significantly worse for cortical bone, articular surfaces, and especially soft tissue. Trabecular bone showed no significant difference. Significantly more CBCT images showed artefacts. Physics-based artefacts were the most common. CBCT scans also showed motion artefacts. There was no significant difference in agreement on AO classification. The agreement on measurements was substantial for both modalities. Slightly more fractures that had undergone MSCT imaging showed adequate reduction.

CONCLUSION

This initial study of an orthopaedic extremity CBCT scanner showed that the image quality of a CBCT scanner remains inferior for most structures at standard settings. Diagnostic validity of both modalities for distal radius fractures seems similar.

KEY POINTS

• Subjectively, CBCT remains inferior to MSCT in depicting most structures. • Similar diagnostic validity for CBCT and MSCT imaging of distal radius fractures. • CBCT is a possible alternative to MSCT in musculoskeletal imaging. • Visual grading characteristics (VGC) analysis proves useful in analyzing visual grading scales.

Distal radius fracture with associated ulnar head fracture

Ulnar head and neck fractures are rare and the mechanism of injury is not always clear. We describe a case of a distal radioulnar joint (DRUJ) fracture dislocation. The fracture included a distal radius fracture with a vertical ulnar head fracture that was treated with open reduction and internal fixation with a headless screw. We describe the mechanism of injury and approach to the treatment of this injury.

Comparison of intraoperative flat panel imaging and postoperative plain radiography for the detection of intraarticular screw displacement in volar distal radius plate ostheosynthesis

OBJECTIVES

To investigate if intraoperative 3D flat panel imaging improves the detection of radiocarpal intraarticular screw misplacement (RCSM) in comparison to standard postoperative x-ray.

METHODS

In a study on cadaver specimens, we evaluated the sensitivity and specificity to detect RCSM using X-ray, intraoperative 3D-fluoroscopy as well as the digital volume tomography. The gold standard reference was computed tomography.

RESULTS

Sensitivity for the detection of RCSM for X-ray was 58% and specificity 88%. For DVT, the sensitivity to detect RCSM was 88% and the specificity 53%. For 3D-fluoroscopy, the sensitivity for RCSM was 68% and specificity 95%. When combining the methods, the best performance was found, when combining the two intraoperative imaging methods, with a resulting sensitivity of 88% and a specificity of 73%.

CONCLUSIONS

Intraoperative 3D fluoroscopy and digital volume tomography appear to be at least as sensitive and specific to detect RCSM than the regular postoperative radiography in two planes. However, especially discrete screw misplacements can be missed with either method.

LEVEL OF EVIDENCE

Level IV. Diagnostic device study.

Distal radius fractures: an epidemiological review

OBJECTIVE

Distal radius fractures are among the most common fractures encountered in clinical practice. Although multiple epidemiological studies have been done in Western populations, there is a lack of data within Asia. Our study aims to fill this knowledge gap.

METHODS

This study included all patients aged 16 years and above with distal radius fractures seen between November 2008 and May 2009 by the Department of Hand and Reconstructive Microsurgery at the Singapore National University Hospital. A retrospective analysis was done. Information captured included clinical data, hand dominance, AO classification of fractures, mechanism of injury, associated injuries as well as treatment modalities.

RESULTS

Of the 431 fractures, 238 were males, 181 were females. These fractures occur at all ages, peaking at the 50 to 60 years age group. The peak incidence of distal radius fractures in females occurred in the perimenopausal age group, whereas the incidence for males peaked between age of 30 to 50. By AO classification, 53% were type A; 13% were type B and 32% were type C. A fall on the outstretched hand from a standing position is the most common mechanism of injury. As the intensity of the injury mechanism increased, the percentage of type C fractures increased correspondingly. Older patients were more likely to be treated conservatively compared to younger patients. AO severity classification correlated well with the clinician's decision to surgically fix the fracture. No correlation between hand dominancy and fracture site found was found.

CONCLUSION

We compared our data with that of previous similar studies, and found similarities as well as differences in results. Nevertheless, the epidemiogical data gathered in this study has added to our knowledge of distal radius fractures in an Asian population.

Comparison of palmar fixed-angle plate fixation with K-wire fixation of distal radius fractures (AO A2, A3, C1) in elderly patients

The objective of this prospective, randomized, controlled trial was to compare the results of two operative techniques used for the treatment of unstable distal radius fractures in elderly patients classified as AO types A2, A3, and C1. Patients were treated with either fixed-angle volar plates or K-wires using a combined Kapandji and Willenegger technique. The functional results were determined after 3, 6, and 12 months. We included 40 patients aged over 65 years. Twenty-one patients were treated with plate fixation and 19 with K-wire fixation. The functional results, after 1 year, were nearly the same in both treatment groups, suggesting that either method is suitable for the treatment of unstable distal radius fractures of AO types A2, A3, and C1 in elderly patients. Sixteen of 21 patients with plate fixation and 17 of 19 patients with K-wire fixation present good results as assessed by the Castaing score. The median DASH score was three in both groups after 1 year. The patients with plate fixation were able to resume activities of daily living 4 weeks earlier. The most common complication was an intermediate post-traumatic median nerve irritation. Both methods are suitable for the treatment of elderly patients with unstable distal radius fractures of AO types A2, A3, and C1. If early functional post-operative care is important, palmar fixed-angle plate fixation is an ideal treatment approach. Otherwise, K-wire fixation is an effective, minimally invasive method with comparable clinical results.

Results of pronator quadratus repair in distal radius fractures to prevent tendon ruptures

BACKGROUND

Distal radius fractures are one of the the most common adult fractures encountered during the clinical practice of an orthopedic surgeon.12 Although several methods of treatment are suggested for these fractures, there are still controversies about the best treatment approach in the literature. Volar plating of distal radius fracture is a method of treatment which has become increasingly popular. One of the complications of this technique is flexor tendon rupture. The purpose of this study was to evaluate the protectiveness of complete repair of pronator quadratus muscle against flexor tendon rupture.

MATERIALS AND METHODS

From September 2010 to September 2012, a consecutive series of 157 patients who were younger than 60 years with unstable distal radius fractures were included in the study. A standard volar approach to the distal radius was carried out. The radial and distal ends of pronator quadratus muscle were meticulously elevated from the radius and after volar plate fixation of the fracture, pronator quadratus muscle was restored to its normal insertion. We achieved full coverage of the plate with this muscle and followed the patients postoperatively.

RESULTS

A total of 135 patients were studied. The mean age of patients was 34 ± 10 years (range 20-60 years). One 55-year-old diabetic female patient with flexor tendon rupture was identified. The flexor pollicis longus tendon had ruptured 16 months after surgery.

CONCLUSIONS

Pronator quadratus repair should be done in distal radius fracture to protect flexor tendons.

Comparison of Volar and Dorsal approaches for surgical treatment in fracture of proximal half of the radius

Objective: Fracture of the proximal half of the radius shaft can be exposed by either one of volar or dorsal approaches. The aim of this study was to compare the results of volar and dorsal approach for surgical treatment of proximal half fracture of the radius.

Methodology: This prospective study was performed from April 2008 to March 2012 in two teaching hospitals. Seventy adults patients with closed fracture in proximal half of the radius or radius and ulna were operated on and fixed using small plate and screw by volar approach (VA) (39 patients) and dorsal approach (DA) (31 patients). Comparison of the results in both surgical approach were the primary measurement outcome. Duration and time of procedure, rate and time of fracture union and motion of the forearm were assessed at 4 months after operation.

Results: Mean age of the patients with VA and DA was 25.3 and 26.5 years respectively. There was 26 male and 13 female in VD and 22 male and 9 female in DA patients. Radial nerve injury in VA and DA occurred in three and two patients, infection in one and nonunion in one other patient was seen in each group. There was no significant difference in duration of procedure or time of union after both approaches =0.643. Mean rotation of forearm was 135 deg. in VA, and 138 deg. in DA patients at 4 months post surgery.

Conclusion: There was no significant difference in term of fracture union, early complications, and range of forearm rotation between volar and dorsal approach for the fixation of radius fractures in its proximal half.

Functional outcome following intramedullary nailing or plate and screw fixation of paediatric diaphyseal forearm fractures: a systematic review

PURPOSE

Unstable paediatric diaphyseal both-bone forearm fractures requiring fixation have traditionally been treated with rigid internal fixation with plate and screws. Intramedullary stabilisation has grown in popularity over the last 25 years but may be associated with rotational deformity and subsequent loss of pronosupination. This systematic review aims to establish which treatment method provides better functional outcome.

METHODS

A systematic review of the published literature was performed, searching Medline, Embase, Pubmed and the Cochrane Library for English-language studies comparing intramedullary nailing with plate and screws in patients less than 18 years old with both-bone diaphyseal forearm fractures.

RESULTS

Seven studies met the inclusion criteria. They were all retrospective comparative studies (level III or IV). One was age- and sex-matched. Three looked specifically at older children. No study reported a significant difference in functional outcome with either treatment.

CONCLUSIONS

The currently available literature shows no difference in functional outcome between intramedullary nailing and plate and screw fixation, even in older children with less remodelling potential. Intramedullary nailing may therefore be the treatment of choice for simple fracture patterns due to shorter operative time, better cosmesis and ease of removal. Plating may still have a role in more complex injuries.

Ulnar nerve palsy following closed fracture of the distal radius: a report of 2 cases

Ulnar nerve palsy subsequent to a fracture of the distal radius is extremely rare compared to a median nerve injury. The lesion tends to occur in younger patents with a high-energy mechanism of injury and a severe injury pattern consisting of wide displacement, comminution, combined distal ulnar fracture and open fracture. The mechanism of injury can contribute to a direct contusion and traction, compression secondary to prolonged edema and tissue fibrosis, intraneural fibrosis and laceration. We report 2 cases of progressive ulnar nerve palsy subsequent to closed fractures of the distal radius. The neurological symptoms recovered in all cases who underwent nerve decompression and neurolysis at 2 or 3 months after the trauma. It is recommended that cases with high-energy, widely displaced or comminuted fractures of the distal radius be evaluated carefully for ulnar nerve as well as median nerve injury.