Investigation of the parameters affecting the functional results in conservatively followed distal radius fractures

Ipsilateral olecranon and distal radius fracture: A case report

Background: One of the most common injuries encountered in orthopedic practice are Distal Radius fractures. This comprises of 8%−15% of all fractures in adults. The reason for comminuted DER fractures is high-energy trauma in young and low-energytrauma in elderly. They present as shear and impacted fractures involving the articular surface of the distal radius with displacement of the fragments. External fixation for distal radius fracture relies on the principle of Ligamentotaxisin which, a distraction force applied to the carpus aligns the fragments by means of intact ligaments. The length and alignment of fracture fragment is guided by pull and counter pull which are otherwise difficult to control. Objective: To study functional outcome of distal end radius fracture treated by ligamentotaxis with evaluation of functional results according to Disabilities of the Arm, Shoulder and Hand (DASH) score system. Material and Methods: We included 30 patients (Male 24 and Female 6) treated for distal end radius fracture during a period from 2015 to 2017. Patients were evaluated clinically by subjective assessment using DASH Scoring system. Result: After functional evaluation of patients according to the scheduled follow up with mean DASH Score of 76.08 at 1st month, 62.92 at 3rd month and 42.60 at 6th month, and was found to be Highly Significant (p<0.001) among all the compared groups. Conclusion: We concluded that external fixation and ligamentotaxis applied to complex distal radius fractures, when added with augmented K-wire fixation can provide direct augmentation of fracture stability and a good wrist function.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters

Background There is an increasing trend for most surgeons to choose open reduction and internal fixation of simultaneous distal radius and scaphoid fractures; however, it is not clear if there is any evidence to support this. Case Description The purpose of this systematic review was to investigate the evidence for management of simultaneous distal radius and scaphoid fractures. Literature Review We performed searches of the EMBASE and MEDLINE databases (CRD42020167403). We included a total of 20 studies, involving 178 patients with 182 simultaneous fractures of the distal radius and scaphoid. The distal radius fractures were mostly intra-articular (112/182). The scaphoid fractures were mostly undisplaced (120/148) and at the scaphoid waist (152/178). All distal radius fractures went on to unite, and just 2 of 182 scaphoid fractures went on to nonunion. All included studies were retrospective case series, and therefore all were found to have a critical risk of bias due to confounding. The union rate for both the distal radius and scaphoid fractures is high with both operative and nonoperative treatments. Clinical Relevance Although there are no comparative studies to evaluate the most effective treatment, there is evidence to support operative management. Level of Evidence This is a Level IV, systematic review study.

Distal Radius Fracture Risk Reduction With a Comprehensive Osteoporosis Management Program

Objective To diagnose and evaluate soft tissue injuries in intra-articular fractures of the distal radius using arthroscopy. Methods Twenty young patients with displaced intra-articular fractures of distal radius were recruited in this prospective study. Three AO C2 and 17 C3 fractures were included. After arthroscopic examination fractures of distal radius were treated by external fixation with limited internal fixation or open plate fixation. Results Triangular fibrocartilage complex (TFCC) injury was found in 18 patients (90%). Most were isolated Palmer type ID injuries (67%). Scapho-lunate ligament injury was found in two patients: one partial tear (grade Ⅱ) and one complete tear (grade Ⅲ). Follow-ups ranged from 6 to 18 months. At the last follow-up, wrist function was excellent in one patient (67%), good in eight (44%) and fair in 11 (50%). Conclusion TFCC injuries are common in intra-articular fractures of the distal radius while injuries to scapho-lunate ligament are uncommon.

<p>Background: Fractures of lower end radius are most common fractures of the upper extremity. Increased awareness of the complexity of the distal end radius fractures have stimulated a growing interest and promoted new ideas regarding their management. Close reduction and cast immobilization had been the mainstay of treatment of these fractures but poor functional and cosmetic results are not uncommon. The volar plate system has been shown to be reliable for the fixation of distal radius fractures. As open reduction and volar plating ensures more consistent correction of displacement and maintenance of reduction, this prospective study evaluates the anatomical and functional outcome of open reduction and plate fixation in the management of fracture distal end radius.</p> <p>Method: In this study 40 patients with distal end radius fractures were included, informed consent was and clearance from ethical committee of the institute was taken. The study was Prospective, interventional and observational for the methods used for management of the fracture. Patients were evaluated pre operatively and post operatively at the end of first, fourth, sixth week,3 months and then once in 3months up to 12 months.</p> <p>Results: In the prospective study conducted with forty patients,88% anatomical and 93% functional, excellent to good results suggests that stabilizing the fracture fragments with volar plate and screws in the management of the fractures of distal radius, is an effective method to maintain the reduction till union and prevent collapse of the fracture fragments, even when the fracture is grossly comminuted / intra-articular / unstable and / or the bone is osteoporotic.</p> <p>Conclusion: This study concludes that open reduction and internal fixation with volar plating has excellent functional outcome with minimal complications. The procedure is applicable for all types of Frykman fractures in young patients with a good bone stock as well as in elderly osteoporotic patients.</p>

Background:This study aims to investigate the characteristics of concomitant distal radius and scaphoid fractures and determine outcome differences of operative and nonoperative management.Methods:A retrospective search of a level-1 trauma center’s database over a 15-year period (2007-2022) for concomitant distal radius and scaphoid fractures in adult patients was completed. In all, 31 cases were reviewed for mechanism of injury, method of fracture management, distal radius fracture AO Foundation/Orthopaedic Trauma Association classification, scaphoid fracture classification, time to radiographic scaphoid union, time to motion, and other demographics. A multivariate statistical analysis was completed comparing outcomes in operative versus conservative management of the scaphoid fracture in these patients. Outcomes were defined as time to radiographic union and time to motion.Results:In all, 22 cases of operative fixation of the scaphoid and 9 cases of nonoperative management of the scaphoid were reviewed. One case of nonunion was identified in the operative group. Operative management of scaphoid fractures resulted in a statistically significant reduction in time to motion (2-week reduction) and time to radiographic union (8-week reduction).Conclusions:This study demonstrates that operative management of scaphoid fractures in the setting of a concomitant distal radius fracture reduces the time to radiographic union and time to clinical motion. This suggests that operative management is ideal in patients who are good candidates for surgery and desire earlier return of motion. However, conservative management should be considered, as nonoperative care showed no statistical difference regarding union rates of scaphoid or distal radius fractures.

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Distal radius fractures, proximal femur fractures, and ankle fractures are among the most frequently encountered fractures in adult orthopedic surgery. While the work Relative Value Unit (wRVU) system aims to quantify and standardize the value of physician services based on the effort, skill, and time required for different procedures, discrepancies in wRVU allocation among different fracture types remain a topic of concerns, suggesting that it may not reflect physician compensation appropriately. This study aims to evaluate the adequacy of compensation across these three common fractures using the National Surgical Quality Improvement Program (NSQIP) database, with a particular focus on assessing potential undercompensating in ankle fracture management. Methods: The NSQIP database (2020–2022) was used to analyze distal radius, proximal femur, and ankle fractures identified by CPT codes. The ankle fracture group included open reduction and internal fixation (ORIF) for unimalleolar, bimalleolar, and trimalleolar fractures (CPT 27792, 27766, 27814, 27822, 27823, 27829), excluding pilon fractures. Procedures with fewer than 150 cases over three years were excluded. Proximal femur fractures included ORIF and hemiarthroplasty for femoral neck, intertrochanteric/subtrochanteric, and greater trochanter fractures (CPT 27236, 27244, 27245, 27248). All ORIF cases for distal radius fractures were included (CPT 25607, 25608, 25609). Compensation adequacy was assessed using wRVUs, operative time (OT), wRVU/hour, and reimbursement rates ($/hour). Postoperative complications within 30 days, including mortality, readmission, reoperation, and secondary complications (wound issues, infections, thromboembolic, respiratory, renal, and cardiac events), were analyzed to compare procedural risk profiles. Additionally, covariance analysis was conducted to adjust for the effect of complication rates on compensation adequacy. Results: Total 79,336 cases were identified, including 15,507 ankle fractures, 51,955 proximal hip fractures, and 11,874 distal radius fractures. Compared to other fractures, ORIF for ankle fractures had a significantly longer operative time (OT) (89.16 vs. 65.32 vs. 71.21 minutes, P<.001) and lower mean wRVU (10.29 vs. 17.94 vs. 11.55, P<.001) and wRVU/hour (10.37 vs. 21.66 vs. 11.393, P<.001). These trends persisted after adjusting for the rates of complication (mortality, readmission, reoperation, wound complications, and thromboembolic events). Post-hoc analysis confirmed that ankle fractures had significantly lower wRVU and wRVU/hour, as well as longer OT, compared to proximal hip and distal radius fractures. Mortality, readmission, and reoperation rates were highest in the proximal hip fracture group, while wound complication rates were highest in the ankle fracture group. Conclusion: Our review indicates that the current wRVU system may not fully account for the surgical workload involved in ankle fracture management compared to proximal femur and distal radius fractures. Although ankle fracture fixation required significantly longer operative times, its wRVU/hour remained significantly lower. While variations in complication rates could contribute to differences in wRVU allocation, even after adjusting for these factors, the ankle fracture group continued to exhibit disproportionately lower wRVU/hour and extended operative duration. These findings suggest a potential need for revisions to the wRVU scale to better align compensation with surgical effort for ankle fracture fixation. Comparative Analysis of work Relative Value Units in Surgical Treatment of Common Orthopaedic Fractures: Ankle Fractures vs Distal Radius Fractures vs Proximal Hip Fractures

The aim of this study is to illustrate a case in which the use of a dorsal spanning plate followed by volar plating may be indicated in the setting of a complex intra-articular distal radius fracture. Combined dorsal spanning plate and volar plating is a rare procedure reserved typically for comminuted fractures of the distal radius. This case highlights the first reported incidence in which a dorsal spanning plate of a distal radius fracture resulted in the volar displacement of the fragments, requiring subsequent volar plating. In the end, the outcome was favorable, as the follow-up imaging displayed good bone healing and union with minimal complications. A 52-year-old male presented to the ED at our institution following a traumatic fall onto his left upper extremity. Radiographic imaging revealed fractures at the midshaft of the humerus as well as a very distal three-part intra-articular radius fracture. Due to the nature of the patient's distal radius fracture, initial fixation with a dorsal spanning plate was planned. However, follow-up imaging 3 weeks postoperatively revealed volar displacement of his fracture, so the patient underwent open reduction internal fixation with a volar distal radius plate. Follow-up over the next few months displayed a union of the fracture fragments and the dorsal spanning plate was removed 4 months postoperatively with imaging showing no complications. We present this case to highlight the complication of volar displacement that may follow initial dorsal spanning plate fixation of a three-part intra-articular distal radius fracture that can be resolved with the addition of a volar plate, as well as possible indications for combined dorsal spanning plate and volar plate fixation of complex distal radius fractures at the time of initial fixation.

BACKGROUND AND OBJECTIVES: Preservation of the articular congruity is the principle prerequisite for successful recovery, following distal radius fractures. The best method of obtaining and maintaining an accurate restoration of articular anatomy, however, remains a topic of considerable controversy. The main aim of this study is to evaluate the results obtained by treatment of distal end radius fractures by external fixation.\nMATERIALS AND METHODS: This is a prospective controlled study; fifty cases of unstable distal end radius fractures with/without intra-articular extension were treated with uniplanar static type of external fixation using the principle of ligamentotaxis and augmentation by K-wires from July 2013 to December 2016 at our tertiary rural hospital. The age group of the patients is 18–60 years, external fixator was applied for a duration of 6–8 weeks, and cases were followed up for an average of 6–10 months postoperatively.\nRESULTS: Assessed as per Demerit Point System of Gartland and Werley (modified by Sarmiento 1975) for functional results and criteria for anatomical results by Sarmiento (1975) at the end of 6–8 months of follow-up. Excellent anatomical result was seen in 11 patients, good result seen in 32 patients, and fair result seen in five patients with two poor result patients.\nCONCLUSION: External fixation and ligamentotaxis provide better functional and anatomical results in comminuted intra-articular and unstable extra-articular wrist injuries. The functional result of treatment of distal radius fractures not only depends on the anatomical restoration of the articular surface but also depends on the associated soft tissue injuries and articular damage.

Objective To report the effects of surgical treatment of old die-punch fractures of the distal radius. Methods A retrospective study of case series was made of the 21 old die-punch fractures of the distal radius which had been surgically treated from January 2012 to January 2017 at Department of Orthopaedics, Shandong Provincial Hospital. There were 13 males and 8 females, aged from 34 to 63 years (average, 46.9 years). According to the preoperative definite diagnoses by the X-ray and CT images, there were 14 metacarpal compression fractures and 7 dorsal compression fractures. The palmar approach was used in 13 cases, the dorsal approach in 7 and the combined approach in one. Autogenous iliac bone grafting was performed for all the cases. Their preoperative and postoperative Cooney scoring and visual analogue scale (VAS) of the wrist, and postoperative complications as well, were observed and recorded. Results This cohort was followed up for 8 to 14 months (average, 9.2 months). All their postoperative wounds healed by the first intention. Their Cooney functional scores of the wrist were, respectively, 58.5±4.2 and 84.0±3.1 points preoperatively and at the final follow-up, and their corresponding VAS scores 7.6±0.9 and 3.4±1.3 points, showing significant differences between preoperation and the final follow-up (P<0.05). Carpal arthritis was observed in one case. Conclusion For old die-punch fractures of the distal radius, surgical treatment can obviously reduce pain, improve function of the wrist and enhance the quality of life of the patients. Key words: Wrist joint; Fracture fixation, internal; Range of motion, articular; Die-punch fractures

Objective To compare volar plating and nonoperative treatment for senile comminuted fractures of the distal radius. Methods From October 2012 to June 2015, 46 senile comminuted fractures of the distal radius (AO types B and C) were treated surgically or conservatively. Twenty old patients were managed by open reduction and fixation with a volar locked plate. They were 7 men and 13 women, with an average age of 67.9±10.7 years, including 7 cases of AO type 23-B and 13 cases of AO type 23-C. Twenty-six patients were managed with closed reduction and plaster cast. They were 8 men and 18 women, with an average age of 66.2±11.5 years, including 10 cases of AO type 23-B and 16 cases of AO type 23-C. The 2 groups were compared in terms of follow-up time, union time and wrist functional scores and complications. Results There was no significant difference between the 2 groups in follow-up time (P>0.05). Fractures in the 2 groups all united about 11 weeks after surgery. According to Dienst scoring for reduction, the volar plating group had 13 excellent cases, 4 good ones, 2 fair ones and one poor case, with an excellent to good rate of 85.0% while the nonoperative group had 5 excellent cases, 10 good ones, 5 fair ones and 6 poor ones, with an excellent to good rate of 57.7%. A significant difference was shown between the 2 groups (P<0.05). At final follow-ups, the volar plating group had significantly lower Gartland & Werley wrist functional score (2.16±1.82) and complication rate (30.0%, 6/20) than the nonoperative group[6.62±3.78 and 53.8% (14/26), respectively] (P<0.05). Conclusion In treatment of senile comminuted fractures of the distal radius, volar locked plating may lead to better functional recovery and fewer complications than nonoperative management. However, one should take full account of the physical condition and preference of the patient when surgery is chosen. Key words: Radial fractures; Fractures, comminuted; Fracture fixation, internal; Bone plates; Conservative treatment

Diagnostic Performance of Artificial Intelligence for Detection of Scaphoid and Distal Radius Fractures: A Systematic Review

Ankle, distal radius, and proximal femur fractures are among the top three most common fractures. Despite the high prevalence and cost of these fractures, the relative valuation of these common fractures within the current US healthcare system has not been evaluated. This study aims to evaluate whether ankle fracture fixation is adequately compensated for in the hospital setting compared with distal radius and proximal femur fractures, using the National Surgical Quality Improvement Program database. Ankle, distal radius, and proximal femur fracture fixations were identified within the National Surgical Quality Improvement Program database from 2020 to 2022 using Current Procedural Terminology codes. The relative valuation between the three fracture fixations was assessed using operative time, work relative value units (wRVUs), wRVU per hour (wRVU/hr), and reimbursement rates ($/hr). A propensity score-matched analysis was performed including age (±2 years) and sex with the ankle fracture group as a reference. Two matched cohorts were constructed: ankle and (1) proximal femur fracture and (2) distal radius fracture. Covariance analysis including postoperative complications and preoperative comorbidities were performed to adjust for their effect on the valuation of compensation metrics. A total of 15,507 ankle fractures, 51,955 proximal hip fractures, and 11,874 distal radius fractures were included. Compared with other fractures, ankle fracture fixation had a significantly longer operative time (89.16 minutes for ankle vs. 65.32 for proximal hip vs. 71.21 for distal radius; respectively, P < 0.001), lower mean wRVU (10.29 vs. 17.94 vs. 11.55, P < 0.001), wRVU/hr (10.37 vs. 21.66 vs. 11.393, P < 0.001), and reimbursement rate (335.32 vs. 700.75 vs. 385.94, P < 0.001). These trends persisted after adjusting for the rates of preoperative comorbidities and postoperative complication as in propensity score-matched analysis. Our findings suggest that ankle fracture fixation is undervalued in the current wRVU system, pointing to the need to reevaluate wRVU allocation more accurately for the surgical treatment in ankle fracture. Level III.