Distal Forearm Fractures Research Articles

The Concentration of Selected Inflammatory Cytokines (IL-6, IL-8, CXCL5, IL-33) and Damage-Associated Molecular Patterns (HMGB-1, HSP-70) Released in an Early Response to Distal Forearm Fracture and the Performed Closed Reduction With Kirschner Wire Fixation in Children.

The evaluation of trauma after surgery through objective analysis of biochemical markers can help in selecting the most appropriate therapy. Thus the aim of the study was the evaluation of the concentration of selected inflammatory cytokines (IL-6, IL-8, CXCL5, IL-33), C-reactive protein (CRP), and damaged-associated molecular patterns (DAMPs): HMGB-1, HSP-70 in the plasma of children in response to bone fracture and 12-14 hours after subsequent surgery performed by closed reduction with percutaneous Kirschner wire fixation (CRKF). The study will answer the question if the CRFK procedure leads to excessive production of inflammatory and damage markers. Blood samples from 29 children with distal forearm fractures were collected 30 min. before CRKF procedure and 12-14 hours after performance of the procedure. The control group was composed of 17 healthy children. IL-6 and CRP concentrations were analyzed using routinely performed in vitro diagnostics tests; the remaining proteins were analyzed with the use of the ELISA method. Increased values of IL-6, CRP, and HSP-70 represented an early inflammatory response to distal forearm fractures classified as SH-II type according to the Salter-Harris classification system. However, the median CRP concentration was within the reference values not indicative of inflammation. The CRKF procedure may be a good solution for the treatment of bone fractures, as damaged associated molecular patterns – HMGB-1 and HSP-70 – did not significantly differ 12-14 hours after the approach was applied as compared to the control group. Moreover, the increase in IL-6 concentration after the CRKF procedure was 1.5-fold to the level before CRKF, while the increase of this marker in response to the distal forearm fracture was 4.3-fold compared to the control group. Based on this data, it appears reasonable to suggest that the CRKF approach caused less damage and inflammatory response in comparison to the response to the fracture itself.

Deformed pediatric forearm fractures: Predictors of successful reduction by emergency providers

Forearm fractures are common pediatric injuries. Most displaced or angulated fractures can be managed via closed reduction in the operating room or in the Emergency Department (ED). Previous research has shown that emergency physicians can successfully perform closed reduction within ED; however, the fracture morphology amendable to ED physician reduction is unclear. The aim of this study is to detail the fracture characteristics associated with successful reduction by ED physicians. We conducted a retrospective study of children (aged <18 years) presenting to the ED of a tertiary care children's hospital (annual census 90,000) between January 2018 and December 2018 with closed distal and midshaft forearm fractures requiring reduction. Data collected included patient demographics, fracture morphology, management, and complications. Successful ED physician reduction was based on predefined criteria. Orthopedic referrals included those patients sent directly to the operating room, closed reductions performed by orthopedic trainees within the ED, and patients requiring orthopedic consultation after failed ED reduction. A total of 340 patients with forearm fractures were included in the study. ED clinicians attempted to reduce 274 (80.6%) of these fractures and were successful in 256/274 (93.4%) cases. Of the 84 orthopedic referrals, 18 were after failed ED clinician attempt, and 66 were ab initio managed by orthopedics (37 in the operating room and 29 in ED). Compared to the fractures with successful ED reduction (n = 256), factors associated with orthopedic referral (n = 84) included: increasing age, midshaft location, higher degree of angulation, and completely displaced fractures. Angulated distal greenstick fractures were most likely to be successfully reduced by ED clinicians. There were no difference in complication rates between the two groups. In this series, fractures most amenable to reduction by ED clinicians include distal greenstick fractures, whereas midshaft and completely displaced fractures are more likely to need treatment by orthopedics.

Redisplacement of paediatric distal radius fractures: what is the problem?

PurposeDistal radius fractures represent one of the most common fractures in children. Our purpose is to analyze risk factors for redisplacement in children with distal radius fractures treated by means of closed reduction and plaster cast immobilization.MethodsRetrospective study, including children under the age of 17 years, who underwent closed manipulation and cast immobilization for a distal third radius fracture, between 2012 and 2015. Preoperative radiographs were reviewed for initial translation, angulation and shortening, distance of the fracture from the physis, degree of fracture obliquity and the presence of an ulna fracture. Postoperative radiographs were analyzed for translation, angulation and shortening, as well as the quality of closed reduction. Cast index, gap index and three-point index, were measured on the postoperative radiographs. Redisplacement and re-intervention during follow-up were registered.ResultsA total of 26 patients were included in this study. Comparison between post-reduction and immediate post-cast removal radiographs did not show any statistically significant difference between translation or shortening. Coronal (p = 0.002) and sagittal (p = 0.002) angulation showed a statistically significant difference, but both median values remained below cut-off values for redisplacement. Redisplacement was observed in four patients. Only one patient underwent remanipulation. All four had full remodelling and proper radiological alignment at final follow-up. Quality of reduction was found to be a statistically significant risk factor for redisplacement (p = 0.013).ConclusionClosed reduction and cast immobilization under general anaesthesia yields good results in the treatment of distal forearm fractures in paediatric patients. Quality of reduction was the only risk factor that we found to be predictive of redisplacement.Level of Evidence:Level III – Retrospective comparative study

Fracture risk across a wide range of physical activity levels, from sedentary individuals to elite athletes.

To examine how physical activity is associated with risk of different fracture outcomes across the full range of physical activity. By combining information from three cohort studies and using generalized structural equation modelling, we estimated a continuous unitless latent variable reflecting physical activity that ranged from sedentary through elite athlete levels. Associations between physical activity and fracture outcomes were assessed with proportional hazards regression using restricted cubic splines with the mean physical activity (corresponding to 20-40min walking or bicycling/day or 2-3h exercise/week) as reference. Among 63,980 men and women (49-68years) and during 13years of follow-up, 8506 fractures occurred, including 2164 distal forearm, 779 proximal humerus, 346 clinical spine, and 908 hip fractures. Both lower and higher physical activity was associated with higher risk of any fracture compared to the mean. Physical activity at 1 standard deviation (SD) below the mean, corresponding to walking/bicycling <20min/day or exercising <1-1h/week, was associated with a lower risk of distal forearm fracture (hazard ratio [HR]: 0.92, 95% confidence interval [CI]: 0.85-0.99) and higher risk of hip fracture (HR: 1.24, 95% CI: 1.13-1.37), but no associations were seen above the mean physical activity level for these fractures. Physical activity was not associated with proximal humerus fracture but had a possible U-shaped association with clinical spine fracture. Physical activity was non-linearly associated with fracture risk and the association differed across fracture sites. Up to 2-3h weekly exercise is beneficial for the prevention of hip fracture but may increase the risk of distal forearm fracture.

Development of a Novel X-ray Compatible 3D-Printed Bone Model to Characterize Different K-Wire Fixation Methods in Support of the Treatment of Pediatric Radius Fractures.

Additive manufacturing technologies are essential in biomedical modeling and prototyping. Polymer-based bone models are widely used in simulating surgical interventions and procedures. Distal forearm fractures are the most common pediatric fractures, in which the Kirschner wire fixation is the most widely used operative method. However, there is still lingering controversy throughout the published literature regarding the number of wires and sites of insertion. This study aims to critically compare the biomechanical stability of different K-wire fixation techniques. Different osteosyntheses were reconstructed on 189 novel standardized bone models, which were created using 3D printing and molding techniques, using PLA and polyurethane materials, and it has been characterized in terms of mechanical behavior and structure. X-ray imaging has also been performed. The validation of the model was successful: the relative standard deviations (RSD = 100 × SD × mean−1, where RSD is relative standard deviation, SD is the standard deviation) of the mechanical parameters varied between 1.1% (10° torsion; 6.52 Nm ± 0.07 Nm) and 5.3% (5° torsion; 4.33 Nm ± 0.23 Nm). The simulated fractures were fixed using two K-wires inserted from radial and dorsal directions (crossed wire fixation) or both from the radial direction, in parallel (parallel wire fixation). Single-wire fixations with shifted exit points were also included. Additionally, three-point bending tests with dorsal and radial load and torsion tests were performed. We measured the maximum force required for a 5 mm displacement of the probe under dorsal and radial loads (means for crossed wire fixation: 249.5 N and 355.9 N; parallel wire fixation: 246.4 N and 308.3 N; single wire fixation: 115.9 N and 166.5 N). We also measured the torque required for 5° and 10° torsion (which varied between 0.15 Nm for 5° and 0.36 Nm for 10° torsion). The crossed wire fixation provided the most stability during the three-point bending tests. Against torsion, both the crossed and parallel wire fixation were superior to the single-wire fixations. The 3D printed model is found to be a reliable, cost-effective tool that can be used to characterize the different fixation methods, and it can be used in further pre-clinical investigations.

Власний досвід лікування ушкоджень дистальних метаепіфізів кісток передпліччя

Актуальність. Ушкодження дистальних метаепіфізів кісток передпліччя (ДМЕКП) залишається актуальною медико-соціальною проблемою внаслідок великої кількості (15 % переломів у дорослих) і значного числа ускладнень їх лікування (30 % і понад). Найбільш тяжкі ускладнення (ранні інфекційно-некротичні та пізні порушення регенерації) характерні для технологій відкритої репозиції і накісткового остеосинтезу. Це відбувається через необґрунтоване розширення показань на ті клінічні ситуації (наприклад, масивні внутрішньосуглобові травматичні деструкції), при яких досягнення анатомічної репозиції і надійної фіксації уламків за допомогою пластин і гвинтів видається дуже проблематичним. Для подібних ситуацій методом вибору можуть бути технології позавогнищевої фіксації. Крім того, вимагають уточнення критерії, що розмежовують показання до консервативного і хірургічного лікування. Мета. Шляхом аналізу клінічних результатів лікування 93 пацієнтів з ушкодженнями ДМЕКП об’єктивізувати критерії вибору технологій лікування, за рахунок чого поліпшити його результати. Матеріали та методи. Базою для розробки раціональної тактики лікування ушкоджень ДМЕКП можуть бути критерії нестабільності ушкоджень, на підставі яких із достатньою коректністю можливо розмежувати показання до консервативного та хірургічного лікування. Накістковий остеосинтез, як травматичну і небезпечну щодо ускладнень технологію, слід застосовувати лише в тих випадках, коли інші методики видаються неспроможними (наприклад, при ушкодженнях Бартона). Застосовувати їх слід лише після детального клініко-рентгенологічного аналізу конкретної ситуації, за наявності високого ступеня ймовірності досягнення цілей внутрішньої фіксації. Результати. В результаті застосованих технологій консервативного лікування (35 пацієнтів), зовнішньої фіксації (43 пацієнти) і внутрішньої фіксації (15 пацієнтів) отримано 72 % добрих результатів, 22 % задовільних і 6 % незадовільних (отриманих при консервативному лікуванні). Висновки. Концентрація уваги на класифікаційних ознаках, критеріях нестабільності та індивідуальних особливостях конкретних ушкоджень призвела до значного звуження показань до накісткового остеосинтезу, одночасно підвищивши його результати, що свідчить про обґрунтованість цієї тенденції. Позавогнищевий остеосинтез, що також показав високу ефективність, видається гідною і біологічно виправданою альтернативою занурювальній фіксації. Наявність відчутної кількості негативних результатів консервативного лікування вимагає розширення показань до позавогнищевого остеосинтезу на ті клінічні ситуації, при яких фіксаційний метод виявився неспроможним.

Operative Fixation of Pediatric Forearm Fractures: Does the Fracture Location Matter?

Background Flexible intramedullary nails (FNs) are successfully used to treat pediatric forearm fractures, especially midshaft fractures. Distal forearm fractures have been described as “difficult to manage” with FN insertion. The purpose of this study was to report the clinical and radiographic outcomes of using flexible nails in pediatric forearm fractures and the impact of fracture location on the outcome of the procedure. Methods This is a retrospective review of pediatric patients who presented with forearm fractures that were surgically treated with flexible nails between 2009 and 2018. Patient demographics, fracture location, and classification were reported. Intraoperative and postoperative complications were reported. The primary outcomes were fracture radiographic union, intraop and postop complications, and the need for additional surgical procedures. Results Fifty-nine patients were included, with a mean age of 11 years. All fractures healed with patients regaining full range of motion. The authors were able to use flexible nails successfully in 48/59 (81%) patients. In eleven cases (19%), FN fixation was not able to provide adequate fixation to maintain reduction. The method of fixation was changed from FN insertion to another method in nine cases. In two cases, FN fixation was augmented with another fixation method. Fractures within 3 inches of the distal articular surface were at a higher risk of intraoperative change/augmentation of the fixation method (29%) compared with fractures that occurred more than 3 inches from the distal articular surface (11%). Conclusion The majority of pediatric forearm fractures can be treated successfully with flexible nails. Surgeons involved in treating these fractures should pay attention to distal third fractures. Stabilizing the distally located fractures using FN fixation can be challenging. Surgeons should be prepared to use an alternative fixation method when needed.

Parathyroid Hormone Disturbances in Postmenopausal Women with Distal Forearm Fracture

BackgroundPrimary hyperparathyroidism (PHPT) is a common endocrine disorder with a wide range of adverse effects, such as osteoporosis. Many women are not diagnosed due to asymptomatic disease or vague symptoms but are still at risk of severe adverse effects. Early identification of patients with PHPT is therefore of importance. The aim of this study was to determine PHPT prevalence among postmenopausal women with a distal forearm fracture.MethodsRecruitment was conducted in conjunction with the occurrence of a distal forearm fracture at Karolinska University Hospital. In total, 161 postmenopausal women were included in a cross-sectional study with repeated evaluations. Analyzes of serum calcium, ionized calcium, phosphate, parathyroid hormone (PTH), and vitamin D were performed. Diagnosis of PHPT was based on clinical evaluations and biochemical definitions of serum calcium and PTH in coherence with previous population prevalence reports.ResultsMean age was 64.7 (9.5) years, serum calcium 2.33 (0.10) mmol/L, ionized calcium 1.25 (0.05) mmol/L and PTH 54 (26) ng/L. PTH was elevated in 32 (20%) women. In total, 11 (6.8%) women were diagnosed with PHPT; 6 with classical PHPT and 5 with mild PHPT. The prevalence of PHPT was significantly increased compared to the population prevalence of 3.4% (p = 0.022).ConclusionScreening postmenopausal women in conjunction with low-energy distal forearm fracture revealed a large number of women with parathyroid disturbance. Evaluation of parathyroid hormone and calcium status in this group of patients seems beneficial.

Costs of patient management over 18 months following a hip, clinical vertebral, distal forearm, or proximal humerus fragility fracture in France—results from the ICUROS study

This prospective observational study assessed the costs related to patient management over the 18-month period following the event of a hip, clinical vertebral, humeral, or distal forearm fracture in France. Individuals aged ≥ 50years old with the diagnosis of a fragility fracture in six French University Hospitals were enrolled in the International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS). All resources used over the defined period and related to fracture and the underlying osteoporosis management were collected by questionnaires at baseline, 4months, 12months, and 18months. Information was collected by direct or phone contact completed by patients' records and interviews of partner, family, and general practitioners. Costs were estimated from a societal perspective, including direct and indirect costs. We implemented recursive partitioning analysis (RPA), a statistical learning algorithm to identify predictors of costs. Four hundred thirty-one patients (mean age 72.5years; 84.6% women) were evaluated. Among them, 17.6% had a prior fracture in the last 5years. Approximately half of the whole group lived alone in the community, and 56.8% were from a low- or middle-income category. Over the 18-month period of evaluation, total costs (including initial fracture-related and follow-up ones) were 23 926 €, 14561 €, and 6 905 € for the hip, clinical vertebral, and distal forearm fracture, respectively. Over a year, costs related to a humeral fracture were 10 319 €. The RPA identified mobility impairment prior to fracture as a predictor of increase in costs related to fracture. Our study for the first time prospectively assessed total costs related to the four main osteoporotic fractures in France. It appears that their levels were much higher than previous estimates, raising the burden of osteoporosis-related fractures on public health expenditures.

Site-Specific Volumetric Skeletal Changes in Women with a Distal Forearm Fracture.

Purpose To assess site-specific volumetric bone and muscle changes, as well as demographic and biochemical changes, in postmenopausal women with a low-energy distal forearm fracture. Methods In a cross-sectional case-control study, postmenopausal women with a distal forearm fracture were compared with age- and gender-matched controls. In total, 203 postmenopausal women (104 cases and 99 controls), with a mean age of 65 years, were included. Measurements included peripheral quantitative computed tomography (pQCT) and dual-energy X-ray absorptiometry (DXA) as well as blood sampling and questionnaires. Results Forearm trabecular volumetric BMD and total BMD assessed with pQCT were significantly lower in fracture cases compared to controls (p < 0.001). Significantly higher cross-sectional area, lower cortical BMD, and lower cortical thickness were seen in women with fracture (p < 0.033, p < 0.001, and p < 0.001, respectively). Postmenopausal women with fracture had significantly lower hip and spine areal BMD assessed with DXA (p < 0.001). Activity level was higher and a history of falling was more frequent in women with fracture (p < 0.019 and p < 0.001, respectively). Vertebral fracture was observed in 24 women (22%) with a distal forearm fracture. Muscle area, muscle density, PTH, and 25OHD did not differ between fracture cases and controls. Conclusion A distal forearm fracture was associated with site-specific and central bone changes. Postmenopausal women with fracture had a larger bone area in combination with a thinner cortex and lower site-specific total BMD. In addition, women with fracture had a higher activity level, an increased occurrence of previous fall accidents, and a high prevalence of vertebral fractures. Forearm muscle composition, PTH, and 25OHD were not associated with forearm fracture. Fracture preventive measures following a low-energy distal forearm fracture seem beneficial.

Evaluation of Geriatric Fractures Admitted to the Emergency Department According to Years and Seasons

Abstract&#x0D; Objective: With the rapidly increasing and diversifying elderly population of industrialized countries, the incidence of geriatric fractures is gradually increasing. The aim of this study is to evaluate the distribution of geriatric fractures according to the prevalence, age, sex, season and years. &#x0D; Material and Method: Analyzes of geriatric fractures in patients aged 65 and over who were admitted to our emergency department between 2015 and 2020 were performed according to the most common fracture locations (hip, distal forearm, proximal humerus and ankle). The distribution of these fractures by age, gender, seasonal characteristics and years was evaluated&#x0D; Results: A total of 370 cases (168 male, and 202 female patients) with an average age of 79.5years were included in the study. The most common fracturestypes in order of decreasing frequency were fractures of the hip (51.6%), distal forearm (25.1%), proximal humerus (12.4%) and ankle (10.8%). The incidence of distal forearm fractures was significantly higher in females than males (p = 0.001), but any statistically significant difference was not found between genders regarding other fractures (p&gt; 0.05). It was observed that the incidence of hip fractures was significantly higher in the people aged 86 years and over, while the other fractures were more frequently seen in the 65-75 age group. A seasonal feature was not observed in all fractures. The highest rate of hip fractures was seen in the year 2020. There was no difference in the distribution of other types of fractures over the years&#x0D; Conclusion: It has been concluded that the incidence of geriatric fractures increases relatively in conditions of social isolation and does not show seasonal characteristics in our region. We are of the opinion that a good management strategy should be determined characterized with both the isolation of these patients and their early treatment and discharge in disasters as pandemics, and the incidence of geriatric fractures that can be mortal with advancing age and higher life expectancy should be very well known.

FUNCTIONAL OUTCOME OF PROXIMAL HUMERUS FRACTURES TREATED WITH OPEN REDUCTION AND INTERNAL FIXATION WITH A LOCKING COMPRESSION PLATE: A CROSS SECTIONAL STUDY

Proximal humerus fractures account for about 4% to 5% of all fractures. Following distal forearm fracture, proximal humeral fracture is the second most common upper extremity fracture. Kirschner (K)-Wires, external fixation, tension band wiring, and rush pins, intramedullary nails, ORIF with plates, and shoulder hemiarthroplasty have all been offered as therapeutic options. The purpose of this study was to assess the functional outcome and complication rates following internal fixation of proximal humerus fractures using a locking compression plate. Patients over the age of 18 with closed proximal humerus fractures or open proximal humerus fractures (Gustilo and Anderson type I, Type II) received open reduction and internal fixation with locking compression plate in the current study. The participants in this study were 60 people who had a proximal humerus fracture and were treated with open reduction and a proximal humerus locking compression plate. Patients ranged in age from 20 to 85 years old, with a mean age of 51.14 +/- 17.30 years. The age group 36–55 years (37 percent) was the most prevalent, followed by 56–75 years (30 %). The majority of patients (76.7 %) were men who had been in automobile accidents on the right side (83 %) (63 %). According to the Neer classification, the most prevalent type of fracture was a three-part fracture (53 %). The maximum union time observed in this study was 16 weeks, with a minimum of 10 weeks. The average time to union is 12.52 +/- 1.14 weeks. The mean flexion at the end of six months was 121.660 +/- 19.84. The mean internal rotation was 57.330 +/- 8.48, the mean external rotation was 530 +/- 11.98, and the mean abduction was 1180 +/- 19.36. 75.28 +/- 9.66 [Mean +/- SD] is the Mean Constant score. Pain 14.10, ADL 18.26, range of motion 22.46, and power 20 were the mean scores observed on Constant Score for its various aspects. According to the Constant score, the functional outcome of the 60 patients was as follows: 8 patients had excellent outcomes (13%), 34 patients had good outcomes (56.7%), 16 patients had moderate outcomes (26.7%), and two patients had poor outcomes (26.7%) and (3 %). Internal fixation of proximal humerus fractures with a locking compression plate results in anatomical reduction and secure fixation, resulting in a favorable functional outcome.

RSPO3 is important for trabecular bone and fracture risk in mice and humans

With increasing age of the population, countries across the globe are facing a substantial increase in osteoporotic fractures. Genetic association signals for fractures have been reported at the RSPO3 locus, but the causal gene and the underlying mechanism are unknown. Here we show that the fracture reducing allele at the RSPO3 locus associate with increased RSPO3 expression both at the mRNA and protein levels, increased trabecular bone mineral density and reduced risk mainly of distal forearm fractures in humans. We also demonstrate that RSPO3 is expressed in osteoprogenitor cells and osteoblasts and that osteoblast-derived RSPO3 is the principal source of RSPO3 in bone and an important regulator of vertebral trabecular bone mass and bone strength in adult mice. Mechanistic studies revealed that RSPO3 in a cell-autonomous manner increases osteoblast proliferation and differentiation. In conclusion, RSPO3 regulates vertebral trabecular bone mass and bone strength in mice and fracture risk in humans.

Treatment Choice of Complete Distal Forearm Fractures in 8 to 14 Years Old Children.

New surgical techniques have challenged traditional guidelines for nonsurgical treatment in pediatric and adolescent distal forearm fractures. This study was performed to compare outcomes and costs between closed reduction with percutaneous pinning (CRPP) and closed reduction with casting in the treatment of complete distal forearm fractures in children 8 to 14 years old. A retrospective cohort study was performed of 175 displaced distal forearm fractures treated with 2 different methods in the emergency department of a children's trauma center. One hundred and fourteen children were managed using CRPP. The remaining 61 were treated with closed reduction and casting. All patients had initial follow-up radiographs. The quality of reduction and the residual angulation in both the coronal and sagittal planes were recorded. Outcomes included the angulation after reduction, residual angulation at final follow-up, radiation exposure, total immobilization time, days absent from school, total costs, and postoperative complications. The postreduction sagittal plane angulation was significantly lower in the CRPP group (P=0.037). While residual deformity between the groups at the 6-month final follow-up was not significantly different in either the sagittal or coronal planes (P=0.486, 0.726), patients in the nonoperative group received greater radiation than those in the operative group (P<0.001). Patients in the nonoperative group missed fewer classes and sustained lower costs (P<0.001, <0.001). The mean immobilization time in each group was not significantly different (31.4±4.4 vs. 32.8±5.9 d; P=0.227). Although the postreduction quality was a little better and radiation exposure was less in the CRPP group, there was no difference between the 2 groups in angulation, total immobilization time, or complication rates after 6 months. The cost and time absent from school of patients in the nonoperative group was significantly lower than in the operative group. There is no clear advantage to CRPP treatment on outcomes. Therefore, closed reduction and casting is recommended in complete distal forearm fractures of children 8 to 14 years old. Level III-therapeutic study.

Recovery of quality of life is associated with lower mortality 5-year post-fracture: the Australian arm of the International Costs and Utilities Related to Osteoporotic Fractures Study (AusICUROS)

Fragility fractures lead to increased mortality and decreased health-related quality of life (HRQoL) in older adults, although whether an association exists between these outcomes remains uncertain. The aim of this study was to determine whether recovery of HRQoL 12-month post-fracture is associated with lower 5-year mortality. This data linkage study included 524 adults (mean age: 70.2years; 79.2% women) with fragility fracture (150 hip, 261 distal forearm, 61 vertebral, 52 humerus) from the Australian arm of the International Costs and Utilities Related to Osteoporotic fractures Study (AusICUROS). HRQoL was measured using the EQ-5D-3L and all-cause mortality post-fracture was ascertained from the Australian National Death Index(NDI). Cox proportional hazards models were used to assess the association between HRQoL recovery (vs. non-recovery) and all-cause mortality within 5years. Overall, 279 participants (53.2%) recovered to their pre-fracture HRQoL at 12-month follow-up. There were 70 deaths (13.4%) during the 5-year post-fracture. Mortality rate was the highest in hip fracture participants (24.7%), followed by vertebral (16.4%), humeral (13.5%), and distal forearm fracture participants (6.1%). After adjustment for age, pre-fracture HRQoL, and fracture site, mortality risk was lower in participants who recovered to their pre-fracture HRQoL at 12-months compared to those who did not recover (HR = 0.56, 95% CI: 0.33-0.96, p = 0.034). This study provides evidence that HRQoL recovery post-fracture is associated with improved 5-year survival in older adults. The extent to whether current interventions known to improve HRQoL post-fracture could prevent some of these deaths is unknown.

Ultrasound in forearm fractures: a pragmatic study assessing the utility of Point of Care Ultrasound (PoCUS) in identifying and managing distal radius fractures.

Point of Care Ultrasound (PoCUS) is a safe, non-invasive tool for identifying distal radius fractures and can potentially be utilised to assist clinicians to reduce displaced fractures. We aim to test whether PoCUS is accurate to identify distal radius fractures and to determine how PoCUS performs as a tool to confirm a successful fracture reduction. A pragmatic prospective observational study was done in adult patients presenting with forearm injuries resulting in Colle's type distal radius fractures. Adults who presented to the emergency department (ED) with a suspected distal forearm fracture from August 2018 to July 2019 were conveniently sampled for inclusion into the study when a trained ED ultra-sonographer was available. PoCUS scans over the point of maximal tenderness were done using a high frequency linear transducer (7.5-10mHz) prior to X-ray. Patients who required a manipulation of the fracture had a second ultrasound scan immediately after the procedure before the second X-ray was ordered. PoCUS scans were compared to X-rays for accuracy in both groups. Fractures were identified in 44 out of 47 included patients using both PoCUS and X-ray modalities. This showed a sensitivity of 100% (95% CI: 90-100%) and specificity of 100% (95% CI: 31-100%). Fracture manipulation was required in 35 out of 44 patients. The sensitivity and specificity of PoCUS in determining alignment accuracy when compared to X-ray were 100% (95% CI: 83-100%) and 64% (95% CI: 32-88%) respectively. The PPV and NPV were 86% (95% CI: 66-95%) and 100% (95% CI: 56-100%) respectively. Ten out of 44 (23%) patients with distal radius fractures ultimately required an Open Reduction and Internal Fixation (ORIF). Our study supports the use of PoCUS for identifying distal radius forearm fractures and may have some value in assisting clinicians to determine post reduction success. We still advocate using standard X-ray radiographs to confirm successful or adequate cortical alignment following a manipulation.

Sex differences in recovery of quality of life 12 months post-fracture in community-dwelling older adults: analyses of the Australian arm of the International Costs and Utilities Related to Osteoporotic Fractures Study (AusICUROS).

Mortality is higher in men than that in women following a fragility fracture, but it is unclear whether recovery of patient-reported outcomes such as health-related quality of life (HRQoL) differs between sexes. This study aimed to identify sex differences in HRQoL recovery 12 months post-fracture. Data were from the Australian arm of the International Costs and Utilities Related to Osteoporotic Fractures Study (AusICUROS). Participants recruited to AusICUROS were adults aged ≥50 years who sustained a fragility fracture. HRQoL was measured using the EQ-5D-3L at three time-points post-fracture: within 2 weeks (including pre-fracture recall) and at 4 and 12 months. Multivariate logistic regression analyses were undertaken, adjusting for confounders including age, education, income, and healthcare utilization post-fracture. Overall, 695 AusICUROS participants (536 women, 77.1%) were eligible for analysis with fractures at the hip (n = 150), distal forearm (n = 261), vertebrae (n = 61), humerus (n = 52), and other skeletal sites (n = 171). At the time of fracture, men were younger, reported a higher income, and were more likely to be employed, compared with women. For all fracture sites combined, there were no differences between men and women in recovery to pre-fracture HRQoL at 12-month follow-up (adjusted OR = 1.09; 95% CI: 0.75-1.61). When stratified by fracture site, no significant sex differences were seen for hip (OR = 1.02; 95% CI: 0.42-2.52), distal forearm (OR = 1.60; 95% CI: 0.68-3.78), vertebral (OR = 2.28; 95% CI: 0.61-8.48), humeral (OR = 1.62; 95% CI: 0.16-9.99), and other fractures (OR = 1.00; 95% CI: 0.44-2.26). Community-dwelling men and women who survived the 12 months following fragility fracture had a similar trajectory of HRQoL recovery at any skeletal site.

Ultrasound-Guided Distal Forearm Fracture Reduction by Pediatric Emergency Physicians: A Single Center Retrospective Study.

Fracture reduction under point-of-care ultrasound (POCUS) guidance facilitates measurement of residual angulation or displacement that may not be apparent on examination. Point-of-care ultrasound is without patient or staff exposure to ionizing radiation and enlists no additional staffing resources or patient transfer. We conducted a chart review of all children who underwent reduction of a distal forearm fracture in the pediatric emergency department over a 2-year period, from September 2018 to September 2020. We compared length of stay (LOS) with that for orthopedist-performed distal forearm reductions during the study period. We allowed a 6-week lag period to ensure no missed rereduction before analyzing the data. After reduction, children were instructed to follow up with an orthopedist within 1 week. Children with loss of reduction on orthopedic follow-up are referred back through our emergency department for operative reduction. A total of 74 children with 75 distal forearm fractures were identified. Average LOS was 179 minutes for the pediatric emergency medicine physician reductions and 215 minutes for the orthopedist reductions (P < 0.001). Ninety-six percent of reductions were completed with POCUS assistance, and 61% had less than 5 degrees of angulation on postreduction radiography. Only 2.7% of children underwent rereduction. Distal forearm fracture reductions by a pediatric emergency medicine physician under POCUS guidance have a high rate of excellent alignment, low rate of failed reduction, and significantly shorter LOS (P < 0.001) than reductions performed by orthopedists.

What Can We Learn From COVID-19 Protocols With Regard to Management of Nonoperative Pediatric Orthopaedic Injuries?

The COVID-19 pandemic has resulted in significant changes to normal practice in pediatric outpatient orthopaedics, with the instigation of telephone fracture clinic appointments, and the use of self-removable casting. We aim to determine any beneficial or detrimental short-term effects of these changes. All patients referred to fracture clinic from the emergency department during the period March 24, 2020 to May 10, 2020 (national lockdown) were assessed for number of face to face and telephone appointments, number of radiographs performed, time to discharge, use of a removable cast, any cast complications, other complications, reattendance or re-referral after discharge. They were compared with patients referred in the same period in 2019. Follow-up was to 6 months for every patient. In 2019, 240 patients were reviewed and 110 in 2020. Changes in practice resulted in significant differences in the number of face to face appointments per patient [2 (1 to 6) 2019 vs. 1 (0 to 5) 2020 (P<0.00001)] and increase in telephone appointments [0 (0 to 1) 2019 vs. 1 (0 to 2) 2020]. Number of radiographs per patient [1 (1 to 7) 2019 vs. 1 (1 to ) 2020 (P=0.0178)] and time to discharge [29 d (0 to 483) 2019 vs. 16 d (0 to 216) 2020 (P<0.00001)] also reduced significantly. Use of a self-removable casting technique increased significantly (2.4% of casts in 2019 vs. 91.8% in 2020 (P<0.00001). There were no significant differences in complications related to cast or otherwise, unplanned attendance or reattendance after discharge. Use of self-removable casts for supracondylar fractures and for simple injuries (including distal radius, forearm, Toddler's, and ankle fractures) also demonstrated no change in complication rate. Significant potential cost savings of >£185 000 per annum could be demonstrated through clinic appointment and cast removal reductions. Changes to the normal management of pediatric orthopaedic trauma brought about by the COVID-19 pandemic have been demonstrated to be safe in the short term with no increase in complications demonstrated. Potential cost savings are possible both to the health care provider and also to the patient because of reduced hospital attendance. It is feasible to continue these practices for the potential benefits as they appear safe in the short term. Level III-therapeutic study-retrospective comparative study.

The use of real-time sonography-assisted fracture reduction in children with displaced forearm fractures.

Pediatric forearm and wrist fractures are common; furthermore, some are displaced and require manipulation and reduction. The procedure is commonly performed without real-time image guidance and evaluated radiographically after reduction and casting, leading to multiple reduction attempts and malalignment. Although fluoroscopy can provide real-time assessment of fracture alignment during the procedure, it is not readily available in many emergency departments (EDs) and involves radiation exposure. Ultrasonography is an alternative real-time imaging modality that is inexpensive and readily available. The purpose of this study was to determine whether the use of real-time bedside sonography during closed reduction of distal and middle third forearm fractures can decrease the number of reduction attempts and reduce the number of patients requiring surgery. We compared the results of a conventional blind manipulation, fracture reduction, and casting to fracture reduction under real-time ultrasonographic guidance, in patients treated in our ED between 2014 and 2016. Overall, 458 patients with distal or middle third fractures were included. Of these reductions, 289 were performed without real-time imaging (group 1) and 169 under real-time ultrasound guidance (group 2). In group 1, 10% of patients required re-reduction, and 5% of patients needed surgery. In group 2, only one patient (0.6%) required re-reduction and 1% of patients required surgery due to fracture instability. In conclusion, the current study shows that real-time ultrasound-guided forearm fracture reduction is an effective and inexpensive method for correction of displaced forearm and wrist fractures in children, which does not involve any radiation exposure.