Open Distal Radius Fractures Research Articles

Comparison of Early Versus Late Debridement Outcomes in the Management of Open Distal Radius Fractures

The optimal timing for surgical treatment of open distal radius fractures remains an area of debate. The purpose of this study was to examine the outcomes of open distal radius fractures treated surgically before or after 24 hours. A multicenter retrospective review was performed on all open distal radius fractures treated over 11 years. Patient demographics, injury mechanism, and initial treatment were recorded. Fracture severity was graded by the Gustilo-Anderson classification. Comparisons were made between those treated surgically within and after 24 hours. Outcomes examined included infection, revision surgery, osteomyelitis, and nonunion. A total of 230 cases met the inclusion criteria. The cohorts of early and delayed surgical intervention were similar with regard to preoperative demographics. The most common mechanism of injury was motor vehicle accident. Approximately 40% of cases were graded as type I, 40% as type II, and 20% as type III. Mean time to debridement in the group treated after 24 hours was 5 days. A mean postoperative follow-up of greater than 6 months was obtained in both cohorts. Similar outcomes were found between cohorts with respect to postoperative infection, revision surgery, osteomyelitis, and nonunion. Similar outcomes with regards to infection, revision, osteomyelitis, and nonunion were found between open distal radius fractures treated emergently versus those managed in a delayed fashion. Patient- and injury-specific factors are important in dictating care. Prognostic IIB.

Association of Timing With Postoperative Complications in the Management of Open Distal Radius Fractures

Background: This study investigates whether open distal radius fractures (ODRFs) treated after 24 hours from time of injury have an increased risk of infection or overall complication profile compared with those treated within 24 hours. Methods: Retrospective review was performed of all patients treated for ODRF over a 6-year period at a single large academic institution. Postoperative complications included surgical site infections, need for revision irrigation and debridement, delayed soft tissue healing, loss of reduction, nonunion, and malunion. Results: One-hundred twenty patients were treated for ODRF. Mean (SD) age at time of injury was 59.92 (17.68) years. Twenty patients (16.7%) had postoperative complications. Regarding mechanism of injury, 78 (65.0%) had a low-energy and 42 (35.0%) had a high-energy injury. Age and fracture grade were not significant factors. Mean (SD) open wound size was 1.18 (1.57) cm. Mean (SD) time from injury presentation to the emergency department (ED) and first dose of intravenous antibiotics was 3.07 (4.05) hours and mean (SD) time from presentation to the ED and operative treatment was 11.90 (6.59) hours, which did not show a significant association with postoperative complications. Twenty-four patients (20.0%) were treated greater than 24 hours after presentation to the ED, which was not significantly distinct from those treated within 24 hours. Conclusion: Patients with ODRFs treated after 24 hours were not associated with a greater risk of postoperative complications. Factors including age, energy and mechanism of injury, and fracture grade did not alter outcome in any statistically significant manner. Level of Evidence: Level IV

Intraoperative O-arm Use for Physeal Bar Excision

Introduction: Growth arrest caused by physeal bar formation in pediatric patients has posed a longstanding challenge in orthopedics. While growth arrest in pediatric distal radius fractures is relatively uncommon, its downstream consequences impact function, pain, and cosmesis. Physeal bar excision can be used to correct and prevent further growth arrest. The results of bar excision have been unreliable due to the difficulty of balancing complete bar resection while minimizing iatrogenic insult to the physis. Materials and Methods: In this article, we present a method utilizing intraoperative computed tomography O-arm for physeal bar excision. Results: A 10-year-old boy sustained an open distal radius fracture that was initially stabilized with plates and screws. Two of these screws were transphyseal and resulted in physeal bars and growth arrest. Due to age and the central location of his bars, bar excision was performed with the addition of intraoperative computed tomography. This resulted in a successful outcome with restoration of longitudinal growth of his distal radius. Discussion: This method offers improved localization of physeal bars intraoperatively and, subsequently, more precise bar excision while minimizing the risk of complications.

Management of Grade 1 Open Distal Radius Fractures: A Survey of Practicing Surgeons.

Introduction Standard of care management for open fractures historically mandates emergent systemic antibiotic administration, followed by urgent irrigation and debridement in the operating room, regardless of injury severity. However, significant controversy exists regarding the specific implementation and importance of these commonly accepted guidelines. We aimed to define differences in the management of grade 1 open distal radius fractures. Methods An anonymous online survey was distributed to attendingsurgeon members of either the Orthopaedic Trauma Association (OTA) between January 2019 and April 2019 or the New York Society for Surgery of the Hand (NYSSH) in January 2019. Results A total of 68 attending surgeons responded to the survey. A total of 24 OTA members and 40 NYSSH members replied and were included in the study. Several factors influenced management in addition to the level of contamination. Of the surgeons,68% stated that litigation was not a major factor of concern. When compared to surgeons who trained in trauma fellowships, more surgeons who trained in hand/upper extremity fellowships considered closed reduction alone as reasonable definitive treatment (when excluding antibiotic administration and debridement considerations, p = 0.024) and oral antibiotics as a supplement to IV antibiotics (p < 0.001). Of the surgeons,90% would nonoperatively treat a patient who presented with a grade 1 open distal radius fracture greater than 72 hours after injury with stable and acceptable alignment on X-rays. Conclusion Some surgeons are willing to deviate from standard-of-care management protocols.

Distal Radius Fracture with Dislocation of the Radioulnar Joint.

The authors report on the case of a 30-year-old male who sustained a wrist injury following a motorcycle accident. Emergency department evaluation revealed a left open distal radius fracture with distal radioulnar joint dislocation. The patient underwent surgical fixation to restore full mobility of his wrist.

Socioeconomic status does not change decision-making in the treatment of distal radius fractures at a level 1 trauma center.

To compare operative rates, total hospital charges, and length of stay between different socioeconomic cohorts in treating distal radius fractures (DRFs). A retrospective cohort study. Large public level 1 trauma center. A retrospective search of all trauma activations over a 7-year period (2013-2020) yielded 816 adult patients diagnosed with DRF. Patients were separated into cohorts of socioeconomic status based on 2010 US Census data and insurance status. DRFs were treated either nonoperatively using closed reduction and splinting or operatively using open reduction and internal fixation, closed reduction percutaneous pinning, or external fixator application. Operative rates of DRF, total hospital charges, and length of stay. Patients who were uninsured or in the low-income socioeconomic cohort had no significant difference in operative rates, total hospital costs, or length of stay when compared with their respective insured or standard income groups. Younger patients and those with OTA/AO type C, bilateral, or open DRFs were more likely to undergo operative intervention. This study demonstrates that low socioeconomic status based on annual household income and insurance status was not associated with differences in operative rates on DRFs, length of stay, or total hospital charges. These results suggest that outcome disparities between groups may be caused by postoperative differences rather than treatment decision-making. Although this study investigates access to surgical care at a publicly funded level 1 trauma center, disparities may still exist in other models of care. Prognostic Level III.

Infection Rate in Type I Open Distal Radius Fractures Surgically Treated >24 Hours Post-Injury: A Comparison Study.

To determine how time to surgical debridement and fixation affects infection and complication rate in type I open distal radius fractures by comparing patients treated within 24 hours with those treated >24 hours post-injury. A retrospective review identified 62 patients who sustained a type I open distal radius fracture that was treated surgically. Patients were stratified into groups based on time to surgical intervention. An additional analysis was performed on patients with an isolated type I open distal radius fracture treated as an inpatient or outpatient. The primary outcome measure was infection rate. Secondary outcome measures were complications, reoperations, and readmissions. Thirty-eight patients underwent surgery ≤24 hours post-injury at an average of 14 hours. Twenty-four patients underwent surgery >24 hours post-injury at an average of 72 hours. There were a total of 9 complications in 8 patients (14.5%). The overall infection rate was 1.6%, with only 1 deep infection occurring in the group treated ≤24 hours post-injury. There were 7 reoperations (11.3%) and 1 readmission (1.6%). No differences were found between groups in any outcome measure. In the 27 patients with an isolated fracture, there were no differences in any outcome measure when treated as an inpatient or outpatient. We suggest that type I open distal radius fractures could be safely treated surgically >24 hours post-injury without increased risk of infection.

Is single-stage minimally invasive plate fixation safe in open distal radius fractures with metadiaphyseal involvement?: Retrospective evaluation of 54 patients.

The aim of this study was to evaluate the safety and results of one-stage surgery in Gustilo grade 1 and 2 open distal radius fractures with metadiaphyseal involvement. This retrospective study included 54 patients with AO-2R3 and metadiaphyseal involvement according to the AO fracture classification. All fractures were treated with a long volar plate using the minimally invasive plate osteosynthesis (MIPO) technique. The patients were divided into two groups as open fracture group (25 patients) and closed fracture group (29 patients), and the groups were compared for their union time and complications and functional and radiological results. There was no statistically significant difference between the groups in terms of clinical and radiographic results (P > .05 for both). The mean union time was 12.77 (range, 8-20) weeks in the open fracture group and 12.75 (range, 8-18) weeks in the closed fracture group. There was no statistically significant difference between the groups in terms of union time (P > .05). Moreover, there was no statistically significant difference between the two groups in terms of major and minor complications. All fractures healed without the need for bone and/or soft tissue grafts. As a result of this study, using with long volar plate immediately minimally invasive plate osteosynthesis might be safely used as a single-stage definitive treatment for Gustilo grade 1 and 2 open distal radius fractures with metadiaphyseal involvement. Level IV, Therapeutic Study.

Is Time Truly of the Essence? Outcomes of Open Distal Radius Fracture Management

BACKGROUND: The standard of care of open distal radius fractures is urgent irrigation and debridement along with operative fixation. Herein, we investigate if open distal radius fractures (ODRF) treated after 24 hours from time of injury have an increased risk of infection or overall complication profile compared to open distal radius fractures treated urgently. METHODS: An IRB-approved retrospective chart review was performed of all patients treated for ODRF over a 6-year period at an academic institution in a large metropolitan city. Post-operative complications included: surgical site infections, need for revision irrigation and debridement, delayed soft tissue healing, loss of reduction, non-union, and malunion. For statistical analyses, nominal data were compared for distributional equality between complication dichotomy via Pearson chi-square or Fisher’s exact test depending on sample size distribution. Ordinal data were tested for ordinal association via exact Kendall’s tau test. Rank equivalency between complication dichotomy was determined for numeric data via Mann-Whitney U tests. All statistical tests were two-sided with p<0.05 considered statistically significant. RESULTS: Ninety-four patients were treated for ODRF with 62% female and 38% male patients included in the cohort. The mean (SD) age at time of injury was 58.6 (17.41) years. Notably, 28% of patients had a history of smoking. Overall, there were 16 patients (16.8%) with post-operative complications: 2 infections, 8 re-operations, 4 wound healing complications, 2 loss of reductions, 7 non-unions, and 1 malunion. Regarding energy and mechanism of injury, 74.4% had a low energy injury and 26.6% had a high energy injury, and this was not statistically significant for any post-operative complications (0.352). Likewise, age (p = 0.197) and fracture grade (p = 0.068) were not statistically significant factors for any surgical complications. The overwhelming majority of patients were treated with irrigation, debridement, and ORIF with volar locking plates. The mean (SD) open wound size was 1.6 (1.66) cm, ulnar sided, and did not correlate with any post-operative complications (p = 0.093). The mean (SD) time from injury presentation to the ER to the first dose of intravenous antibiotics was 4.7 (14.88) hours, and was not statistically significant for any post-operative complications (p = 0.186). The mean (SD) time from presentation to the ER to operative treatment was 19.1 (30.57) hours, and was not statistically significant for the presence of any post-operative complications (p = 0.092). There were 11 patients (11.7%) treated greater than 24 hours after presentation to the ER, which was not significantly distinct from those treated prior to 24 hours (p=1.000). CONCLUSION: Patients with open distal radius fractures treated after 24 hours did not have a greater risk of post-operative complications, including surgical site infections and non-union. Regarding factors that may influence urgent treatment, age, energy and mechanism of injury, and fracture grade were all not statistically significant for any post-operative complications in ODRF management.

Outcomes of Primary Volar Locking Plate Fixation of Open Distal Radius Fractures.

Background: Few studies have reported the outcomes of primary volar locking plate fixation in Gustilo and Anderson type II and IIIA open distal radius fractures. We report the outcomes of treatment of Gustilo and Anderson type II and IIIA open distal radius fractures using primary volar locking plate fixation. Methods: We retrospectively reviewed 24 patients with open distal radius fractures who were treated using primary volar locking plate fixation. The range of motion (ROM) and modified Mayo wrist scores were measured to assess functional outcomes. Radiological outcomes included the bone union period, radial inclination, volar tilt, radial length and ulnar variance. Results: Functional outcomes, including mean ROM in flexion (39.1°) and extension (52.5°), improved following primary volar locking plate treatment. Radiological outcomes were as follows. Mean bone union period, radial length and ulnar variance were 7.8 months, 10.4 and 0.7 mm, respectively. Two patients had superficial wound infection 2 weeks after surgery and one patient had non-union of the radius that required implant removal, autologous iliac crest bone graft and plate re-fixation. Conclusions: Primary volar locking plate fixation is a safe and reliable treatment option for Gustilo and Anderson type II and IIIA open distal radius fractures. By providing firm stabilisation and allowing early ROM exercise, primary volar locking plate fixation resulted in good functional and radiological outcomes. Level of Evidence: Level IV (Therapeutic).

Associations with Discharge to Post-Acute Care Facilities Among Patients Undergoing Open Reduction Internal Fixation of Distal Radius Fractures.

Introduction: Distal radius fractures are a common injury of the hand and wrist that often require intensive rehabilitation. We sought to identify risk factors associated with discharge to a post-acute care facility following distal radius fracture repair. Methods: The 2011 to 2016 National Surgical Quality Improvement Program® (NSQIP) database was queried for all Current Procedural Terminology (CPT) codes that corresponded with open distal radius fracture repair. Patients with concomitant traumatic injuries were excluded. Patient demographics, comorbidities, perioperative factors, laboratory data, and surgical details were collected. Our primary outcome was to determine postoperative discharge destination: home versus a post-acute care facility, and to identify factors that predict discharge to post-acute care facility. Secondary outcomes included unplanned readmission, reoperation, and complications. Results: Between 2011 and 2016, a total of 12,001 patients underwent open distal radius fracture repair and had complete information for their discharge. Of these analyzed patients, 3.24% (n = 389) were discharged to rehabilitation facilities. The following factors were identified on multivariate analysis to have an association with discharge to a post-acute care facility: 65 years or older, White race, underweight, using steroids preoperatively, American Society of Anesthesiologists (ASA) classification > 2, admitted from a nursing home or already hospitalized, anemic, undergoing bilateral surgery, wound classification other than clean, and complications prior to discharge. Conclusion: Factors identified by our study to have associations with discharge to post-acute care facilities following distal radius fracture repair can help in appropriate patient counseling and triage from the hospital to home versus a post-acute care facility.

Outcomes of Type I Open Distal Radius Fractures: A Comparison of Delayed and Urgent Open Reduction Internal Fixation.

Type I open distal radius fractures treated with open reduction internal fixation (ORIF) have demonstrated minimal risk of infection. For this reason, they may not require urgent surgical treatment. The purpose of this study was to evaluate the outcomes of patients with type I open distal radius fractures treated with delayed ORIF compared with urgent ORIF. We identified all Gustilo-Anderson type I open distal radius fractures that had undergone ORIF using volar plating over a 5-year period. Patients were stratified into those treated urgently within 24 hours and those scheduled for delayed surgery. Outcomes including functional scores, complications, reoperations, and radiographic measures were compared. Twenty-four patients (17 treated urgently and 7 treated delayed) had open type I distal radius fractures. All patients were started on empiric antibiotics at initial presentation-patients in the delayed treatment group were prescribed oral antibiotics, whereas those admitted for urgent treatment received intravenous antibiotics. There were no infections in either group and a single reoperation in each group. The mean postoperative Quick Disabilities of the Arm, Shoulder, and Hand score was 29 (range = 0-77) and did not differ significantly between delayed (mean = 19) and urgent (mean = 38) treatment. Rate of complications and radiographic measures did not differ significantly between the groups. Type I open distal radius fractures appear amenable to delayed outpatient ORIF provided that the wound is clean at the time of initial presentation and that antibiotics are initiated appropriately. Further prospective studies comparing delayed and urgent treatment strategies are warranted.

Outcomes of Staged Treatment for Complex Distal Radius Fractures

IntroductionDistal radius fractures are common, but the results and complications of treatment with early external fixation and staged open reduction internal fixation have not been previously reported.Materials and methodsPatients who received staged distal radius fracture treatment from 1/1/2008 to 12/31/2015 at the University of Alabama at Birmingham were identified. Patient, injury, and treatment characteristics, as well as complications, were collected from the medical record.ResultsThere were 50 fractures in 47 patients, with mean follow-up of 9.3 months. Thirty-eight were open and 45 were intra-articular. For definitive treatment, 41 received a volar approach and nine a dorsal approach. Twenty wrists experienced one or more complications, including two non-unions. Five patients developed infections – one Kirschner wire site infection, one external fixator (ex-fix) pin site infection, and three deep infections. All deep infections occurred in tobacco users. The rate of deep infection with volar approach was 2.4%, compared to 22.2% with dorsal approach. Ex-fix pin sites overlapped radiographically with the plate in 20 fractures, with three deep infections in this group (15%) and no deep infections in the group without overlap. None of these differences reached statistical significance.ConclusionsThis protocol results in reliable healing of complex fractures, with a 96% union rate. However, 40% sustained complications. We conclude that this protocol is useful for temporizing complex fractures but caution that the complication rate is high. Since recent literature indicates that low-grade open distal radius fractures do not require emergent debridement and that immediate internal fixation is safe, complications might be avoided by restricting this protocol to complex or physiologically unstable patients.

The Declining Use of Wrist-Spanning External Fixators.

Background: External fixation has been traditionally used to treat comminuted or open distal radius fractures that are not amenable to open reduction internal fixation. This procedure is associated with a relatively high complication rate and has been used with decreasing frequency in recent years. However, trends in external fixation utilization for the treatment of distal radius fractures have not been described. Methods: Using the Nationwide Inpatient Sample, patients with a distal radius fracture treated with external fixation from 2003 to 2014 were identified. The annual incidence was reported, and hospital and demographic variables associated with external fixation use were determined. Results: During the study period, 593 929 patients with a distal radius fracture were identified, of which 51 766 (8.7%) were treated with a wrist-spanning external fixator. Wrist external fixation for the treatment of distal radius fractures declined steadily from 2003 to 2014. In 2003, external fixation use was highest, accounting for 17.4% of distal radius fractures. By 2014, only 4.9% of distal radius fracture were treated with external fixation. During this period, the incidence of distal radius fractures declined by 6.9% while external fixator utilization decreased by 73.7%. Patients receiving an external fixator were more likely to be male, low-income, and treated in a rural, nonteaching, privately owned hospital. Conclusions: External fixator use for the treatment of distal radius fractures steadily declined during the study period. Males and those with lower incomes treated in rural, nonteaching, and privately owned hospitals are more likely to receive external fixation.

Necrotising fasciitis following a supracondylar fracture and an open radius fracture in a child

Background: Necrotising fasciitis is a rare, rapidly progressing soft-tissue infection with a high mortality rate. Historically, necrotising fasciitis has been associated with penetrating injuries, and more recently with immunocompromise and severe comorbidities. This case report highlights the association of necrotising fasciitis in a child with an open distal radius fracture and a supracondylar fracture. Method and results (case report): A 10-year-old boy was admitted 24 hours after falling from a tree with a Gustilo and Anderson grade II distal radius fracture and a Gartland grade III supracondylar humerus fracture. The wound was debrided and the fractures reduced and stabilised with Kirschner wires. Within 48 hours of admission he developed a necrotising fasciitis that extended onto the chest and eventually resulted in a shoulder disarticulation. The tissue defects were covered with flaps and skin grafts and the patient was discharged home. Conclusions: This case highlights the importance of having an early and high index of suspicion for necrotising fasciitis in a child with an open contaminated fracture and delay to both antibacterial chemotherapy and surgical debridement. Tissue trauma due to open fractures may obscure the early skin signs of necrotising fasciitis as well as laboratory risk factors. In the South African context, urgent administration of cephazolin and surgical exploration must be done to prevent the devastating complication of necrotising fasciitis. Level of evidence: Level 5

橈骨遠位端開放骨折後の骨髄炎に対し有茎尺骨移植術を施行した 1 例

橈骨遠位端開放骨折後の骨髄炎に対し有茎尺骨移植術を施行した 1 例

Treatment of Open Distal Radius Fracture through External Fixation: A Case Report

Treatment of Open Distal Radius Fracture through External Fixation: A Case Report

Motion-preserving wrist reconstruction using a microsurgical medial femur condylus bone graft and radio-scapho-lunate (RSL) limited fusion after osteomyelitis following open distal radius fracture

Motion-preserving wrist reconstruction using a microsurgical medial femur condylus bone graft and radio-scapho-lunate (RSL) limited fusion after osteomyelitis following open distal radius fracture

An Open Distal Radius Fracture Inflicted by a Bear Mauling: A Case Report and Literature Review.

Contact with bears has become more frequent, as have the resultant maulings. Herrero et al.1 showed a positive linear relationship between the number of fatal bear attacks per decade and human population size in the United States and Canada per decade. Studies on human injury as a result of bear maulings are few, and orthopaedic management of open fractures caused by such attacks is rarely reported. It is known that infection is the most common and devastating complication of open fractures, and this complication rate is increased even more with an animal attack because of the potential for microbial contamination from claws, teeth, and the environment2. It is well documented that injuries from large attacking animals may lead to deep infection as a result of substantial soft-tissue wounds that are contaminated with a variety of pathogens3. To complicate matters, many animal attacks occur in remote wilderness areas, and there are substantial delays in notification, rescue, and presentation to definitive care treatment centers4. We present a patient who sustained an open fracture of the distal part of the radius as a result of a black bear (Ursus americanus) mauling. We also review the literature on orthopaedic injuries associated with bear maulings. We followed a standard protocol for the management of open fractures with this patient, which eventually led to a good result. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A fifty-four-year-old man presented to the trauma center following an attack by a large black bear while hunting. The initial attack occurred approximately sixty to ninety minutes prior …

Outcomes After Volar Plate Fixation of Low-grade Open and Closed Distal Radius Fractures Are Similar

Low-grade (Gustilo and Anderson Type I or II) open distal radius fractures (DRFs) have been treated by volar locking plate fixation. However, it is unclear whether the outcomes after volar locking plate fixation for low-grade open DRFs are comparable to those for closed DRFs. We asked whether low-grade open DRFs had worse DASH scores and higher infection rates than closed DRFs when the DRFs were treated by volar plate fixation. Twenty consecutive patients treated by volar locking plate fixation for low-grade open DRFs constituted the open fracture group, and 40 patients were selected from among the total number of patients treated by volar, locking plate fixation for closed DRFs as the closed fracture group. Complications including infection were recorded. Clinical outcomes and radiographic assessments were performed postoperatively at 3 months and 1 year. At 3 postoperative months, wrist flexion and extension, grip strengths, and DASH scores were better in the closed fracture group; however, no difference was observed postoperatively between the two groups in terms of any functional outcome measure at 1 year. Any of the radiographic parameters were not different between the groups. There were no differences in infection rate and in any other complication rate between the groups. Although functional outcomes of open DRFs were inferior to those of closed DRFs at 3 months, at 1 year, outcomes of low-grade open DRFs were found to be comparable to those of closed DRFs when volar plate fixation was used.