Osteoporotic Distal Radius Fractures Research Articles

Distraction Plating for the Treatment of Highly Comminuted Distal Radius Fractures in Elderly Patients

ABSTRACT Purpose To evaluate the use of internal distraction plating for the management of comminuted, intra-articular distal radius fractures in patients over 60 years of age at two level one trauma centers. Our hypothesis was that distraction plating of comminuted distal radius fractures in the elderly would result in acceptable outcomes regarding range of motion, disabilities of the arm, shoulder and hand (DASH) score, and radiographic parameters and would thereby provide the upper extremity surgeon with another option for the treatment of these fractures. Materials and methods A retrospective review was performed on 33 patients over 60 years of age with comminuted distal radius fractures treated by internal distraction plating at two level 1 trauma centers. Patients were treated with internal distraction plating across the radiocarpal joint. At the time of final follow-up, radiographs were evaluated for ulnar variance, radial inclination, and palmar tilt. Range of motion, complications and DASH scores were also obtained. Results Thirty-three patients with a mean age of 70 years were treated with distraction plating for comminuted distal radius fractures. At final follow-up, all fractures had healed and radiographs demonstrated mean palmar tilt of 5° and mean positive ulnar variance of 0.6 mm. Mean radial inclination was 20°. Mean values for wrist flexion and extension were 46° and 50° respectively. Mean pronation and supination were 79° and 77° respectively. At the final follow-up, the mean DASH score was 32. Conclusion In the elderly, distraction plating is an effective method of treatment for comminuted, osteoporotic distal radius fractures. Level of evidence Therapeutic, Level IV (Retrospective case series). Richard MJ, Katolik LI, Hanel DP, Wartinbee DA, Ruch D. Distraction Plating for the Treatment of Highly Comminuted Distal Radius Fractures in Elderly Patients. The Duke Orthop J 2013;3(1):93-98.

Relationship between the Length of Distal Locking Screws and Diaphyseal Screws in Volar Plate Fixation of Distal Radius Fractures

Wall LB, Brodt MD, Silva MJ, Boyer MI, Calfee RP. The effects of screw length on stability of simulated osteoporotic distal radius fractures fixed with volar locking plates. J Hand Surg Am. 2012;37:446-453. Length of the distal locking screws can be estimated with length of a diaphyseal screw. This information may help surgeons to select adequate length of distal locking screws during volar plating of distal radius fractures. During volar plate fixation of distal radius fractures, determining the adequate screw length may be difficult due to the metaphyseal comminution. We hypothesized that the length of distal locking screws would correlate with the length of diaphyseal screws which can be measured more easily with depth gauge. The purpose of this study was to determine the relationship between the length of distal locking screws and diaphyseal screws in volar plate fixation of distal radius fractures.

Early Initiation of Bisphosphonate does not Affect Healing and Outcomes of Volar Plate Fixation of Osteoporotic Distal Radius Fractures: Level 2 Evidence

Methods: Fifty women older than fifty years of age who had undergone volar locking plate fixation of a distal radial fracture and had been diagnosed with osteoporosis were randomized to Group I (n = 24, initiation of bisphosphonate treatment at two weeks after the operation) or Group II (n = 26, initiation of bisphosphonate treatment at three months). Patients were assessed for radiographic union and other radiographic parameters (radial inclination, radial length, and volar tilt) at two, six, ten, sixteen, and twenty-four weeks, and for clinical outcomes that included Disabilities of the Arm, Shoulder and Hand (DASH) scores, wrist motion, and grip strength at twenty-four weeks. The two groups were compared with regard to the time to radiographic union, the radiographic parameters, and the clinical outcomes. Results: No significant differences were observed between the two groups with respect to radiographic or clinical outcomes after volar locking plate fixation. All patients obtained fracture union, and the mean times to radiographic union inGroupsIandIIweresimilar(6.7 and6.8weeks,respectively;p=0.65).Furthermore,thetime toradiographicunionwas not related to osteoporosis severity or fracture type. Conclusions: In patients with an osteoporotic distal radial fracture treated with volar locking plate fixation, the early initiation of bisphosphonate treatment did not affect fracture-healing or clinical outcomes. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The Effects of Screw Length on Stability of Simulated Osteoporotic Distal Radius Fractures Fixed with Volar Locking Plates: Not a clinical study

The Effects of Screw Length on Stability of Simulated Osteoporotic Distal Radius Fractures Fixed with Volar Locking Plates: Not a clinical study

Distal Radius Fracture Risk Reduction With a Comprehensive Osteoporosis Management Program

To study risk factors associated with osteoporotic distal radius fractures and evaluate the effectiveness of the screening and treatment components of a comprehensive osteoporosis program. We retrospectively identified a cohort of patients aged 60 years or older from a large health maintenance organization. For the period 2002 to 2008, information on age, race, sex, diabetes status, osteoporosis diagnosis, osteoporosis screening activity, medications dispensed, and fracture events, including distal radius, proximal humerus, and hip fractures were recorded. We compared demographic and clinical characteristics for patients with and without distal radius fractures. We estimated multivariable estimates of the associations between pharmacologic treatment, and osteoporosis screening and distal radius fracture risk using Cox proportional hazards methods, and adjusted them for age, sex, race, diabetes status, and prior history of hip or proximal humerus fractures. Overall, 1.7% of the cohort (n = 8,658) of the study population (N = 524,612) sustained a new distal radius fracture during 2002 to 2008. In the multivariable model, we found that patients who received pharmacological intervention were 48% less likely to sustain a distal radius fracture. Similarly, patients who were screened for osteoporosis were 83% less likely to sustain a distal radius fracture. Patients with osteoporosis were 8.9 times more likely to have a distal radius fracture than patients without osteoporosis. White subjects had a 1.6 times higher risk of distal radius fracture than non-whites, and women had a 3.8 times higher risk than men. White race, female sex, and a diagnosis of osteoporosis are high risks for distal radius fracture. Screening for and pharmacologic management of osteoporosis using a multidisciplinary team approach in a comprehensive osteoporosis management program resulted in a statistically significant decrease in the risk of distal radius fracture. Therapeutic III.

Distraction Plating for the Treatment of Highly Comminuted Distal Radius Fractures in Elderly Patients

To evaluate internal distraction plating for the management of comminuted, intra-articular distal radius fractures in patients greater than 60 years of age at two level 1 trauma centers. We specifically desired to determine whether patients would have acceptable results from the clinical standpoint of range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and the radiographic measurements of ulnar variance, radial inclination, and palmar tilt. Our hypothesis was that distraction plating of comminuted distal radius fractures in the elderly would result in acceptable outcomes regarding range of motion, DASH score, and radiographic parameters and would, thereby, provide the upper extremity surgeon with another option for the treatment of these fractures. A retrospective review was performed on 33 patients over 60 years of age with comminuted distal radius fractures treated with internal distraction plating at two level 1 trauma centers. Patients were treated with internal distraction plating across the radiocarpal joint. At the time of final follow-up, radiographs were evaluated for ulnar variance, radial inclination, and palmar tilt. Range of motion, complications, and DASH scores were also obtained. We treated 33 patients (mean age, 70 y) with distraction plating for comminuted distal radius fractures. At final follow-up, all fractures had healed, and radiographs demonstrated mean palmar tilt of 5° and mean positive ulnar variance of 0.6 mm. Mean radial inclination was 20°. Mean values for wrist flexion and extension were 46° and 50°, respectively. Mean pronation and supination were 79° and 77°, respectively. At final follow-up, the mean DASH score was 32. In the elderly, distraction plating is an effective method of treatment for comminuted, osteoporotic distal radius fractures. Therapeutic IV.

The Effects of Screw Length on Stability of Simulated Osteoporotic Distal Radius Fractures Fixed With Volar Locking Plates

Volar plating for distal radius fractures has caused extensor tendon ruptures resulting from dorsal screw prominence. This study was designed to determine the biomechanical impact of placing unicortical distal locking screws and pegs in an extra-articular fracture model. We applied volar-locking distal radius plates to 30 osteoporotic distal radius models. We divided radiuses into 5 groups based on distal locking fixation: bicortical locked screws, 3 lengths of unicortical locked screws (abutting the dorsal cortex [full length], 75% length, and 50% length to dorsal cortex), and unicortical locked pegs. Distal radius osteotomy simulated a dorsally comminuted, extra-articular fracture. We determined each construct's stiffness under physiologic loads (axial compression, dorsal bending, and volar bending) before and after 1,000 cycles of axial conditioning and before axial loading to failure (2 mm of displacement) and subsequent catastrophic failure. Cyclic conditioning did not alter the constructs' stiffness. Stiffness to volar bending and dorsal bending forces were similar between groups. Final stiffness under axial load was statistically equivalent for all groups: bicortical screws (230 N/mm), full-length unicortical screws (227 N/mm), 75% length unicortical screws (226 N/mm), 50% length unicortical screws (187 N/mm), and unicortical pegs (226 N/mm). Force at 2-mm displacement was significantly less for 50% length unicortical screws (311 N) compared with bicortical screws (460 N), full-length unicortical screws (464 N), 75% length unicortical screws (400 N), and unicortical pegs (356 N). Force to catastrophic fracture was statistically equivalent between groups, but mean values for pegs (749 N) and 50% length unicortical (702 N) screws were 16% to 21% less than means for bicortical (892 N), full-length unicortical (860 N), and 75% length (894 N) unicortical constructs. Locked unicortical distal screws of at least 75% length produce construct stiffness similar to bicortical fixation. Unicortical distal fixation for extra-articular distal radius fractures should be entertained to avoid extensor tendon injury because this technique does not appear to compromise initial fixation. Using unicortical fixation during volar distal radius plating may protect extensor tendons without compromising fixation.

The Effects of Screw Length on Stability of Simulated Osteoporotic Distal Radius Fractures Fixed With Volar Locking Plates

The Effects of Screw Length on Stability of Simulated Osteoporotic Distal Radius Fractures Fixed With Volar Locking Plates

A Systematic Review of Outcomes and Complications of Treating Unstable Distal Radius Fractures in the Elderly

As the population in developed countries continues to age, the incidence of osteoporotic distal radius fractures (DRFs) will increase as well. Treatment of DRF in the elderly population is controversial. We systematically reviewed the existing literature for the management of DRFs in patients aged 60 and over with 5 common techniques: the volar locking plate system, nonbridging external fixation, bridging external fixation, percutaneous Kirschner wire fixation, and cast immobilization (CI). We reviewed articles retrieved from MEDLINE, Embase, and CINAHL Plus that met predetermined inclusion and exclusion criteria in 2 literature reviews. Outcomes of interest included wrist arc of motion, grip strength, functional outcome measurements, radiographic parameters, and the number and type of complications. We statistically analyzed the data using weighted means and proportions based on the sample size in each study. We identified 2,039 papers and selected 21 papers fitting the inclusion criteria in the primary review of articles with a mean patient age of 60 and older. Statistically significant differences were detected for wrist arc of motion, grip strength, and Disabilities of the Arm, Shoulder, and Hand score, although these findings may not be clinically meaningful. Volar tilt and ulnar variance revealed significant differences among groups, with CI resulting in the worst radiographic outcomes. The complications were significantly different, with CI having the lowest rate of complications, whereas the volar locking plate system had significantly more major complications requiring additional surgical intervention. This systematic review suggests that despite worse radiographic outcomes associated with CI, functional outcomes were no different from those of surgically treated groups for patients age 60 and over. Prospective comparative outcomes studies are necessary to evaluate the rate of functional recovery, cost, and outcomes associated with these 5 treatment methods.

Minimally invasive osteosynthesis with an intramedullary nail for osteoporotic distal radius fractures

Background Since 2006, the authors have been using minimally invasive osteosynthesis with an intramedullary nail (MICRONAIL; Wright Medical Technologies, Arlington, TN) for treating osteoporotic distal radius fractures. The purpose of this study is to retrospectively evaluate the clinical outcome of patients treated with this method.

A Representative Case of Osteoporotic Distal Radius Fracture

We present a case with nonsimultaneous bilateral dorsally displaced unstable osteoporotic distal radius fractures treated by open reduction and internal fixation using a volar and dorsal locking-plate system in a 69-year-old man. On the left side the patient had a loss of reduction as a result of plate bending 1 week after palmar plating. Correction of the dorsopalmar tilt was achieved through additional dorsal plating. Three months later the same patient sustained a distal radius fracture on his right forearm. Open anatomic reduction could only be achieved using palmar and dorsal locking plates, and the large metaphyseal defect was filled with resorbable bone substitute. Six weeks after surgery the patient reported persisting wrist pain. The x-rays showed loss of reduction. Because of flexor tendon irritation, the plate had to be removed after healing malunited. At the final follow-up at 18 months, the patient showed good subjective results according to the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire results. Active wrist motion was 60 degrees extension on the left and 55 degrees extension on the right. The active range of flexion was 50 degrees for left and right wrist, and active pronation and supination were unrestricted for both forearms. Grip strength was 50 kg on either side. Although recently good and excellent results have been reported treating distal radius fractures using volar locking plates in elderly individuals, we believe these implants still have their limits depending on local bone quality and fracture pattern. Decisionmaking for surgery versus conservative treatment should balance the risks and advantages for each patient accurately.

Osteoporosis and vertebral compression fractures—continued missed opportunities

Background context Untreated osteoporosis causes decreased bone mineral density, which predisposes to fragility fractures. Low-energy vertebral compression fractures are the most common type of osteoporotic fragility fracture. Prior studies have shown that only one-quarter of patients diagnosed with an osteoporotic fracture are referred or treated for osteoporosis. Purpose To identify the rate of therapeutic interventions for patients aged 50 years and older within a capitated population who sustained low impact vertebral compression fractures over a 6-month period. Study design/setting Retrospective observational study. Patient sample The reports of all imaging studies of the chest, abdomen, and spine taken from July to December 2002 within a large military health-care system were queried on the Composite Health Computer System (CHCS). The sample included patients 50 years or older who had a low-energy vertebral compression fracture. Outcome measures The computerized medical records were examined for osteoporotic medication prescriptions, referrals to endocrinology, and to dual-energy X-ray absorptiometry (DEXA) scans. These results were compared with results obtained from a similar study on osteoporotic distal radius fractures. Results The records of 156 patients (average age: 77.3 y; 78 women, 78 men) meeting the inclusion criteria were analyzed to determine what proportion was followed-up with osteoporosis interventions. Within 1 year after the fracture, 39% (37 females, 24 males) had undergone a DEXA scan, 35% (37 females, 18 males) had been referred to endocrinology, 38% (47 females, 12 males) were receiving active osteoporosis treatment, and 51% (55 females, 25 males) were receiving any form of osteoporosis-directed medication. The rate of medical intervention was similar to the rate of intervention after distal radius fragility fractures (n=111; 30% active medication; 47% any osteoporosis medication) (p>.21). The rate of all interventions was significantly greater for women than men. Conclusions Although the likelihood of intervention is slightly greater after vertebral compression fractures than for distal radius fractures, orthopedic surgeons, emergency room physicians, and primary care providers continue to miss opportunities, especially in males, to diagnose and/or initiate active therapeutic interventions for osteoporosis in patients presenting with osteoporosis-related fragility fractures.

Cement pinning of osteoporotic distal radius fractures with an injectable calcium phosphate bone substitute: report of 6 cases

The treatment of osteoporotic distal radius fractures is frequently complicated by secondary displacements, mainly because of the posterior comminution. This work studies the advantages of injectable calcium phosphate cement, applied in addition to osteosynthesis with intrafocal pins. Our series comprises six osteoporotic patients with an average age of 77.5 years, showing a fracture of the distal radius osteosynthesized with pins. Cement has then been injected via the radial styloid. The result has been evaluated at an average interval of 14.7 months. The pain has been measured on an analogue visual scale and overall function by the DASH score. Mobility and gripping strength have been compared with the controlateral side. Radiographies have shown the presence of cement leakages, studied the resorption rate and measured secondary displacement. On the clinical level, the pain at the last examination was estimated at an average of 0.66 and total function at 30.28. Compared to the controlateral side, flexion-extension mobility was on average 95.3%, prono-supination 99%, and gripping strength 80.25%. There have been complaints of two resolutive reflex sympathetic dystrophy. Radiologically, the cement has distributed itself along the path of the trocar, in average quantities of 2 ml. Three anterior leaks of cement have been noticed, resorbed within a few months. The radio-ulnar index has lost on average 1.7 mm but the inclination of the radial glene has remained stable. At the last examination, resorption of the intra-osseous cement was partial three times and subtotal three times. Despite the paucity of the sample, it appears that adding calcium phosphate cement does not reduce secondary displacements. The asymptomatic extra-osseous leakages of cement disappeared on average in 6 months. The intra-osseous cement’s resorption rate was slower. Despite the partial results, calcium phosphate cements retain a place in the treatment of distal radius fractures, provided that they remain injectable and address unstable fractures in porotic bone. Cimentobrochage des fractures du radius distal osteoporotique avec un substitut osseux phosphocalcique injectable: a propos d’une serie preliminaire de 6 cas

骨粗しょう症性とう骨遠位端骨折に対する小切開掌側ピンを追加したＤｅｓｍａｎｅｔ変法

Increasingly higher functional results are reguired in the treatment of distal radius fractures with osteoporosis and surgical procedures must be selected carefully in case of inadequate reduction of the fracture. Of these surgical procedures, pinning using K-wire is widely used for ease and minimum invasion, however, complications are occasionally seen. To solve these problems, we have been using modified Desmanets intrameddullary pinning in recent years. In some cases, we experience over collection, and add the volar pin for better results. From 2003 to 2004, 10 patients with osteoporotic distal radius fractures were treated at our hospital. The clinical results were satisfactory according to the demerit point system of Saito; six were assessed as excellent and four as good. Dorsal 2 pins aid reduction of the fracture and maintain reduction by 3 point support. Moreover, the added volar pin acts as to prevent over-reduction. This technique minimizes morbidity by successfully handling the osteoporotic bone allowing early return to function and provides good final results.

Treatment of osteoporotic distal radius fractures

Fracture of distal radius is most commonly an injury of the fit osteoporotic patient. As the population and health of older individuals continue to expand, osteoporotic distal radius fractures will become increasingly common. While many older patients have limited functional demands and can accept some deformity and wrist dysfunction, others remain very active into older age and desire optimal wrist alignment and function. The difficulty obtaining reliable fixation in osteoporotic bone presents a challenge to the surgeon that has been partially addressed by newer implants with screws that directly engage the plate, creating fixed angle bolts that have better fixation in osteoporotic bone. Decision-making is based upon a balance of the goals of the individual patient with the risks of intervention.

Osteoporotic distal radius curettage?filling with an injectable calcium phosphate cement. A cadaveric study

Osteoporotic distal radius fractures are a public health problem that medical osteoporosis treatment is unable to check. We have described a bone substitute method to improve mechanical properties in bone. Our current study aims at improving the technique by maximising the filling of the distal radius. Cavities were created by curettage in the distal radius using a styloid process approach in ten randomly selected wrists from the sample population of ten cadavers. All radii were injected percutaneously with calcium phosphate cement. Cement quantities injected were calculated and corrected for observed cement leakage. Our results show that distal radius curettage before cementoplasty can double the amount of calcium phosphate cement injected. Prevention of osteoporotic distal radius fractures by cementoplasty seems a promising technique. Slowly absorbed micro-porous biomaterial use is preferable in long-term preventive treatment. Nevertheless, in the future, this technique should apply in specific cases, such as medical osteoporosis treatment failure with contra-lateral wrist fracture.

Condylar Stabilizing Technique with AO/ASIF Distal Radius Plate for Colles' Fracture Associated with Osteoporosis

The author established a new reduction and fixation technique for osteoporotic distal radius fracture with a use of AO/ASIF volar distal radius plate, referring to the condylar plating technique in distal femoral fracture. This technique is performed in three steps. First, distal fixation is through the insertion of buttress pins just beneath the subchondral bone with a convergent angle of 10 degrees to the articular surface under fluoroscopic assistance. Second, the proximal limb of the plate is lined up with the radius shaft so that the fracture is reduced automatically and anatomically. Third, by rotating the proximal limb of the plate ulnarly and lifting up the ulnar border of the articular surface, the fracture is fixed less than the contralateral ulnar variance, to apply an adequate tension on the triangular fibrocartilage complex (TFCC). This method represents a valuable treatment modality for the most frequent types of unstable distal radius in elderly women.