in measurement, and the source of idea to evaluate interobserver and intraobserver reliability (3). Distalradius radiographic indices including radial length, radial inclination in posteroanterior (PA) view and radial tilt in lateral view are important in evaluation of radiographs before and after reduction of distalradius fracture. Despite the variety of classification systems, evaluation of reliability of the radiographic indices seems logical (4). This study is conducted to evaluate the interobserver and intraobserver reliability of measurements of the distalradius radiographic indices.
The studies from Oslo and Bergen were conducted sev- eral decades ago. More recent studies show a considerably lower incidence and are closer to our findings [1, 8, 15]. The present study might therefore indicate a true decline in incidence in DRFs. The study population, criteria of in- clusion, and study design differ however between the vari- ous studies, making comparison challenging. The studies from Bergen and Oslo started their inclusion in patients above the age of 20 years. The incidence of distalradius fractures among children is high, but decreases towards the age of 15 – 16 years in both genders . In our study, the incidence among women aged 16–19 years is relatively low compared to the other age groups. This will give a low total incidence among women compared to studies not including this group. The incidence in males of the same age group is the second highest, which will increase the total incidence among men.
treated with a cast for a six-week period. Plain radiographs and computed tomography images showed distalradius malunion with a loss of volar tilt and radial inclination and positive ulnar variance (Figure 1). Volar corrective osteotomy and internal fixation with a stainless steel volar locking plate (VLP) (Trimed Volar Bearing Plate, Valencia, CA, USA) were performed (Figure 1). Distal to the osteotomy, three angle-stable locking screws were used on the radial side and one cancellous screw was placed on the ulnar side. One nonlocking cortical screws and three angle-stable locking screws were used proximally. The osteotomy site was grafted with demineralized bone matrix (Allomatrix, Wright Medical Corporation). The postoperative radiographs showed an improvement of the palmar tilt and radial inclination from −16 ∘ to 2 ∘ and 20 ∘ to 22 ∘ . Ulnar variance decreased from
The evidence for the cost-effectiveness in respect of any form of treatment of tibial and distalradius fractures is poor both in term of quantity and quality of evidence. A number of studies have presented some information which may help to identify hospital resource usage. The costs to patients, their families, and the wider economy have not been calculated in any of the papers researched. This is unfortunate given that a key effectiveness criterion is to return the patient to full functionality. Very few papers have indicated any intention to analyse cost-effectiveness, even though the additional costs to the studies of including an economic analysis would have been relatively small.
A correlation analysis was performed using Pearson’s product moment in IBM SPSS statistics (version 21) to determine firstly, if the radiographic parameters correlate with the functional outcome measures, and secondly if the physical measures of function correlate with the patient reported outcome measures. Correlations with the radiographic parameters were considered between the 6-week post-operative radiographs and the 3-month, 6-month and 12- month functional measures, and between the 12-month radiographs and the 12 months functional measures. For the second correlation analysis, each of the physical measures were considered independently with respect to each of the patient reported outcome measures, for the 3-month, 6-month and 12-month data collection time points. All correlations were also performed separately using the DRAFFT trial stratification factor for age (patients over and under 50 years old) in order to reflect the main demographic groups presenting with a fracture of the distalradius, and to assess for potential differences in the relationship between function and impairment that may result from differences in the biomechanics of the wrist with age. Approximate normality was presumed for the data variables based upon the precedent
Distalradius fractures (DRFs) are the most common fractures encountered in orthopedic practice and ac- count for 20% of all fractures seen in the emergency room (1). Following near anatomic close reduction and cast immobilization, various factors can cause second- ary displacement of the fracture fragments, including shortening, angle of reduction (dorsal angulation), and articular congruence. These factors determine the treat- ment outcomes of DRFs. In young adults, the fractures are typically the result of high-energy injuries such as motor accidentsor fall from height. In contrast, most of the DRFs in the elderly occur from low-energy injuries such as fall from a standing height or on an outstretched hand (2, 3). Management of DRFs is still controversial and may be influenced by the initial fracture classification (4). Even though numerous classification systems have been proposed e.g., Frykman, Mayo, Melone, and AO, the evaluation and management of these fracture is yet con-
The incidence of distalradius fracture has been studied frequently and shown to have increased over the years. In Sweden, the incidence rate in the city of Malmö had almost doubled between the time periods of 1953–1957 and 1980–1981 . In the United States, a 17% increase in distalradius fractures was shown in Rochester, Minne- sota, between 1945–1954 and 1985–1994 . This change over time has been understood as a real increase in age-specific incidence rather than a result of an increase in diagnosed distalradius fractures . Studies of fracture incidence in northern Europe have been carried out both on populations of larger cities such as Oslo and Bergen in Norway and Malmö in Sweden [1,3,4], and in whole counties such as Dorset in England, Fredriksborg in Den- mark, and Uppsala in Sweden [5-7]. Studies have not shown statistically significant differences in the incidence rates of distalradius fracture in rural versus urban com- munities [8,9]. However, evidence of epidemiologic dif- ferences across Europe has been reported, with higher incidence rates of distalradius and other osteoporotic fractures in Scandinavia than in other European regions .
Elevate extensively and purely in the cut on the volar and back sides according to the amount of MIR before operating. Cut ulna periost hori- zontal 2 cm away from the tumor on the part of the separating ulna, pull the tumor inside, cut the interosseous membranes up to the wrist, and cut out the wrist capsular ligament to remain as much as possible wrist capsular liga- ment, the ulnar part of the low radius capsular ligament and TFCC without entering the tumor bump. Cut the radius firm and the tumor out- side film, cut out the pulp cavity tissue left in the bone and do a routine fast pathology check to confirm there is no tumor bump left. The inju- ry should be immersed in distilled water. According to the cut length in the radius bone, choose ilium transplant to rebuild the radius wrist joint. Change the suit, gloves and the appliances, cut an arc in the ilium ridge, and take a 2 cm wide ilium, whose length is the same as the cut part of radius. Fix one piece of the ilium to form a radius wrist surface, then put it in the distalradius, and the other in the nearer end. Select the proper fix steel plate to the left end of the radius. When the edges touch discontentedly, apply the ilium to improve the recovery of bone. Use a needle to pin the low ulnar radius and two needles to fix radius wrist joint. Fix one piece of the ilium to form the radius wrist surface, then put it in the distalradius, and the other in the near end. Select the proper fix steel plate to the left end of radi- us. When the edges touch discontentedly, apply the ilium to improve the recovery of the bone. A needle to pin the low ulnar radius and two nee- dles to fix the radius wrist joint. For pictures of the surgical procedure, see: Figures 1-4. Postoperative management
Fractures of the distalradius are encountered mainly in postmenopausal women, but may occur in any sub- ject with osteoporosis (1). A variety of management op- tions have been devised. Since the outcome of treatment appears to depend to a large extent, on bone density (2, 3), this factor should be taken into account when choos- ing the most suitable management strategy for each pa- tient. However, distalradius fractures are very common and frequently occur when full imaging facilities are not available. As a result, the medical staff on duty will rarely be able to determine bone quality as a guide for treat- ment planning. In the absence of more sophisticated techniques, many physicians will look at standard radio- graphs and intuitively use the cortical thickness of the distalradius as a rough indicator of bone density. This ap- proach was first described, for the femoral diaphysis, by Barnett and Nordin (4). Similarly, the cortical thickness of the humerus has been used to estimate osteoporosis (5, 6).
Distalradius fractures (DRFs) are the most common type of fracture presented in hospitals, clinics, orthopaedic centers, and trauma practices all over the world. Thus, there is a very large body of literature on the many aspects of DRFs, particularly, nonsurgical and surgical treatment/management modalities. The present contribution has two focus areas. The first is a summary of many aspects of DRF on which there is controversy or inadequate coverage. As a consequence of this summary, the second focus is detailed expositions on opportunities for future work in nine areas. Results from some of this future work may aid selection of treatment/management modality for a specified patient-fracture pattern combination; for example, detailed cost-utility analyses of candidate modalities. Results from other future studies may translate to improved patient outcomes; for example, further studies on the photodynamic bone stabilization system for intramedullary fixation of fractures.
This study protocol was approved by the Institutional Review Board (no. 14-21). This was a randomized controlled trial using block randomization (levels of evidence II). This study was registered as NCT03764501 at ClinicalTrials.gov. This study was performed in accordance with the relevant guide- lines and regulations. Informed consent was obtained from all individual participants included in the study. Forty-two wrists of 42 distalradius fracture patients who underwent osteosynthesis using volar locking plates (32 females, 10 males, mean age 63.3 years, age range 19–91) were evaluated. Patients were excluded if they reported a previous history of traumatic arm injuries. The patients were divided into two groups. The image fusion group (n = 21) utilized 3D pre- operative planning and an image fusion system for osteo- synthesis. The control group (n = 21) utilized only 3D preoperative planning. According to the preoperative CT scans, fractures were classified using the AO classification system. Patients with a common age group, sex, and fracture type were assigned to each group.
After eight weeks of postoperative care, a CT scan of the operated forearm was acquired to verify consoli- dation. As described in a previous publication , the residual malalignment error was measured by comparing the planned model with the postoperative result in 3D. Additionally, the postoperative plate and screw position was compared to the position in the 3D planning. Only if the distal part of the postopera- tive radius was present in the postoperative CT scan, axial alignment of the postoperative bone model with the model of the malunion was performed as follows: After superimposing, using the Iterative Closest Point (ICP) sur- face registration algorithm , the exact visual alignment of the cortical cross-section, on the proximal end of both models, was conducted by displaying the postoperative bone model in transparency mode (Fig. 3). The residual malalignment error was measured by calculating the rela- tive transformation between the distalradius parts in
When an individual falls forward fall on pronated forearm with the hand and wrist in extension, bending of the metaphyseal bone because the weight of the body is transmitted along the long axis of the radius. Also the hard diaphyseal bone causes impaction of cancellous metaphyseal bone that result in metaphyseal collapse. During the fall, compressive forces over the dorsal cortex and tensile stress acting over the volar cortex result in volar and dorsal cortical bone disruption. When there is a supination of distal end of radius with respect of the radial diaphysis, a dorsal displacement fracture occurs. In about fifty to sixty percent of distalradius fractures, associated ulnar styloid fractures. Also ulnar styloid fractures may be associated with triangular fibrocartilage disruption which may sometimes be an isolated finding.
This study has several potential shortcomings. First, this is a retrospective study, which has its drawbacks such as selection bias and limited clinical data. Second, due to lack of a very good or excellent inter- and intra-observer repro- ducibility in the existing classifications of distalradius fractures , AO subclassifications based on X-ray and/ or CT scans may also have inconsistencies, leading to changes in our conclusion. Ma et al. described that X-ray results might be false negative in diagnosis of die-punch fracture. The X-ray-missed diagnosis rate was 11.1%, and the misdiagnosis rate was 15.6% . Third, the issue of how to avoid variability in ROM measurement still cannot be completely solved. Hohmann et al. reported there was accurate, valid, and reliable use of a goniometer according to a standardized protocol advised by the American Soci- ety for Hand Therapists . Therefore, we used the goni- ometer to measure wrist ROM following the standard guideline to reduce variability. And we supported that clinical examination comparing between the injured and uninjured contralateral sides was a reasonable way to re- duce individual differences in the assessment of objective indicators of wrist function after distalradius fractures.
Facilitating healthy ageing through active living is important. Distalradius fracture (DRF) can interfere with active living, and may result in a functional decline of the individual (Edwards, Song, Dunlop, Fink, & Cauley, 2010). Fracture of the radius and ulna accounts for 44% of all hand and wrist emergency department visits (Chung & Spilson, 2001). More than 90% of fracture of radius and ulna results from falls (Tamblyn, 2000). The direction of fall determines the site of the fracture. Hip fracture mostly occurs due to a sideways fall while a wrist fracture occurs with a fall in a backwards direction (Nevitt & Cummings, 1993). However, the common mechanism of injury in DRF is a fall on an outstretched hand (Meena, Sambharia, Sharma, & Dawar, 2014).
The primary study outcome was the proportion of participants referred to the PCP for follow-up of a distalradius buckle fracture who, after ED discharge, received PCP follow-up and did not have visits to other physicians for this injury (ie, exclusive PCP follow-up). This outcome is clinically relevant as a measure of physician ability and willingness to manage the injury without additional specialty consultation, and it also measures the feasibility of this follow-up strategy for parents. Although follow-up of this fracture was not routinely accepted at the study institution's orthopedic clinic, follow-up of distalradius buckle fractures are routinely accepted into several other orthopedic clinics in the study region; thus, PCPs do have the option of referring these children to fracture clinics at a different hospital. As secondary outcomes, we also reported the frequency of each type of deviation from exclusive PCP follow-up. To explore PCP management of these injuries, the following factors were examined: (1) mean number of physician visits; (2) proportion of children who received repeat radiographs at the PCP visit; (3) comparison of physician-recommended timelines on splint usage and return to activities versus those applied by the parents; and (4) variables that may be independently associated with lack of anticipatory guidance on return to activity provided at the PCP visit (pediatrician versus family physician; age ≤ 5 years versus >5 years; radius and ulna fractures
Distalradius fractures are one of the most common fractures, and biomechanical models are used to validate and develop novel treatment methods. Recent research suggests that the distal fracture fragment is smaller than observed in previous studies. Based on this data, an improved fracture model was developed. We were able to show that the biomechanical parameters assessed through biomechanical fracture models are sensitive to the position of the extra-articular comminuted fracture. The degree of sensitivity is dependent on the type of osteosynthetic device used. Consequently the fracture model introduced here should be used as the new gold standard for future research until more studies on fracture location have been done.
Ulnar-sided injuries of the wrist have received more attention recently for their potential negative impact on the outcome of distalradius fractures. Some studies have revealed that inappropriate treatment of distal ulna fractures with appropriately treated distalradius fractures resulted in distal radio ulnar joint instability and hence poor functional outcome at later years. There have been proponents for both operative and non-operative methods. Various studies are coming forth with various fixation techniques being described for distal ulna fractures with concomitant distalradius fractures. Good functional results were reported with either modality in low energy fractures in elderly but the ideal treatment for high energy injuries with associated distal ulna fractures is still being debated.
The treatment of distalradius fractures with VLDRPs has been an area of increased research interest in the last ten years. Recently, many authors have focused on the fact that outcomes when compared with non-operative treatment are similar after 12 to 24 mo. There have also been recent publications showing that volar plating is significantly more expensive when compared to other treatment modalities. There are, however only very limited data on return to work and function in the short term. Earlier return of function and ability to work, which is potentially possible with volar locking plates could mean significant overall cost savings when compared to other treatment options which necessitate 6 wk of immobilisation.