Changes in the incidence and treatment of distal radius fractures in adults – a 22-year nationwide register study of 276,145 fractures

IntroductionThe incidence of distal radius fractures (DRFs) is reported, with conflicting results. To ensure evidence-based practice, the variation in treatment over time should be monitored. Treatment in the elderly population is particularly interesting because newer guidelines find little indication for surgery. Our primary aim was to assess the incidence and treatment of DRFs in the adult population. Secondly, we assessed the treatment stratified on non-elderly (aged 18–64 years) and elderly (aged 65+ years) patients.MethodsThis is a population-based register study comprising all adult patients (i.e. aged over 18 years) with DRFs in the Danish National Patient Register from 1997 to 2018. Data were extracted using the ICD-10 code for DRF (DS52.5), and the incidence was calculated using data from Statistics Denmark. We defined a case as surgically treated if a relevant procedure was performed within three weeks of the DRF diagnosis. Nordic procedure codes were used to define surgical treatments as either plate (KNCJ65), external fixation (KNCJ25), k-wire (KNCJ45), or ‘other’ (KNCJ35,55,75,85,95).ResultsA total of 276,145 fractures were included, with an overall increase in DRFs of 31% during the study period. The overall incidence was 228/100,000/year, which increased by 20% during the study period. The increased incidence was especially notable among women and those aged 50–69 years. Surgical treatment steadily increased from 8% in 1997 to 22% in 2010, thereafter reaching a plateau at 24% in 2018. The surgical rate in the elderly group was as high as in the non-elderly group. In 1997, the treatment distribution of DRFs was as follows: 59% external fixation, 20% plate fixation, and 18% k-wire fixation. From 2007 and onwards, plating was the primary choice of surgery, and in 2018, 96% of patients were treated with a plate.ConclusionWe found a 31% increase in DRFs over a 22-year period, mostly driven by an increase in the size of the elderly population. The surgical rate increased markedly even in the elderly group. There is a lack of evidence on how beneficial surgery is for elderly patients, and similar surgical rate between the elderly and non-elderly calls for hospitals to re-evaluate their treatment strategies.     

Does socioeconomic status influence the epidemiology and outcome of distal radial fractures in adults?

Purpose

The aim of this study in adult patients with a distal radial fracture was to determine whether socioeconomic status influenced the epidemiology, mechanism of injury, fracture severity, or the outcome according to function, radiographic assessment, and rate of associated complications.

Methods

We identified 3983 distal radial fractures over a 7-year period. Socioeconomic status was assigned using the Carstairs score, and the population was divided into quintiles depending on deprivation. Patient demographics, mechanism of injury, fracture severity, and radiographic assessment at time of injury were assessed for epidemiological differences according to social quintile. Functional outcome was assessed using grip strength, Moberg pickup test, return to normal use of the hand, and range of movement. Radiographs were assessed at 1 week, 6 weeks, and 1 year. Complications were defined as malunion, carpal tunnel syndrome, complex regional pain syndrome (CRPS), persistent pain, and subjective cosmetic deformity of the wrist.

Results

Socioeconomically deprived patients were significantly younger (p < 0.001) and more likely to be male (p = 0.017); after adjusting for confounding factors, deprived patients were 3.1 (95% CI 1.4–4.7) years younger than the most affluent patients (p < 0.001). Deprived patients were more likely to sustain their fracture by a high-energy mechanism (p = 0.004). There were no significant differences between quintiles in outcome. There was a significantly greater prevalence of CRPS in more affluent patients (p = 0.004).

Conclusions

Socioeconomically deprived patients sustaining a distal radial fracture are more likely to be younger and male. Outcome is not influenced by socioeconomic status, but the prevalence of CRPS is greater in more affluent patients.

     

Single-centre study of hip fractures in Prague, Czech Republic, 1997�C2007

This study examines the epidemiological data of patients with hip fractures from 1997–2007. Adult patients treated for hip fracture between the years 1997–2007 were included in the study. Retrospective statistical assessment of continually gathered data focussed on epidemiology and demographics. The study involved 3,683 patients (2,678 women and 1,005 men). Patients older than 70 years accounted for 82% of all cases. There were 2.7 times more women; in patients younger than 60 years men significantly outnumbered women (p < 0.001). The mean patient age was 77.9 years (SD ± 12.6; women, 80.3 years; men, 71.5 years). There was a slight increase in the average age in both sexes. Trochanteric fractures accounted for 54.7% and femoral neck fractures accounted for 45.3% of fractures. The ratio of men to women was the same in femoral neck (AO-31B) and trochanteric (AO-31A) fractures. The average year-to-year increase in the number of fractures was 5.9%. For femoral neck fractures (AO-31B), there was a statistically insignificant increase in the number of fractures (p = 0.63); for intertrochanteric factures (AO-31A3) there was a statistically insignificant decrease (p = 0.65). There was an increase in the number of hip fractures resulting in a significant increase in pertrochanteric fractures (AO-31A1+2) (p < 0.001). The ratio of trochanteric to neck fractures increased from 0.99 to 1.53. Continual monitoring of patients with hip fracture offers data which allows comparisons between regions and countries. There has been a continual increase in the number of patients with hip fractures.     

Locking plates in distal humerus fractures： study of 43 patients

Objective:The treatment of multifragmentary,intraarticular fractures of the distal humerus is difficult,even in young patients with bone of good quality.Small distal fragment,diminished bone mineral qu...     

Comments on the paper titled locking plates in distal humerus fractures： study of 43 patients

To the editor： we read the article Locking plates in distal humerus fractures： study of 43 patients with great interest. We would like to congratulate the authors for the excellent work but we have some concerns.     

A revolution in the management of fractures of the distal radius?

The recent development of locking-plate technology has led to a potential revolution in the management of fractures of the distal radius. This review examines the evidence for pursuing anatomical restoration of the distal radius and the possible advantages and pitfalls of using volar locking plates to achieve this goal. The available evidence for adopting volar locking plates is presented and a number of important and, as yet unanswered, questions are highlighted.     

External or internal fixation in the treatment of non-reducible distal radial fractures?: A 5-year follow-up of a randomized study involving 50 patients

Background and purpose

We have previously shown in a randomized study that in the first year after treatment, open reduction and internal fixation resulted in better grip strength and forearm rotation than closed reduction and bridging external fixation. In the present study, we investigated whether this difference persists over time.

Patients and methods

The 50 patients included in the original study (mean age 53 years, 36 women) were sent a QuickDASH questionnaire and an invitation to a radiographic and clinical examination after a mean of 5 (3–7) years.

Results

All 50 patients returned the QuickDASH questionnaire and 45 participated in the clinical and radiographic examination. In the internal fixation group, the grip strength was 95% (SD 12) of the uninjured side and in the external fixation group it was 90% (SD 21) of the uninjured side (p = 0.3). QuickDASH score, range of motion, and radiographic parameters were similar between the groups.

Interpretation

The difference originally found between internal and external fixation in distal radial fractures at 1 year regarding grip strength and range of motion was found to diminish with time. At 5 years, both groups had approached normal values.In unstable, non-reducible distal radial fractures, surgical treatment is recommended but can be complex. The choice of method is still controversial (Chen and Jupiter 2007), especially regarding the result over time (Downing and Karantana 2008). External fixation has been the method of choice for decades (Atroshi et al. 2006, Krukhaug et al. 2009), but with the introduction of the volar locking plate technique, internal fixation has rapidly become more and more popular—but without any solid evidence (Margaliot et al. 2005).Recently, we showed in a randomized study that open reduction and internal fixation (O) of distal radial fractures using the TriMed fragment-specific system resulted in better grip strength and forearm rotation than closed reduction and bridging external fixation (C) (Abramo et al. 2009). The difference was seen early (at 3 months), which might be expected since the mobilization started earlier, but the difference prevailed at the 1-year follow-up. That study was initiated to investigate whether better anatomical reduction, achieved by the open technique, was important for the final result. Apart from the positive results regarding rotation and grip strength after internal fixation, we found a tendency for closed reduction to result in more malunions, but the difference was not statistically significant. Subjective outcome was similar between the groups, which we believe is either due to an absence of such a difference or to blunt outcome instruments. In the present report, we evaluated the same cohort at a later point in time, between 3 and 7 years, with the primary aim of determining whether the superior short-term results of internal fixation in unstable distal radial fractures persist over time.     

Can radiological results be surrogate markers of functional outcome in distal radial extra-articular fractures?

The purpose of this study was to evaluate the relationship between radiological and functional results in patients with extra-articular fractures of the distal radius. We conducted a prospective study of radiological and functional assessment in 95 consecutively selected extra-articular distal radius fractures. There were two patient groups: more than 60 and less than 60 years of age. The final fracture union radiographs were analysed for their functional outcome using the Michigan Hand Outcomes Questionnaire (MHQ) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. In patients with acceptable radiological results, 62% (MHQ group) and 72% (DASH group) of patients had satisfactory functional outcome. Analysing patients with satisfactory functional results, 56% (MHQ group) and 59% (DASH group) had satisfactory radiological results. There was a higher proportion of patients with better functional results, despite poor radiological results, in both of the age groups. There was a statistically significant correlation between satisfactory radial tilt and functional outcome in the younger patients. In the older age group, patients with satisfactory radiological results had satisfactory functional outcome (p < 0.05). However, in the older age group, satisfactory functional results were achieved, despite unsatisfactory radiological results.     

“PAF” analysis of acute distal radius fractures in adults. Preliminary results

There is not enough evidence in the literature to support the use of any treatment in distal radius fractures, mainly because of the heterogeneous aspects of most series. There is a need for more standardized analyses of distal radius fractures that should allow the identification of more homogeneous groups of patients. The authors propose a novel synthetic method to analyse acute distal radius fractures in adults. A one-page chart includes criteria related to the patient (P), the energy of the accident (A), and the characteristics of the fracture (F) along with associated ulnar and carpal lesions. The preliminary results of the use of this chart in 258 consecutive patients are presented. Four homogeneous groups of patients are described and the principles of their treatment are discussed.     

High incidence of screw penetration in the proximal and distal tibiofibular joints after intramedullary nailing of tibial fractures—A prospective cohort and mapping study

BackgroundIntramedullary-nails (IMN) are the treatment of choice for most tibial shaft fractures due to their minimally-invasive nature and non-demanding surgical technique. However, a potential iatrogenic pitfall is intra-articular interlocking screw positioning within the proximal (PTFJ) and distal (DTFJ) tibiofibular joints that may go unrecognized.ObjectiveTo evaluate the incidence of intra-articular screw penetration of the PTFJ and DTFJs after interlocking of IMN for tibial fractures.InterventionReamed IMN using modern techniques, including proximal interlocking via standard aiming jig and distal interlocking either freehand or using SureShot^®.MethodsProspective series of 165 consecutive patients with a tibial shaft fracture managed with an IMN. Diagnosis and incidence of penetration of the PTFJ and DTFJ was assessed on protocolled low-dose postoperative CT-scans (standardized clinical practice for assessing rotational alignment). The degree of penetration of the TFJ’s was graded as: Grade 1–slight breach of the tibial cortex; Grade 2–clear penetration of the tibial cortex with intra-articular screw tip; and Grade 3–penetration of both tibial- and fibular cortices with screw tip in fibula.ResultsOf the 165 tibial shaft fractures, using the AO/OTA classification, 69% were simple, 16% wedge and 15% complex fractures. Following IMN 42% of patients had intra-articular screw penetration of their PTFJ whilst 39% had penetration of their DTFJ. 66% of patients had penetration of either one- or both of their TFJs. The grading of PTFJ violation was distributed as follows: Grade 1 in 24 patients; Grade 2 in 26 patients and Grade 3 in 19 patients. DTFJ violation was graded as: Grade 1 in 21 patients; 40 patients had Grade 2 violation; and four patients had a Grade 3 penetration.ConclusionsThis diagnostic imaging study reports a high rate of intra-articular screw penetration of the PTFJ and DTFJ after interlocking of IMN for tibia shaft fractures. A prospective cohort study is underway to evaluate its clinical significance.Changes to enable alteration in forced angle of interlocking screw trajectory and avoidance of the anteromedial to posterolateral locking screw may reduce the incidence of TJF violation.Level of evidenceLevel II – Diagnostic Imaging Study     

Long-term outcome of displaced radial neck fractures in adulthood: 16�C21 year follow-up of 5 patients treated with radial head excision

Background There have been no reports on the long-term outcome of radial neck Mason type IIIb fractures in adults.Methods 3 women and 2 men, aged 46 (22–69) years when they sustained a radial neck Mason type IIIb fracture, were evaluated after an average of 18 (16–21) years. All had been treated with radial head excision.Results 3 individuals had no subjective elbow complaints while 2 reported occasional weakness. None had severe elbow complaints. The maximum elbow-to-elbow difference in range of motion was a deficit of mean 10° in extension in the injured elbow. Mean deficits in elbow flexion, forearm pronation, and forearm supination were below 5° and the mean difference in cubitus valgus angle was only 2° . There was no instability and no recurrent elbow dislocations. Radiographically, there were cysts, sclerosis, and osteophytes in all formerly injured elbows but none in the uninjured elbows. We found reduced joint space in 1 elbow that had been formerly injured.Interpretation Mason type IIIb fracture in adults, treated with radial head excision, appears to have a favorable long-term outcome.     

Is distal locking of long nails for intertrochanteric fractures necessary? A clinical study

Background

Few clinical studies have examined the utility of distal interlocking nails when fixing intertrochanteric fractures with intramedullary devices. In this study we performed a retrospective analysis comparing fixation method of intertrochanteric fractures with either a long unlocked cephalomedullary nail versus a long locked cephalomedullary nail. Our hypothesis was there would be no difference in device related failures or complications in stable intertrochanteric fractures treated with long locked or long unlocked cephalomedullary nails.

Methods

A retrospective chart review was performed of all stable intertrochanteric fractures treated with a long cephalomedullary nail between 2006 and 2012 at our institution. Clinical history as well as perioperative radiography was carefully reviewed for all subjects. AO classification, the use of locked or unlocked technique, and failure status was recorded.

Results

Overall, a device related failure rate of 1.8% (2/107) was observed for stable intertrochanteric fractures treated with long cephalomedullary nails. No statistical difference in failure rate was found between locked and unlocked nails within our studied population (0% long locked (0/56) versus 3.9% long unlocked (2/51), p = 0.224).

Conclusion

This clinical study supports our hypothesis that long cephalomedullary nails do not need to be locked for stable intertrochanteric fractures. We found no difference in failure rates between the two approaches across 107 patients.     

Does frailty predict increased risk of falls and fractures? A prospective population-based study

Summary

A frailty concept that includes psychological and cognitive markers was prospectively shown to be associated with increased risk of multiple falls and fractures among 1,509 community dwelling older adults, especially in those aged 75 and over. The predictive ability of frailty is not superior to falls history.

Introduction

The concept of frailty has been defined with or without psychological and cognitive markers. Falls are associated with multiple risk factors, including cognitive and mood disorders. The purpose of this study was to investigate the association of a comprehensive concept of frailty and its components with falls and fractures in community-dwelling older adults and to compare its predictive ability with having a history of falls.

Methods

One thousand five hundred nine participants in the Longitudinal Aging Study Amsterdam aged ≥65 were assessed to determine fall history and the prevalence of nine frailty markers, including cognitive and psychological factors. The number of falls and time to second fall were prospectively registered for 1 year. Fractures were registered for 6 years.

Results

Frailty was significantly associated with time to second fall: hazard ratio of 1.53 [95 % confidence interval (CI), 1.07–2.18] and area under the receiver operating characteristic curve (AUC) of 0.58 (CI, 0.53–0.62). In participants aged ≥75, frailty was associated with ≥2 falls: odds ratio (OR) of 1.74 (CI, 1.19–2.55) and AUC of 0.62 (CI, 0.55–0.68). Frailty, adjusted for age and sex, was significantly associated with ≥2 fractures: OR of 3.67 (CI, 1.47–9.15). The AUCs for falls history (aged ≥75) ranged from 0.62 (CI, 0.58–0.67) for ≥1 falls to 0.67 (CI, 0.59–0.74) for ≥3 falls.

Conclusions

A concept of frailty including psychological and cognitive markers is associated with both multiple falls and fractures. However, frailty is not superior to falls history for the selection of old persons at increased risk of recurrent falls.     

Does Kapandji wiring help in older patients? A retrospective comparative review of displaced intra-articular distal radial fractures in patients over 55 years

Forty-six patients aged 55–90 with intra-articular displaced fractures of the distal radius were reviewed retrospectively. All patients were treated with either manipulation and plaster of Paris or Kapandji wiring. Radiographic and functional review was performed by an independent observer a mean of 17 months after the fracture.

The results showed superior anatomical and functional results in the group treated with Kapandji wiring. The mean dorsal angle was significantly better in the wired group, and the improvement in dorsal angle, radial angle and radial length from presentation to final result was also significantly better. Functional results were excellent or good in 19/23 of the wired group, compared with 12/23 of the plaster group. There was a strong correlation between functional outcome and both dorsal angle and radial length at union.

These results support the use of this method of wire fixation in older patients, as the technique is simple and complications were few.     

Patient–accident–fracture (PAF) classification of acute distal radius fractures in adults

There is not enough evidence in the literature to support the use of any classification system for distal radius fractures (DRF) in adults. However, there is a need for identification of more homogeneous groups of patients with DRF so that the extent of preoperative workup and sophistication of treatment would best match the needs of the patient. The authors propose an innovative method to analyse and stratify acute DRF in adults. A one-page chart includes criteria related to the patient (P), the energy of the accident (A) and the pathology of the fracture (F). Analysis of the pathology includes not only the distal radius itself but also the associated ulnar and carpal lesions. Radiological suspicion of associated carpal of distal radio-ulnar joint ligamentous injuries is included in the analysis. The preliminary results of the use of this chart in 1610 consecutive adult patients (16–102 years) with unilateral acute DRF are presented. A total of six homogeneous groups of patients are described, and the relevance of this classification regarding the therapeutic options is discussed.     

Is there a benefit of proximal locking screws in osteoporotic distal radius fractures? – A biomechanical study

IntroductionThe distal radial fracture is a common fracture and frequently seen in geriatric patients. During the last years, volar plating has become a popular treatment option. While the application of locking screws at the distal fragment is widely accepted, there is no evidence for their use at the radial shaft.Materials and methodsIn six osteoporotic pairs of matched human cadaver radii an extra-articular model creating an AO 23-A2.1 fracture was employed. Osteosynthesis were performed using the APTUS 2.5 Adaptive TriLock Distal Radius System (Medartis AG) with locking (LS) or non-locking screws (NLS) for proximal fixation. Biomechanical testing was performed in a staircase fashion: starting with 50 cycles at 200 N, the load was continuously increased by 50 N every 80 cycles up to a maximum force of 400 N. Finally, load to failure was analyzed with failure defined as sudden loss of force measured (20%) or major deformation of the radii (10 mm).ResultsAt 200 N, 250 N, 300 N, 400 N and load to failure, the NLS group showed a higher degree of elastic modulus. In contrast, the LS group showed higher elastic modulus at 350 N. Maximum force was higher in the LS group without reaching statistical significance. Reasons for loss of fixation were longitudinal shaft fractures, horizontal peri-implant fractures and distal cutting out. No difference was seen between the two groups concerning the development of the above mentioned complications.ConclusionOur study did not show biomechanical superiority for distal radius fracture fixation by using locking screws in the proximal holes in an osteoporotic cadaver study. At load to failure, longitudinal shaft fractures and peri-implant fractures seemed to be a more relevant problem rather than failure of the proximal fixation.     

Undertreatment of osteoporosis in persons with dementia? A population-based study

Summary  

In this population-based study of more than 2,600 elderly, people with dementia received less preventive treatment for osteoporosis compared to people without dementia, although osteoporotic fractures were more common in patients with dementia. Thus, our results indicate an undertreatment of osteoporosis in dementia.     

Important risk factors and attributable risk of vertebral fractures in the population-based Tromsø study

ABSTRACT: BACKGROUND: Vertebral fractures, the most common type of osteoporotic fractures, are associated with increased risk of subsequent fracture, morbidity, and mortality. The aim of this study was to examine the contribution of important risk factors to the variability in vertebral fracture risk. METHODS: Vertebral fracture was ascertained by VFA method (DXA, GE Lunar Prodigy) in 2887 men and women, aged between 38 and 87 years, in the population-based Tromso Study 2007/2008. Bone mineral density (BMD; g/cm2) at the hip was measured by DXA. Lifestyle information was collected by questionnaires. Multivariable logistic regression model, with anthropometric and lifestyle factors included, was used to assess the association between each or combined risk factors and vertebral fracture risk. Population attributable risk was estimated for combined risk factors in the final multivariable model. RESULTS: In both sexes, age (odds ratio [OR] per 5 year increase: 1.32; 95% CI 1.19-1.45 in women and 1.21; 95% CI 1.10-1.33 in men) and BMD (OR per SD decrease: 1.60; 95% CI 1.34-1.90 in women and1.40; 95% CI 1.18-1.67 in men) were independent risk factors for vertebral fracture. At BMD levels higher than 0.85 g/cm2, men had a greater risk of fracture than women (OR 1.52; 95% CI 1.14-2.04), after adjusting for age. In women and men, respectively, approximately 46% and 33% of vertebral fracture risk was attributable to advancing age (more than 70 years) and low BMD (less than 0.85 g/cm2), with the latter having a greater effect than the former. CONCLUSIONS: These data confirm that age and BMD are major risk factors for vertebral fracture risk. However, in both sexes the two factors accounted for less than half of fracture risk. The identification of individuals with vertebral fracture is still a challenge.