Aims. It is not clear which type of casting provides the best initial treatment in adults with a distal radial fracture. Given that between 32% and 64% of adequately reduced fractures redisplace during immobilization in a cast, preventing redisplacement and a disabling malunion or secondary surgery is an aim of treatment. In this study, we investigated whether circumferential casting leads to fewer fracture redisplacements and better one-year outcomes compared to plaster splinting. Methods. In a pragmatic, open-label, multicentre, two-period cluster-randomized superiority trial, we compared these two types of casting. Recruitment took place in ten hospitals. Eligible patients aged ≥ 18 years with a displaced distal radial fracture, which was acceptably aligned after closed reduction, were included. The primary outcome measure was the rate of redisplacement within five weeks of immobilization. Secondary outcomes were the rate of complaints relating to the cast, clinical outcomes at three months, patient-reported outcome measures (PROMs) (using the numerical rating scale (NRS), the abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Patient-Rated Wrist/Hand Evaluation (PRWHE) scores), and adverse events such as the development of compartment syndrome during one year of follow-up. We used multivariable mixed-effects logistic regression for the analysis of the primary outcome measure. Results. The study included 420 patients. There was no significant difference between the rate of redisplacement of the fracture between the groups: 47% (n = 88) for those treated with a plaster splint and 49% (n = 90) for those treated with a circumferential cast (odds ratio 1.05 (95% confidence interval (CI) 0.65 to 1.70); p = 0.854). Patients treated in a plaster splint reported significantly more pain than those treated with a circumferential cast, during the first week of treatment (estimated mean NRS 4.7 (95% CI 4.3 to 5.1) vs 4.1 (95% CI 3.7 to 4.4); p = 0.014). The rate of complaints relating to the cast, clinical outcomes and PROMs did not differ significantly between the groups (p > 0.05). Compartment syndrome did not occur. Conclusion. Circumferential casting did not result in a significantly different rate of redisplacement of the fracture compared with the use of a plaster splint. There were comparable outcomes in both groups. Cite this article: Bone Joint J 2024;106-B(7):696–704

Aims. The primary aim of this study is to quantify and compare outcomes following a dorsally displaced fracture of the distal radius in elderly patients (aged ≥ 65 years) who are managed conservatively versus with surgical fixation (open reduction and internal fixation). Secondary aims are to assess and compare upper limb-specific function, health-related quality of life, wrist pain, complications, grip strength, range of motion, radiological parameters, healthcare resource use, and cost-effectiveness between the groups. Methods. A prospectively registered (ISRCTN95922938) randomized parallel group trial will be conducted. Elderly patients meeting the inclusion criteria with a dorsally displaced distal radius facture will be randomized (1:1 ratio) to either conservative management (cast without further manipulation) or surgery. Patients will be assessed at six, 12, 26 weeks, and 52 weeks post intervention. The primary outcome measure and endpoint will be the Patient-Rated Wrist Evaluation (PRWE) at 52 weeks. In addition, the abbreviated version of the Disabilities of Arm, Shoulder and Hand questionnaire (QuickDASH), EuroQol five-dimension questionnaire, pain score (visual analogue scale 1 to 10), complications, grip strength (dynamometer), range of motion (goniometer), and radiological assessments will be undertaken. A cost-utility analysis will be performed to assess the cost-effectiveness of surgery. We aim to recruit 89 subjects per arm (total sample size 178). Discussion. The results of this study will help guide treatment of dorsally displaced distal radial fractures in the elderly and assess whether surgery offers functional benefit to patients. This is an important finding, as the number of elderly distal radial fractures is estimated to increase in the future due to the ageing population. Evidence-based management strategies are therefore required to ensure the best outcome for the patient and to optimize the use of increasingly scarce healthcare resources. Cite this article: Bone Jt Open 2024;5(10):920–928

Despite the variety of implants or techniques that exist to treat displaced distal radial fractures, the majority fail to provide sufficient stability to permit early functional recovery. However, locking plates have the advantage over other implants in that locking screws add considerably to the overall stability. The aim of this study was to assess the functional outcome of patients with displaced distal radial fractures treated with a volar distal radial locking plate (Synthes). During a two year period, details of 98 patients admitted to our unit with inherently unstable dorsally displaced distal radial fractures treated with volar locking plates were collected prospectively. For the purpose of this analysis, only those patients (55) with unilateral fracture, able to attend the study clinic at 6 months post-injury were considered. Patients were immobilised in wool and crepe for a 2 week period. The group consisted of 15 males and 40 females with an average age of 54 (28 to 83). At 6 months, patients' perceived functional recovery averaged 80%. Objective assessment was considered in relation to the uninjured side: grip strength 73%; pinch strength 83%; palmarflexion 77%, dorsiflexion 80%; radial deviation 74%; ulnar deviation 74%; pronation 93%, and supination 92%. Seven patients complained of symptoms relating to prominent metalwork. Good/excellent early subjective and objective functional recovery was made following open reduction and internal fixation using volar locking plates of dorsally displaced distal radial fractures. We suggest that objective assessment of grip strength and dorsiflexion can be used as a measure of patient perception of function

Objectives. The patient-rated wrist evaluation (PRWE) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire are patient-reported outcome measures (PROMs) used for clinical and research purposes. Methodological high-quality clinimetric studies that determine the measurement properties of these PROMs when used in patients with a distal radial fracture are lacking. This study aimed to validate the PRWE and DASH in Dutch patients with a displaced distal radial fracture (DRF). Methods. The intraclass correlation coefficient (ICC) was used for test-retest reliability, between PROMs completed twice with a two-week interval at six to eight months after DRF. Internal consistency was determined using Cronbach’s α for the dimensions found in the factor analysis. The measurement error was expressed by the smallest detectable change (SDC). A semi-structured interview was conducted between eight and 12 weeks after DRF to assess the content validity. Results. A total of 119 patients (mean age 58 years (. sd. 15)), 74% female, completed PROMs at a mean time of six months (. sd. 1) post-fracture. One overall meaningful dimension was found for the PRWE and the DASH. Internal consistency was excellent for both PROMs (Cronbach’s α 0.96 (PRWE) and 0.97 (DASH)). Test-retest reliability was good for the PRWE (ICC 0.87) and excellent for the DASH (ICC 0.91). The SDC was 20 for the PRWE and 14 for the DASH. No floor or ceiling effects were found. The content validity was good for both questionnaires. Conclusion. The PRWE and DASH are valid and reliable PROMs in assessing function and disability in Dutch patients with a displaced DRF. However, due to the high SDC, the PRWE and DASH are less useful for individual patients with a distal radial fracture in clinical practice. Cite this article: Y. V. Kleinlugtenbelt, R. G. Krol, M. Bhandari, J. C. Goslings, R. W. Poolman, V. A. B. Scholtes. Are the patient-rated wrist evaluation (PRWE) and the disabilities of the arm, shoulder and hand (DASH) questionnaire used in distal radial fractures truly valid and reliable? Bone Joint Res 2018;7:36–45. DOI: 10.1302/2046-3758.71.BJR-2017-0081.R1

Distal radial fractures are amongst the most common trauma referrals, however controversy remains regarding their optimum management. We undertook a retrospective review of the management of distal radial fractures in our department. The prospectively maintained trauma database was used to identify patients admitted for operative management of a dorsally displaced distal radial fracture between June 2008 and June 2009. Only extra-articular or simple intra-articular fractures were included (AO classification A2/A3/C1/C2). Operation notes were reviewed to determine the method of fixation. Patients were contacted by post and asked to complete a functional outcome score - Disabilities of the Arm, Shoulder and Hand (DASH). A further 12 patients with similar fractures who had been managed conservatively were also asked to complete a DASH score to provide a comparison between operative and non-operative management. 98 patients were identified - 67 female, 31 male. Mean age was 51 years, range 15-85 years. All patients were at least 1 year post-op. 26 patients had manipulation under anaesthesia (MUA). 48 patients had MUA and K-wire fixation, which was supplemented with synthetic bone substitute in 16 cases. 3 patients had MUA and bone graft and 21 patients had open reduction and internal fixation (ORIF) with a volar plate. 34 correctly completed DASH scores were returned. A lower score equates to a better functional outcome. Mean DASH scores were: MUA 14.8; MUA+K-wire 13.1; ORIF 13.6; conservative 47.1. This data would indicate that patients with a significantly displaced distal radial fracture have a better functional outcome with operative management to improve the fracture alignment. However, all of the methods of fixation used resulted in similar functional outcomes at one year

Aim: To compare the outcome of open reduction and internal fixation with MUA and k-wire stabilisation of dorsally displaced distal radial fractures. Methods: A review of patients that had ORIF or MUA and k-wire stabilisation for dorsally displaced distal radial fractures was carried out and patients with a follow period of more than 6 months were selected for this study. The patient history and the management of the injury were obtained and the wrist examined. Each patient completed a patient-rated wrist evaluation form and the range of movement and strength of the wrist was determined by the senior occupational therapist. Standard radiographs were obtained and volar tilt, radial inclination and radial length were measured. Results: This study provides results on 24 patients, which were grouped according to the two different surgical procedures; ORIF and MUA and k-wire stabilisation. The procedure undertaken depended on consultant preferences and in the majority of cases patients were treated with MUA and k-wire stabilisation. Patients of both groups were of similar age and all sustained either a low or medium energy injury. All patients from each group received physiotherapy post operatively. There was no significant difference between both groups for range of movement and grip strength. There was also no difference between the patient’s perception of pain and function which was assessed using the patient rated wrist evaluation (PRWE). Radiologically, the k-wire stabilisation group averaged better volar tilt compared with the ORIF group. For radial height and inclination the outcome was similar. Conclusion: MUA and k-wire stabilisation has been the most popular surgical management for unstable dorsally displaced fractures of the distal radius. More recently ORIF with the locking compression plate has been used with good results. This study showed that the outcome of ORIF and MUA and k-wire stabilisation were similar and therefore either surgical management can be used with good results

Aims. Displaced distal radius fractures were investigated at a level 1 major trauma centre during the COVID-19 2020 lockdown due to the implementation of temporary changes in practice. The primary aim was to establish if follow-up at one week in place of the 72-hour British Orthopaedic Association Standards for Trauma & Orthopaedics (BOAST) guidance was safe following manipulation under anaesthetic. A parallel adaptation during lockdown was the non-expectation of Bier’s block. The secondary aim was to compare clinical outcomes with respect to block type. Methods. Overall, 90 patients were assessed in a cross-sectional cohort study using a mixed, retrospective-prospective approach. Consecutive sampling of 30 patients pre-lockdown (P1), 30 during lockdown (P2), and 30 during post-lockdown (P3) was applied. Type of block, operative status, follow-up, and complications were extracted. Primary endpoints were early complications (≤ one week). Secondary endpoints were later complications including malunion, delayed union or osteotomy. Results. In P1, 86.6% of patients were seen between days one to three, 26.7% in P2, and 56.7% in P3. There were no documented complications from days one to three. Operative rate was 35.5%, which did not vary significantly (p= 0.712). Primary endpoints occurred between day four to seven, and included one patient each period treated for plaster cast pain. Secondary endpoints in P1 included delayed union (one patient). During P2, this included malunion (one patient), a pressure sore (one patient) and ulnar cutaneous nerve symptoms (two patients). In P3, malunion was identified in one patient. Mean follow-up was six months (4 to 9) with union rate 96%. Change in block practice varied significantly (p =＜0.05). The risk ratio of complications using regional block (Bier’s) over haematoma block was 0.65. Conclusion. Follow-up adaptations during lockdown did not adversely affect patient outcomes. Regional anaesthesia is gold standard for manipulation of displaced distal radial fractures. Cite this article: Bone Jt Open 2021;2(5):338–343

Aims: In recent years, volar locking plates have increased in popularity for the treatment of displaced distal radial fractures. The angular stability of the screws help maintain reduction permitting early mobilisation. The aim of this study was to assess functional outcome using both subjective and objective methods. Methods: The study was a prospective cohort study. Over a 2 year period 110 patients with closed, displaced distal radial fractures were considered suitable for treatment with the distal radius volar locking plate. Of these, 51 patients were followed up for a full 12 months. One year post-operatively all patients were reviewed and both subjective and objective measurements made:. Subjective:. Pain – visual analogue scale (VAS) (0 = no pain, 10 = worst pain ever). Overall function – patients’ perception – VAS (0 = no function, 100 = full function). Objective: Strength – grip and pinch – measured objectively as a percentage of the uninjured side. Range of Motion – Flexion, extension, pronation and supination – measured objectively as percentages of the uninjured side. For the purpose of this analysis, the fractures were divided into intra- and extra-articular fracture patterns based on the initial pre-operative X-rays. Results: The mean age was 55 years (28 – 83), 36 were female and 15 male. Of the fractures, 26 were extra-articular and 25 intra-articular. 28 of the 51 patients had a period of physiotherapy post-operatively. 23 patients were either not referred to physiotherapy or failed to attend. Subjectively 75% of patients had an excellent result with a pain VAS score of 0–1/10 (mean 0.9 for extra-articular and 1.2 for intra-articular) and an overall function VAS score of 9–10/10 (mean 92% for extra-articular and 86% for intra-articular). Objective outcome measures were also very good. The results for the extra-articular group showed a mean grip strength of 85%, a mean pinch grip of 91%, a mean flexion of 82%, a mean extension of 88%, a mean pronation of 98% and a mean supination of 98%. The results for intra-articular fractures showed a mean grip strength of 80%, a mean pinch grip of 88%, a mean flexion of 78%, a mean extension of 83%, a mean pronation of 94% and a mean supination of 93%. Conclusions: Overall patients made an excellent recovery. The majority of patients had little or no pain and almost complete return to function at 12 months post-operatively. Interestingly, individual patient demographics (age, sex, fracture type, physiotherapy) did not make a statistically significant difference to the outcome measures. This study confirmed excellent functional results comparable with other methods of fixation for extra-articular fractures, but it also showed good results with the more complex intra-articular fractures

Aims: The aim of this study was to þnd out if undisplaced displaced distal radial fractures require plaster immobilisation. Methods: In this prospective study, undisplaced distal radial fractures were divided into two groups; plaster immobilisation was used for one group while removable volar splint was used for the other group. Follow up was at six weeks, three months and six months. Patients were assessed by clinical examination, grip strength, radiological assessment, EQ-5D and a Short Form 12 questionnaire. Results: At 3 months, no difference was found between the two groups in clinical evaluation, radiological assessment, the functional outcome, grip strength, and visual analogue score for pain. Conclusions: We conclude that undisplaced distal radius fractures can probably be treated with out a plaster cast and put straight into wrist orthosis

Displaced distal radial fractures in adults are commonplace. Acknowledging that satisfactory radiographic parameters typically will beget satisfactory functional outcomes, management of these fractures includes a reduction followed by either cast/splint immobilisation or internal fixation. While we can generally rely on internal fixation to maintain the reduction the same is not true of cast immobilisation. There are, however, limited data defining the fate of a fracture reduction in those treated in a cast and up to the time of radial union. Traditional practice is to recommend six weeks of immobilisation. Our goal was to detail the radiographic patterns of change in the radiographic parameters of radial inclination (RI), ulnar variance (UV) and radial tilt (RT) over the first twelve weeks in women fifty years old and older who had sustained a displaced distal radial fracture. We examined serial standard PA and lateral distal radius radiographs of 647 women treated by closed reduction and casting for a displaced fracture of the distal radius. Measurements of RI, UV and RT from standardised radiographs were made immediately post-reduction as well as, as often as possible/feasible, at 1,2,3,6,9 and 12 weeks post fracture. All measurements were made by the senior author (accuracy range: 2 degrees for RI, 1 mm for UV and 4 degrees for RT, in 75% of cases). The primary outcome measure was the change in fracture position over time. Secondary outcomes included changes related to age group; known bone density; the relation to associated ulnar fractures; and independence of the variables of RI, UV and RT. The mean immediate post-reduction values for RI, UV and RT were 21 degrees, 1.5 mm, and −6 degrees, respectively. These all changed in the first six weeks, and did not in the second six week period. The mean change in RI was 3 degrees, 60% of the change occurring in the first week post-reduction; only 0.3 degrees of change was noted beyond three weeks. The mean UV increased by 2.2 mm over the first 6 weeks, 23% in the first week post reduction. The mean RT change of 7.7 degrees was also gradual over the first 6 weeks, with no significant change afterwards. The RI changes identified were not influenced by patient age, while UV and RT changes were greater in older groups. Those fractures of the distal radius associated with a distal ulnar shaft or neck fracture did not lose radial inclination over the study period. We have defined patterns of loss of reduction that commonly occur post reduction of a displaced distal radius fracture in women fifty years and older. Such patterns ought to guide our closed management of distal radial fractures, whether by altering the duration or method of casting. Women fifty years old and older, and physicians alike, must be advised that conventional casting post distal radial fracture reduction unreliably maintains fracture reduction

Aim: To assess the ability of volar locking plates to maintain fracture reduction when used to treat dorsally displaced extra and intra-articular distal radial fractures. Methods: This prospective study was conducted over a 12 month period. Consenting patients who had sustained a closed, dorsally displaced distal radial fracture, treated by open reduction and internal fixation using a volar distal radial locking plate, were included in the study. Radial inclination, volar tilt and ulnar variance were measured from radiographs taken at least 3 months after surgery and compared with radiographs of the uninjured side. Only two of the eight participating surgeons have a specialist interest in upper limb surgery. Results: Thirty-three patients were included in the study. There were 23 females and 10 males. The mean age was 49.5 years, range 26–82 years. According to the OTA classification there were 19 Type A, 1 Type B and 13 Type C fractures. The mean restoration of volar tilt was 1° of under-correction, median 1.1° under-correction with a range of 7.3° of under-correction to 3.7° of over-correction, when compared with the uninjured side. The mean restoration of radial inclination was 1.9° of under-correction, median 1.6° under-correction with a range of 10° of under-correction to 8.4° of over-correction. As a group the mean ulnar variance was 0mm with a range of 2mm of relative ulnar shortening to 3.5mm of ulnar prominence when compared with the uninjured side. Conclusion: In the hands of general trauma surgeons, the volar approach combined with the application of a suitable volar locking plate is a good treatment for restoring and maintaining the anatomy of dorsally displaced intra and extra-articular distal radial fractures

Introduction. Several clinical and radiological studies have confirmed the benefits of using Volar Locking Plates (VLPs) to treat unstable distal radius fractures. The “theoretical” advantage of VLPs compared to standard plate fixation is that VLPs, through their design, intrinsically provide angular stability for most fracture configurations including comminuted fractures and, quite possibly, osteoporotic fractures. However few studies have compared the clinical results of patients of different ages who have been treated using VLPs. Aim. The aim of this study was to compare the clinical outcomes of VLP fixation of displaced distal radius in younger (<59 yrs) and older (>60yrs) patients. Patients & Methods. We reviewed 78 consecutive patients who had undergone ORIF of their displaced distal radial fractures using a VLP. All patients were reviewed at predetermined time points by an independent observer and the findings at 6 months are presented. In addition to documenting the standard demographics for each patient and classifying the fractures using the OTA/AO system, wrist function was assessed using Range of Movement (ROM), Grip strength (GS), the Modified Gartland & Werley score (MGWS), the Patient Rated Wrist Evaluation (PRWE), the Quick DASH scores, and overall scores of wrist Pain and Function using Visual Analogue Scores (VAS). Results. 43 patients were under 60 years of age and 35 patients were 60 years or over. The proportion of extra-articular to intra-articular fractures were similar for both age groups. There was little difference in terms of patient perception of Pain and Function, or ROM, MGWS (7.2 versus 6.9), PRWE (24 versus 23.6) and quick DASH scores (17.3 versus 19.1) between the two groups at 6 months. The younger group did have significantly better grip strength, but when compared as a percentage of the uninjured wrist, the results were also similar (83% vs 80%). Conclusions. VLPs are a suitable option for fixing distal radial fractures in older patients (>60yrs) and the clinical results appear to be just as good as they are in younger patients

Older fracture patients frequently ask whether their osteoporosis will affect fracture healing. There is only limited previous data about this. We investigated recovery after distal radial fracture, and compared it with BMD of the other distal radius and the lumbar spine (measured using quantitative CT). All 28 patients had sustained a dorsally displaced distal radial fracture which was deemed to require treatment by intrafocal wire fixation. All patients had acceptable correction of dorsal and radial angle at final x ray (3 months). Wrist function was measured using the Patient Rated Wrist Evaluation (PRWE – a validated outcome measure for use after distal radial fractures), grip strength,and range of motion. All measurements were made at 6, 12 and 26 weeks. BMD was measured in the opposite wrist and the lumbar spine using QCT at 6 weeks after fracture. There was no correlation between recovery of grip strength (% of contralateral grip strength) at 6,12,or 26 weeks with BMD at either site. Similarly, there was no correlation between BMD and either absolute PRWE scores at any time point or improvement in PRWE between time points. The strongest predictor of recovery of grip appeared to be the proportion of grip recovered at 6 weeks (correlation between% grip recovered at 6 weeks and 3 months r = 0.85; at 6 weeks and 6 months r= 0.56; both p < 0.001). This was not affected by age or variations in measured final dorsal or radial angles or length within this group. It was not affected by degree of preoperative fracture displacement. These data suggest that recovery of function after distal radial fractures is not influenced by osteoporosis. The data about the importance of initial recovery of grip suggest that factors other than bone position and bone healing may affect rate of functional recovery after distal radial fracture

Various studies report a correlation between the severity of the primary displacement, carpal malalignment & an expectant loss of reduction over a given time period when treating distal radius fractures with cast immobilization. Recently, studies have attempted to classify carpal malalignments associated with displaced distal radial fractures based on Effective radio-lunate flexion (ERLF) into: midcarpal with ERLF < 250 and radiocarpal malalignment with ERLF > 250. The aim of this study was to assess the frequency of carpal instability as a concomitant lesion to fractures of the distal radius, delineate further various factors including associated carpal malalignment based on ERLF that are predictive of instability based on a timeline of early (one week) and late failure (six weeks) in an attempt to predict the final radiological outcome accurately. Radiographic alignment parameters were compared before and after reduction using paired t-tests and then also analysed in a multiple logistic regression analysis. Early failure group: Regression analysis showed high correlation between the severity of axial shortening before reduction and at one week. Age, gender, presence of dorsal comminution, ulnar styloid fracture, initial dorsal angulation and flattening of radial angle were unreliable in predicting early failure at one week. Late failure group: We found radial shortening, dorsal tilt, presence of dorsal comminution & ERLF > 25 to be significant predictors of adverse radiological outcome at six weeks. Age, Gender, flattening of radial angle, ulnar styloid fracture as factors for secondary displacement when analyzed independently or in combination were not found to be significant predictors of late failure. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) and both at one and six weeks when analysed independently or in combination (p< 0.01). Our study reaffirms the need to attention to initial fracture characteristics and highlights the importance of radiocarpal instability pattern on post reduction radiographs as a predictor of late instability. This would allow the surgeon to inform the patient of chance of success with closed treatment and alternative treatment options

Measurement of the rate of fracture healing is a major problem in fracture research. Bone mineral density (BMD) of fracture callus has been used as a measure of healing in diaphyseal fractures. However, metaphyseal fractures (especially in the elderly) are now the commonest type of fracture and are a significant public health problem. This study investigated whether measurement of BMD at the fracture site in the distal radius can be used as a measure of fracture healing. We recruited 28 patients who had sustained a dorsally displaced distal radial fracture which was deemed to require treatment by intrafocal wire fixation. All patients had acceptable correction of dorsal and radial angle at final x ray (3 months). Wrist function was measured using the Patient Rated Wrist Evaluation (PRWE – a validated outcome measure for use after distal radial fractures), grip strength,and range of motion. All measurements were made at 6, 12 and 26 weeks. BMD was measured at the fracture site (examining the BMD of the medullary bone at the fracture site after removal of wires), in the opposite wrist and the lumbar spine using QCT at 6 weeks after fracture. There was no correlation between fracture site BMD and BMD at the other wrist or the lumbar spine (r < 0.3). The BMD at the fracture site was higher than the BMD at the other wrist (mean 168 vs 70 HU; p< 0.001 paired T test). There was no relationship between fracture site BMD or the ratio of BMDs fracture site / normal wrist, and any of the functional assessments (proportion grip strength recovered, range of motion or PRWE (r < 0.3)). 15 of these patients underwent a second QCT at 12 weeks after fracture. There was no significant change in fracture site BMD between the first and second scan. These data indicate that fracture site BMD is unlikely to be a useful method of measuring metaphyseal bone healing. The increase in BMD at the fracture site was unexpected; possible explanations include impaction of bone or high BMD in woven bone (the relationship of which to bone stiffness is uncertain)

Background: Extraarticular distal radius fracture is the second most common osteoporotic fracture seen in the elderly patients. Purpose: To establish relationship between radiological parameters and final functional outcome in conservatively treated displaced extraarticular distal radial fractures in elderly patients. Methods: Twenty-two wrists with displaced extraar-ticular distal radial fractures in twenty sedentary, low demand elderly patients treated with manipulation under anaesthesia and plaster application between May 1999 and June 2000. The case notes and radiographs of these patients were assessed retrospectively and subjective outcome was evaluated with validated DASH Questionnaire at 3 years post- reduction. Overall satisfaction, ability to return to the previous level of activity and concern over wrist appearance was further analyzed. Only those patients with more than 5 mm of shortening and more than 15 degrees of dorsal angulation at initial radiographs were included. Results were analysed using Pearson Correlation Sig.(2 –Tailed) formula. Results: There were 16 female and 4 male patients with a mean age of 71 years. The mean follow-up was 3 years. DASH score of less than 25 was seen in 14, between 25-50 in 3 and between 50-75 in 3 patients with mean of 21.426 and standard deviation of 22.353. Despite residual deformity in some patients, there was high degree of patient satisfaction consistent with low level of DASH score found in 71% patients. It was also noticed that Males in the study group were younger and have lower dash scores. Patients with more than 5 mm of shortening and more than 15 degrees of dorsal angu-lation at initial radiographs showed no adverse correlation with subjective outcome. Statistical analysis of the results confirmed that higher the age lower the DASH score there by better functional result. Conclusion: It was noted that the higher the age the lower the dash score. Radiological picture and functional outcome are found to be two independent variables in the elderly subgroup of patients with displaced extrar-ticular distal radius fractures. Nonoperative treatment yields satisfactory results with high patient satisfaction rate and is advocated in elderly patients

Restoration of normal anatomy following a distal radial fracture is an important factor in determining functional recovery. However, current methods of assessing dorsal tilt and displacement require ‘true’ lateral radiographs, and important reference points are often obscured by metalwork. Aims: to investigate if an easily identifiable and predictable relationship exists in the normal wrist between the distal radius and lunate; and if so,to compare fractured wrists (pre and postoperatively)using conventional and new assessment methods. 22 patients with displaced distal radial fractures treated by ORIF, were included. Patients had pre and postoperative radiographs taken of the injured and uninjured wrists. From lateral radiographs, measurements were performed using the PACS system. A line was superimposed upon the dorsal radial cortex 2cm proximal to the wrist passing distally. The following measurements were performed: lunate height, distance from the ‘line’ to the superior and inferior poles of the lunate, and conventional measurements of dorsal tilt and angulation. Uninjured wrist: Most noticeably the dorsal radial line always passed superior to the lunate, mean distance of 3.27mm (1.75-6.6mm). As a ratio, the distance from the line to the superior pole of the lunate divided by the distance to the inferior pole (‘lunate ratio’) had a mean of 0.16 (0.11-0.19). Fractured wrist, PreORIF: Using conventional methods, the mean fracture displacement was 2.64mm (0-5.1mm) and the mean dorsal tilt was 23.3 degrees(4 degrees volar tilt to 43 degrees dorsal tilt). Using the dorsal reference ‘line’, in all cases the lunate was either above or transected by the line; mean lunate ratio of 1.61 (0.54-8.05). The mean height of the lunate projecting dorsal to the line was 9.5mm (6.1-16.1mm). Fractured wrist, PostORIF: Apart from one radiograph, the ‘line’ passed superior to the lunate; mean distance of 2.64mm (0-3.9mm), with a mean lunate ratio of 1.13 (0.61-2.74). These measurements correlated well with measurements of dorsal tilt and displacement. Our study suggests that there is a strong relationship between the distal radius and the lunate that could be used to assess fracture displacement and quality of reduction. Its main advantages are simplicity and ease of use despite the presence of metalwork

Restoration of normal anatomy following a distal radial fracture is an important factor in determining functional recovery. However, current methods of assessing dorsal tilt and displacement require ‘true’ lateral radiographs, and important reference points are often obscured by metalwork. Aims: To investigate if an easily identifiable and predictable relationship exists in the normal wrist between the distal radius and lunate; and if so, to compare fractured wrists (pre and postoperatively)using conventional and new assessment methods. Methods: 22 patients with displaced distal radial fractures treated by ORIF, were included. Patients had pre and postoperative radiographs taken of the injured and uninjured wrists. From true lateral radiographs, measurements were performed using the PACS system. A line was superimposed upon the dorsal radial cortex at least 2cm proximal to the wrist and extending distally. The following measurements were performed: lunate height, distance from the ‘line’ to the superior and inferior poles of the lunate, and conventional measurements of dorsal tilt and angulation. Results: Uninjured wrist: Most noticeably the dorsal radial line always passed superior to the lunate, mean distance of 3.27mm (1.75–6.6mm). As a ratio, the distance from the line to the superior pole of the lunate divided by the distance to the inferior pole (‘lunate ratio’) had a mean of 0.16 (0.11–0.19). Fractured wrist, PreORIF: Using conventional methods, the mean fracture displacement was 2.64mm (0–5.1mm) and the mean dorsal tilt was 23.3 degrees(4 degrees volar tilt to 43 degrees dorsal tilt). Using the dorsal reference ‘line’, in all cases the lunate was either above or transected by the line; mean lunate ratio of 1.61 (0.54–8.05). The mean height of the lunate projecting dorsal to the line was 9.5mm (6.1–16.1mm). Fractured wrist, PostORIF: Apart from one radiograph, the ‘line’ passed superior to the lunate; mean distance of 2.64mm (0–3.9mm), with a mean lunate ratio of 1.13 (0.61–2.74). These measurements correlated well with measurements of dorsal tilt and displacement. Discussion: Our study suggests that there is a strong relationship between the distal radius and the lunate that could be used to assess fracture displacement and quality of reduction. Its main advantages are simplicity and ease of use despite the presence of metalwork

The standard of treatment for most fractures of distal radius remains closed reduction and immobilization. It is essential to discern which fracture patterns are more susceptible to failure so that surgical intervention can be considered when an acceptable reduction cannot be achieved or has a risk of secondary displacement. A correlation between the severity of the primary displacement, carpal malalignment & an expectant loss of reduction over a given time period when treating distal radius fractures with cast immobilization is reported. Recently, studies have attempted to classify carpal malalignments associated with displaced distal radial fractures based on Effective radio-lunate flexion (ERLF) into: midcarpal with ERLF < 25 and radio-carpal malalignment with ERLF > 25. The aim of this study was to assess the frequency of carpal instability as a concomitant lesion to fractures of the distal radius, delineate further various factors including associated carpal malalignment based on ERLF that are predictive of instability based on a timeline of early (I week) and late failure (six weeks). Radiographic alignment parameters were compared using paired t-tests and then also analysed in a multiple logistic regression analysis. There was a significant improvement in all the parameters measured (p< 0.01) with mean correction falling within acceptable limits. Early failure group: Regression analysis showed high correlation between the severity of axial shortening before reduction and at six weeks. Age, gender, presence of dorsal comminution and ulnar styloid fracture, initial dorsal angulation and flattening of radial angle were unreliable in predicting early failure at one week. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) at one week when analysed independently or in combination(p< 0.01). In the late failure group:Radial shortening, dorsal tilt, presence of dorsal comminution & ERLF > 25 to be significant predictors of adverse radiological outcome. Age, Gender, flattening of radial angle, ulnar styloid fracture, for secondary displacement when analyzed independently or in combination were not found to be significant predictors of failure at 6-week. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) and at 6weeks when analysed independently or in combination.(p< 0.01) Our study reaffirms the need to attention to initial fracture characteristics and highlights the importance of radiocarpal instability pattern on post reduction radiographs as a predictor of late instability & anticipate the radiological outcome. This would allow the surgeon to inform the patient of chance of success with closed treatment and alternative treatment options

Aim: A prospective randomised clinical trial was performed to evaluate two forms of immobilisation in the treatment of colles fractures not requiring manipulation. Methods: Patients were randomised to either plaster cast (PC) or a removable splint: wrist splint (FWS) according to date of presentation. Patients who had associated injuries to the same upper limb, previous wrist fracture, and open fractures, below 20 years or impaired cognitive function were excluded. The hospital ethical committee approved the study and informed consent was obtained from patients. Patients were reviewed at one week, two weeks, six weeks and twelve weeks following enrolment into the trial. Radiographs were performed on the first four visits. Subjective data was obtained using a patient questionnaire. Levels of pain, comfort in cast, swelling and any modifications to the cast were documented. Was used at six and twelve weeks to assess Clinical assessment was performed by a qualified physiotherapist using the demerit score of Sarmiento which combines range of motion, grip strength and functional assessment. Results: There were thirty-seven patients in the PC group and thirty-four in the FWS group. They were well matched in terms of age and sex distribution One patient in the PC group required manipulation under anaesthesia due to loss of position at one week. There was no statistical difference between either treatment method in radiological position. Nine patients in the PC group required change of cast due to loosening or discomfort. A further eight patients in the PC group required cast trimming. Visual analogue scores for pain and cast discomfort were lower in the FS group (p< 0.05). Grip strength compared to the opposite side was higher in the FS group (55.9% Vs 47.8% at week six, 71.8% Vs 65% at week twelve). Functional assessment demonstrated a higher score in the FS group at six weeks. However the difference did not reach statistical significance at repeat examination at twelve weeks. Conclusion: In this study there was no difference in either method in maintaining fracture position. However there was greater patient satisfaction and earlier rehabilitation in those patients treated in a futura wrist splint. Patients treated in plaster cast required a greater use of plaster room resources. We feel that the use of a removable wrist splint in suitable patients with either undisplaced or minimally displaced distal radial fractures is validated by this study