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The optimal management of distal radius fractures (DRFs) in older patients remains debatable. A knowledge gap exists concerning how to manage fractures with early malalignment during nonoperative treatment. We conducted a prospective, multicenter, and randomized controlled trial to compare nonoperative treatment to operative treatment with volar locking plating (VLP) in the management of primarily malaligned DRFs and DRFs that exhibit early malalignment during nonoperative treatment. The DRIFT trial was conducted at five trauma centers in Finland, Sweden, and Denmark. Patients aged 65 years or older with a dorsally displaced AO-type A or C DRF were included in the trial. Patients with DRF who did not maintain alignment after closed reduction (CR) were randomized in 1:1 ratio to nonoperative treatment or VLP. Patients with acceptable alignment after CR visited the outpatient clinic 5-10 days after CR. If the alignment was lost, the patients were randomized in 1:1 ratio to either continue nonoperative treatment or to VLP. The primary outcome measure was Patient Rated Wrist Evaluation (PRWE) at 12 months. The primary analysis method for PRWE was a linear mixed model. In the linear mixed model, patient was a random factor and age and intra/extra articularity of the fracture were fixed. Participants and orthopedic investigators were not blinded. The statisticians and investigators responsible for the analysis remained blinded to the treatment groups during data analysis and the drawing of conclusions. Between March 15, 2018 and June 6, 2023, 291 patients aged 65 years or older (mean age 73 years (standard deviation (SD) 5.8), 258 women, 33 men) who had sustained a DRF were included in the trial. The 12-month follow-up was completed on June 11, 2024. One hundred twenty-four DRFs did not maintain acceptable fracture alignment after CR; 66 were randomized to nonoperative treatment and 58 to VLP. These patients are referred to as primarily malaligned DRFs. Eighty-six patients lost fracture alignment during the first 5-10 days of follow-up; 44 patients were randomized to continue nonoperative treatment, and 42 patients to VLP. These patients are referred to as early malaligned DRFs. In primarily malaligned DRFs, the estimated mean effect for PRWE at 12 months was -9.6 points (95% confidence interval (CI) [-17.4, -1.7]; p = 0.0178) in favor of VLP, which is smaller than the predefined minimal clinically important difference (MCID) of the PRWE (11 points). In early malaligned DRFs, the mean effect for PRWE at 12 months was -6.2 points (95% CI [-15.4, 3.0]; p = 0.1816). At 12-month follow-up, we found 25 treatment-related adverse events (AE) (10/66, 15% in primarily malaligned DRFs nonoperative; 5/58, 8.6% in primarily malaligned DRFs operative; 2/44, 4.5% in early malaligned DRFs nonoperative; 3/42, 7.1% in early malaligned DRFs operative; 5/63, 7.9% in well-aligned DRFs) and 11 other AE. The trial recruitment period was longer than expected due to the restrictions caused by the global COVID-19 pandemic. Due to the decreased inclusion rate, we had to cease the recruitment of patients with early malaligned DRF before reaching the predefined 57 patients per Arm, which was the main limitation of the trial. Operative treatment of primarily malaligned DRF with VLP may slightly improve wrist function at 12 months. The estimated mean difference between the groups was, however, smaller than the predefined MCID of the PRWE (11 points). In DRFs with early loss of alignment, operative treatment does not appear to provide benefit. Our results suggest that the choice of treatment modality should be made following primary fracture reduction because subsequent monitoring of fracture alignment does not offer any additional benefit in terms of expected wrist function. This questions the need for early radiographic follow-up during the nonoperative treatment. The trial was registered at ClinicalTrials.gov (Identifier: NCT02879656, registration date 08/17/2016).

Background External fixation has been one of the conventional managements of unstable distal radius fracture. The main aim of this paper is to compare two methods of applying distractive force along the radius shaft versus perpendicular to the distal radius articular surface. Design Sixty patients with unstable distal radius fracture were included in present clinical trial and randomized in two groups, using block randomization method. In group A (first arm), distraction force was exerted parallel to the radius shaft. In group B (second arm), the external fixator was adjusted based on radial and palmar tilt of the mean population healthy wrist so that distraction was exerted perpendicular to the wrist articular surface. Methods Radiological and clinical parameters were evaluated in both groups of patients pre-operatively, immediately after surgery, and 6 weeks post-operatively. We also followed up patients clinically at 12 weeks after surgery. Patient-Rated Wrist Evaluation (PRWE), Mayo wrist score, and Quick Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires were used in order to assess patients’ clinical and functional states. Results The method used in group B resulted in better improvement of palmar tilt both immediately ( P  = 0.007) and at 6 weeks follow up ( P  = 0.013) post-operatively in comparison with patients in group A. Radius height and radial inclination were also better restored when using the proposed modified method ( P  = 0.001 and < 0.001, respectively). There was no difference in any of clinical results (range of motion, grip strength, PRWE, Mayo, and DASH scores) between two groups of study, 12 weeks after surgery. Conclusion Applying distractive force perpendicular to the distal radius articular surface seems to improve some radiological outcomes, probably due to better reduction maintenance, when compared with the technique of applying distraction force along distal radius shaft axis. Level of Evidence Level I (clinical trial study). Trial registration This study is registered at Iranian Registry of Clinical Trials (IRCT) with approval code of IRCT20200313046759N1.

Postoperative immobilization protocols after volar fixed-angle plate fixation of distal radius fractures (DRF) vary among surgeons. This study aimed to compare functional outcomes, radiographic parameters, and complications between early and delayed mobilization after volar fixed-angle plate fixation of DRF. This study is a randomized controlled trial. The early group was allowed to perform wrist motion exercise immediately after surgery and the delayed group was allowed to perform it after 2 weeks of external immobilization. Postoperative patient-rated wrist evaluation (PRWE), disabilities of arm, shoulder, and hand (DASH), wrist range of motion, visual analog scale (VAS) pain score, and grip strength were evaluated. Forty-eight patients with DRF were enrolled and randomly allocated to the early or delayed mobilization groups. The PRWE, DASH, VAS pain score, grip strength, and wrist motion of both groups significantly improved over time. However, there were no significant differences between groups at any timepoint. Radiographic parameters were not different between groups. There were no significant differences in functional outcomes, radiographic parameters, and complications between early and delayed mobilization after volar fixed-angle plate of DRF. Immediate postoperative wrist range-of-motion exercise can be safely initiated after volar fixed-angle plate fixation of DRF without external immobilization. Clinical trial registration: Thaiclinicaltrials.org identifier: TCTR20180927005. Registered 27/09/2018—retrospectively registered. https://www.thaiclinicaltrials.org/show/TCTR20180927005 .

Non-invasiveness and comfort are crucial in the conservative management of distal radius and scaphoid fractures. While fiberglass casts are standard, three-dimensional (3D)-printed orthoses offer a promising alternative. To compare patient experiences, safety perceptions, and satisfaction between a 3D orthosis and fiberglass cast for distal radius or scaphoid fractures. Randomized feasibility trial. Nineteen adult patients were randomly assigned (3D orthosis group, n = 10; fiberglass cast group, n = 9) and followed until orthosis or cast removal at 6–8 weeks. X-rays at weeks 1 and 6 documented bone healing, with weekly hand therapy visits assessed orthosis satisfaction and function. The Patient-Rated orthosis Satisfaction Questionnaire (PRSEQ) measured satisfaction at weeks 2, 4, and removal. Descriptive statistics and non-parametric correlation tests were used for data analysis. The 3D orthosis group achieved significantly higher PRSEQ scores (mean difference [MD]= 15.7%, p = 0.005 to 0.01, r = −.581 to −.638) and lower perceived pain (MD=−1.0 to −2.2, p = 0.001 to 0.048, r = −0.45 to −0.75) compared to the cast group. By week 4, the 3D group reported less discomfort (MD=−2.2, p = 0.03, r = −0.5) and felt safer (MD=1.6, p = 0.043, r = −0.46). Routine activities were easier for the 3D group at weeks 2 and 6 (MD=−2.8 to −3.0, p = 0.033 to 0.034, r = −0.49). Satisfaction scores were higher in the 3D group (mean 8.4 vs. 5.6 points, p < 0.001 to 0.01, r = −0.57 to −0.82). Compliance was excellent in both groups. No significant differences were observed in radiological outcomes, finger sensibility, or edema. Bone healing occurred in both groups without fracture displacement; however, one cast patient required subsequent surgery for scaphoid non-union. Treatment with a 3D-printed orthosis appeared feasible and safe, with patients reporting higher satisfaction and better self-perceived hand function compared to a custom-made fiberglass cast, although further research is needed to confirm these findings. •Three-dimensional (3D)-printed orthoses seem feasible and safe for scaphoid and radius fractures.•Patients using 3D orthoses reported higher satisfaction and less pain than fiberglass casts.•Both groups demonstrated excellent compliance and comparable recovery outcomes.•Addressing 3D printing costs and production times is crucial for wider adoption.

Background There is no consensus concerning the optimal casting technique for displaced distal radius fractures (DRFs) following closed reduction. This study evaluates whether a splint or a circumferential cast is most optimal to prevent fracture redisplacement in adult patients with a reduced DRF. Additionally, the cost-effectiveness of both cast types will be calculated. Methods/design This multicenter cluster randomized controlled trial will compare initial immobilization with a circumferential below-elbow cast versus a below-elbow plaster splint in reduced DRFs. Randomization will take place on hospital-level (cluster, n  = 10) with a cross-over point halfway the inclusion of the needed number of patients per hospital. Inclusion criteria comprise adult patients (≥ 18 years) with a primary displaced DRF which is treated conservatively after closed reduction. Multiple trauma patients (Injury Severity Score ≥ 16), concomitant ulnar fractures (except styloid process fractures) and patients with concomitant injury on the ipsilateral arm or inability to complete study forms will be excluded. Primary study outcome is fracture redisplacement of the initial reduced DRF. Secondary outcomes are patient-reported outcomes assessed with the Disability Arm Shoulder Hand score (DASH) and Patient-Rated Wrist Evaluation score (PRWE), comfort of the cast, quality of life assessed with the EQ-5D-5L questionnaire, analgesics use, cost-effectiveness and (serious) adverse events occurence. In total, 560 patients will be included and followed for 1 year. The estimated time required for inclusion will be 18 months. Discussion The CAST study will provide evidence whether the type of cast immobilization is of influence on fracture redisplacement in distal radius fractures. Extensive follow-up during one year concerning radiographic, functional and patient reported outcomes will give a broad view on DRF recovery. Trial registration Registered in the Dutch Trial Registry on January 14th 2020. Registration number: NL8311 .

Purpose With this prospective randomized control trial (RCT), we aim to provide the outcome analyses of the three most used treatment modalities for distal end of radius (DER) fracture management in the elderly. Methods A prospective randomized control trial was performed. Fifty-two patients with DER fractures (AO A2, A3, C1, or C2) were randomized to the casting ( n  = 17), percutaneous pinning ( n  = 18), and the volar plating group ( n  = 17). Radiological measurements measured were radial inclination (RI), radial height (RH), volar tilt (VT), and ulnar variance (UV). The outcome was measured based on range-of-motion, grip strength, Patient-Related-Wrist-Evaluation (PRWE) score, and the Quick-Disabilities-of-the-Arm-Shoulder-Hand (QDASH) score. Results Immediate post-operative and 1-year-follow-up X-rays showed a significant difference measurement between the groups ( p  < 0.05). Pairwise comparisons of the casting and pinning groups ( p  < 0.05) and the casting and plating groups ( p  < 0.05) revealed significant differences at the 1-year follow-up, but not the pinning and plating groups ( p  > 0.05). The analysis found significant differences in clinical outcomes after 1 month of follow-up, with the plating group outperforming the other two ( p  > 0.05). However, after a year of follow-up, all groups had comparable outcomes; however, the plating group showed improved palmar flexion ( p  < 0.001), radial deviation ( p  < 0.001), and a lower PRWE score ( p  < 0.05), indicating better wrist function. Complications were more in casting group. Conclusion The study found a radiologically significant difference between groups throughout the follow-up, but it did not affect functional results. Clinical outcomes were similar across the groups, with plating showing better palmar flexion and radial deviation. Grip strength was also better in the plating group, but statistically insignificant. The study suggests plating should be chosen over other treatments for high-demand patients.

Background Distal radius fractures (DRFs) are among the most common orthopedic injuries and are often challenging for students to fully understand when taught using only 2D radiographs or healthy models. This study aimed to evaluate the educational impact of tomography-based 3DP DRF models on medical students’ knowledge acquisition and anatomical understanding compared with conventional teaching methods. Methods The study was designed as a parallel-group, single-blinded prospective randomized controlled trial conducted over two days of structured education. Ninety-four second year physiotherapy students (19.62 ± 1.2 years; 45 F, 49 M) were enrolled and randomly assigned into intervention ( n  = 47) and control ( n  = 47) groups. The intervention group received tomography-based fracture 3DP training, while the control group received a healthy 3D-printed model. Primary outcomes included theoretical knowledge (MCQs) and practical case-solving. Secondary outcomes were Test-Taking Motivation Questionnaire (TTMQ); Test Anxiety Inventory (TAI), puzzle assembly time, satisfaction, and willingness-to-recommend ratings. Assessments were conducted pre- and post-training, with knowledge retention re-assessed at one month after education. Statistical analyses were performed using independent samples t-tests and chi-square tests for between-group comparisons, paired t-tests for within-group changes. Results The intervention group included 47 students (19.51 ± 1.1 years; 36 F, 11 M), while the control group consisted of 47 students (19.74 ± 1.3 years; 33 F, 14 M). Demographic characteristics were similar between the groups. In the 3D group, theoretical knowledge scores improved (50.68 [45.34, 55.93], p  < .001), TTMQ scores increased (28.06 [24.22, 31.91], p  < .001), and TAI scores decreased (–10.89 [–14.33, − 7.46], p  < .001). Similarly, in the control group, theoretical knowledge scores improved (49.46 [44.86, 54.03], p  < .001), TTMQ scores increased (21.60 [17.13, 26.06], p  < .001), and TAI scores decreased (–9.70 [–14.35, − 5.05], p  < .001). Post-training comparisons showed that the intervention group achieved significantly higher scores in case-solving (–18.55 [–23.87, − 13.23], p  < .001), MCQ performance (4.17 [0.15, 8.18], p  = .042), puzzle assembly time (11.34 [4.24, 18.44], p  = .002), TTMQ (8.04 [3.20, 12.87], p  = .030), and TAI (–4.42 [–7.54, − 1.30], p  = .030). No significant between-group differences were observed for color recognition ( p  = .301), weight identification ( p  = .161), detail recognition ( p  = .669), or knowledge retention ( p  = .160). Conclusions Within the limits of this study, tomography-based fracture-specific 3D printed models led to greater improvements in knowledge, motivation, reduced anxiety, and better practical performance compared with conventional teaching methods. These models showed educational benefits; further research is needed to confirm long-term and clinical impacts. Trial registration clinicaltrials.gov NCT06061003 24/09/2023.

Background Recently, computerized virtual surgery planning has been increasingly applied in various orthopedic procedures. In this study, we developed an image fusion system for 3D preoperative planning and fluoroscopy for the osteosynthesis. To assess the utility of image fusion system, we evaluated the reproducibility of preoperative planning in the osteosynthesis of distal radius fractures with using the image fusion system, and compared with the reproducibility of the patients without using the image fusion system. Methods Forty-two wrists of 42 distal radius fracture patients who underwent osteosynthesis using volar locking plates were evaluated. The patients were divided into two groups. Image fusion group utilized three-dimensional (3D) preoperative planning and image fusion system. Control group utilized only 3D preoperative planning. In both groups, 3D preoperative planning was performed in order to determine reduction, placement, and choice of implants. In the image fusion group, the outline of planned image was displayed on a monitor overlapping with fluoroscopy images during surgery. Reductions were evaluated by volar tilt and radial inclination of 3D images. Plate positions were evaluated with distance to joint surface, plate center axis position, and inclination relative to the radius axis. Screw choices were recorded for the plan and actual choices for each screw hole. Differences in the parameters between pre- and postoperative images were evaluated. Differences in reduction shape, plate positions, and screw choices were compared between groups. Results The differences in the distance from plate to joint surface were significantly smaller in the image fusion group compared to the control group ( P  < 0.01). The differences in the distal screw choices were significantly smaller in the image fusion group compared to the control group ( P  < 0.01). Conclusions The image fusion system was useful to reproduce the planned plate position and distal screw choices in the osteosynthesis of distal radius fractures. Trial registration ClinicalTrials.gov, NCT03764501

Objectives The objective of this study was to compare the results of two methods for sparing the pronator quadratus in volar plating of distal radius fractures. Methods A total of 110 patients were randomized to volar plating with sparing of the pronator quadratus either by a transverse incision along the distal border of the pronator quadratus (Group A, 55 people) or by the brachioradialis splitting method (Group B, 55 people). The operative and radiation time, range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, Visual Analog Scale (VAS) scores, and complications were recorded. Results There were no significant differences in the mean operative time, radiation time, mean bone union time, or total complication rate between the groups. We found no significant differences in range of motion, grip strength, VAS scores, and DASH scores at any of the study intervals between the groups. Although neurapraxia of the superficial branch of the radial nerve was more common in Group B than in Group A (6.7% vs. 0%), the difference was not significant. Conclusions Both methods were efficient approaches for sparing the pronator quadratus and had similar clinical outcomes, but they had different indications.

Background Distal radial fractures are one of the most common orthopaedic cases that present to the A&E department. Surgical intervention is warranted in displaced intraarticular fractures and fractures with more than the recommended angulation or shortening, and is most commonly treated with volarly placed fixed angle locking plates. The aim of this study is to determine and compare the efficacy of two different plates for surgical treatment of distal radius fractures. The VRP 2.0 is a new plate produced by the Austofix company and this system will be compared against the VA-LP (Variable angle-locking plate) produced by Depuy-Synthes which has been used as the standard treatment device. Methods and Design Patients between the ages of 18 and 80 presenting to the Royal Adelaide Hospital with isolated closed distal radial fractures will be invited to participate in this study. A total of 200 patients are required to provide 90% statistical power at a 5% alpha level to detect a difference of 11.5 points on the PRWE (Patient rated Wrist evaluation) score. The primary outcome measure will be the PRWE score while the secondary outcome measures will include the DASH score, EQ5D score, clinical range of movements, grip strength as well as patient perceived return of function at the wrist and time to resumption to work. These will be measured at 6 weeks, 3 months and 12 months. Radiographic indices including the radial tilt, length, volar inclination and plate prominence will also be measured. Complications will be recorded up to 12 months. Post hoc comparisons will be done using paired t tests. An intention to treat and a per protocol analysis will be done to compare the 2 groups. Discussion Distal radial fractures are increasingly being treated by internal fixation using volar locking plates. However, there is no prospective study to date comparing one plate against another in terms of outcome and complications. This study could provide more information about the best way to treat these injuries surgically. Trial registration The trial is registered with the Australia New Zealand Clinical Trials Registry (ANZCTR). Trial registration date-17/11/2016. Trial registration number- ACTRN12616001590459 .