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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).

Objectives To compare the clinical effectiveness of Kirschner wire fixation with locking plate fixation for patients with a dorsally displaced fracture of the distal radius.Design A multicentre two arm parallel group assessor blind randomised controlled trial with 1:1 treatment allocation.Setting 18 trauma centres in the United Kingdom.Participants 461 adults with a dorsally displaced fracture of the distal radius within 3 cm of the radiocarpal joint that required surgical fixation. Patients were excluded if the surgeon thought that the surface of the wrist joint was so badly displaced it required open reduction.Interventions Kirschner wire fixation: wires are passed through the skin over the dorsal aspect of the distal radius and into the bone to hold the fracture in the correct anatomical position. Locking plate fixation: a locking plate is applied through an incision over the volar (palm) aspect of the wrist and secured to the bone with fixed angle locking screws.Main outcome measures Primary outcome measure: validated patient rated wrist evaluation (PRWE). This rates wrist function in two (equally weighted) sections concerning the patient’s experience of pain and disability to give a score out of 100. Secondary outcomes: disabilities of arm, shoulder, and hand (DASH) score, the EuroQol (EQ-5D), and complications related to the surgery.Results The baseline characteristics of the two groups were well balanced, and over 90% of patients completed follow-up. The wrist function of both groups of patients improved by 12 months. There was no clinically relevant difference in the patient rated wrist score at three, six, or 12 months (difference in favour of the plate group was −1.3, 95% confidence interval −4.5 to 1.8; P=0.40). Nor was there a clinically relevant difference in health related quality of life or the number of complications in each group.Conclusions Contrary to the existing literature, and against the rapidly increasing use of locking plate fixation, this trial found no difference in functional outcome in patients with dorsally displaced fractures of the distal radius treated with Kirschner wires or volar locking plates. Kirschner wire fixation, however, is cheaper and quicker to perform.Trial registration Current Controlled Trials ISCRTN 31379280. UKCRN 8956.

Prolonged immobilization of joints after distal radius fracture (DRF) causes cerebral disuse-dependent plasticity (DDP) and deterioration of upper extremity function. Action observation therapy (AOT) can improve DDP. This nonrandomized controlled trial (UMIN 000039973) tested the hypothesis that AOT improves hand-use difficulties during activities of daily living in patients with DRF. Right-handed women with volar locking plate fixation for DRF were divided into AOT and Non-AOT groups for a 12-week intervention. The primary outcome was difficulty in using the fractured hand, assessed with the Japanese version of the Patient-related Wrist Evaluation (PRWE). The secondary outcomes were range of motion (ROM) of the injured side and gap between measured ROM and patient-estimated ROM. The survey was administered immediately post operation and at postoperative weeks 4, 8, and 12. The AOT group used a head-mounted display and three-dimensional video during ROM exercises. The Non-AOT group used active ROM exercises alone. A generalized linear model (GLM) was used to confirm interactions and main effects by group and time period, and multiple comparisons were performed. Thirty-five patients were assigned to the AOT group (n = 18, median age, 74 years) or the Non-AOT group (n = 17, median age, 70 years). In the GLM, PRWE Total, PRWE Specific, and PRWE Usual scores revealed interactions between groups and periods. The post-hoc test revealed that the PRWE Specific scores (z = 3.43, p = 0.02) and PRWE Usual scores (z = 7.53, p<0.01) were significantly lower in the AOT group than in the Non-AOT group at 4 weeks postoperatively, whereas PRWE Total scores (z = 3.29, p = 0.04) were lower at 8 weeks postoperatively. These results suggested that AOT can improve hand-use difficulties in right-handed women after DRF surgery. AOT positively affects the motor imagery of patients with DRF and can reverse the patient's perceived difficulty in using the fractured hand during rehabilitation.

Background Distal radius fractures are very common injuries and surgical treatment for them can be painful. Achieving early pain control may help improve patient satisfaction and improve functional outcomes. Little is known about which anesthesia technique (general anesthesia versus brachial plexus blockade) is most beneficial for pain control after distal radius fixation which could significantly affect patients’ postoperative course and experience. Questions/Purposes We asked: (1) Did patients receiving general anesthesia or brachial plexus blockade have worse pain scores at 2, 12, and 24 hours after surgery? (2) Was there a difference in operative suite time between patients who had general anesthesia or brachial plexus blockade, and was there a difference in recovery room time? (3) Did patients receiving general anesthesia or brachial plexus blockade have higher narcotic use after surgery? (4) Do patients receiving general anesthesia or brachial plexus blockade have higher functional assessment scores after distal radius fracture repair at 6 weeks and 12 weeks after surgery? Methods A randomized controlled study was performed between February, 2013 and April, 2014 at a multicenter metropolitan tertiary-care referral center. Patients who presented with acute closed distal radius fractures (Orthopaedic Trauma Association 23A-C) were potentially eligible for inclusion. During the study period, 40 patients with closed, displaced, and unstable distal radius fractures were identified as meeting inclusion criteria and offered enrollment and randomization. Three patients (7.5%), all with concomitant injuries, declined to participate at the time of randomization as did one additional patient (2.5%) who chose not to participate, leaving a final sample of 36 participants. There were no dropouts after randomization, and analyses were performed according to an intention-to-treat model. Patients were randomly assigned to one of two groups, general anesthesia or brachial plexus blockade, and among the 36 patients included, 18 were randomized to each group. Medications administered in the postanesthesia care unit were recorded. Patients were discharged receiving oxycodone and acetaminophen 5/325 mg for pain control, and VAS forms were provided. Patients were called at predetermined intervals postoperatively (2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours) to gather pain scores, using the VAS, and to document the doses of analgesics consumed. In addition, patients had regular followups at 2 weeks, 6 weeks, and 12 weeks. Pain scores were again recorded using the VAS at these visits. Results Patients who received general anesthesia had worse pain scores at 2 hours postoperatively (general anesthesia 6.7 ± 2.3 vs brachial plexus blockade 1.4 ± 2.3; mean difference, 5.381; 95% CI, 3.850–6.913; p < 0.001); whereas reported pain was worse for patients who received a brachial plexus blockade at 12 hours (general anesthesia 3.8 ± 1.9 vs brachial plexus blockade 6.3 ± 2.4; mean difference, −2.535; 95% CI, −4.028 to −1.040; p = 0.002) and 24 hours (general anesthesia 3.8 ± 2.2 vs brachial plexus blockade 5.3 ± 2.5; mean difference, −1.492; 95% CI, −3.105 to 0.120; p = 0.031).There was no difference in operative suite time (general anesthesia 119 ± 16 minutes vs brachial plexus blockade 125 ± 23 minutes; p = 0.432), but time in the recovery room was greater for patients who received general anesthesia (284 ± 137 minutes vs 197 ± 90; p = 0.0398). Patients who received general anesthesia consumed more fentanyl (64 μg ± 93 μg vs 6.9 μg ± 14 μg; p < 0.001) and morphine (2.9 μg ± 3.6 μg vs 0.0 μg; p < 0.001) than patients who received brachial plexus blockade. Functional outcome scores did not differ at 6 weeks (data, with mean and SD for both groups, and p value) or 12 weeks postoperatively (data, with mean and SD for both groups, and p value). Conclusions Brachial plexus blockade pain control during the immediate perioperative period was not significantly different from that of general anesthesia in patients undergoing operative fixation of distal radius fractures. However, patients who received a brachial plexus blockade experienced an increase in pain between 12 to 24 hours after surgery. Acknowledging “rebound pain” after the use of regional anesthesia coupled with patient counseling regarding early narcotic administration may allow patients to have more effective postoperative pain control. It is important to have a conversation with patients preoperatively about what to expect regarding rebound pain, postoperative pain control, and to advise them about being aggressive with taking pain medication before the waning of regional anesthesia to keep one step ahead in their pain control management. Level of Evidence Level 1, therapeutic study.

Background Treatment of displaced distal forearm fractures in children has traditionally been closed reduction and pin fixation, although they might heal and remodel without surgery with no functional impairment. No randomized controlled trials have been published comparing the patient-reported functional outcome following non-surgical or surgical treatment of displaced paediatric distal forearm fractures. Methods A multicentre non-inferiority randomized controlled trial. Children aged 4–10 years with a displaced distal forearm fracture will be offered inclusion, if the on-duty orthopaedic surgeon finds indication for surgical intervention. They will be allocated equally to non-surgical treatment (intervention) or surgical treatment of surgeon’s choice (comparator). Follow-up will be 4 weeks and 3, 6, and 12 months. The primary outcome is the between-group difference in 12 months QuickDASH score. We will need a sample of 40 patients to show a 15-point difference with 80% power. Discussion The results of this trial may change our understanding of the healing potential of paediatric distal forearm fractures. If non-inferiority of non-surgical treatment is shown, the results may contribute to a reduction in future surgeries on children, who in turn can be treated without the risks and psychological burdens associated with surgery. Trial registration www.clinicaltrials.gov (ID: NCT05736068). Date of registry: 17 February 2023.

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-operative treatment is the most common treatment option for older patients with distal radius fracture (DRF). Traditionally, wrists have been placed in volar-flexion and ulnar deviation position (VFUDC). In recent years, there has been a trend towards using a functional position cast (FC). However, long-term results for these different casting positions are lacking. This randomized, controlled, prospective study evaluates the functional results and costs of the 2 casting positions in patients 65 and older with DRF. Primary end point in this study was Patient-Reported Wrist Evaluation (PRWE) at 24 months, and secondary end points were cost-effectiveness of treatment, health-related quality of life measurement (15D), short version of Disabilities of arm, shoulder and hand score (QuickDASH), and VAS at 24 months. The trial was registered in ClinicalTrials.gov (NCT02894983, https://clinicaltrials.gov/ct2/show/NCT02894983). We enrolled 105 patients, of which 81 (77%) continued until 24-month follow-up. 8 patients (18%) were operated in the VFUDC group and 4 (11%) in the FC group. Patients in the VFUDC group also received more frequent physical therapy. The difference in PRWE score between the VFUDC and FC groups at 24 months was -4.31. The difference in the cost of treatment per patient was €590. Both findings favored FC. We found a slight, but consistent difference in the functional results between groups. These results suggest that VFUDC is not superior to FC when treating Colles' type DRF. Cost analysis revealed overall costs in the VFUDC group are nearly double those in the FC group, mostly due to more physical therapy, additional visits to hospital, and additional examinations. Therefore, we recommend FC in older patients with Colles' type DRF.

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.

Introduction The purpose of this study is to evaluate whether using a Fracture Healing Patch (FHP) device that generates pulsed electromagnetic fields (PEMF), applied at the fracture site immediately after open reduction and internal fixation surgery, can accelerate healing of acute distal radius fractures. Methods In a prospective, double-blind, randomized, and sham-controlled study, thirty-two patients with DRFs treated with ORIF were included. Patients were allocated to a PEMF (active) group ( n  = 15) or a control (sham) group ( n  = 17). All patients were assessed with regard to functional Patient-Rated Wrist Evaluation (PRWE), SF12, and radiological union outcomes (X-rays and computed tomography (CT) scans) at 2, 4, 6, and 12 weeks postoperatively. Results Patients treated with the FHP demonstrated significantly bone bridging at 4 weeks as assessed by CT (70% vs 54%, p  = 0.05). Mean grip strength in the active group was significantly higher as compared to control (16 ± 9 kg vs 7 ± 3.5 kg, respectively, p  = 0. 02). The function subscale of the PRWE was significantly better in PEMF-treated group at 6 weeks after surgery (27.2 VS 35.5, p  = 0.04). No statistically significant differences were found in SF12. Conclusion PEMF application after ORIF of DRFs is safe, may accelerate bone healing which could lead to an earlier return to daily life activities and work. Level of evidence I

One out of every 5 elderly patients will suffer a distal radius fracture and these injuries are often related to poor bone health. Several surgical subspecialties have demonstrated that pre-injury activity level can impact patient outcomes. To determine the importance of physical activity, we examined the relationship between pre-injury activity and patient-reported and functional outcomes among fracture patients. This is a retrospective analysis of prospectively collected data from participants enrolled in the Wrist and Radius Injury Surgical Trial (WRIST) from April 10, 2012 to December 31, 2016. This study included 304 adults, 60 years or older with isolated unstable distal radius fractures; 187 were randomized to one of three surgical treatments and 117 opted for casting. Participants opting for surgery were randomized to receive volar locking plate, percutaneous pinning, or external fixation. Participants who chose not to have surgery were treated with casting. All participants were stratified prior to analysis into highly and less-active groups based on pre-injury Rapid Assessment of Physical Activity Scores. 280 patients had 12-month assessments of outcomes. Highly active participants scored 8 and 5 points greater on the Michigan Hand Questionnaire at 6 weeks and 3 months respectively, p<0.05. Highly active participants demonstrated greater grip strength at the 3-month (p = 0.017) and 6-month (p = 0.007) time-points. Highly active participants treated with volar locking plate scored 10+ points greater on the Michigan Hand Questionnaire compared to the less-active group at the 6-week (p = 0.032), 3-month (p = 0.009) and 12-month (0.004) time points, with an effect size larger than 0.50, suggesting pre-injury level of activity had a significant clinical impact. Higher levels of pre-injury activity are predictive of patient-reported and functional outcomes following distal radius fracture. Because of the greater PROs, the early mobility and lower risk of hardware infection reported in the literature, volar plating is preferable to other treatments for highly active patients who request and meet indications for surgery. clinicaltrials.gov identifier: NCT01589692.