Tag Archive | distal radial fracture

What’s New in Orthopaedic Trauma

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.

This month, David Teague, MD, co-author of the July 7, 2016 Specialty Update on orthopaedic trauma, selected the eight most clinically compelling findings from among the 35 studies summarized in the Specialty Update.

Shoulder

–The randomized PROFHER trial found that surgical treatment of acute displaced proximal humeral fractures (with either ORIF or hemiarthroplasty) yielded no difference in patient outcomes compared with nonsurgical sling treatment at time points up to 2 years. Surgery was also significantly more expensive.1

Wrist

–A randomized trial of 461 patients with an acute dorsally displaced distal radial fracture found no difference at one year in primary or secondary outcomes between a group that received ORIF and a group that received Kirschner-wire fixation. K-wire fixation was also more cost-effective.2

Tibia

–A retrospective study of 137 type-III open tibial fractures concluded that both antibiotic prophylaxis and definitive wound coverage should occur as soon as possible for severe open tibial fractures. Prehospital antibiotic administration should be considered when transport is expected to take longer than one hour. 3

Ankle

–A randomized trial of 214 patients who received either supervised physical therapy or engaged in self-directed home exercise after six weeks of immobilization treatment for an ankle fracture found no difference in activity and quality-of-life outcomes at 1, 3, and 6 months.4

Managing Thromboembolism

–A registry study examining the incidence of deep venous thrombosis (DVT)/pulmonary embolism (PE) after surgery for a fracture distal to the knee identified the following risk factors for a thromboembolic event: previous DVT or PE, oral contraceptive use, and obesity.

Wound Care

–A randomized controlled trial of 2,447 patients compared irrigation with normal saline solution at various pressures to castile soap irrigation. Saline was superior in terms of reoperation rates after 12 months but irrigation pressure did not influence the reoperation rate.5

–A retrospective cohort study involving 104 patients who required a fasciotomy found that hospital stays were shorter among patients who underwent delayed primary closure (DPC) or a split-thickness skin graft on the first post-fasciotomy surgery. The authors noted limited utility of repeat surgeries to achieve DPT if fasciotomy wounds were not closed primarily on the first return trip.6

Obesity

–A prospective observational study of 376 trauma patients requiring orthopaedic surgery found that those with a BMI of >30 kg/m2 had an overall complication rate of 38% and had longer hospital stays, longer delays to definitive fixation, and higher infection rates than nonobese patients.7


References

  1. Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, Goodchild L, Chuang LH, Hewitt C,Torgerson D; PROFHER Trial Collaborators. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015 Mar 10;313(10):1037-47.
  2. Costa ML, Achten J, Plant C, Parsons NR, Rangan A, Tubeuf S, Yu G, Lamb SEUK. UK DRAFFT: a randomised controlled trial of percutaneous fixation with Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius. Health Technol Assess.2015 Feb;19(17):1-124: v-vi
  3. Lack WD, Karunakar MA, Angerame MR, Seymour RB, Sims S, Kellam JF, Bosse MJ. Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. J Orthop Trauma. 2015 Jan;29(1):1-6.
  4. Moseley AM, Beckenkamp PR, Haas M, Herbert RD, Lin CW; EXACT Team. Rehabilitation after immobilization for ankle fracture: the EXACT randomized clinical trial. JAMA. 2015 Oct 6;314(13):1376-85.
  5. Bhandari M, Jeray KJ, Petrisor BA, Devereaux PJ, Heels-Ansdell D, Schemitsch EH, Anglen J, Della RoccaGJ, Jones C, Kreder H, Liew S, McKay P, Papp S, Sancheti P, Sprague S, Stone TB, Sun X, Tanner SL,Tornetta P 3rd., Tufescu T, Walter S, Guyatt GH; FLOW Investigators. A trial of wound irrigation in the initial management of open fracture wounds. N Engl J Med. 2015 Dec 31;373(27):2629-41. Epub 2015 Oct 8.
  6. Weaver MJ, Owen TM, Morgan JH, Harris MB. Delayed primary closure of fasciotomy incisions in the lower leg: do we need to change our strategy? J Orthop Trauma. 2015 Jul;29(7):308-11.
  7. Childs BR, Nahm NJ, Dolenc AJ, Vallier HA. Obesity is associated with more complications and longer hospital stays after orthopaedic trauma. J Orthop Trauma. 2015 Nov;29(11):504-9.

JBJS Editor’s Choice: The Harder They Fall

Balance_7_20_16.gifIn the July 20, 2016 issue of The Journal, Louer et al. detail the association between distal radial fractures and poor balance. We have long understood that inherently poor balance was a major contributor to fall risk, and now we have more hard evidence thanks to this research team.

In this case-control evaluation comparing 23 patients ≥65 years of age who had sustained a low-energy distal radial fracture with 23 age- and sex-matched control patients, the authors found that those in the fracture cohort:

  • Demonstrated poorer balance based on dynamic motion analysis (DMA) scores
  • Were able to perform the balance test for significantly less time
  • Rated themselves as having worse mobility

Among both cohorts, only 3 patients had completed an evaluation of or treatment for balance deficiencies.

The orthopaedic community has begun to pay attention to fragility fracture risk reduction through programs such as the AOA’s “Own the Bone” initiative, which focuses on identifying patients with fragility fracture and applying evidence-based treatment and prevention guidelines. Fragility fracture programs led by nurse practitioners or physician assistants have gained traction in many centers and have been proven effective in identifying at-risk patients and providing appropriate follow-up care.

Any intervention for patients presenting with the first fragility fracture must include assessing fall risk. Home evaluations addressing hazards such as loose carpets, poor lighting, and poorly designed stairway transitions are critical. We also know that activities such as tai chi, low-impact aerobics, and yoga, when regularly practiced, can help preserve balance. Now, developing programs that actually improve postural balance must be part of our collective research agenda as we attempt to address the major public health issue of fall-related fragility fractures.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

What’s New in Hand Surgery

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.

This month, OrthoBuzz asked Sanjeev Kakar, MD, the author of the March 16, 2016 Specialty Update on hand surgery, to select the five most clinically compelling findings from among the more than 30 he cited in his article.

Wrist Trauma

–In the treatment of distal radius fractures, is volar plating superior to closed reduction and pin fixation? A prospective randomized trial of 461 adults with acute dorsally displaced distal radial fractures that were amenable to closed reduction found no clinically significant differences in Patient-Rated Wrist Evaluation (PRWE) scores among those who underwent percutaneous wire fixation and those who underwent locking-plate fixation. The findings led the authors to conclude that when looking at functional outcomes, treatments other than plate fixation may suffice.1

–Authors of a cost and utility analysis of 268 patients with a surgically treated distal radial fracture concluded that the routine use of radiographs made at two weeks postoperatively is of little clinical benefit, except in cases of patients with high-energy intra-articular fractures or those who sustain an injury after surgery.2

Wrist Arthritis

–To challenge conventional dogma that the contralateral wrist of rheumatoid arthritis patients who undergo wrist arthrodesis must maintain motion in order for them to perform activities of daily living, a long-term study followed 13 bilateral wrist arthrodesis patients for an average of 14 years. The major functional limitations noted were turning a door knob and opening a tight jar lid. Increasing age, preoperative corticosteroid use, and concomitant shoulder or elbow disorders were associated with worse outcomes. Ninety-three percent of the patients expressed satisfaction and said they would repeat the bilateral procedure.3

Carpal Tunnel Syndrome

–Should one perform staged or simultaneous carpal tunnel surgery? A cost-effectiveness study of simultaneous versus staged bilateral carpal tunnel release in 198 patients found that those who underwent simultaneous surgery had significantly fewer days off work and fewer postoperative follow-up visits, and they also incurred significantly lower costs in terms of mean amounts billed and fees collected.4

Trapeziometacarpal Joint Arthritis

–Is there an optimal suspension arthroplasty for the treatment of basilar thumb arthritis? A randomized controlled trial of 79 patients with trapeziometacarpal arthritis found that functional/clinical outcomes at 12 months were essentially the same between a group that underwent ligament reconstruction and tendon interposition (LRTI) and a group that underwent trapeziectomy and flexor carpi radialis weave around the abductor pollicis longus tendon. The notable exception was an improvement in PRWE scores at three months among those who underwent the LRTI procedure.5

References

  1. Costa ML, Achten J, Parsons NR, Rangan A, Griffin D, Tubeuf S, Lamb SE;DRAFFT Study Group. Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults with dorsally displaced fracture of distal radius: randomised controlled trial. BMJ. 2014;349:g4807. Epub 2014 Aug 5
  2. Stone JD, Vaccaro LM, Brabender RC, Hess AV. Utility and cost analysis of radiographs taken 2 weeks following plate fixation of distal radius fractures. J Hand Surg Am. 2015 Jun;40(6):1106-9. Epub 2015 Mar 31.
  3. Wagner ER, Elhassan BT, Kakar S. Long-term functional outcomes after bilateral total wrist arthrodesis. J Hand Surg Am. 2015 Feb;40(2):224-228.e1. Epub 2014 Dec 13.
  4. Phillips P, Kennedy J, Lee T. Cost effective analysis of simultaneous versus staged bilateral carpal tunnel release. Read at the American Association for Hand Surgery Annual Meeting; 2015 Jan 21-24; Paradise Island, Bahamas. Paper no. 104.
  5. VermeulenGM, Spekreijse KR, Slijper H, Feitz R, Hovius SE, Selles RW.Comparison of arthroplasties with or without bone tunnel creation for thumb basal joint arthritis: a randomized controlled trial. J Hand Surg Am. 2014 Sep;39(9):1692-8. Epub 2014 Jun 10.

Protecting Surgeons’ Hands from Radiation during Fluoroscopy

The InF1.mediumternational Commission on Radiological Protection (ICRP) currently recommends a maximum of 50 rem (500 millisieverts, or mSv) of occupational hand-radiation exposure annually. A fascinating study using a surgeon manikin, mini and standard fluoroscopic c-arms, and a Sawbones model of distal radial fracture fixation showed that hand-radiation exposure averaged 31 µSv per minute. That finding suggests that hand surgeons would not approach the ICRP-recommended hand-exposure limit unless they performed close to 2,000 hand procedures involving fluoroscopy each year. However, authors Hoffler et al. are quick to add that “the effect of consistent exposure that does not exceed the annual limit, but continues for a multiple-decade career, is unknown.”

It comes as little surprise that treating a distal radial fracture can be a high-exposure event. To quantify the situation more precisely, Hoffler et al. fit a surgeon manikin with radiation-attenuating glasses, thyroid shield/apron, and gloves, and measured radiation exposure with dosimeters placed on the manikin in both exposed and shielded positions. They exposed the Sawbones model and the manikin, which was in a standard seated position for hand surgery, to radiation from three mini and three standard fluoroscopes for fifteen minutes continuously. The authors explained their rationale for fifteen minutes of continuous exposure as follows: “The mean fluoroscopy time for volar radial plating at our institution is sixty seconds…It is common for hand surgeons to use a fluoroscope fifteen times a month…If exposures average sixty seconds each, the hand surgeon could be routinely exposed to fifteen minutes of fluoroscopy monthly.”

The authors found that hand exposure was 13 times higher than exposures at the thyroid, groin, or chest. The eyes, the second-most exposed site, received an average of 4 µSv per minute. Radiation-attenuating gloves reduced hand exposure by a mean of 69%, and radiation-attenuating glasses decreased eye exposure by a mean of 65%. There were no significant differences in hand exposure between the mini and standard fluoroscopes.

OrthoBuzz encourages orthopaedic surgeons to consider these findings in light of the current proliferation of fluoroscopes outside the OR, especially in office settings. For their part, the authors encourage surgeons to minimize their own and their patients’ radiation exposure “by understanding the basic physics of x-ray radiation and maximizing all of the safety technologies that their specific fluoroscopy units offer,” including the use of personal protective equipment.

What’s New in Hand Surgery: Level I and II Studies

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in the March 18, 2015 Specialty Update on hand surgery:

Distal Radial Fractures

–A study that randomized 50 patients with unstable radial fractures and Kirschner-wire fixation to receive demineralized bone-matrix allograft or no graft found no significant differences in bone density or function throughout one year of follow-up.

–Among 130 patients with a displaced distal radial fracture who were randomized for treatment with either a volar plate or percutaneous pins (with or without external fixation), plate-treated patients had a quicker return to function, but functional results were similar between the two groups at three months and one year.

Trapeziometacarpal Arthritis

–A randomized trial of 43 women aged 40 and older with trapeziometacarpal osteoarthritis comparing trapeziectomy with trapeziometacarpal arthrodesis (with plate and screws) was terminated early because of the high complication rate in the arthrodesis group.

Carpal Tunnel Release

–A Cochrane Database systematic review of 28 studies comparing endoscopic and open carpal tunnel release concluded that both techniques provided similar outcomes, but that the current literature on the subject is rife with low-quality studies.

–A meta-analysis of 21 studies comprising 1,859 patients that compared endoscopic and open carpal tunnel release showed that endoscopically treated patients had modestly greater strength at early follow-up but that the difference disappeared after six months.

This Specialty Update also includes many recent findings from papers presented at 2014 meetings of the American Society for Surgery of the Hand and the American Association for Hand Surgery.

What’s New in Pediatric Orthopaedics: Level I and II Studies

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in the February 18, 2015 Specialty Update on pediatric orthopaedics:

Spine

–The landmark BrAIST study found that bracing helps prevent adolescent idiopathic scoliosis curves from progressing to a surgical range (≥50°), with a number needed to treat of 3. (See related OrthoBuzz article.)

–A randomized trial comparing the SpineCor brace to rigid bracing for correction of scoliosis found that the rate of curve progression was significantly higher in the SpineCor group.

Neuromuscular Conditions

–A study on the role of steroids in patients with Duchenne muscular dystrophy found that glucocorticoid therapy decreased the need for spinal surgery to treat scoliosis.

Trauma

–A randomized trial among patients 4 to 12 years of age with a distal radial or distal both-bone fracture found that the use of a double-sugar-tong splint for immediate post-reduction immobilization was at least as effective as the use of a plaster long arm cast.

–A randomized controlled trial of 61 patients from 5 to 12 years old who had a supracondylar humeral fracture found no functional or elbow-motion benefits associated with hospital-based physical therapy after short-term casting.

Foot and Ankle

–A randomized trial of 27 children less than 9 months of age who had resistant metatarsus adductus found that a group receiving orthotic treatment had greater improvement in footprint heel bisector measurements than those receiving serial casting. The orthotic program required more active parental participation but was about half the cost of casting.

–A randomized study of children under 3 months of age with idiopathic clubfoot who were treated with the Ponseti method found that the failure rates and treatment times were significantly higher in a below-the-knee casting group than in an above-the-knee casting group.