Comparison of surgical and conservative therapy in older patients with distal radius fracture: a prospective randomized clinic al trial.

INTRODUCTION: The distal radius fracture is considered the most common fracture in humans. For fractures classified as Arbeitsgemeinschaft für Osteosynthese (AO) 23-C1 + C2, there is no consensus on treatment in older patients due to inconsistent study results. The aim of this study was to compare conservative and surgical treatment in relation to wrist function and satisfaction in patients older than 65 years. METHODS: In this prospective randomized clinical trial, patients aged older than 65 years who suffered an isolated AO-classified C1 or C2 distal radius fracture were randomized to surgical treatment using palmar plate osteosynthesis or conservative treatment. Patient-rated wrist evaluation (PRWE) score and disabilities of arm, shoulder, and hand (DASH) was assessed 3, 6 and 12 months post-interventionally. Satisfaction, range of motion (ROM) and pain scores were evaluated at 6 weeks and 3, 6 and 12 months post-interventionally. RESULTS: A total of 80 patients with a mean age of 77.3 years (± 6.1 years) in the conservative group and 72.5 years (± 5.3 years) in the surgery group were included. Both the PRWE score, and the DASH score showed a statistically significant difference between the two groups after 3 months, 6 months and 12 months (p < 0.001). Patients in the surgical cohort showed a statistically significant higher satisfaction at the 6-week, 6-month and 12-month follow-up (p < 0.001 6 weeks + 12 months; p = 0.004 6 months). CONCLUSION: In this prospective randomized study, surgical treatment proved to be superior to conservative treatment in terms of the primary outcome variable PRWE score. Satisfaction was significantly better in the surgical group.

Assessment of Pain Severity and Grip Strength as the Most Accurate Predictors of the Outcome of Treatment of Distal Radial Fractures.

BACKGROUND: Distal radial fractures are common injuries, accounting for approximately 25% of fractures in the paediatric population and up to 18% of all fractures in the elderly age group. Assessment of treatment outcomes of these fractures includes objective measurements of wrist joint range of motion and grip strength as well as subjective parameters such as the intensity of perceived pain, hand function and quality of life. The recent years have ushered in a trend towards using several outcome measures for a more comprehensive evaluation of the results of the treatment. The objective of this study was to investigate whether the assessment of pain severity and grip strength is sufficiently accurate for correct assessment of the outcome of the treatment of distal radial fractures. MATERIALS AND METHODS: One hundred and two patients, 79 women (77%) and 23 men (23%), at a mean age of 54 years with distal radial fractures were treated operatively. Treatment outcomes were assessed at 3 and 6 months by measurements of intensity of pain (according to a numerical rating scale, NRS), grip strength (with a dynamometer) and hand function with the DASH questionnaire. The results of these measurements were compared in order to investigate the strength of the possible correlation between variables. RESULTS: An analysis of the correlation between the variables of interest at 3 and 6 months' assessment showed statistically significant correlations (Spearman rank test, R=0,26-0,41; p<0,01). The NRS correlated negatively with grip strength (less pain - greater strength) and positively with DASH scores (less pain - better hand function). The correlation between grip strength and the DASH was the strongest (Spearman rank test R=0,61; p<0,001, showing that greater power of the hand indicated better function, whereas weaker grip indicated worse function. CONCLUSIONS: 1. The severity of pain and the degree of weakness of the hand show (independently of each other) a very good correlation with the comprehensive assessment of hand function using the DASH questionnaire. 2. It follows that pain severity and hand weakness are sufficient to reliably assess the outcome of the treatment of a distal radius fracture.

Bilateral anterior shoulder dislocation: A case report.

Bilateral anterior shoulder dislocation (BASD) is a rare condition typically associated with a history of trauma. This case report presents a patient with BASD resulting from trauma and discusses treatment options. A 51-year-old male patient was admitted to the emergency department following a fall from a height. Radiographic examination revealed BASD and a comminuted intra-articular fracture of the distal end of the left radius. The patient did not have any other additional pathologies. After a preoperative evaluation, the patient was urgently taken to the operating room, where both shoulders underwent reduction using the Hippocratic maneuver under sedation anesthesia. Immediately after this procedure, the left wrist was reduced closed, and a penning-type external fixator was inserted under fluoroscopic guidance. Following the reductions, both shoulders were wrapped with a Velpeau bandage and immobilized. An elastic bandage was wrapped around the wrist. By the end of the third week, shoulder mobility exercises were initiated, with a gradual increase in the intensity of the exercises. The wrist fixator was removed in the fifth week after radiographic evaluations, followed by the initiation of passive and then active exercises. Given the rarity of BASD, it is crucial to obtain a detailed clinical history, conduct a comprehensive clinical examination, and perform detailed imaging studies-radiography, computed tomography, and magnetic resonance imaging to avoid overlooking such pathologies in emergency situations. Bilateral anterior shoulder dislocation is a pathology that results from major trauma. It is important to remember that this particular type of pathology may be accompanied by various other pathologies, such as fractures (of the tuberculum majus), rotator cuff injuries, and neurovascular injuries.

Creation of a replicable anatomic model of terrible triad of the elbow.

BACKGROUND: Terrible triad of the elbow (TTE) is a complex dislocation associating radial head (RH) and coronoid process (CP) fractures. There is at present no reproducible anatomic model for TTE, and pathophysiology is unclear. The main aim of the present study was to create and validate an anatomic model of TTE. Secondary objectives were to assess breaking forces and relative forearm rotation with respect to the humerus before dislocation. METHODS: An experimental comparative study was conducted on 5 fresh human specimens aged 87.4 ± 8.6 years, testing 10 upper limbs. After dissection conserving the medial and lateral ligaments, interosseous membrane and joint capsule, elbows were reproducibly positioned in maximal pronation and 15° flexion, for axial compression on a rapid (100 mm/min) or slow (10 mm/min) protocol, applied by randomization between the two elbows of a given cadaver, measuring breaking forces and relative forearm rotation with respect to the humerus before dislocation. RESULTS: The rapid protocol reproduced 4 posterolateral and 1 divergent anteroposterior TTE, and the slow protocol 5 posterolateral TTE. Mean breaking forces were 3,126 ± 1,066 N for the lateral collateral ligament (LCL), 3,026 ± 1,308 N for the RH and 2,613 ± 1,120 N for the CP. Comparing mean breaking forces for all injured structures in a given elbow on the rapid protocol found a p-value of 0.033. Comparison of difference in breaking forces in the three structures (LCL, RH and CP) between the slow and rapid protocols found a mean difference of -4%. Mean relative forearm rotation with respect to the humerus before dislocation was 1.6 ± 1.2° in external rotation. CONCLUSIONS: We create and validate an anatomic model of TTE by exerting axial compression on an elbow in 15° flexion and maximal pronation at speeds of 100 and 10 mm/min.

[Study on automatic and rapid diagnosis of distal radius fracture by X-ray].

This article aims to combine deep learning with image analysis technology and propose an effective classification method for distal radius fracture types. Firstly, an extended U-Net three-layer cascaded segmentation network was used to accurately segment the most important joint surface and non joint surface areas for identifying fractures. Then, the images of the joint surface area and non joint surface area separately were classified and trained to distinguish fractures. Finally, based on the classification results of the two images, the normal or ABC fracture classification results could be comprehensively determined. The accuracy rates of normal, A-type, B-type, and C-type fracture on the test set were 0.99, 0.92, 0.91, and 0.82, respectively. For orthopedic medical experts, the average recognition accuracy rates were 0.98, 0.90, 0.87, and 0.81, respectively. The proposed automatic recognition method is generally better than experts, and can be used for preliminary auxiliary diagnosis of distal radius fractures in scenarios without expert participation.

Patient-specific finite element analysis of four different fixation methods for transversely unstable radial head fractures.

Plate fixation is a common treatment option for radial head fractures (RHFs). Due to the benefits of less invasiveness and fewer complications of internal fixation, the application of small-diameter headless compression screws (HCSs) to treat RHFs has become a new trend. This study aimed to compare the mechanical stability of four distinct internal fixation protocols for transversely unstable RHFs via finite element analysis. Using computed tomography data from 10 patients, we developed 40 patient-specific FE models of transversely unstable RHFs fixed by parallel, crossed, and tripod HCSs and mini-T plate (MTP). Under simulated physiological loading of the elbow joint, the construct stiffness, displacement, and von Mises stresses were evaluated and verified by a biomechanical experiment. Under shear loading, the MTP group exhibited lower construct stiffness, larger displacement, and higher Von Mises stress than the HCSs group. The stiffness of tripod HCSs was greater than parallel and crossed screw fixation techniques. There was a strong relationship between apparent bone density and construct stiffness (R = 0.98 to 0.99). In the treatment of transversely unstable RHFs, HCSs have superior biomechanical stability than MTP. The tripod technique was also more stable than parallel and crossed fixation.

Comparison of operatively and nonoperatively treated isolated mason type II radial head fractures: a systematic review and meta-analysis.

BACKGROUND: Radial head fractures are the most common bony injury of the elbow in adults. The current literature does not agree on whether isolated stable type II radial head fractures should be treated operatively or nonoperatively. This review aims to determine the preferred treatment for Mason type II radial head fractures and compare the outcomes of conservative and surgical treatment. METHODS: Our study used PRISMA guidelines and conducted a thorough search of multiple electronic databases, including PubMed, Cochrane, Embase, Web of Science, CNKI, and Wanfang databases, initially identifying 545 relevant publications on surgical and conservative treatment of Mason type II radial head fractures. The final search date for this study is July 7, 2024.Through a comprehensive meta-analysis, we evaluated several outcomes, including functional scores (DASH, OES, and MEPS scores), clinical outcomes (elbow flexion, elbow extension deficit, elbow pronation, and elbow supination), and complication rate (total complications and elbow pain). The mean difference (MD) was compared for continuous outcomes, and the odds ratios (ORs) were compared for categorical outcomes. RESULT: A total of 271 patients from 4 studies met the inclusion criteria. Among them, 142 patients received surgical treatment and 129 patients received non-surgical treatment. The study found no statistically significant differences between surgical and non-surgical treatments in DASH, OES, MEPS, elbow flexion, elbow extension impairment, and elbow pain. Compared with surgical treatment, non-surgical treatment was associated with greater elbow pronation (OR = -3.10, 95% CI = [-4.96, -1.25], P = 0.55, I2 = 0%) and a lower complication rate (OR = 5.54, 95% CI = [1.79, 17.14], P = 0.42, I2 = 0%). CONCLUSION: Based on the current evidence, conservative management of isolated Mason II radial head fractures yields favorable therapeutic outcomes with a low incidence of complications.

The outcomes of surgical treatment of complex radial head fractures.

Aims: The aim of this study was to evaluate the outcome of complex radial head fractures at mid-term follow-up, and determine whether open reduction and internal fixation (ORIF) or radial head arthroplasty (RHA) should be recommended for surgical treatment. Methods: Patients who underwent surgery for complex radial head fractures (Mason type III, ≥ three fragments) were divided into two groups (ORIF and RHA) and propensity score matching was used to individually match patients based on patient characteristics. Ultimately, 84 patients were included in this study. After a mean follow-up of 4.1 years (2.0 to 9.5), patients were invited for clinical and radiological assessment. The Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score were evaluated. Results: Patients treated with ORIF showed significantly better postoperative range of motion for flexion and extension (121.1° (SD 16.4°) vs 108.1° (SD 25.8°); p = 0.018). Postoperative functional scores also showed significantly better results in the ORIF group (MEPS 90.1 (SD 13.6) vs 78 (SD 20.5); p = 0.004). There was no significant difference between the groups in terms of the complication rate (RHA 23.8% (n = 10) vs ORIF 26.2% (n = 11)). Implant-related complications occurred in six cases (14.3%) in the RHA group and in five cases (11.9%) in the ORIF group. Conclusion: Irrespective of the patient's age, sex, type of injury, or number of fracture fragments, ORIF of the radial head should be attempted initially, if a stable reconstruction can be achieved, as it seems to provide a superior postoperative outcome for the patient compared to primary RHA. If reconstruction is not feasible, RHA is still a viable alternative. In the surgical treatment of complex radial head fractures, reconstruction shows superior postoperative outcomes compared to RHA. Good postoperative results can be achieved even after failed reconstruction and conversion to secondary RHA. Therefore, we encourage surgeons to favour reconstruction of complex radial head fractures, regardless of injury type or number of fragments, as long as a stable fixation can be achieved.

[Clinical effects of percutaneous elastic intramedullary nail assisted by arthrography for the treatment of radial neck fractures in children].

OBJECTIVE: To explore clinical effect of closed reduction percutaneous elastic intramedullary nail assisted by arthrography in the treatment of radial neck fracture in children. METHODS: A retrospective analysis was performed on 23 children with radial neck fracture treated with arthrography assisted closed reduction and percutaneous elastic intramedullary nail internal fixation (arthrography with elastic nail group) from January 2019 to December 2022, including 12 males and 11 females, aged from 2 to 12 years old with an average of (7.36±1.89) years old;According to Judet fracture types, 14 children were type Ⅲ and 9 children were type Ⅳ. In addition, 23 children with radial neck fracture were selected from January 2015 to December 2018 who were treated with closed reduction and percutaneous elastic intramedullary nail fixation (elastic nail group), including 11 males and 12 females, aged from 2 to 14 years old with an average of (7.50±1.91) years old;Judet classification included 15 children were type Ⅲ and 8 children were type Ⅳ. Operative time and intraoperative fluoroscopy times were compared between two groups. Metaizeau evaluation criteria was used to evaluate fracture reduction, and Tibone-Stoltz evaluation criteria was used to evaluate functional recovery of elbow between two groups. RESULTS: Both groups were followed up for 12 to 24 months with an average of (16.56±6.34) months. Operative time and intraoperative fluoroscopy times of elastic nail group were (56.64±19.27) min and (21.13±7.87) times, while those of joint angiography with elastic nail group were (40.33±11.50) min and (12.10±3.52) times;there were difference between two groups (P<0.05). According to Metaizeau evaluation, 11 patients got excellent result, 9 good and 3 fair in joint angiography with elastic nail group, while in elastic nail group, 5 excellent, 13 good, 4 acceptable, and 1 poor;the difference between two groups was statistically significant (P<0.05). According to Tibone-Stoltz criteria, 14 patients got excellent result, 8 good, and 1 fair in joint arthrography with elastic nail group;while in elastic nail group, 12 patients got excellent result, 9 good, 1 fair and 1 poor;there was no significant difference between two groups (P>0.05). CONCLUSION: Compared to percutaneous elastic intramedullary nail fixation, closed reduction assisted by arthrography has advantages of reduced operation time, decreased intraoperative fluoroscopy frequency, and improved fracture reduction. Arthrography enables clear visualization of the anatomical structures of radius, head, neck, bone, and cartilage in children, facilitating comprehensive display of fracture reduction and brachioradial joint alignment. This technique more precisely guides the depth of elastic intramedullary nail implantation in radius neck, thereby enhancing surgical efficiency and success rate.

[Radial neck fracture in children-"A benign fracture?"] / Die Radiushalsfraktur im Kindesalter ­ "eine gutartige Fraktur"?

Radial neck fractures in children are rare but clinically relevant injuries that are often accompanied by concomitant injuries. Girls between the ages of 8 and 12 years old are more frequently affected, whereby a cubitus valgus variant can be a predisposing factor. The main trauma mechanism is a fall onto the outstretched, supinated arm with additional valgus stress. Radial neck fractures can be associated with concomitant injuries of the elbow joint, including an olecranon fracture and elbow dislocation. The diagnosis is typically made by conventional X­radiographs, although ultrasonography can be indicated in younger children.The treatment depends on the fracture dislocation. Conservative treatment is certainly possible at any age if the proximal fragment is angulated less than 20°, while a surgical intervention can be indicated for larger dislocations depending on age. Closed reduction with internal fixation using a elastic stable intramedullary nail (ESIN) according to Métaizeau has become established as the standard procedure. Complications such as premature epiphyseal joint closure, synostosis, avascular necrosis, pseudarthrosis and deformation of the radial head can occur and affect the functional outcome. The treatment of such complications often requires a comprehensive multidisciplinary approach and can include both conservative and surgical measures. Long-term studies show that most patients with radial neck fractures achieve good to very good outcomes, although certain predictive factors are associated with poorer outcomes.Knowledge of the potential complications and their treatment is crucial for the successful management of children with radial neck fractures and should be considered when making clinical decisions.

The potential benefit of artificial intelligence regarding clinical decision-making in the treatment of wrist trauma patients.

PURPOSE: The implementation of artificial intelligence (AI) in health care is gaining popularity. Many publications describe powerful AI-enabled algorithms. Yet there's only scarce evidence for measurable value in terms of patient outcomes, clinical decision-making or socio-economic impact. Our aim was to investigate the significance of AI in the emergency treatment of wrist trauma patients. METHOD: Two groups of physicians were confronted with twenty realistic cases of wrist trauma patients and had to find the correct diagnosis and provide a treatment recommendation. One group was assisted by an AI-enabled application which detects and localizes distal radius fractures (DRF) with near-to-perfect precision while the other group had no help. Primary outcome measurement was diagnostic accuracy. Secondary outcome measurements were required time, number of added CT scans and senior consultations, correctness of the treatment, subjective and objective stress levels. RESULTS: The AI-supported group was able to make a diagnosis without support (no additional CT, no senior consultation) in significantly more of the cases than the control group (75% vs. 52%, p = 0.003). The AI-enhanced group detected DRF with superior sensitivity (1.00 vs. 0.96, p = 0.06) and specificity (0.99 vs. 0.93, p = 0.17), used significantly less additional CT scans to reach the correct diagnosis (14% vs. 28%, p = 0.02) and was subjectively significantly less stressed (p = 0.05). CONCLUSION: The results indicate that physicians can diagnose wrist trauma more accurately and faster when aided by an AI-tool that lessens the need for extra diagnostic procedures. The AI-tool also seems to lower physicians' stress levels while examining cases. We anticipate that these benefits will be amplified in larger studies as skepticism towards the new technology diminishes.

Diagnosis of suspected pediatric distal forearm fractures with point-of-care-ultrasound (POCUS) by pediatric orthopedic surgeons after minimal training.

BACKGROUND: Several studies have advocated the use of ultrasound to diagnose distal forearm fractures in children. However, there is limited data on the diagnostic accuracy of ultrasound for distal forearm fractures when conducted by pediatric surgeons or trainees who manage orthopedic injuries in children. The objective of this study was to determine the diagnostic accuracy of point-of-care ultrasound (POCUS) for pediatric distal forearm fractures when conducted by pediatric surgeons and trainees after minimal training. METHODS: This diagnostic study was conducted in a tertiary hospital emergency department in Germany. Participants were children and adolescents under 15 years of age who presented to the emergency department with an acute, suspected, isolated distal forearm fracture requiring imaging. Pediatric surgeons and trainees, after minimal training for sonographic fracture diagnosis, performed 6-view distal forearm POCUS on each participant prior to X-ray imaging. All data was retrospectively collected from the hospital's routine digital patient files. The primary outcome was the diagnostic accuracy of POCUS compared to X-ray as the reference standard. RESULTS: From February to June 2021, 146 children under 15 met all inclusion and exclusion criteria, and 106 data sets were available for analysis. Regarding the presence of a fracture, X-ray and Wrist-POCUS showed the same result in 99.1%, with 83/106 (78.3%) fractures detected in both modalities and one suspected buckle fracture on POCUS not confirmed in the radiographs. Wrist-POCUS had a sensitivity of 100% (95% CI [0.956, 1]) and a specificity of 95.8% (95% CI [0.789, 0.999]) compared to radiographs. In 6 cases, there were minor differences regarding a concomitant ulnar buckle. The amount of prior ultrasound training had no influence on the accuracy of Wrist-POCUS for diagnosing distal forearm fractures. All fractures were reliably diagnosed even when captured POCUS images did not meet all quality criteria. CONCLUSION: Pediatric surgeons and trainees, after minimal training in POCUS, had excellent diagnostic accuracy for distal forearm fractures in children and adolescents using POCUS compared to X-ray.

Comparison of free vascularized fibular grafts and the Masquelet technique for the treatment of segmental bone defects with open forearm fractures: a retrospective cohort study.

PURPOSE: Severe open forearm fractures commonly involve segmental bone defects. Although several methods have been proposed to treat segmental bone defects with such fractures, research comparing the radiological and clinical outcomes of free vascularized fibular grafts (FVFG) and the Masquelet technique (MT) is rare. METHODS: Data on 43 patients with open forearm fractures and segmental bone defects treated surgically in our hospital from January 2005 to January 2021 were retrospectively analyzed, and these patients were divided into an FVFG group (18 cases) and an MT group (25 cases). Clinical and radiological evaluations were performed regularly, and the minimum follow-up was 18 months. RESULTS: All 43 patients were followed up for 18 to 190 months, with a mean of 46.93 months. The mean follow-up time was significantly longer in the FVFG group than in the MT group (p = 0.000). Bone healing time was 3-16 months, with a mean of 4.67 months. The QuickDASH score at the last follow-up was 0-38.6, with a mean of 17.71, and there was no statistically significant difference between the two groups. Operative time, hospital stay, and intraoperative bleeding for bone defect reconstruction were higher in the FVFG group compared to the MT group (p = 0.000), whereas the number of procedures was lower in the FVFG group than in the MT group (p = 0.035). CONCLUSIONS: FVFG and the MT showed satisfactory clinical results for segmental bone defects of the forearm. Compared with FVFG, the MT exhibited a lower operative time, hospital stay, and intraoperative bleeding. LEVEL OF EVIDENCE: Level IV. Trial registration This study was registered in the Chinese Clinical Trial Registry (registration no. ChiCTR2300067675; registered 17 January 2023), https://www.chictr.org.cn/showproj.html?proj=189458 .

Minimal intervention (removable splint or bandage) for the management of distal forearm fractures in children and adolescents: A scoping review.

INTRODUCTION: Distal forearm fractures are common in children and adolescents with a spectrum of severity. There are fracture patterns that are suitable for minimal interventions, such as a splint or bandage. The objective of this review was to identify which types of paediatric distal forearm fractures can be safely and effectively managed with a removable splint or bandage. MATERIALS AND METHODS: A scoping review was performed. Databases searched were PubMed, Embase, The Cochrane Library and CINAHL; two trial registries were also searched. All primary study designs with children <18 years of age with a distal forearm fracture that was managed in either a splint or bandage were included. Quality of evidence was determined using the GRADE tool. RESULTS: Twenty-two eligible articles were included from 20 unique studies: 12 randomised controlled trials, seven cohort studies and a case report. Twelve studies focused solely on buckle/torus fractures, with remaining studies including other fracture types, such as incomplete ('greenstick'), complete ('transverse'), or physeal (Salter-Harris). Twelve studies reported that participants with either bandage or splint had appropriate reduction in pain and recovery of function at completion of follow-up for all fracture types. All 20 studies reported minimal adverse events related to fracture management. One study reported worsening angulation with bandage immobilisation for complete fractures in two participants, which required manipulation under anaesthesia. DISCUSSION: There is high quality evidence to support the safety and effectiveness of a splint or bandage for treatment of distal radius buckle and non-displaced incomplete fractures. Several studies supported the use of minimal interventions for various distal radius cortical breach fracture types, with good outcomes, but were limited by heterogeneity (methodology, interventions, outcome measures, reference standard) and potential bias. CONCLUSIONS: Included studies confirmed the inherent stability of buckle fractures. The current literature gap to support minimal interventions for a range of other paediatric distal forearm fracture types was highlighted. High-quality evidence with well-designed, large, multicentre randomised control trials in defined age groups is required to identify which paediatric distal forearm fractures can be safely and effectively managed with either a removable splint or bandage.

[Greenstick fractures of the forearm shaft-Is it obligatory or facultative to break the cortex?] / Grünholzfraktur des Unterarmschafts ­ Überbrechen obligatorisch oder fakultativ?

BACKGROUND: To break or not to break-That is the question that has been asked in pediatric traumatology for many years regarding the treatment of greenstick fractures of the diaphyseal forearm shaft. OBJECTIVE: The frequency of greenstick fractures of the forearm shaft in children and adolescents; the influence of breaking the fracture on the refracture rate. METHODS: Analysis and discussion of relevant articles, analysis of the refracture rate of pediatric greenstick fractures of the forearm shaft in our own patient population. RESULTS: Greenstick fractures frequently occur in the area of the forearm shaft and incomplete consolidation leads to an increased refracture rate. In the patient collective of the authors of 420 children with greenstick fractures of the diaphyseal forearm, there was a refracture rate of 9.5%; however, the rate for non-completed fractures was significantly higher compared to the group with completed fractures (15.2% vs. 3%). While in the subgroup of conservatively treated fractures (n = 234), breaking the intact cortex significantly reduced the refracture rate, breaking the intact cortical bone during surgical treatment with elastic stable intramedullary nailing (ESIN) did not change the refracture rate. CONCLUSION: As part of the conservative treatment of greenstick fractures of the diaphyseal forearm, completing the fracture can be recommended in order to lower the refracture rate. Completing the fracture does not appear to be necessary during surgical treatment using ESIN.

Efficacy and safety of volar locking plate versus cast immobilization for distal radius fractures: a systematic review and meta-analysis of randomized controlled trials.

Volar locking plates (VLPs) are increasingly used for distal radius fractures (DRFs), yet their efficacy compared to cast immobilization remains debated. This meta-analysis aimed to compare VLPs versus cast immobilization for DRFs across various follow-up durations. Randomized controlled trials reporting patient-reported functional scores, wrist range of motion (ROM), radiological assessments, and complications were included. Meta-analysis was performed for 6-week, 3-month, 6-month, 12-month, and >12-month follow-ups. Subgroup analysis stratified studies by age group, ≥ 60 years and < 60 years. VLPs showed significantly lower Disabilities of the Arm, Shoulder, and Hand (DASH) scores at 6 weeks (p < 0.001), 3 months (p < 0.001), 12 months (p = 0.012), and > 12 months (p < 0.001), and lower PRWE scores at 6 weeks (p < 0.001), 3 months (p = 0.048), and >12 months (p = 0.032). Wrist ROM favored VLPs at 6 weeks (p < 0.05), with higher flexion and supination at 3 months (p = 0.027) and 12 months (p = 0.003). Radiologically, VLPs showed improved parameters at 3- and 12-month follow-up. Overall complications did not significantly differ. Subgroup analysis in patients < 60 years generally supported these findings, while in patients ≥ 60 years, radiological outcomes aligned, yet only lower DASH scores were observed with VLPs at 3 months (p < 0.001). VLPs may offer superior clinical, functional, and radiological outcomes compared to cast immobilization at 3- and 12-month follow-up for patients < 60 years, with comparable safety profiles. For patients ≥ 60 years, VLPs may yield better radiological outcomes at 3- and 12-month follow-up, though clinical benefits remain uncertain.

Recovery of Comfort and Capability After Upper Extremity Fracture Is Predominantly Associated With Mindset: A Longitudinal Cohort From the United Kingdom.

OBJECTIVES: To determine the relative influence of mindset and fracture severity on 9-month recovery trajectories of pain and capability after upper extremity fractures. DESIGN: Secondary use of longitudinal data. SETTING: Single Level-1 trauma center in Oxford, United Kingdom. PATIENT SELECTION: English-speaking adults with isolated proximal humerus, elbow, or distal radius fracture managed operatively or nonoperatively were included, and those with multiple fractures or cognitive deficit were excluded. OUTCOME MEASURES AND COMPARISONS: Incapability (Quick-DASH) and pain intensity (11-point rating scale) were measured at baseline, 2-4 weeks, and 6-9 months after injury. Cluster analysis was used to identify statistical groupings of mindset (PROMIS Depression and Anxiety, Pain Catastrophizing Scale, and Tampa Scale for Kinesiophobia) and fracture severity (low/moderate/high based on OTA/AO classification). The recovery trajectories of incapability and pain intensity for each mindset grouping were assessed, accounting for various fracture-related aspects. RESULTS: Among 703 included patients (age 59 ± 21 years, 66% women, 16% high-energy injury), 4 statistical groupings with escalating levels of distress and unhelpful thoughts were identified (fracture severity was omitted considering it had no differentiating effect). Groups with less healthy mindset had a worse baseline incapability (group 2: ß = 4.1, 3: ß = 7.5, and 4: ß = 17) and pain intensity (group 3: ß = 0.70 and 4: ß = 1.4) (P < 0.01). Higher fracture severity (ß = 4.5), high-energy injury (ß = 4.0), and nerve palsy (ß = 8.1) were associated with worse baseline incapability (P < 0.01), and high-energy injury (ß = 0.62) and nerve palsy (ß = 0.76) with worse baseline pain intensity (P < 0.01). Groups 3 and 4 had a prolonged rate of recovery of incapability (ß = 1.3, ß = 7.0) and pain intensity (ß = 0.19, ß = 1.1) (P < 0.02). CONCLUSIONS: Patients with higher levels of unhelpful thinking and feelings of distress regarding symptoms experienced worse recovery of pain and incapability, with a higher effect size than fracture location, fracture severity, high-energy injury, and nerve palsy. These findings underline the importance of anticipating and addressing mental health concerns during recovery from injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of N-acetylcysteine in reducing inflammation and oxidative stress to prevent complex regional pain syndrome type 1.

This study aimed to evaluate the effectiveness of N-acetylcysteine (NAC) in preventing complex regional pain syndrome type 1 (CRPS-1) by reducing proinflammatory cytokines and oxidative stress markers in patients with distal radius fractures. A retrospective single-center study at Bursa City Hospital involves patients over 50 years of age with distal radius fractures treated between January 2021 and December 2023. A total of 60 patients (mean age, 62.8 ±â€…5.1 years; 26 males and 34 females) were analyzed. Patients were divided into 2 groups: the NAC group (31 patients receiving 600-mg NAC daily for 3 months) and the control group (29 patients with no prophylactic medication). CRPS-1 diagnosis was based on Budapest criteria during multiple follow-up visits. Serum levels of interleukin (IL)-1 beta, IL-6, tumor necrosis factor-alpha (TNF-α), total oxidant status (TOS), and total antioxidant status (TAS) were measured at baseline and study end point. CRPS-1 positive patients had significantly higher levels of IL-6, TNF-α, and IL-1 (P < .001 for all), higher TOS (P < .001) and oxidative stress index (P < .001), and lower TAS (P < .001) compared with CRPS-1 negatives. The incidence of CRPS-1 was significantly lower in the NAC group (9.7%) compared with the control group (31.0%; P = .039). Logistic regression indicated a 78% reduction in CRPS-1 odds ratio with NAC treatment (odds ratio, 0.219 [95% confidence interval, 0.053-0.895]; P = .0322). NAC significantly reduced end-point levels and changes in IL-6 (P < .001), TNF-α (P < .001), and IL-1 (P = .038) and improved oxidative stress markers, showing higher TAS (P < .001), lower TOS (P < .001), and oxidative stress index (P < .001) compared with controls. NAC significantly reduced the risk of developing CRPS-1 by decreasing levels of proinflammatory cytokines and oxidative stress. This study highlights NAC's potential as a preventive treatment for CRPS-1 and emphasizes the importance of early intervention.

Distal Radius Fracture Rehabilitation.

Distal radius fracture (DRF) is arguably the most common upper extremity fracture resulting from a fall accident. These clinical practice guidelines (CPG) were developed to guide all aspects of the management of DRF by physical therapists and other rehabilitation practitioners, such as certified hand therapists. This CPG employed a systematic review methodology to locate, appraise, and synthesize contemporary evidence while developing practice recommendations for determining the prognosis of outcomes, examination, and interventions while managing individuals with DRF. The quality of the primary studies found in the literature search was appraised using standardized tools. The strength of the available evidence for a particular practice domain (e.g., prognosis or intervention) was graded as strong, moderate, weak, or conflicting, where such gradings guided the level of obligation for each practice recommendation. Lastly, the CPG also provided the gaps in the evidence pool for the rehabilitation of DRF that future research efforts can address. J Orthop Sports Phys Ther 2024;54(9):CPG1-CPG78. doi:10.2519/jospt.2024.0301.