Low-energy distal radius fractures in middle-aged and elderly men and women--the burden of osteoporosis and fracture risk : A study of 1794 consecutive patients.

UNLABELLED: One third of 218 men and half of 1,576 women with low-energy distal radius fractures met the bone mineral density (BMD) criteria for osteoporosis treatment. A large proportion of patients with increased fracture risk did not have osteoporosis. Thus, all distal radius fracture patients >or=50 years should be referred to bone densitometry. INTRODUCTION: Main objectives were to determine the prevalence of patients with a low-energy distal radius fracture in need of osteoporosis treatment according to existing guidelines using T-score or=50 years were included. BMD was assessed by dual energy X-ray absorptiometry (DXA) at femoral neck, total hip, and lumbar spine (L2-L4). The WHO fracture risk assessment tool (FRAX(R)) was applied to calculate the 10-year fracture risk. RESULTS: T-scores or=50 years should be referred to bone densitometry, and if indicated, offered medical treatment.

Simultaneous scaphoid and distal radial fractures.

Simultaneous fractures of the distal radius and scaphoid are uncommon. In a prospective 3-year study we registered 2,330 distal radial fractures and 390 scaphoid fractures, and 12 were combined. Ten of these had high energy trauma; six were styloid fractures, four Colles' fractures, one was a greenstick fracture and one Salter-Harris Type 2 epiphyseal fracture. All but one of the 12 scaphoid fractures were stable and healed without problems, and one was a trans-scaphoid, trans-styloid peri-lunate fracture-dislocation. The study supports the opinion that the distal radial fracture constitutes the principal injury that determines the outcome and hence the treatment. If the scaphoid fracture is unstable or dislocated, we recommend internal fixation of the scaphoid. Only a small proportion of these injuries represent a more serious disruption with carpal instability.

Clinicopathological characteristics of melanomas of the hand.

A 25-year clinicopathological review of 19 patients with malignant melanoma of the hand is reported. There were 11 women (median age 73 years) and eight men (median age 70 years). Eleven tumours were subungual, six on the dorsum of the hand, and two had a palmar location. Seven tumours were acral lentiginous melanomas, six were superficial spreading melanomas, and five were of the nodular subtype. Eleven patients presented with localized disease (clinical stage I), four with local spread (clinical stage II), and four with regional lymph node metastases (clinical stage III). Nine of the patients have died of the disease, with a median survival time of 30 months (range, 10-84 months). The subungual melanomas were thicker and the patients were older at presentation compared with the non-subungual sites. Review of our patients emphasized the need for early diagnosis.

Corrective osteotomies after injuries of the distal radial physis in children.

Six children had corrective osteotomies of the distal forearm because of growth disturbance from post-traumatic closure of the distal radial physis. Lengthening osteotomy of the radius was performed in three patients with grafts from the iliac crest. All osteotomies healed in a satisfactory position. Three patients had only moderate mal-angulation of the radius and were treated by shortening of the ulna. The median postoperative palmar angulation of the distal radius was 4 (0-13) degrees, the radial inclination 22 (15-28) degrees, and the ulnar variance was -2 (-4(-)+2) mm. The postoperative pain relief was complete in all patients and the total range of motion was 96 (93-100)% compared with the opposite side.

Dynamic traction for unstable fractures of the distal radius.

We have designed a flexible distracter through which dynamic traction is applied to fractures of the distal radius. The distraction is maintained during flexion and extension as well as radial and ulnar deviation. The results in 30 patients showed that the majority of the fractures maintained reduction during the period of dynamic traction. In several patients the radiological variables even improved during dynamic traction. The median radial shortening was 0 mm, the palmar angulation 7 degrees, and the radial inclination 23 degrees. Continuous dynamic traction applied to fractures of the distal radius did not lead to redisplacement of the fracture, and the overall functional results were good.

Prediction of secondary displacement in Colles' fracture.

In a prospective study, 645 consecutive Colles' fractures treated conservatively were followed until union. The fractures subsequently lost some of their manipulated position during the immobilization period. However, the anatomical end result was significantly improved compared with the initial deformity. The mean shortening of the radius during plaster-cast treatment was 3 mm, and the mean increase of dorsal angulation was 7 degrees. Multiple regression analyses showed that initial dorsal angulation, age, and Older type were important predictor variables for the end result of dorsal angulation. Initial radial length, age and initial dorsal angulation were of importance for the end result of radial length. The strongest linear relationship was found between the end result of radial length and the initial radial length (r = 0.67). This may indicate that the patients who will malunite with radial shortening are those with significant radial axial shortening at the initial presentation. Thus, these patients should be treated with a more stable fixation device.

Fractures of the hand. Distribution and relative incidence.

One thousand consecutive fractures of the metacarpals, phalanges, and carpal bones have been recorded over a period of about 10 months in Bergen, Norway, to find out the relative incidence of these fractures in an unselected series: this corresponds well with the few other reports of the incidence of hand fractures that we could find. In the total series the metacarpals, phalanges, and carpal bones account for 36%, 46%, and 18% of the fractures, respectively. Fractures of the scaphoid make up 10.6% of the total, fractures of the neck of the fifth metacarpal 9.7%, and Bennett's fractures 1.4%. The outer areas of the hand are most commonly damaged,--the fifth ray, the thumb ray, and the distal phalanx of the third finger account for half of all fractures of the hand.

Nerve entrapment and reflex sympathetic dystrophy after fractures of the distal radius.

In a series of 542 conservatively-treated fractures of the distal radius 30 patients (5,5%) developed compression neuropathy: of the median nerve (n = 23), of the ulnar nerve (n = 5), and of the radial nerve (n = 2). Three patients required decompression of the carpal tunnel, and one patient's ulnar symptoms were relieved after shortening osteotomy of the ulna. The remaining neuropathies resolved spontaneously over a period of three months. Five patients developed typical reflex sympathetic dystrophy with diffuse pain, loss of hand function, and significant autonomic dysfunction. None of them had specific signs of compression neuropathy anteceding the development of reflex dystrophy. All five had their joints mobilised under regional intravenous block combined with regional perfusion of soluble corticosteroid.

Epidemiology of scaphoid fractures in Bergen, Norway.

During a three-year period, 330 fractures of the scaphoid were diagnosed, 273 of these in subjects resident in Bergen, Norway. The population at risk was 211719, and 82% of the fractures occurred in male subjects. The mean (range) age was 25 (11-79) years. The annual incidence was 4.3/10000 people. The age-specific incidence for men was highest between the ages of 20-30 years followed by a rapid decrease. The age-specific incidence for men was significantly higher than the corresponding rates for women up to about 50 years of age, whereas the rates for men and women over 60 were similar. Fractures of the scaphoid accounted for about 2% of the total number of fractures in our area, 11% of the hand fractures, and 60% of the carpal fractures.

Chronic erosion of a digit caused by a ring. Case report.

A 36-year-old woman had worn a small ring all the time since she was 5 years old. The ring caused chronic erosion through skin, extensor tendon, and most of the bone of the fourth digit of the right hand. The ring caused an infection and was removed; two years later the eroded bone had healed but she had a persistent extension contracture of the proximal interphalangeal joint.

Epidemiology of burns in Bergen, Norway.

We organised a prospective series to study, the epidemiology and causes of burns in the city of Bergen, Norway. We included 361 patients treated during one year at the casualty centre or at the burn centre at the hospital. Thirty-six per cent (n = 131) of the patients were less than 15 years old, and 9% (n = 33) were over 60. The incidence of burns was 17/10,000 inhabitants, 0.7 for patients who were admitted and 17 for outpatients. Burns were most common among male subjects aged 40 years or less, while women were more at risk in the older age groups. Almost half the injuries were caused by scalds, and 92 (26%) were from contact with hot surface. Scalds were more common among women than among men, while firework and flame burns were more common among men. Burns occurred at home in 227 patients (63%), at work in 58 (16%), and during leisure activities in 76 (21%). The mean surface area burned was 3.5% total body surface area (TBSA); patients who were admitted had a TBSA of 18% compared with 1.8% among those treated as outpatients.

Salvage of failed resection of the distal ulna. Case report.

A 45-year-old woman completely lost the ability of active supination of the forearm after a Darrach resection for malunited fracture of the distal radius. A three-component reconstruction was performed to stabilise the distal stump of the ulna and prevent convergence between the two forearm bones. The procedure combined advancement lengthening osteotomy of the ulna, longitudinal intramedullary tenodesis of the extensor carpi ulnaris tendon, and dorsal transfer of the pronator quadratus through the interosseous space. Four months after the salvage procedure she again had full active supination of the forearm and she returned to work two months later.

Anatomical and functional results five years after remanipulated Colles' fractures.

During 1988 we recorded all Colles' fractures (n = 530) in a prospective study in the city of Bergen. According to defined criteria, the fractures were treated by immobilisation in plaster cast with or without reduction; reduction and immobilisation by a Hoffman external fixation device; or open reduction and internal fixation. Included in the present study were 26 patients with secondary displacement after immobilisation in a plaster cast (8% of the reduced fractures). The fractures were remanipulated and splinted in a new cast for four more weeks. The patients were followed up five years after the fracture, and underwent subjective, radiographic, and functional evaluation. The anatomical end result was significantly improved compared with the initial deformity. The dorsal angulation improved significantly compared with the "slipped' position, whereas the radial length did not. The functional end result was excellent or good in 20 patients (77%). The total movement in all directions was correlated negatively with ulna plus, and the grip strength correlated negatively with the degree of osteoarthrosis. There were no other significant linear relationships between anatomical and functional variables. Total pronation and supination correlated with the initial radial length and dorsal angulation, and the total movement in all directions correlated with the initial radial length.

Fractures of the distal radius in a Norwegian city.

During a prospective one-year study (1988) all fractures of the distal radius in people over 20 years old were registered in Bergen, Norway. Six hundred patients with 609 fractures were treated. The incidence was 38/10000 population, and 79% of the fractures occurred in women. The age-specific incidence in women increased rapidly after the menopause and reached a maximum between 60 and 69 years. The incidence for women over 60 years of age is the highest reported. Among women over 50 years the incidence of fractures caused by minor falls varied depending on the season. The mean number of fractures was 3.6 times higher on days when there was snow on the ground compared with days when there was no snow. More than half the distal radial fractures occurred while out walking. Possible strategies to prevent fractures must include prevention of falls, in particular among postmenopausal women on winter days.

Closed reduction and external fixation of unstable fractures of the distal radius.

The anatomical and functional outcome and complications after closed reduction and external fixation of unstable fractures of the distal radius were reviewed in 29 patients. The fractures were reduced by longitudinal traction and closed manipulation under fluoroscopic control, and the reduced position was retained by a standard half-frame Hoffmann external fixator for six to eight weeks. The mean follow-up time was four (3-7) years. The reduction failed in three patients after too early removal of the fixator (three to five weeks). For the rest of the patients the dorsal angulation, the radial length, the articular step-off, and the intra-articular gap between fragments were significantly improved. Twenty-two patients had excellent or good anatomical alignment and in seven it was fair. One patient had a superficial pin infection, six patients had transient paraesthesias, and one patient transient mild dystrophia. At follow-up one patient had some finger stiffness; this was the only persistent complication. The median Gartland and Werley functional score was 3. The functional end result was excellent or good in 22 patients, fair in four, and poor in three.

The results of 479 thumb carpometacarpal joint replacements reported in the Norwegian Arthroplasty Register.

In this study we report the results of thumb carpometacarpal (CMC) joint replacements in the Norwegian population over a 17-year period. In total, 479 primary replacements performed from 1994 to 2011 were identified in the Norwegian Arthroplasty Register. Implant survival and risk of revision were analyzed using Cox regression analyses. Four different implant designs were compared and time trends were analyzed. The overall 5 and 10 year survivals were 91% and 90%, respectively. The newer metal total arthroplasties did not outperform the older silicone and mono-block implants. At 5 years, the implant survival ranged from 90% to 94% for the different implant brands. Gender, age, and diagnosis did not influence the risk of revision. The incidence of thumb CMC joint replacement did not change during the study period. Despite relatively satisfactory implant survivorship in our register study, current evidence does not support widespread implementation of thumb CMC replacements.

Delayed rupture of the thumb extensor tendon. A 5-year study of 18 consecutive cases.

18 consecutive cases of delayed rupture of the extensor pollicis longus tendon were recorded during 5 years; 4 were spontaneous, and 14 after distal radius fracture, most of which were undisplaced or only slightly displaced. 15 cases were operated upon with tendon transfers: 13 had extensor indicis proprius transfer, 1 transfer of the extensor carpi radialis longus, and 1 reoperated with the extensor communis to the little finger as a motor unit. Subjectively, nearly complete satisfaction was reported; all patients were able to elevate the thumb to the level of the palm and full independent index finger movements were noted. In this 5-year-period 4,400 patients with distal radius fractures were treated, giving an incidence of delayed tendon rupture after distal radius fracture of 0.3 percent.

Surgery for posttraumatic wrist deformity. Radial osteotomy and/or ulnar shortening in 16 Colles' fractures.

16 patients with pain and impaired function after malunited fracture of the distal radius were treated with opening wedge lengthening osteotomy of the radius with bone grafting (12 cases), shortening osteotomy of the ulna (3 cases), or a combination of these methods (1 case), with or without reattachment of the triangular fibrocartilage complex. 4 patients had to be reoperated because of redislocation, resorption of the graft, fracture of the plate, or persistent non-union. At re-examination after a median of 4 years, all patients but 2 were improved by the procedure.

Posterior tibial tendon transfer for drop-foot. 20 cases followed for 1-5 years.

From 1991 to 1997 we performed 20 tibialis posterior tendon-transfer operations in 17 patients with drop-foot, in 11 of peripheral neurogenic origin and in 6 because of neuromuscular disease. Postoperatively, all patients could walk without an ankle-foot orthosis. At follow-up after mean 2 (1-5) years, all patients had active dorsiflexion of the foot and toes, with a median active ankle dorsiflexion of 5 degrees (-15-10 degrees). The median active plantar flexion was 40 degrees (10-45 degrees), and the total range of movement was 40 degrees (15-50 degrees). At follow-up, the gait was good in 15 and improved in 2 of the 17 patients.