Treatment of radius or ulna fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and current practice.

BACKGROUND: The objective of the present study was to evaluate effectiveness, complications and cost-effectiveness of any surgical or non-surgical treatment for radius or ulna fractures in elderly patients. Secondary objectives were to analyze present treatment traditions of distal radius fractures (DRF) in Sweden and to calculate resource usage for its treatment. METHODS AND FINDINGS: The assessment contains a systematic review of clinical and health economic studies comparing treatment options for radius or ulna fractures. The results regarding the effectiveness of the treatments are summarized in meta-analyses. In addition, the assessment contains a cost analysis for different treatment options commonly used for DRF care, and an analysis of registry data on the incidence and treatment of DRF. In total 31 randomized controlled trials were included in meta-analyses. When comparing functional outcome for plate fixation versus non-surgical treatment for DRF, there were no clinically important differences at one-year follow-up (mean difference [MD], -3.29, 95% CI, -7.03; 0.44). Similar results were found when comparing plating and percutaneous methods with respect to functional outcome (standardized mean difference [SMD], -0.07, 95% CI, -0.21; 0.07) and grip strength (MD, -3.47, 95% CI, -11.21; 4.28). There were no differences for minor complications, (risk difference [RD], -0.01, 95% CI, -0.07; 0.05) whereas major complications were less common for the percutaneous group, (RD, 0.02, 95% CI, 0.02; 0.03). Given the low number of studies, the evidence above was rated as moderate certainty. The cost for plate fixation versus plaster cast was estimated to 1698 compared to 137 US dollars. For DRF, plate fixation increased in Sweden between 2005 and 2013, and was the most common surgical method in 2013. CONCLUSIONS: Surgical treatment of moderately displaced distal radius fractures in elderly patients offers no clear benefit compared to non-surgical treatment. Plating procedures have become more common during the second millennium and involve higher costs and higher risk of major complications than percutaneous options.

A Dedicated Fracture Reduction Room: A Cost-Effective Alternative to the Operating Room.

INTRODUCTION: Charges, procedural efficiency, return to activity, and complications after closed treatment of fractures performed in an operating room (OR) versus closed reduction in a dedicated fracture reduction room (FRR) were compared. METHODS: Patients with closed fractures of the forearm who underwent closed reduction in the year before (OR), and after implementation of the FRR, were retrospectively reviewed. Charges, American Society of Anesthesiologists class, sex, age, length of follow-up, prior reduction, fracture location/displacement, time from injury to procedure, procedural time, time to return to activity, and complications were recorded. RESULTS: Eighteen patients met the inclusion criteria in the FRR group (13 men, 5 women), and 22 in the OR group (18 men, 4 women). No notable differences in age, sex, follow-up, American Society of Anesthesiologists class, fracture location/displacement, incidence of prior reduction, or time to return to activity were observed. Two (9.5%) complications occurred in the FRR group versus 7 (32%) in the OR group, P > 0.05. No anesthesia complications were present. Patients treated in the FRR incurred charges of $5,299 ± $1,289 versus $10,455 ± $2,290 in the OR, P < 0.001. Total time of visit in the FRR was ∼30% less than the OR, P < 0.001. No notable delay in treatment was observed. DISCUSSION: In the era of finite resources and value-based care, implementation of a FRR resulted in safe, cost-effective, and increased procedural efficiency.

Cost analysis and performance in distal pediatric forearm fractures: is a short-arm cast superior to a sugar-tong splint?

The aim of this study is to compare splint versus cast immobilization for maintaining alignment following closed reduction of distal 1/3 radius and both-bone forearm fractures. We performed a retrospective review of patient records between 5 and 14 years old with a distal 1/3 radius or radius and ulna fracture requiring reduction. A cost comparison was also performed using facility costs for materials. Reduction was maintained with acceptable alignment in most cases (94%). Although a sugar-tong splint slightly maintained fracture alignment better, this was not significant. Cost analysis favored initial placement of a short-arm cast ($23.59) versus a splint with later cast conversion ($26.95). Pediatric patients with a distal 1/3 radius and/or both-bone fracture requiring reduction maintain postreduction alignment irrespective of the immobilization method used, but initial placement of a short-arm cast is more cost-effective.

Construct Choice for the Treatment of Displaced, Comminuted Olecranon Fractures: are Locked Plates Cost Effective?

BACKGROUND: Cost effective implant selection in orthopedic trauma is essential in the current era of managed healthcare delivery. Both locking and non-locking plates have been utilized in the treatment of displaced fractures of the olecranon. However, locking plates are often more costly and may not provide superior clinical outcomes. The primary aim of the present study is to assess the clinical and functional outcomes of olecranon fractures treated with locked and non-locking plate and screw constructs while providing insight into the cost of various implants. METHODS: We performed a retrospective chart review of a single institution database identifying Mayo IIB type olecranon fractures treated surgically from 2003 to 2012. All fractures were treated with either a locked plate or a one-third tubular hook plate construct. Clinical and radiographic outcomes were evaluated. Minimum 6-month follow-up was required. Outcomes were compared between fixation constructs, including rate of union, early failure, postoperative range of motion, and complication rates. Statistical analysis included Pearson's Chi-squared and Fisher's exact test for categorical variables, and the Student's ttest for continuous variables. RESULTS: The one-third tubular construct was equivalent to locking plate constructs with respect to union, post-operative range of motion, and rates of complications. There were no early or late failures. Locking plates were associated with a relative cost increase of $1,263.50 compared to the one-third tubular hook plate per case. CONCLUSION: Surgeons should consider the cost of implants when treating Mayo IIB olecranon fracture. In this cohort, one-third tubular plates provided equivalent outcomes to locked plates with a notable decrease in cost.

Reducing Cost and Radiation Exposure During the Treatment of Pediatric Greenstick Fractures of the Forearm.

BACKGROUND: We hypothesize that after successful closed reduction of pediatric greenstick fractures of the forearm, there is a low rate of lost reduction requiring intervention. By reducing the frequency of clinical and radiographic follow-up, we can reduce costs and radiation exposure. METHODS: A retrospective analysis was performed on patients aged 2 to 16 years treated with closed reduction and cast immobilization for greenstick fractures of the forearm at our institution between 2003 and 2013. The primary endpoint was a healed fracture with acceptable alignment at the final radiographic evaluation. Time-derived activity-based costing was used for cost analysis. We estimated radiation exposure in consultation with our hospital's radiation safety office. RESULTS: One hundred and nine patients with an average age of 6.9 years (range, 2 to 15 y) met the inclusion criteria. The initial maximal fracture angulation of the affected radius and/or ulna averaged 19.3 (SD=±8.7) degrees (range, 2 to 55 degrees). Patients were followed for an average of 60 days (range, 19 to 635 d). On average, patients received 3.6 follow-up clinical visits and 3.5 sets of radiographs following immediate emergency department care. Ninety-four percent of patients met criteria for acceptable radiographic alignment. Only 1 patient (0.9%; 95% confidence interval, 0.2%-5.0%) underwent rereduction, as determined by the treating physician. If clinical follow-up were limited to 2 visits and 3 sets of radiographs total, there would be a 14.3% reduction in total cost of fracture care and a 41% reduction in radiation exposure. CONCLUSIONS: This retrospective study suggests that pediatric greenstick fractures of the forearm rarely require intervention after initial closed reduction. We propose that 2 clinical follow-up visits and 3 sets of radiographs would reduce overall care costs and radiation exposure without compromising clinical results. LEVEL OF EVIDENCE: Level IV-economic and decision analyses.

Hospital admission rates for distal forearm fractures: an epidemiological survey in patients referred to a large emergency department in Northern Italy.

UNLABELLED: In this survey, the proportion of patients with distal forearm fractures admitted to the Parma University Hospital during 2012 (13 %) was relatively low and generally lower than that reported in other studies. In our region, the main orthopedic approach remains conservative. PURPOSE: The purpose of this study was to define the ratio between hospitalized and non-hospitalized fragility fractures of the distal forearm in our province (Parma, Northern Italy). METHODS: All forearm fractures referred during 2012 to the emergency department of the Parma University Hospital (the main hospital in the province with a catchment area of approximately 345,000) were retrieved from the hospital database using both ICD-9-CM codes and text strings. The diagnosis of distal forearm fracture due to low-energy trauma and the need for hospitalization were individually confirmed by medical records and X-ray reports. The analysis was limited to subjects aged 40 years and over. RESULTS: In both sexes combined, 66 subjects out of 505 were hospitalized (13.1 %; confidence interval (CI) 95 % 10.4-16.3 %), 47 immediately (8.1 %) and 25 (5 %) after a few days. The percentage of cases hospitalized was 12 % in women (CI 95 % 9.2-15.6 %) and 17 % in men (CI 95 % 11.1-25 %; p = 0.16). CONCLUSIONS: The percentage of fragility distal forearm fractures hospitalized in our area is relatively low and generally lower than that reported in other studies.

The treatment of stable paediatric forearm fractures using a cast that may be removed at home: comparison with traditional management in a randomised controlled trial.

We investigated whether, in the management of stable paediatric fractures of the forearm, flexible casts that can be removed at home are as clinically effective, cost-effective and acceptable to both patient and parent as management using a cast conventionally removed in hospital. A single-centre randomised controlled trial was performed on 317 children with a mean age of 9.3 years (2 to 16). No significant differences were seen in the change in Childhood Health Assessment Questionnaire index score (p = 0.10) or EuroQol 5-Dimensions domain scores between the two groups one week after removal of the cast or the absolute scores at six months. There was a significantly lower overall median treatment cost in the group whose casts were removed at home (£150.88 (sem 1.90) vs £251.62 (sem 2.68); p < 0.001). No difference was seen in satisfaction between the two groups (p = 0.48).

Racing prognosis of horses following surgically repaired olecranon fractures.

Olecranon fracture is a common orthopedic problem in juvenile horses. Prognosis for complete fracture healing when various methods of internal fixation are used is good; however, the impact of olecranon fracture stabilization on the likelihood that foals will start on a racecourse is unknown. Medical records of foals undergoing internal fixation for an olecranon fracture were reviewed. The dam's foaling records were obtained and lifetime racing records were then retrieved for both the affected foals and 1 of their siblings. Twenty-two of 24 repaired fractures healed completely, subsequently, 16 of the foals started in at least 1 race. Statistical calculations suggest that when compared with their siblings, the occurrence of olecranon factures requiring internal fixation in juvenile racehorses will not significantly reduce the likelihood that they will race; however, the siblings had significantly more lifetime race starts and higher career earnings.

Incidence and cost of osteoporotic fractures in France during 2001. A methodological approach by the national hospital database.

The objective of this study was to describe the hospital incidence rate and the in-patient costs of three peripheral "osteoporotic" fractures (proximal humerus and hip, distal radius and/or ulna) in women and men aged over 45 in France during 2001. Each stay for fracture was selected from the dataset of the French national hospital database in 2001. The incidence rate (CI 95%) was standardized by age and gender according to the last census of the French population (1999). The effect of age and existence of geographical difference in incidence rates has been studied. For each fracture, we described the number of stays, rate of surgical procedure and in-patient costs according to the 2004 French list of cost per diagnosis-related group (2004 Euros); 118,839 fractures were registered during 2001 (61% hip, 28% distal radius and 11% proximal humerus; sex ratio 0.26). The incidence rate for all fracture was 7,567 (7,519-7,615) and 2,312 (2,283-2,341) for 10(6) inhabitants in women and men aged over 45 years, respectively. The incidence increased significantly whatever type of fracture and gender. There were more fracture incidents in the east of France compared to the west and in the south compared to the north, whatever type of fracture in women and only for hip fracture in men. Surgical procedures were performed in 91% of proximal hip fractures, 83% of distal radius fractures and 53% of proximal humerus fractures. The median in-patient costs were 3,786 Euros for the humerus, from 2,363 to 2,574 Euros for the radius and from 8,048 to 8,727 Euros for the hip. The evaluation of the burden of peripheral fractures is possible using national hospital data in France. The incidence of fractures increased with age and is more common in women. Hip fracture with its higher occurrence, rate of procedure and in-patient costs could be used as a marker of osteoporosis for evaluating strategies of management.

Reduction of forearm fractures in children using axillary block anesthesia.

One hundred eleven patients (age range 15 months-16 years, mean 9.6 years) with displaced forearm fractures who had axillary blocks performed by orthopaedists in the emergency room were retrospectively reviewed. Thirty-seven fractures involved the distal radius, 56 involved both bones of the forearm, and 12 involved the physis of the distal forearm. Three Monteggia fractures, one radial neck fracture, one olecranon with an associated radial neck fracture, and one distal radius fracture with an associated elbow dislocation also were included. Of the 111 axillary blocks, 105 were rated as effective. Potential complications of axillary block anesthesia (systemic toxicity, hematoma, infection, and brachial neuralgia) were not observed in this group of patients. The cost of axillary block reduction in the emergency room was less than one third that of general anesthesia in the operating room. Axillary block anesthesia is reliable, safe, and cost effective, and this study supports its use by orthopaedists in displaced forearm fractures in children.