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.

The Cost and Utility of Postreduction Radiographs After Closed Reduction of Pediatric Wrist and Forearm Fractures.

BACKGROUND: Formal radiographs are frequently obtained after reduction of closed pediatric wrist and forearm fracture performed under mini C-arm fluoroscopy. However, their utility has not been clearly demonstrated to justify the increased time, cost, and radiation exposure. We hypothesized that formal postreduction radiographs do not affect the rereduction rate of pediatric wrist and forearm fractures. We further sought to determine the time, monetary, and opportunity costs associated with obtaining these radiographs. METHODS: A total of 119 patients presented to our urban, level I pediatric trauma center from April 2015 to September 2015 with isolated, closed wrist and forearm fractures who underwent sedation and reduction using mini C-arm fluoroscopy. Demographic and injury variables were collected, along with incidence of rereduction and need for future surgery. Time intervals for sedation, awaiting x-ray, and total encounter periods were noted, and total direct and variable indirect costs for each encounter were obtained from our institution's cost accounting and billing databases. Marginal time and monetary costs were noted and further calculated as a percentage of the total encounter. Opportunity costs were calculated for the time spent obtaining the postreduction radiographs. RESULTS: Of 119 patients with isolated, closed wrist or forearm fractures, none required rereduction after initial reduction using sedation and mini C-arm fluoroscopy. Postreduction radiographs required an average of 26.2 minutes beyond the end of sedation, or 7.3% of the encounter time and cost. The direct cost of the x-ray was 2.6% of the encounter cost. With our institution's annual volume, this time could have been used to see an additional 656 patients per year. CONCLUSIONS: Postreduction formal radiographs did not result in changes in management. There are significant direct and opportunity costs for each patient who undergoes additional formal radiographs. Pediatric patients with isolated, closed wrist or forearm fractures do not routinely need formal radiographs after reduction under mini C-arm fluoroscopy. LEVEL OF EVIDENCE: Level IV-Therapeutic.

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.

Objective assessment of plaster cast quality in pediatric distal forearm fractures: Is there an optimal index?

BACKGROUND: Several so-called casting indices are available for objective evaluation of plaster cast quality. The present study sought to investigate four of these indices (gap index, padding index, Canterbury index, and three-point index) as compared to a reference standard (cast index) for evaluation of plaster cast quality after closed reduction of pediatric displaced distal forearm fractures. METHODS: Forty-three radiographs from patients with displaced distal forearm fractures requiring manipulation were reviewed. Accuracy, sensitivity, specificity, false-positive probability, false-negative probability, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio were calculated for each of the tested indices. RESULTS: Comparison among indices revealed diagnostic agreement in only 4.7% of cases. The strongest correlation with the cast index was found for the gap index, with a Spearman correlation coefficient of 0.94. The gap index also displayed the best agreement with the cast index, with both indices yielding the same result in 79.1% of assessments. CONCLUSION: When seeking to assess plaster cast quality, the cast index and gap index should be calculated; if both indices agree, a decision on quality can be made. If the cast and gap indices disagree, the padding index can be calculated as a tiebreaker, and the decision based on the most frequent of the three results. Calculation of the three-point index and Canterbury index appears unnecessary.

Intramedullary Nailing System in Unstable Both Bone Diaphyseal Fractures in Children.

Background Forearm fractures in pediatric population is usually managed conservatively. Unstable fractures need operative intervention like closed or open intramedullary nailing or open reduction and internal fixation with plates and screws. However, there is no consensus regarding the method of treatment according to age group. Objective To standardize the use of elastic nailing system as effective form of treatment in terms of function, cost and lower complications as compared to widely used titanium nails in developed countries.Method Sixty eight pediatric patients with both bone forearm diaphyseal fractures were managed with closed reduction and intramedullary fixation with rush nail or k-wire and followed at least for 6 months for evaluation of radiological and functional outcome. Result Patients were divided into two age groups, Group A for age of 5 to 9 years (26 patients) and Group B for age of 10-15 years (42 patients). The mean time for union for Group A patient was 7.31 weeks which was significantly lower than that of Group B patients of 9.33 weeks (p-value < 0.05). All the patients in Group A had excellent outcome and 36 (85.7%) patients had excellent outcome and 6 (14.3%) had good outcome in Group B. 5 out of 68 cases (7.35 %) had minor complications (2 in Group A and 3 in Group B). The mean time for implant removal was 17.9 weeks in Group A and 22.9 in Group B. Conclusion Intramedullary fixation for unstable diaphyseal both bone fractures of forearm is safe and cost effective method of treatment with good to excellent functional outcome with union time being significantly lower in younger age group.

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.

Rereduction for Redisplacement of Both-Bone Forearm Shaft Fractures in Children.

BACKGROUND: There is a high rate of redisplacement after closed reduction and cast treatment of displaced both-bone forearm shaft fractures in children. Little evidence is available on the efficacy of rereduction of these redisplaced fractures. This study evaluates the impact of rereduction on radiographic outcomes and compares the cost to surgical stabilization. METHODS: This retrospective study included 31 children (mean age, 6.3 y; 18 boys) treated with rereduction for redisplacement of a displaced both-bone forearm shaft fracture between 2008 and 2013. Angulation was measured on anteroposterior and lateral radiographs of the radius and ulna at injury, after reduction, at redisplacement, after rereduction, and at fracture union. Average procedure costs for rereduction and surgical stabilization were calculated. RESULTS: Initial reduction decreased apex volar angulation (initially >20 degrees) of both bones to a median of ≤2 degrees. After an average of 15 days (range, 4 to 35 d), apex volar angulation of the radius worsened to 9 degrees, and apex ulnar angulation worsened to >10 degrees for both bones. For every 5 days after initial reduction, apex ulnar angulation of the radius worsened by 4 degrees. Rereduction reduced apex ulnar and volar angulation of both bones to <5 degrees, which was maintained after cast removal. There were no complications. The average procedure cost for rereduction was $2056 compared with $4589 for surgical stabilization with or without implant removal. CONCLUSION: Rereduction of both-bone forearm shaft fractures after redisplacement following initial closed reduction had satisfactory radiographic outcomes and is a safe, effective, and less expensive option than surgical stabilization. LEVEL OF EVIDENCE: Level IV-therapeutic.

Radiographic Evaluation During Treatment of Pediatric Forearm Fractures: Implications on Clinical Care and Cost.

BACKGROUND: As ≥30% of displaced pediatric forearm fractures demonstrate loss of reduction (LOR) following closed reduction (CR); radiographic follow-up is advocated at 1, 2, 4, and 6 weeks for detection of redisplacement. We hypothesized that there is minimal change in fracture alignment 2 weeks after CR, and consequently, that radiographs at 4 weeks add cost but little value to clinical care. METHODS: A total of 184 patients enrolled in a prospective study of pediatric forearm fractures including both distal and diaphyseal injuries were evaluated. All were treated with CR, casting, and radiographic evaluation at 1, 2, 4, and 6 weeks postinjury. Primary endpoint was radiographic LOR. Secondary endpoint was need for any intervention. A modified number-needed to treat analysis estimated the utility of the week 4 x-ray in predicting intervention. Relative value unit (RVU) costing, time-derived activity-based costing (TDABC), and billing totals were used for cost analysis. RESULTS: Seventy patients (38%) demonstrated radiographic LOR. Independent predictors of LOR were initial radius displacement >75% (OR=5.40; CI, 2.23-12.60), concomitant ulna fracture (OR=1.71; CI, 1.15-2.54), and dominant arm involvement (OR=2.87; CI, 1.40-5.87). Eighty percent of all LORs occurred within the first 2 weeks. There was no statistically significant change in radiographic alignment after week 2. Of 40 total interventions, all were performed within the first 2 weeks of follow-up. The 4-week x-ray did not influence decision to intervene, and at most, 1 in every 40 patients would require an intervention after week 2. Elimination of the 4-week x-ray would result in a savings of 4.8% (RVU method) to 11.9% (TDABC method) in the overall cost of nonoperative fracture care. CONCLUSIONS: There is minimal change in fracture alignment 2 weeks following CR of pediatric forearm fractures, and all interventions are based on early radiographic follow-up. The week 4 x-ray adds little value to clinical decision making, and its elimination would result in savings up to 11.9% of the overall cost of nonoperative fracture care. LEVEL OF EVIDENCE: Level II-prognostic.

Post-splinting radiographs of minimally displaced fractures: good medicine or medicolegal protection?

BACKGROUND: Many institutions perform radiographic documentation following splint application even when no manipulation had been performed. The purpose of this study was to evaluate the utility of post-splinting radiographs of acute non-displaced or minimally displaced fractures that did not undergo manipulation. Our hypothesis was that post-splinting radiographs do not demonstrate changes in fracture alignment or impact the management of the patient. METHODS: After institutional review board exemption had been granted, consultations performed by orthopaedic residents at a level-I trauma center from September 2008 to April 2010 were reviewed. Of 2862 consultations, 1321 involved acute fractures that were splinted. Radiographs revealed that 342 (25.9%) of the fractures were non-displaced or minimally displaced and angulated (defined as <5 mm and <10°, respectively) and 204 of them had been assessed with radiographs after splinting. Consults were reviewed to ensure that the patients had not undergone manipulation prior to or during splinting. Consult notes and radiographs obtained in the emergency room (ER), as well as follow-up radiographs, were reviewed to assess ultimate outcome. RESULTS: None of the 204 fractures (134 non-displaced and seventy minimally displaced) changed alignment following splinting. Two splints were reapplied, and the fractures sites were reimaged for undocumented reasons. Patients were subjected to an average of ten radiographs (range, four to twenty-five radiographs) of their extremities in the acute setting. On average, three post-splinting radiographs (range, one to ten radiographs) were obtained. The mean time between the initial and post-splinting radiographs was three hours and thirty minutes (range, nine minutes to twenty-four hours). The most common injury was a fracture about the hand or wrist. The 122 patients with that type of injury waited an average of almost three hours for an average of three post-splinting radiographs, contributing to a total of nine radiographs performed acutely. ER visits tended to be longer for patients with post-splinting radiographs compared with those without them (p = 0.06). Follow-up radiographs were available for eighty-two patients. All fractures demonstrated maintained alignment. CONCLUSIONS: Post-splinting radiographs of non-displaced and minimally displaced fractures that do not undergo manipulation before or during immobilization are associated with longer ER waits, additional radiation exposure, and increased health-care costs without providing helpful information. While certain circumstances call for additional imaging, routine performance of post-splinting radiography of non-displaced or minimally displaced fractures should be discouraged.

[Assessment of surgical and conservative treatment of forearm fractures: results in juveniles]. / Büyük çocuklarda önkol çift kiriklarinin konservatif ve cerrahi tedavi sonuçlarinin degerlendirilmesi.

BACKGROUND: We aimed to assess treatment outcomes of forearm fractures in patients aged between 10-18 years, for whom strict guidelines for surgical and conservative treatment are not yet clear. METHODS: From a total of 41 patients between the ages of 10-18 years, 34 patients with a minimum of one-year follow-up in our clinic with the diagnosis of forearm fracture were evaluated retrospectively. All the patients had open epiphyses. Twenty-three of these patients were treated conservatively and 11 surgically. Patients were evaluated according to time of union, function and cosmesis. Average follow-up was two years (12-36 months). RESULTS: Conservative treatment gave excellent and good results in 21 (91%), while surgical treatment gave excellent and good results in 9 (82%) of the patients when evaluated according to Anderson's criteria. A bad result was seen in one patient who did not accept an operation, and had an angulation of over 15 degrees. We also had one bad result in the operatively treated group because of implant failure and a need for a second operation. CONCLUSION: According to our results, conservative treatment should be the mainstay in the treatment of childhood fractures of the forearm. However, we should not hesitate in considering surgical treatment when the patients have a malalignment of more than 15 degrees.

Cost-effectiveness analysis of sedation and analgesia regimens during fracture manipulation in the pediatric emergency department.

OBJECTIVE: To conduct a cost-effectiveness analysis, from a hospital's perspective, of 4 procedural sedation and analgesia (PSA) regimens to facilitate forearm fracture manipulation in the pediatric emergency department (ED): deep sedation with ketamine/midazolam (K/M) administration, propofol/fentanyl administration, fentanyl/midazolam (F/M) administration, and axillary block. DESIGN/METHODS: We constructed a decision analytic model using relevant probabilities from published studies of pediatric patients who underwent fracture manipulation in the EDs. Total costs were calculated by assessing ED resource utilization associated with uncomplicated PSA and with PSA complicated by adverse events. Costs of consumable equipment were considered to be fixed. Total sedation time, personnel time, and drug costs were considered variable. We assumed that all PSA regimens provided effective relief from procedural distress. Failure rates for axillary block were estimated based on reports in the literature. When patients experienced emesis, recovery agitation, respiratory depression, lidocaine toxicity, or regional block failure, we assumed that the patients would require 1 additional hour of ED stay. Sensitivity analyses of all key variables in the model were performed to identify those that may result in a change in the preferred option. Monte Carlo simulations were performed to assess model robustness. RESULTS: Under baseline assumptions, the propofol/fentanyl regimen was the most cost-effective choice (expected cost, 84.06 US dollars), followed by axillary block (88.18 US dollars), K/M (105.32 US dollars), and F/M (159.79 US dollars), respectively. Varying the fixed and variable costs by 50% to 200% of their baseline values did not alter the ranking. When ketamine and propofol were administered without adjunctive midazolam and fentanyl, respectively, propofol remained the optimum choice. With total PSA time as the outcome measure, the incremental cost-effectiveness ratios were 8.1 US dollars and 24.9 US dollars per hour of ED time saved, for propofol/fentanyl versus axillary block and for axillary block versus K/M, respectively. CONCLUSIONS: Among PSA regimens during forearm fracture manipulation in the pediatric ED, propofol/fentanyl is the most cost-effective regimen followed by axillary block, K/M, and F/M.

Assessment of instability factors in adult distal radius fractures.

BACKGROUND: The purpose of this study was to evaluate the radiographic outcome of unstable distal radius fractures treated by closed reduction and sugar tong splinting and to quantitatively evaluate Lafontaines' criteria of instability. METHODS: Fifty patients with 3 or more instability factors as described by Lafontaine were treated by finger trap traction, closed reduction, and sugar-tong splinting. They were evaluated radiographically for initial angulation, radial inclination, radial length, and palmar tilt at the time of injury, after reduction, and 1 week, 2 weeks, and 4 weeks after reduction. The fracture either maintained an adequate reduction or failed to maintain an adequate reduction and showed secondary displacement based on specific criteria. RESULTS: At 4 weeks after reduction 46% of these unstable distal radius fractures maintained an adequate reduction. Of the 54% of fractures that failed to maintain an adequate reduction, age was the only statistically significant predictor of secondary displacement. After obtaining an acceptable initial closed reduction, patients 58 years of age were found to be at 50% risk for secondary displacement. The risk for displacement with an unacceptable radiographic result was found to increase with increasing age and decrease with decreasing age. CONCLUSION: In the closed management of these potentially unstable distal radius fractures, age was the only statistically significant risk factor in predicting secondary displacement and instability. These data help guide treatment by closed reduction and immobilization with serial x-rays or by surgical stabilization.

Power Doppler assessment of vascular changes during fracture treatment with low-intensity ultrasound.

OBJECTIVE: To study the use of power Doppler sonography for assessing changes in vascularity during treatment of fracture sites with low-intensity ultrasound. METHODS: In 6 dogs (3 pairs), subcutaneous dissection of the midshaft of the ulna allowed symmetrical osteotomies to be made with a reciprocation saw. Three dogs were treated and 3 were used as controls. The fracture site was subjected to 1.5-MHz low-intensity ultrasound (30 mW/cm2) for 20 minutes daily from a therapeutic ultrasonic device. Gray scale sonography was performed to evaluate the fracture site. Power Doppler sonography was used to assess flow patterns at the fracture site and surrounding soft tissue. A sonographic contrast agent was administered intravenously. The dose was 0.2 mL/kg. RESULTS: Power Doppler sonography showed an increase in flow around the fracture site in the treated dogs compared with that in control dogs. Color pixel values on day 7 were 3-fold higher in treated legs than control legs and on day 11 were 33% higher in treated legs than control legs. Enhancement after contrast agent administration was consistently higher in treated legs than control legs. CONCLUSIONS: Power Doppler sonography showed increased vascularity around the fracture sites in treated dogs with and without contrast agent administration.

Isolated ulnar shaft fractures treated with functional braces.

OBJECTIVE: To report the results from functional bracing of isolated ulnar shaft fractures. DESIGN: Retrospective review. SETTING: Two university hospitals. PATIENTS: Isolated ulnar shaft fractures in 444 patients were stabilized in functional braces that permitted full range of motion of all joints. INTERVENTION: Prefabricated braces that extended from below the elbow to above the wrist were applied within the first week after the initial injury. OUTCOME MEASURES: Union of the fracture, fracture angulation, and final range of motion of the forearm were evaluated. RESULTS: Two hundred eighty-seven patients were available for follow-up (65 percent). Union took place in 99 percent of the fractures. Shortening of the ulna averaged 1.1 millimeters (range 0 to 10 millimeters). Final radial angulation averaged 5 degrees (range 0 to 18 degrees). Dorsal angulation averaged 5 degrees (range 0 to 20 degrees). Average loss of pronation was greatest in fractures of the proximal third of the ulna, averaging 12 degrees. Fractures in the distal third averaged a loss of 5 degrees of pronation. CONCLUSIONS: Functional bracing is a viable therapeutic alternative in the management of isolated ulnar shaft fractures. It is associated with a 99 percent union rate and good to excellent functional results in more than 96 percent of patients.