Analysis of factors influencing hospitalization cost of patients with distal radius fractures: an empirical study based on public traditional Chinese medicine hospitals in two cities, China.

BACKGROUND: Distal radius fractures (DRFs) have become a public health problem for all countries, bringing a heavier economic burden of disease globally, with China's disease economic burden being even more acute due to the trend of an aging population. This study aimed to explore the influencing factors of hospitalization cost of patients with DRFs in traditional Chinese medicine (TCMa) hospitals to provide a scientific basis for controlling hospitalization cost. METHODS: With 1306 cases of DRFs patients hospitalized in 15 public TCMa hospitals in two cities of Gansu Province in China from January 2017 to 2022 as the study object, the influencing factors of hospitalization cost were studied in depth gradually through univariate analysis, multiple linear regression, and path model. RESULTS: Hospitalization cost of patients with DRFs is mainly affected by the length of stay, surgery and operation, hospital levels, payment methods of medical insurance, use of TCMa preparations, complications and comorbidities, and clinical pathways. The length of stay is the most critical factor influencing the hospitalization cost, and the longer the length of stay, the higher the hospitalization cost. CONCLUSIONS: TCMa hospitals should actively take advantage of TCMb diagnostic modalities and therapeutic methods to ensure the efficacy of treatment and effectively reduce the length of stay at the same time, to lower hospitalization cost. It is also necessary to further deepen the reform of the medical insurance payment methods and strengthen the construction of the hierarchical diagnosis and treatment system, to make the patients receive reasonable reimbursement for medical expenses, thus effectively alleviating the economic burden of the disease in the patients with DRFs.

Assessment of Patients' Quality of Life during Conservative Treatment after Distal Radius Fracture.

Introduction: This study aimed to assess patients' quality of life after distal radius fracture treatment (at least six months, but no more than ten years, after the treatment) based on the analysis of objective and subjective parameters and the influence of the fractured side on the final results. Materials and Methods: The study sample consisted of 30 women who claimed to be right-handed, divided depending on the side of the fracture (left vs. right limb). Patients were evaluated with a goniometer for active wrist movement, pronation, and supination in the elbow joint. Furthermore, the global grip strength of the upper limb was assessed using a dynamometer (Biometrics Ltd.) device, after which patients were asked to complete a wrist evaluation questionnaire (PRWE) and the Polish version of the SF-36 questionnaire assessing the quality of life. Results: There were statistically significant differences in the active movement of the wrist of the injured limb compared to the non-injured limb. In addition, inferior results were reported for injury of the right limb to those of the left. Conclusions: Injury of the right limb as opposed to injury of the left limb can have a negative impact on the assessment of quality of life in patients with right-limb dominance.

Paediatric forearm fractures: assessment and initial management.

The forearm is the most common site of fracture in children. At the time of initial assessment, a thorough examination and neurovascular assessment of the limb is necessary. X-rays allow evaluation of the fracture location and type, in addition to the degree of displacement. With the help of intranasal opiates, manipulation of fracture fragments can be performed in the emergency department. Immobilisation in plaster is the gold standard treatment for paediatric forearm fractures where the degree of displacement is within acceptable parameters. Manipulation and casting should be followed by orthogonal radiographs and a repeated neurovascular assessment of the limb. Oral analgesia and safety netting information should be provided on discharge and the child should be reviewed in fracture clinic within a week of the injury. This article reviews the British Orthopaedic Association Standards for Trauma and Orthopaedics for the early management of paediatric forearm fractures that do not require operative management.

Outcomes and Cost of Reduction of Overriding Pediatric Distal Radius Fractures.

BACKGROUND: This study compared radiographic outcomes of pediatric patients undergoing closed reduction of 100% displaced distal radius fractures to a historical, published cohort treated with casting alone. We also examined the expense associated with sedated reduction. METHODS: Single-center, retrospective cohort study examining radiographic outcomes following reduction of 100% translated distal radius fractures in 50 consecutive pediatric patients. Radiographic outcomes were compared with a historical cohort published by Crawford and colleagues. Charges associated with emergency department (ED) and clinic visits were compared between the reduction cohort and a comparison cohort of 13 patients with fractures not requiring reduction. RESULTS: Forty-nine children (mean age 4.7 y) were included in this study. Duration of casting averaged 51 days and ED visit duration was 6.6±2.5 hours. Mean sagittal and coronal angulation at time of injury were 16.4 and 15.6 degrees, respectively, and were 13.2 and 9.4 degrees at the time of final follow-up. All fractures achieved radiographic union. Eighteen patients underwent a total of 21 unexpected cast changes. No patients required repeat sedation or surgical management.Angulation after casting was significantly better in the reduction cohort compared with the casting-only cohort initially, however, at final follow-up, both coronal and sagittal angulation were significantly worse in the reduction cohort compared with the casting-only cohort (coronal angulation 8.59 vs. 0.75, P<0.0001; sagittal angulation 13.49 vs. 2.2, P<0.0001).Charge analysis compared 46 patients in the reduction cohort to 13 patients with unreduced fractures from the same institution during the same time period. Mean clinic charges were similar ($1957 vs. $2240, P=0.3008). ED charges were higher in the reduction cohort compared with the nonreduction cohort ($7331 vs. $3501, P<0.001), resulting in higher total charges in the reduction cohort ($9245.04 vs. $5740.99, P<0.001). CONCLUSIONS: While closed reduction of 100% translated distal radius fractures in the pediatric population improves angulation initially, casting alone may provide similar or better radiographic outcomes, expedited care, reduced patient exposure to the risks of procedural sedation, and avoidance of ED charges associated with procedural sedation. LEVEL OF EVIDENCE: Level III-therapeutic.

Remodeling of distal radius fractures in children: preliminary retrospective cost/analysis in level II pediatric trauma center.

BACKGROUND AND AIM: Children displaced distal radius fractures (DRFs) are commonly treated by reduction. Yet, their excellent remodeling ability provides good clinical-radiographic outcomes even in case of non-anatomical reduction. The reduction under analgesia or sedation involves hospitalizations, greater risks, and higher hospital costs. The aim of this preliminary study is to demonstrate the accountability and conveniency of non-anatomical reduction. METHODS: The study involved all 0-8 years-old children who were affected by a closed overriding DRF from February 2017 to December 2018 and were managed non-operatively by a long arm cast without reduction, analgesia, or sedation treatments. We retrospectively evaluated their clinical-radiographic outcomes and healing time. The costs of no-reduction treatments were compared with those of the two main approaches to DRFs, that is: closed reduction under sedation and application of a long arm cast; closed reduction under anesthesia, percutaneous pinning, and application of a long arm cast. The comparison was based on the Diagnosis Related Group system. RESULTS: We treated 11 children with an average initial radial shortening of 5±3 mm and average initial sagittal and coronal angulations of 4.0° and 3.5°, respectively. Average casting duration was 40 days. All patients achieved a full range of wrist motion without deformities. The procedure was respectively 7 times less expensive than closed reduction in emergency room under sedation and application of a long arm cast, and 64 times less expensive than closed reduction in the operating room under anesthesia, percutaneous pinning, and application of a long arm cast. CONCLUSIONS: In children aged 0-8 years, non-operative treatment of closed overriding DRFs with a long arm cast without reduction is a simple and cost-effective procedure with both clinical and radiographic medium-term excellent outcomes.

Cost Analysis of Volar Plate Fixation Versus Plaster Cast Immobilization for Intra-Articular Distal Radial Fractures.

BACKGROUND: The aim of this study was to compare the cost-effectiveness and cost-utility between plaster cast immobilization and volar plate fixation for acceptably reduced intra-articular distal radial fractures. METHODS: A cost-effectiveness analysis was conducted as part of a randomized controlled trial comparing operative (volar plate fixation) with nonoperative (plaster cast immobilization) treatment in patients between 18 and 75 years old with an acceptably reduced intra-articular distal radial fracture. Health-care utilization and use of resources per patient were documented prospectively and included direct medical costs, direct non-medical costs, and indirect costs. All analyses were performed according to the intention-to-treat principle. RESULTS: The mean total cost per patient was $291 (95% bias-corrected and accelerated confidence interval [bcaCI] = -$1,286 to $1,572) higher in the operative group compared with the nonoperative group. The mean total number of quality-adjusted life-years (QALYs) gained at 12 months was significantly higher in the operative group than in the nonoperative group (mean difference = 0.15; 95% bcaCI = 0.056 to 0.243). The difference in the cost per QALY (incremental cost-effectiveness ratio [ICER]) was $2,008 (95% bcaCI = -$9,608 to $18,222) for the operative group compared with the nonoperative group, which means that operative treatment is more effective but also more expensive. Subgroup analysis including only patients with a paid job showed that the ICER was -$3,500 per QALY for the operative group with a paid job compared with the nonoperative group with a paid job, meaning that operative treatment is more effective and less expensive for patients with a paid job. CONCLUSIONS: The difference in QALYs gained for the operatively treated group was equivalent to an additional 55 days of perfect health per year. In adult patients with an acceptably reduced intra-articular distal radial fracture, operative treatment is a cost-effective intervention, especially in patients with paid employment. Operative treatment is slightly more expensive than nonoperative treatment but provides better functional results and a better quality of life. LEVEL OF EVIDENCE: Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

Home Management Versus Primary Care Physician Follow-up of Patients With Distal Radius Buckle Fractures: A Randomized Controlled Trial.

STUDY OBJECTIVE: In patients with a distal radius buckle fracture, we determine whether home removal of a splint and physician follow-up as needed (home management) is noninferior to primary care physician follow-up in 1 to 2 weeks with respect to functional recovery. We also compare groups with respect to health care and patient-level costs. METHODS: This was a noninferiority randomized controlled trial conducted at a tertiary care children's hospital. Eligible patients were randomized to home management versus primary care physician follow-up and received telephone contact at 3 and 6 weeks after the index ED visit. Functional recovery was measured with the Activities Scale for Kids-performance, and participants reported wrist-injury-related health care interventions and expenses. The primary outcome was a comparison of the performance score between groups at 3 weeks. RESULTS: We enrolled 149 patients with mean age 9.5 years (SD 2.7 years), and 81 (54.4%) were male patients. Of the 133 patients (89.3%) with completed 3-week follow-up, the mean Activities Scale for Kids-performance score was 95.4% in the home management group (n=66) and 95.9% in the primary care physician follow-up group (n=67) (mean difference -0.4%; lower bound of the 95% confidence interval -2.4%). There was a mean costs savings of -$100.10 (95% confidence interval -$130.0 to -$70.20) in health care and -$28.2 (95% confidence interval -$49.6 to -$7.0) in patient costs in the home management versus primary care physician follow-up group. CONCLUSION: In patients with distal radius buckle fractures, home management is at least as good as primary care physician follow-up with respect to functional recovery. Implementation of the home management strategy also demonstrated significant cost savings.

Application of 3D-Printed Orthopedic Cast for the Treatment of Forearm Fractures: Finite Element Analysis and Comparative Clinical Assessment.

OBJECTIVE: This pilot study is aimed at investigating the mechanical characteristics of a cast-wrapped fractured forearm and performing a clinical comparative study of our own developed 3D-printed orthopedic cast. METHODS: An integrated finite element (FE) model including a forearm and a 3D-printed cast wrapping the forearm was created. The distal radial ulna in this model was cut through to mimic the bone fracture. A 400 N force and 1 Nm rotation moment, which were much larger than the loading conditions encountered in daily life for a human being, were applied on the palm. We conducted a comparative clinical study by using statistical assessment. 60 patients with forearm fractures were selected and treated with manual reduction and external fixation cast. All patients were divided into three groups with equal members (20): (a) 3D-printed external cast group, (b) traditional plaster external fixation group, and (c) splint external fixation group. The clinical efficacy, wrist function, and patient satisfaction were scored and compared. RESULTS: In the condition of 400 N loading, the fracture displacements in anterior-posterior (AP), posterior-anterior (PA), medial to lateral (ML), and lateral to medial (LM) compression directions were 1.2648, 1.3253, 0.8503, and 0.8957 (mm), respectively, and the corresponding fracture stresses were 4.5986, 3.9129, and 5.0334, 7.9197 (MPa), respectively. In the inward (IR) and outward (OR) rotations, the fracture displacements were both 0.02628 (mm), and the corresponding fracture surface stresses were 0.1733 and 0.1723 (MPa), respectively. In the clinical efficacy, wrist function, and patient comfort evaluation, the total scores of group A were both higher than those in groups B and C (P < 0.05). CONCLUSION: A 3D-printed orthopedic cast was capable of exerting appropriate mechanical correction loads on specific areas to maintain optimal alignment of a fractured forearm and thus could achieve the favorable clinical efficacy and patient comfort.

Distal radius fractures: an evidence-based approach to assessment and management.

Distal radius fractures account for one in five bony injuries in both primary and secondary care. These are commonly the result of a fall on outstretched hands or high-energy trauma. On assessment, clinicians should determine the mechanism of injury, associated bony or soft tissue injuries, and neurovascular symptoms. Investigations should always include radiographs to evaluate for intra-articular involvement and fracture displacement. Owing to the heterogeneous injury patterns and patient profiles, the preferred management should consider the severity of the fracture, desired functional outcome and patient comorbidities. Non-operative management in select patients can give good results, especially in older adults. Immobilisation with or without reduction forms the mainstay of non-operative treatment. Surgical management options include closed reduction and application of a cast, percutaneous K-wires, open reduction and internal fixation with plates, or external fixation. Patients should be encouraged to mobilise as soon as it is safe to do so, to prevent stiffness. Median nerve compression is the most common complication followed by tendon rupture, arthrosis and malunion. This article outlines the British Orthopaedic Association Standards for Trauma and Orthopaedics for the management of distal radius fractures.

Volar Plate Fixation in Adults with a Displaced Extra-Articular Distal Radial Fracture Is Cost-Effective.

BACKGROUND: To our knowledge, a health economic evaluation of volar plate fixation compared with plaster immobilization in patients with a displaced extra-articular distal radial fracture has not been previously conducted. METHODS: A cost-effectiveness analysis of a multicenter randomized controlled trial was performed. Ninety patients were randomly assigned to volar plate fixation or plaster immobilization. The use of resources per patient was documented prospectively for up to 12 months after randomization and included direct medical, direct non-medical, and indirect non-medical costs due to the distal radial fracture and the received treatment. RESULTS: The mean quality-adjusted life-years (QALYs) at 12 months were higher in patients treated with volar plate fixation (mean QALY difference, 0.16 [bias-corrected and accelerated 95% confidence interval (CI), 0.07 to 0.27]). (The 95% CIs throughout are bias-corrected and accelerated.) In addition, the mean total costs per patient were lower in patients treated with volar plate fixation (mean difference, -$299 [95% CI, -$1,880 to $1,024]). The difference in costs per QALY was -$1,838 (95% CI, -$12,604 to $9,787), in favor of volar plate fixation. In a subgroup analysis of patients who had paid employment, the difference in costs per QALY favored volar plate fixation by -$7,459 (95% CI, -$23,919 to $3,233). CONCLUSIONS: In adults with a displaced extra-articular distal radial fracture, volar plate fixation is a cost-effective intervention, especially in patients who had paid employment. Besides its better functional results, volar plate fixation is less expensive and provides a better quality of life than plaster immobilization. LEVEL OF EVIDENCE: Economic Level I. See Instructions for Authors for a complete description of levels of evidence.

Incidence and Reason for Readmission and Unscheduled Health Care Contact After Distal Radius Fracture.

Background: Understanding risk factors for readmission may help decrease the rate of these costly events. The purpose of this study is to define the incidence of 30-day readmission and unscheduled health care contact (UHC) after distal radius fracture (DRF). In addition, we aim to define risk factors for readmission and UHC. Methods: A retrospective review of patients who sustained a DRF at our trauma center was performed. We recorded baseline demographics, fracture characteristics, and treatment. Any UHC or readmission (including emergency department [ED] visits) was documented. Reasons for readmission and UHC were stratified by cause. We utilized a case-control design comparing patients readmitted within 30 days after DRF versus those who were not, as well as patients with and without UHC. Results: About 353 patients were identified. The 30-day incidence of readmission after DRF was 7% with 2% of patients readmitted for reasons related to their fracture. Twenty percent of patients had UHC within 30 days, most frequently due to pain. Patients with anxiety or depression and those with open fractures were more likely to be readmitted. Patients with UHC were younger, more likely to have depression or anxiety, and more likely to have undergone operative treatment. Conclusions: For patients sustaining DRF, we report a 30-day readmission rate of 7% with 20% of patients having UHC. Patients with depression or anxiety were more likely to be both readmitted and have UHC. Identifying risk factors for readmission during initial presentation may help reduce readmissions. Improving pain relief strategies early may aid in decreasing the burden of UHC.

Implementation of research evidence in orthopaedics: a tale of three trials.

OBJECTIVE: To examine implementation of evidence in orthopaedic practice following publication of the results of three pivotal clinical trials. DESIGN: Case studies based on three orthopaedic trials funded in sequence by the National Institute for Health Research Health Technology Assessment (HTA) programme. These trials dealt with treatment of fractures of the humerus, radius and ankle, respectively. For each case study, we conducted time-series analyses to examine the relationship between publication of findings and the implementation (or not) of the findings. RESULTS: The results of all three trials favoured the less expensive and less invasive option. In two cases, a change of practice, in line with the evidence that eventually emerged, preceded publication. Furthermore, the upturn in use of the intervention most supported by each of these two trials corresponded to the start of recruitment to the respective trial. The remaining trial failed to influence practice despite yielding clear-cut evidence. CONCLUSIONS: Implementation of results of all three HTA orthopaedic trials favoured the less expensive and less invasive option. In two of the three studies, a change in practice, in line with the evidence that eventually emerged, preceded publication of that evidence. A trend or a change in practice, at around the start of the trial, indicates that the direction of causation opposes our hypothesis that publication of trial findings would lead to changes in practice. Our results provide provocative insight into the nuanced topic of research and practice, but further qualitative work is needed to fully explain what led to the pre-emptive change in practice we observed and why there was no change in the third case.

Increasing Brace Treatment for Pediatric Distal Radius Buckle Fractures: Using Quality Improvement Methodology to Implement Evidence-based Medicine.

BACKGROUND: Multiple randomized trials have showed equivalent outcomes and improved patient/family satisfaction using a removable brace to treat pediatric distal radius buckle fractures (DRBF). We tested the hypothesis that we could use quality improvement (QI) methodology to increase the proportion of patients with DRBF treated with removable braces at 2 tertiary care orthopaedic clinics from a baseline of 34.8% to 80%. METHODS: Clinic billing records were reviewed monthly to determine treatment (brace vs. cast) of DRBF and tracked using control charts (p-chart). Balance measures including correct application of the diagnostic criteria and algorithm were monitored. Process measures including the number of follow-up visits, radiographs obtained, and total cost of treatment were collected. Baseline data were obtained over a 3-month period, followed by a 12-month period of interventions using Plan-Do-Study-Act cycles targeting both individuals and groups of providers. RESULTS: The proportion of DRBF treated in a brace increased from a combined baseline of 34.8% to a combined 84% at the end of the study period. Following intervention, 83% (15/18) of providers began using braces for a majority of patients (defined as >67%), with only 1 provider continuing to use casts 100% of the time. Patient preference was cited as the most common reason for use of cast treatment. There was a significant decrease in the number of radiographs obtained at 1 of 2 institutions. The charges for brace treatment averaged $630 less per patient than for cast treatment, leading to an estimated medical-cost savings of $205,000 following intervention. CONCLUSIONS: Implementation of brace treatment for pediatric DRBF using QI methodology resulted in a shift toward brace treatment in the majority of patients, leading to substantial medical and nonmedical cost savings. Although patient preference was cited as the most common reason for persistent cast treatment, the data show the use of cast treatment to be more dependent upon individual provider preference. LEVEL OF EVIDENCE: Level II-therapeutic.

The efficacy, safety, and cost benefits of splints for fractures of the distal radius in children: A systematic review and meta-analysis protocol.

BACKGROUND: Distal radius fractures (DRFs) is one of the most common bone injuries in children, which may lead to deformity and other complications if the treatment is not prompt or appropriate. Splints external fixation is a common conservative treatment for such fractures. Therefore, we conducted a systematic review and meta-analysis to explore the efficacy, safety and cost benefits of splints in the treatment of DRFs in children. METHODS: PubMed, Web of Science, Embase, Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov, Chinese National Knowledge Infrastructure Database (CNKI), Wanfang Database, and VIP Database were searched for eligible randomized controlled trials (RCTs). The methodological quality of the included studies and the level of evidence for results were assessed, respectively, using the risk bias assessment tool of Cochrane and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. Statistical analysis was conducted with Revman 5.3. RESULTS: This study will analyze and integrate the existing evidence for effectiveness, safety and cost benefits of splints on DRFs in children. CONCLUSION: The conclusion of this study will provide evidence to effectiveness, safety and cost benefits of splints on DRFs in children, which can further guide the selection of appropriate interventions. PROSPERO REGISTRATION NUMBER: CRD42019123429.

Assessment of Distal Radius Fracture Complications Among Adults 60 Years or Older: A Secondary Analysis of the WRIST Randomized Clinical Trial.

Importance: Complications affect treatment outcomes and quality of life in addition to increasing treatment costs. Objectives: To evaluate complication rates after the treatment of a distal radius fracture, to determine whether the rate or complication type is associated with treatment method, and to determine predictors of complications. Design, Setting, and Participants: The multicenter Wrist and Radius Injury Surgical Trial (WRIST), a randomized clinical trial, enrolled participants from April 10, 2012, to December 31, 2016. The study included 304 adults 60 years or older with isolated unstable distal radius fractures; 187 were randomized and 117 opted for casting. The study was conducted at 24 health systems in the United States, Canada, and Singapore. Data for this secondary analysis were collected from April 24, 2012, to February 28, 2018. Interventions: Participants opting for surgery were randomized to receive the volar locking plate system (n = 65), percutaneous pinning (n = 58), or bridging external fixation with or without supplemental pinning (n = 64). Patients who chose not to have surgery (n = 117) were not randomized and were enrolled for casting. Main Outcomes and Measures: Complication rate. Results: The WRIST enrolled a total of 304 participants, of whom 8 casting group participants were later found to be ineligible and were excluded from the analysis, leaving 296 participants. Randomized participants' mean (SD) age was 68 (7.2) years, 163 (87%) were female, and 165 (88%) were white. Casting participants' mean (SD) age was 75.6 (9.6) years, 93 (84%) were female, and 85 (85%) were white. The most common type of complications varied by treatment. Twelve of 65 participants (18.5%) in the internal fixation group reported a median nerve compression, while 16 of 26 participants (25.8%) who received external fixation and 13 of 56 participants (23.2%) who received pinning sustained pin site infections. Compared with the internal fixation group, complication rate for any severity complication was higher in participants who initially received casting (adjusted rate ratio, 1.88; 95% CI, 1.22-2.88), whereas the rate for moderate complications was higher in the external fixation group (adjusted rate ratio, 2.52; 95% CI, 1.25-5.09). Conclusions and Relevance: The distal radius fracture treatment decision-making process for older patients should incorporate a complication profile for each treatment type. For example, external fixation and pinning could be used for patients after apprising them of pin site infection risk. Internal fixation can be done in patients with high functional demands who are willing to receive surgery. Internal fixation use should be substantiated owing to the time and cost involved. Trial Registration: ClinicalTrials.gov Identifier: NCT01589692.

A systematic review of the quality of distal radius systematic reviews: Methodology and reporting assessment.

BACKGROUND: Many systematic reviews (SRs) have been published about the various treatments for distal radius fractures (DRF). The heterogeneity of SRs results may come from the misuse of SR methods, and literature overviews have demonstrated that SRs should be considered with caution as they may not always be synonymous with high-quality standards. Our objective is to evaluate the quality of published SRs on the treatment of DRF through these tools. METHODS: The methods utilized in this review were previously published in the PROSPERO database. We considered SRs of surgical and nonsurgical interventions for acute DRF in adults. A comprehensive search strategy was performed in the MEDLINE database (inception to May 2017) and we manually searched the grey literature for non-indexed research. Data were independently extracted by two authors. We assessed SR internal validity and reporting using AMSTAR (Assessing the Methodological Quality of Systematic Reviews and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyzes). Scores were calculated as the sum of reported items. We also extracted article characteristics and provided Spearman's correlation measurements. RESULTS: Forty-one articles fulfilled the eligibility criteria. The mean score for PRISMA was 15.90 (CI 95%, 13.9-17.89) and AMSTAR was 6.48 (CI 95% 5.72-7.23). SRs that considered only RCTs had better AMSTAR [7.56 (2.1) vs. 5.62 (2.3); p = 0.014] and PRISMA scores [18.61 (5.22) vs. 13.93 (6.47), p = 0.027]. The presence of meta-analysis on the SRs altered PRISMA scores [19.17 (4.75) vs. 10.21 (4.51), p = 0.001] and AMSTAR scores [7.68 (1.9) vs. 4.39 (1.66), p = 0.001]. Journal impact factor or declaration of conflict of interest did not change PRISMA and AMSTAR scores. We found substantial inter observer agreement for PRISMA (0.82, 95% CI 0.62-0.94; p = 0.01) and AMSTAR (0.65, 95% CI 0.43-0.81; p = 0.01), and moderate correlation between PRISMA and AMSTAR scores (0.83, 95% CI 0.62-0.92; p = 0.01). CONCLUSIONS: DRF RCT-only SRs have better PRISMA and AMSTAR scores. These tools have substantial inter-observer agreement and moderate inter-tool correlation. We exposed the current research panorama and pointed out some factors that can contribute to improvements on the topic.

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.

Complex regional pain syndrome in distal radius fractures: How to implement changes to reduce incidence and facilitate early management.

STUDY DESIGN: Implementation paper. INTRODUCTION: Complex regional pain syndrome (CRPS) is relatively a common condition in the distal radius fracture (DRF) population with the effects resulting in many sufferers experiencing persistent pain and impairment 2 to 6 years after onset. Prevention is desirable as there is no known proven cure. PURPOSE OF THE STUDY: This study demonstrates how knowledge about CRPS and its prevention generated through iterative studies can be translated into practice in the workplace and how an interdisciplinary community of practice with therapists at the core can effect change. METHODS: A series of practice changes were introduced including a patient information leaflet, a local gold standard for care of DRF, education for staff regarding risk factors and early warning signs of CRPS, and simple patient and staff visual aids. RESULTS: The incidence of CRPS was reduced from 25% to 1% in the DRF population at the study site, and collaborative care pathways were ingrained onto the working culture. DISCUSSION: The process of learning together fostered the development of an interdisciplinary team with therapists acting as CRPS champions. Interdisciplinary team reflective practice facilitated simple but effective interventions, which reduced the incidence of CRPS in DRF population locally. It is not yet known whether this is transferable. CONCLUSIONS: Simple interventions can have a significant impact on the incidence of CRPS in a community of practice where a culture of team reflection and shared learning occurs.

Patient injury claims involving fractures of the distal radius.

Background and purpose - Optimal treatment for distal radius fractures remains controversial, with a significant number of fractures resulting in complications and long-term morbidity. We investigated patient injury claims related to distal radius fractures to detect the critical steps in the treatment leading to avoidable adverse events Patients and methods - We analyzed all compensated patient injury claims in Finland between 2007 and 2011. Claims were collected from the Patient Insurance Center's (PIC) nationwide claim register. Patients of all ages were included. Each claim decision, original patient records, and radiographs related to treatment were reviewed. Results - During the study period, the PIC received 584 claims regarding distal radius fractures, of which 208 (36%) were compensated. Pain and impaired wrist function were the most common subjective reasons to file claims among compensated patients. In 66/208 patients, more than 1 adverse event leading to patient injury was detected. The detected adverse events could be divided into 3 main groups: diagnostic errors (36%, n = 103), decision/planning errors (30%, n = 87), and insufficient technical execution (32%, n = 91). Issues related to malalignment were the main concerns in each group. Diagnostic errors were often related to incorrect assessment of the fracture (re)displacement (75%, n = 78). All of the decision-making errors concerned physicians' decisions to accept unsatisfactory fracture alignment. The most common technical error was insufficient reduction (29%, n = 26). Interpretation - We identified avoidable adverse events behind patient injuries related to distal radius fracture treatment. This study will help physicians to recognize the critical steps in the treatment of this common fracture and enhance patient safety.

Improved Safety and Cost Savings from Reductions in Cast-Saw Burns After Simulation-Based Education for Orthopaedic Surgery Residents.

BACKGROUND: The purpose of this investigation was to characterize the clinical efficacy and cost-effectiveness of simulation training aimed at reducing cast-saw injuries. METHODS: Third-year orthopaedic residents underwent simulation-based instruction on distal radial fracture reduction, casting, and cast removal using an oscillating saw. The analysis compared incidences of cast-saw injuries and associated costs before and after the implementation of the simulation curriculum. Actual and potential costs associated with cast-saw injuries included wound care, extra clinical visits, and potential total payment (indemnity and expense payments). Curriculum costs were calculated through time-derived, activity-based accounting methods. The researchers compared the costs of cast-saw injuries and the simulation curriculum to determine overall savings and return on investment. RESULTS: In the 2.5 years prior to simulation, cast-saw injuries occurred in approximately 4.3 per 100 casts cut by orthopaedic residents. For the 2.5-year period post-simulation, the injury rate decreased significantly to approximately 0.7 per 100 casts cut (p = 0.002). The total cost to implement the casting simulation was $2,465.31 per 6-month resident rotation. On the basis of historical data related to cast-saw burns (n = 6), total payments ranged from $2,995 to $25,000 per claim. The anticipated savings from averted cast-saw injuries and associated medicolegal payments in the 2.5 years post-simulation was $27,131, representing an 11-to-1 return on investment. CONCLUSIONS: Simulation-based training for orthopaedic surgical residents was effective in reducing cast-saw injuries and had a high theoretical return on investment. These results support further investment in simulation-based training as cost-effective means of improving patient safety and clinical outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.