Forgetting the Frail: National Trends in Vitamin D Prescription After Fragility Fracture-A Large Insurance Claims Database Study.

INTRODUCTION: Vitamin D plays a critical role in bone health, affecting bone mineral density and fracture healing. Insufficient serum vitamin D levels are associated with increased fracture rates. Despite guidelines advocating vitamin D supplementation, little is known about the prescription rates after fragility fractures. This study aims to characterize vitamin D prescription rates after three common fragility fractures in patients older than 50 years and explore potential factors influencing prescription rates. METHODS: The study used the PearlDiver Database, identifying patients older than 50 years with hip fractures, spinal compression fractures, or distal radius fractures between 2010 and 2020. Patient demographics, comorbidities, and vitamin D prescription rates were analyzed. Statistical methods included chi-square analysis and univariate and multivariable analyses. RESULTS: A total of 3,214,294 patients with fragility fractures were included. Vitamin D prescriptions increased from 2.50% to nearly 6% for all fracture types from 2010 to 2020. Regional variations existed, with the Midwest having the highest prescription rate (4.25%) and the West the lowest (3.31%). Patients with comorbidities such as diabetes, tobacco use, obesity, female sex, age older than 60 years, and osteoporosis were more likely to receive vitamin D prescriptions. DISCUSSION: Despite a notable increase in vitamin D prescriptions after fragility fractures, the absolute rates remain low. Patient comorbidities influenced prescription rates, perhaps indicating growing awareness of the link between vitamin D deficiency and these conditions. However, individuals older than 60 years, a high-risk group, were markedly less likely to receive prescriptions, possibly because of practice variations and concerns about polypharmacy. Educational initiatives and revised guidelines may have improved vitamin D prescription rates after fragility fractures. However, there is a need to raise awareness about the importance of vitamin D for bone health, particularly in older adults, and additional study variations in prescription practices. These findings emphasize the importance of enhancing post-fracture care to reduce morbidity and mortality associated with fragility fractures. LEVEL OF EVIDENCE: III.

Pre-existing osteoporosis and serum vitamin D levels in patients with distal radius fractures: are we missing something?

INTRODUCTION: Given the significant therapeutic gap for osteoporosis, this study aims to investigate the most common osteoporosis-related fracture. The analysis will also consider patients' serum vitamin D levels and the indications for basic osteoporosis diagnostic tests and osteoporosis therapy prior to fracture. MATERIALS AND METHODS: This prospective clinical trial included patients with distal radius fractures who underwent surgery at our hospital between 1 April 2021 and 7 April 2022. Blood samples were taken from all participants and existing risk factors for osteoporosis were recorded. In addition, the indication for a guideline-based osteoporosis diagnosis was assessed and the risk of another future fracture with FRAX® was calculated. This information was used to decide whether there was an indication for specific osteoporosis therapy. RESULTS: A diagnosis gap of 53% and a treatment gap of 84% were identified among the 102 patients investigated. The patients' ages ranged from 46 to 91 years, with an average vitamin D level of 57 nmol/l, which was below the recommended level of 75 nmol/l. It was noted on a monthly basis that the vitamin D level (without substitution) never exceeded the recommended value of 75 nmol/l in any month. Three-quarters of patients had indications for a baseline osteoporosis diagnosis, yet less than 50% received one. According to FRAX® data, 57% of patients had indications for specific osteoporosis treatment before experiencing the fracture. CONCLUSION: Even without a previous distal radius fracture, many patients are in need of osteoporosis diagnosis or treatment. Our research suggests that patients with distal radius fractures should have their vitamin D levels checked via a blood test and be evaluated for osteoporosis. As endogenous vitamin D levels are often inadequate, year-round vitamin D supplementation should be considered for the prevention of osteomalacia and as a basis for the treatment of osteoporosis. GERMAN CLINICAL TRIAL REGISTER ID: DRKS00028085.

Regional Anesthesia as an Alternative to Procedural Sedation for Forearm Fracture Reductions in the Pediatric Emergency Department.

BACKGROUND: Pediatric forearm fractures are common injuries in the pediatric emergency department (PED). Pediatric procedural sedation (PPS) is often required for forearm fracture reductions and pain control for casting. Bier blocks and hematoma blocks are types of regional anesthesia (RA) procedures that can be performed as a potential alternative to PPS. OBJECTIVE: The objective of this study is to compare the safety of RA with that of PPS. We hypothesized that RA has a safety profile that is equal or superior to PPS as well as a shorter duration of treatment in the PED. METHODS: Pediatric emergency department encounters in patients presenting with a diagnosis of radius fracture, ulna fracture, distal "both-bone" fracture, Monteggia fracture, and/or Galeazzi fracture were included. Outcomes of interest included patient adverse events (AEs), sedation medications used, PED duration of treatment (arrival time to disposition time), sedation failures, and reduction failures. RESULTS: Propensity matching was performed resulting in 632 well-matched RA-PPS pairs. The PPS cohort had 13% of encounters with at least 1 AE compared with 0.2% in the RA cohort, P < 0.001. The most common AE in the PPS group was hypoxia (9.8%), and the only AE in the RA group was an intravenous infiltrate (0.16%). Within the matched cohorts, PPS required more medications than RA (100% vs 60%, P < 0.001). Ketamine alone was more commonly used in the PPS group than the RA group (86% vs 0.2%, P < 0.001). Propofol was used only in the PPS group. The average duration of treatment was 205 (SD, 81) minutes in the PPS group and 178 (SD, 75) minutes in the RA group ( P < 0.001). There were no reduction failures in either group. CONCLUSIONS: Bier blocks and hematoma blocks are an acceptable alternative to PPS for children requiring forearm reductions. The AE rate is low and the reduction success rate is high. Duration of treatment in the PED is shorter for patients receiving RA compared with PPS.

Wide-awake local anesthesia and no tourniquet (WALANT) in upper limb fractures.

Wide-awake local anesthesia and no tourniquet (WALANT), first used for hand surgery, has been sparingly described for use in fracture fixation of the upper limb. We present our experience using this technique. 26 patients with upper limb fractures (3 distal radius, 6 radial shaft, 11 ulnar shaft, and 6 olecranon fractures) were operated on using WALANT by three orthopedic surgeons. We used 35-40ml of 2% Lignocaine with 1:80000 Adrenaline(7mg/kg) diluted with normal saline. Numeric Pain Rating (NPR) scoring was done during injection and per-operatively, and the Likert scale was used for the surgeon's satisfaction. The average NPR score was reported as 0.65 (1-3) during injection and 0.15 (0-2) preoperatively. All three surgeons reported excellent satisfaction in all the cases operated on. No complication occurred due to anesthesia. WALANT is a much simpler option and can be safely used in place of general anesthesia or regional blocks for fixation of fractures of the upper limb, with added advantages of no need for a tourniquet and better intraoperative assessment of fracture fixation.

Comparison of distal radius fracture plating surgery under wide-awake local anesthesia no tourniquet technique and balanced anesthesia: a retrospective cohort study.

BACKGROUND: Distal radius fractures (DRF) are frequently treated with internal fixation under general anesthesia or a brachial plexus block. Recently, the wide-awake local anesthesia with no tourniquet (WALANT) technique has been suggested as a method that results in higher patient satisfaction. This study aimed to evaluate the functional outcomes, complications, and patient-reported outcomes of DRF plating surgery under both the WALANT and balanced anesthesia (BA). METHODS: Ninety-three patients with DRFs who underwent open reduction and plating were included. Regarding the anesthetic technique, 38 patients received WALANT, while 55 received BA, comprised of multimodal pain control brachial plexus anesthesia with light general support. The patient's overall satisfaction in both groups and the intraoperative numerical rating scale of pain and anxiety (0-10) in the WALANT group were recorded. The peri-operative radiographic parameters were measured; the clinical outcomes, including Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, wrist mobility, and grip strength, were recorded in up to 1-year follow-up. Results presented with a mean difference and 95% confidence intervals and mean ± standard deviation. RESULTS: The mean age of patients in the WALANT group was higher than in the BA group (63 ± 17 vs. 54 ± 17, P = 0.005), and there were fewer intra-articular DRF fractures in the WALANT group than in the BA group (AO type A/B/C: 30/3/5 vs. 26/10/19, P = 0.009). The reduction and plating quality were similar in both groups. The clinical outcomes at follow-up were comparable between the two groups, except the WALANT group had worse postoperative 3-month pronation (88% vs. 96%; - 8.0% [ - 15.7 to - 0.2%]) and 6-month pronation (92% vs. 100%; - 9.1% [ - 17.0 to - 1.2%]), and better postoperative 1-year flexion (94% vs. 82%; 12.0% [2.0-22.1%]). The overall satisfaction was comparable in the WALANT and BA groups (8.7 vs. 8.5; 0.2 [ - 0.8 to 1.2]). Patients in the WALANT group reported an injection pain scale of 1.7 ± 2.0, an intraoperative pain scale of 1.2 ± 1.9, and an intraoperative anxiety scale of 2.3 ± 2.8. CONCLUSION: The reduction quality, functional outcomes, and overall satisfaction were comparable between the WALANT and BA groups. With meticulous preoperative planning, the WALANT technique could be an alternative for DRF plating surgery in selected patients. Trial registration This retrospective study was approved by the Institutional Review Board of Kaohsiung Medical University Hospital (KMUHIRB-E(I)-20210201).

Occupational Performance 1 Year After a Distal Radius Fracture From the Perspective of the International Classification of Functioning, Disability and Health.

IMPORTANCE: Distal radius fractures (DRFs) frequently compromise independent functioning. OBJECTIVE: To analyze occupational performance post-DRF using the Canadian Occupational Performance Measure (COPM) and related interviews, guided by the International Classification of Functioning, Disability and Health (ICF). COPM score was compared with standard metrics: Patient-Reported Wrist Evaluation (PRWE) and Participation Behavior Questionnaire (PBQ). METHOD: Through a semistructured COPM interview, participants highlighted self-care, productivity, and leisure. They completed the PRWE and PBQ, linking results to ICF sets. DESIGN: Prospective cohort. SETTING: Outpatient hand surgery clinic at a trauma center. PARTICIPANTS: Patients (N = 120), 1 yr post-DRF. OUTCOMES AND MEASURES: Incorporated COPM, PRWE, and PBQ, linked to ICF. RESULTS: Analysis identified 73 codes, aligning with 30 ICF Hand Conditions codes. Main concerns related to self-care (15.21%), leisure (12.16%), and productivity (16.22%). Major challenges pertained to domestic (67.00%) and civic life (64.53%) within ICF. Occupational performance was positively correlated with participation (r = .62) and inversely with disability (r = -.62). CONCLUSIONS AND RELEVANCE: DRFs result in varied occupational challenges that are not always reflected in standard measures. The COPM offers a comprehensive insight into post-DRF patient challenges, emphasizing the value of diverse clinical assessment approaches. What This Article Adds: This study highlights the importance of a holistic approach in occupational therapy for DRF patients, revealing that standard measurements might overlook key challenges that they face. By adopting broader evaluative methods, occupational therapists can better address patient-specific needs and enhance their rehabilitation outcomes.

Depth camera-based model for studying the effects of muscle loading on distal radius fracture healing.

BACKGROUND: Distal radius fractures (DRFs) treated with volar locking plates (VLPs) allows early rehabilitation exercises favourable to fracture recovery. However, the role of rehabilitation exercises induced muscle forces on the biomechanical microenvironment at the fracture site remains to be fully explored. The purpose of this study is to investigate the effects of muscle forces on DRF healing by developing a depth camera-based fracture healing model. METHOD: First, the rehabilitation-related hand motions were captured by a depth camera system. A macro-musculoskeletal model is then developed to analyse the data captured by the system for estimating hand muscle and joint reaction forces which are used as inputs for our previously developed DRF model to predict the tissue differentiation patterns at the fracture site. Finally, the effect of different wrist motions (e.g., from 60° of extension to 60° of flexion) on the DRF healing outcomes will be studied. RESULTS: Muscle and joint reaction forces in hands which are highly dependent on hand motions could significantly affect DRF healing through imposed compressive and bending forces at the fracture site. There is an optimal range of wrist motion (i.e., between 40° of extension and 40° of flexion) which could promote mechanical stimuli governed healing while mitigating the risk of bony non-union due to excessive movement at the fracture site. CONCLUSION: The developed depth camera-based fracture healing model can accurately predict the influence of muscle loading induced by rehabilitation exercises in distal radius fracture healing outcomes. The outcomes from this study could potentially assist osteopathic surgeons in designing effective post-operative rehabilitation strategies for DRF patients.

Radial Nerve Supracondylar Block Versus Fracture Hematoma Block. Comparison of Their Efficacy in Cases of Fractures of the Distal Third of the Radius / Bloqueio supracondilar de nervo radial versus bloqueio de hematoma de fratura. Comparativo de sua eficácia em casos de fraturas do terço distal do rádio

Abstract Objective The present study compares the analgesic efficacy of two techniques to perform non-surgical reduction: fracture hematoma block and radial nerve supracondylar block. Methods Forty patients with fractures of the distal third of the radius, who required reduction, were selected in a quasi-randomized clinical trial to receive one of the anesthetic techniques. All patients signed the informed consent form, except for those who did not wish to participate in the study, had neurological injury, had contraindication to the procedure in the emergency room, or with contraindication to the use of lidocaine. To measure analgesia, the numerical pain rate scale was used at four different moments: preblock, postblock, during reduction, and after reduction; then three differences were calculated: the first between before and after blocking; the second between during reduction and after blockade; and the third between before blocking and after reduction. Results The fracture hematoma and supracondylar block groups showed the following mean values, respectively: 3.90 (1-10) and 3.50 (-6-10) in difference 1; 4.35 (-5-10) and 5.00 (-3-10) in difference 2; and 4.65 (1-10) and 3.80 (-3-10) in difference 3. Conclusion Both techniques proved to be efficient for analgesia, with mild superiority of hematoma block, but without statistical significance.

Resumo Objetivo O estudo compara a eficácia analgésica de duas técnicas para realizar redução incruenta: o bloqueio de hematoma da fratura e o bloqueio supracondilar de nervo radial. Métodos Quarenta pacientes com fraturas do terço distal do rádio, que necessitassem redução, foram selecionados em um ensaio clínico quasi-randomizado, para receber uma das técnicas anestésicas. Todos os pacientes assinaram o termo de consentimento ou assentimento, com exceção daqueles que não desejassem participar do estudo, tivessem lesão neurológica, com contraindicação ao procedimento na sala de emergências, ou com contraindicação ao uso da lidocaína. Para aferir a analgesia foi utilizada a escala numérica da dor em quatro momentos distintos: pré-bloqueio, pós-bloqueio, durante a redução e após a redução; em seguida, foram calculadas três diferenças: a primeira entre antes e após o bloqueio; a segunda entre durante a redução e após o bloqueio; e a terceira entre antes do bloqueio e após a redução. Resultados Os grupos do bloqueio de hematoma de fratura e bloqueio supracondilar apresentaram respectivamente os seguintes valores médios: 3.90 (1-10) e 3.50 (-6-10) na diferença 1; 4.35 (-5-10) e 5.00 (-3-10) na diferença 2; e 4.65 (1-10) e 3.80 (-3-10) na diferença 3. Conclusão As duas técnicas se provaram eficientes para analgesia, com discreta superioridade do bloqueio de hematoma, mas sem significância estatística.

Risk of radial head arthroplasty revision is correlated with radial head diameter: a multicenter analysis of 405 cases.

BACKGROUND: Radial head arthroplasty (RHA) is commonly used for the treatment of comminuted radial head fractures. Indications as well as implant types continue to evolve. RHA has had good outcomes with midterm longevity. The literature is limited to small case series with varying implant types, and larger studies are needed to determine the optimal implant type and radial head diameter. METHODS: A retrospective analysis of RHA cases performed by 75 surgeons at 14 medical centers in an integrated health care system between 2006 and 2017 was completed. Patient demographics, comorbidities, implant type and head diameter, and indications for revision were recorded. Patients' in-person clinical visit data were recorded. Patients were also contacted via telephone at a minimum of 2 years to obtain abbreviated Disabilities of the Arm, Shoulder, and Hand questionnaire and Oxford scores. Implant survivorship was also captured within our integrated system. RESULTS: 405 cases met our inclusion criteria. Mean age was 51.5 ± 15.5 years (range 16-88 years) and more common in females (62%). Chart review and telephone follow-up was performed at a mean of 68.9 ± 31.5 months (range 24-146 months). Our study found that revision rate was positively correlated with increasing radial head diameter. A 26-mm head had 7.7 odds of revision compared to a size 18-mm head (95% confidence interval 1.2-150.1). More than 95% of revision cases were performed within the first 36 months of the index procedure. Obese patients had a significantly lower mean postoperative Oxford score (35.5) compared to controls (38.3) (P = .02). There was a significantly higher overall reoperation rate for terrible triad (18.4%) vs. isolated injuries (10.4%) (P = .04). There was no difference between Acumed Anatomic and Evolve radial head implants in overall reoperation, implant revision, postoperative range of motion, or patient-reported outcomes. CONCLUSIONS: Risk of revision is directly correlated with implanted radial head diameter. There were no differences in outcomes and complications between the 2 main implants used. Individuals who did not undergo a revision by 3 years' time tend to retain the implant. Terrible triad injuries had a higher all-cause reoperation rate than isolated radial head fractures, but no difference in the rate of RHA revision. These data reinforce the practice of downsizing radial head implant diameter.

Vitamin D-A Risk Factor for Bone Fractures in Children: A Population-Based Prospective Case-Control Randomized Cross-Sectional Study.

BACKGROUND: Vitamin D is an essential component in calcium metabolism. Seasonality, advanced age, sex, dark skin pigmentation, and limited exposure to sunlight were reported as causes of vitamin D deficiency. This study aims to determine whether children with lower levels of vitamin D suffer more fractures than those with sufficient levels. MATERIALS AND METHODS: Our institution underwent a prospective case-control randomized cross-sectional single-blinded study that included 688 children. They were split into two groups: the study group and the control group. The study group received supplements of vitamin D and calcium for 6 months. Another reference cohort was observed, which comprised 889 patients in the pediatric ward for different respiratory or gastroenterological conditions without a history of fractures. This group was used for age-sex matching tests. RESULTS: Logistic regression showed that with every one unit increase of vitamin D level, the chance of having a middle third fracture in both bones of the forearm decreased by 7% (OR 1.07); distal third fracture incidence decreased by 1.03 times; middle third radius fracture incidence decreased by 1.03 times; distal third radius fracture incidence decreased by 1.06 times. The risk of having a distal third both-bone forearm fracture increased by 1.06 times with every year of age. Comparing the healing process, we noticed an improvement in bony callus formation for patients in the study group. CONCLUSIONS: Dosing the serum level of 25-OH-vitamin D should be taken into consideration for pediatric low-energy trauma fractures. Supplementing with vitamin D and calcium throughout childhood can be a solution for healthy bones. Our preliminary results show that the normal level of vitamin D in children should start at 40 ng/mL.

Manipulation of distal radius fractures: a comparison of Bier's block vs haematoma block.

INTRODUCTION: Displaced distal radius fractures often require manipulation under anaesthesia. Many anaesthetic techniques are described, with the two most commonly used being Bier's block (BB) and haematoma block (HB). Despite national guidance preferring a BB, an HB is often performed instead. This study aims to compare the analgesic properties of a BB with those of an HB when manipulating distal radius fractures. METHODS: This is an observational cohort study comparing the management of displaced distal radius fractures requiring reduction across two National Health Service trusts. Patients aged over 18 with isolated, displaced distal radius fractures were recruited. Patient demographics, AO fracture classification and grade of clinician performing the procedure were recorded. A numeric rating scale (NRS) pain score was obtained for each patient after manipulation. The quality of reduction was judged against standardised anatomical parameters. RESULTS: Some 200 patients were recruited (100 HB, 100 BB). There were no differences in age (BB: median 66.5 years, interquartile range [IQR] 55-74; HB: median 67 years, IQR 55-74; p = 0.79) or fracture characteristics (p = 0.29) between cohorts. Patients undergoing BB had significantly lower pain scores with a lower IQR than those undergoing HB (p < 0.005). Patients undergoing BB manipulation were more likely to have the fracture reduced and normal anatomy restored (p < 0.005). BBs were performed mainly by Foundation Year 2 junior doctors, whereas HB manipulations were performed by a range of clinicians from emergency nurse practitioners to consultants. CONCLUSIONS: BB provides better analgesia than an HB. This can be performed successfully and reliably by Senior House Officer-level junior doctors.

Circumferential periosteal block versus hematoma block for the reduction of distal radius and ulna fractures: a randomized controlled trial.

PURPOSE: To assess the analgesic efficacy of the circumferential periosteal block (CPB) and compare it with the conventional fracture hematoma block (HB). METHODS: This study was a prospective single-center randomized controlled trial performed in a national orthopedic hospital. Fifty patients with displaced distal radius (with or without concomitant ulna) fractures requiring reduction were randomized to receive either CPB or HB prior to the reduction. Pain was sequentially measured using the visual analogue scale (VAS) across three stages; before administration of local anesthesia (baseline), during administration (injection) and during manipulation and immobilization (manipulation). Further, the effect of demographic factors on the severity of pain was analyzed in multivariate regression. Finally, complications and end outcomes were compared across both techniques. RESULTS: Patients receiving CPB experienced significantly less pain scores during manipulation (VAS = 0.64) compared with HB (VAS = 2.44) (p = < 0.0001). There were no significant differences between groups at baseline (P = 0.55) and injection (P = 0.40) stages. CONCLUSION: The CPB provides a superior analgesic effect over the conventional HB with no documented complications in either technique. LEVEL OF EVIDENCE: Therapeutic Level II.

Efficacy of electroacupuncture in assisting postoperative healing of distal radius fractures: study protocol for a randomized controlled trial.

BACKGROUND: Manual reduction and surgical treatment are common methods for distal radius fractures (DRFs). The existing literature suggests that postoperative combined rehabilitation treatment and medication are effective for the healing of DRFs. However, the side effects of these treatments remain to be solved. Previous studies have shown that electroacupuncture (EA) can effectively relieve wrist swelling and improve the joint function in patients with DRFs, but more evidence is needed to prove the effectiveness of EA. This trial aims to explore the efficiency and feasibility of combined EA treatment in postoperative treatment of DRFs compared with routine treatment. METHODS: This is a parallel randomized controlled trial. A total of 222 patients diagnosed with moderate DRFs will be recruited and randomly assigned to an EA group or a routine treatment group at a ratio of 1:1. Routine treatment group will receive medication and rehabilitation. Yangxi (LI 5), Yangchi (TE 4), Yanggu (SI 5), Hegu (LI 4), and Taiyuan (LU 9) will be selected in the EA group for intervention three times a week on the basis of routine treatment. Both groups will receive 8 weeks of treatment and 4 weeks of follow-up. The primary outcome will be ulnar positive variance. The secondary outcomes will include radiographic healing rate, bone strength, hemorheological indices, serum biochemical indicators and inflammatory factors, grip strength, wrist swelling score, patient-rated wrist evaluation, disabilities of arm, shoulder and hand, and visual analogue scale. Outcomes will be evaluated at baseline, postoperative 3rd day, 2nd, 4th, 6th, 8th, and 12th weeks. DISCUSSION: The results of this study will help establish a more optimized scheme to treat patients with DRFs. Trial registration Chinese Clinical Trial Registry ChiCTR2200062857. Registered on 21 August 2022, www.chictr.org.cn/com/25/showproj.aspx?proj=175567 .

Overall Effects and Moderators of Rehabilitation in Patients With Wrist Fracture: A Systematic Review.

OBJECTIVE: Wrist fractures constitute the most frequently occurring upper limb fracture. Many individuals report persistent pain and functional limitations up to 18 months following wrist fracture. Identifying which individuals are likely to gain the greatest benefit from rehabilitative treatment is an important research priority. This systematic review aimed to summarize effectiveness of rehabilitation after wrist fracture for pain and functional outcomes and identify potential effect moderators of rehabilitation. METHODS: A comprehensive search of 7 databases (including MEDLINE, EMBASE, and the Physiotherapy Evidence Database) was performed for randomized controlled trials involving adults >50 years of age who sustained wrist fracture and had received 1 or more conservative treatments (eg, exercise/manual therapy, lifestyle, diet, or other advice). Study selection, data extraction, and risk-of-bias assessment were conducted independently by 2 reviewers. Results of included trials were summarized in a narrative synthesis. RESULTS: A total of 3225 titles were screened, and 21 studies satisfying all eligibility criteria were reviewed. Over one-half of the included studies (n = 12) comprised physical therapist and/or occupational therapist interventions. Rehabilitative exercise/manual therapy was generally found to improve function and reduce pain up to 1 year after wrist fracture. However, effects were small, and home exercises were found to be comparable with physical therapist-led exercise therapy. Evidence for the effects of other nonexercised therapy (including electrotherapy, whirlpool) was equivocal and limited to the short term (<3 months). Only 2 studies explored potential moderators, and they did not show evidence of moderation by age, sex, or patient attitude of the effects of rehabilitation. CONCLUSION: Effectiveness of current rehabilitation protocols after wrist fracture is limited, and evidence for effect moderators is lacking. Currently available trials are not large enough to produce data on subgroup effects with sufficient precision. To aid clinical practice and optimize effects of rehabilitation after wrist fracture, potential moderators need to be investigated in large trials or meta-analyses using individual participant data. IMPACT: Many patients report persistent pain and functional limitations up to 18 months following wrist fracture. Effectiveness of current rehabilitation protocols after wrist fracture is limited and may be due to insufficient targeting of specific rehabilitation to individuals who are likely to benefit most. However, evidence for effect moderators is lacking within the currently available literature. To aid clinical practice and optimize effects of rehabilitation, investigating potential moderators of rehabilitation in individuals with wrist fracture via large trials or meta-analysis of individual participant data is research and policy imperative.

Charges for Distal Radius Fracture Fixation Are Affected by Fracture Pattern, Location of Service, and Anesthesia Type.

BACKGROUND: This study sought to characterize charges associated with operative treatment of distal radius fractures and identify sources of variation contributing to overall cost. METHODS: A retrospective study was performed using the New York Statewide Planning and Research Cooperative System database from 2009-2017. Outpatient claims were identified using the International Classification of Diseases-9/10-Clinical Modification diagnosis codes for distal radius fixation surgery. A multivariable mixed model regression was performed to identify variables contributing to total charges of the claim, including patient demographics, anesthesia method, surgery location (ambulatory surgery center [ASC] versus a hospital outpatient department [HOPD], operation time, insurance type, Charlson Comorbidity Index, and billed procedure codes. RESULTS: A total of 9029 claims were included, finding older age, private primary insurance, surgery performed in a HOPD, and use of local anesthesia (vs general or regional) associated with increased total charges. There was no difference between gender, race, or ethnicity. Additionally, open reduction and internal fixation (ORIF), increased operative time/fracture complexity, and use of perioperative medications contributed significantly to overall costs. CONCLUSIONS: Charges for distal radius fracture surgery performed in a HOPD were 28.3% higher than compared to an ASC, and cases with local anesthesia had higher billed claims compared to regional or general anesthesia. Furthermore, charges for percutaneous fixation were 54.6% lower than ORIF of extraarticular fracture, and claims had substantial geographic variation. These findings may be used by providers and payers to help improve value of distal radius fracture care. LEVEL OF EVIDENCE: Level III.

Pain and Disability of Conservatively Treated Distal Radius Fracture: A Triple-Blinded Randomized Placebo-Controlled Trial of Photobiomodulation Therapy.

Objective: Many patients with distal radius fracture (DRF) experience pain and disability after removal of the cast. The aim of this study was to investigate if photobiomodulation therapy (PBMT) applied after cast removal provides an add-on effect to a home-based exercise program in rehabilitation after DRF. Methods: In this triple-blinded placebo-controlled trial, 50 patients with conservatively treated DRF were randomized to receive either active PBMT or placebo PBMT after cast removal in addition to a home-based exercise therapy program. The outcome measures were the Patient-Rated Wrist and Hand Evaluation (PRWHE) questionnaire, night pain (NP), and consumption of analgesic medication (AM) and were evaluated after cast removal at 4 (baseline), 8, 12, and 26 weeks after injury. NP and AM were also evaluated 7 weeks after injury (end of active/placebo PBMT). Results: There was a significant between-group difference in PRWHE scores in favor of active PBMT 8, 12, and 26 weeks after DRF. NP and consumption of AM were significantly lower in the active PBMT group from 7 to 26 weeks. There was a minimum clinically important improvement between the groups in favor of active PBMT in total score at 12 weeks, in pain subscore at 8, 12, and 26 weeks, and in disability subscore at 8 and 12 weeks. Conclusions: PBMT is safe and has long-term positive effect on pain and disability in DRF patients, when applied in combination with a home-based rehabilitation exercise program. Clinical Trial registration number: NCT03014024.

Standard radiographic assessments of distal radius fractures miss involvement of the distal radioulnar joint: a diagnostic study.

INTRODUCTION: Distal radius fractures account for one-fifth of all fractures in the emergency department. Their classification based on standard radiographs is common practice although low inter-observer reliabilities and superiority of computer tomography (CT) scanning in evaluation of joint congruency have been reported. MATERIALS AND METHODS: We retrospectively analyzed 96 displaced distal radius fractures scheduled for open reduction and internal fixation using standard radiographic assessment. The radiographs were classified with the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA), Fernandez and Frykman classifications by three observers and inter-rater reliabilities were calculated. Additional CT scanning was performed in all cases and the following parameters were assessed: radiocarpal joint involvement, fracture extent into the radial sigmoid notch, i.e. the distal radio-ulnar joint, comminution of the metaphysis, and concomitant ulnar styloid fracture. The CT scans were used as a reference standard to determine sensitivity and accuracy of standard radiographic assessment in evaluation of distal radius fractures. RESULTS: The inter-rater agreement for the AO classification was 35.4%, 68.8% for the Fernandez and 38.5% for the Frykman classification. Fracture extension into the radiocarpal joint was present in 81 cases (84.4%). Sigmoid notch involvement was found in 81 fractures (84.4%). Involvement of both joints was present in 72 cases (75%). The sensitivity of standard radiographs regarding radiocarpal joint involvement was 93.8%. Considering involvement of the distal radio-ulnar joint the false-negative rate using standard radiographs was 61.7% and the test's accuracy for sigmoid notch involvement was 45.8%. CONCLUSION: This study demonstrates that involvement of the sigmoid notch is frequently missed in standard radiographs. The presented data support the frequent use of CT imaging to allow the holistic illustration of a fracture's complexion and to ensure optimal pre-operative planning.

Effectiveness of manual therapy in patients with distal radius fracture: a systematic review and meta-analysis.

OBJECTIVE: To determine the effectiveness of manual therapy (MT) for functional outcomes in patients with distal radius fracture (DRF). METHODS: An electronic search was performed in the Medline, Central, Embase, PEDro, Lilacs, CINAHL, SPORTDiscus, and Web of Science databases. The eligibility criteria for selecting studies included randomized clinical trials that included MT techniques with or without other therapeutic interventions in functional outcomes, such as wrist or upper limb function, pain, grip strength, and wrist range of motion in patients older than 18 years with DRF. RESULTS: Eight clinical trials met the eligibility criteria; for the quantitative synthesis, six studies were included. For supervised physiotherapy plus joint mobilization versus home exercise program at 6 weeks follow-up, the mean difference (MD) for wrist flexion was 7.1 degrees (p = 0.20), and extension was 11.99 degrees (p = 0.16). For exercise program plus mobilization with movement versus exercise program at 12 weeks follow-up, the PRWE was -10.2 points (p = 0.02), the DASH was -9.86 points (p = 0.0001), and grip strength was 3.9 percent (p = 0.25). For conventional treatment plus manual lymph drainage versus conventional treatment, for edema the MD at 3-7 days was -14.58 ml (p = 0.03), at 17-21 days -17.96 ml (p = 0.009), at 33-42 days -15.34 ml (p = 0.003), and at 63-68 days -13.97 ml (p = 0.002). CONCLUSION: There was very low to high evidence according to the GRADE rating. Adding mobilization with movement and manual lymphatic drainage showed statistically significant differences in wrist, upper limb function, and hand edema in patients with DRF.

Traditional Versus Digital Media-Based Hand Therapy After Distal Radius Fracture.

PURPOSE: Distal radius fractures (DRFs) are common injuries with a rising incidence. A substantial portion of the cost of care is attributable to therapy services. Our purpose was to evaluate the effectiveness of a self-directed hand therapy program guided by digital media compared with that of traditional therapy. METHODS: We conducted a randomized controlled trial in patients aged 18 years or older who underwent open reduction and internal fixation of a DRF with volar plating. Subjects were randomized to traditional hand therapy using a 12-week protocol or an identical protocol presented in digital videos and performed at home. Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores were collected as the primary outcome at 2 weeks (baseline), 6 weeks, and 12 weeks or greater. Pain visual analog scale (VAS) scores, Veterans RAND 12-Item Health Survey (VR-12) scores, wrist and forearm range of motion, wrist circumference, and grip strength were recorded as secondary outcomes. RESULTS: Fifty-one patients were enrolled. Forty-nine patients were included in the analysis-21 in the digital media group and 28 in the traditional group. Both groups demonstrated significant improvements in QuickDASH scores between baseline and 12-week or greater time points. The QuickDASH scores in the digital media group were slightly more improved than those in the traditional group at the 6-week and 12-week or greater time points; however, these differences were not statistically significant. Pain VAS and VR-12 scores were comparable between group differences at each time point. CONCLUSIONS: Our digital media program was at least as effective as traditional therapy for patients undergoing volar plating of DRF. These results may help inform the design of future trials investigating the effectiveness of digital media-based hand therapy programs. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.