Ultrasound Directed Reduction of Colles' type distal radial fractures in ED (UDiReCT): a feasibility randomised controlled trial.

BACKGROUND: There is a high rate of surgical fixation of displaced Colles' type distal radial wrist fractures despite fracture manipulation in the ED. Point-of-care ultrasound has been used to guide ED manipulations but its effect on the quality of fracture reduction or subsequent need for surgical fixation is unknown. This study aims to assess the feasibility of conducting a definitive randomised controlled trial to assess the use of ultrasound to guide these fracture manipulations. METHODS: We conducted a pragmatic randomised controlled feasibility trial in two EDs in England over a 6-month period (7 October 2019 to 6 April 2020). Adult patients with wrist fractures undergoing manipulation in the ED were randomised 1:1 to ultrasound-guided distal radial fracture manipulation or manipulation with sham ultrasound. The primary outcome for this study was trial recruitment rate. Other measures were recorded to assess potential future definitive trial outcomes and feasibility. RESULTS: Of 120 patients meeting inclusion criteria, 48 (40%) were recruited and randomised in the two centres, giving overall recruitment rates of 0.3 and 1.8 participants per week at each site, respectively, and 1 participant per week overall. The most common reason that patients were not included was research staff availability. After 6 weeks, six patients in each group (26% intervention, 24% control) had undergone surgical fixation, with 98% data completeness for this potential definitive trial primary outcome. Randomisation, blinding and data collection processes were effective but there were data limitations in the X-ray assessment of fracture positions. CONCLUSION: A definitive study of a similar design would be feasible within UK ED practice but organisational factors and research staff availability should be considered when estimating the predicted recruitment rate and required sites. 6-week surgical fixation rate was the most reliable outcome measure. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03868696).

BFR Training Improves Patients' Reported Outcomes, Strength, and Range of Motion After Casting for Colles' Fracture.

PURPOSE: This study compared traditional rehabilitation as a treatment modality after plaster cast treatment of Colles' fracture with a combination of individualized blood flow restriction (BFR) and traditional rehabilitation. METHODS: Twenty-eight participants were randomized into a BFR group and a non-BFR group after plaster cast treatment of Colles' fracture. The BFR group completed traditional rehabilitation with a medical grade tourniquet applied to the upper arm, and the non-BFR group underwent traditional rehabilitation only. Patients were followed up with radiographic outcomes (palmar tilt and radial inclination) to ensure the stability of the fracture. Clinical assessment of patient-rated wrist evaluation (PRWE) score, grip strength, pinch strength, wrist range of motion (ROM), and muscle stiffness was conducted at cast removal and 6 wk after cast removal. Two-way repeated-measures ANOVA determined significant interactions between time and group in the aforementioned variables. An independent-sample t -test assessed the differences in baseline variables and radiographic outcomes. RESULTS: Significant interactions between time and group were noted for PRWE score ( F = 11.796, P = 0.002, η2p = 0.339), grip strength ( F = 5.445, P = 0.029, η2p = 0.191), and wrist ROM (ulnar deviation; F = 7.856, P = 0.010, η2p = 0.255). No significant interactions between time and group were found in measurements of pinch strength or wrist ROM (flexion, extension, radial deviation, pronation, supination). An independent-sample t -test showed no significant difference in baseline variables and radiographic outcomes between the groups before or after intervention. CONCLUSIONS: This study found that combining individualized BFR with traditional rehabilitation resulted in greater increases in PRWE score, grip strength, and wrist ROM (ulnar deviation) than traditional rehabilitation alone. Therefore, adding individualized BFR to traditional rehabilitation might be a better option for treatment for similar patients.

The Influence of Ibuprofen on the Healing of Nonsurgically Treated Colles' Fractures.

Nonsteroidal anti-inflammatory drugs can delay bone healing. This knowledge is mainly derived from retrospective and animal studies. The authors therefore conducted a human study to investigate whether ibuprofen affects radiological, functional, densitometrical, and biochemical outcomes following a Colles' fracture, as well as the analgesic effect of ibuprofen. This was a single-center, triple-blinded, randomized, placebo-controlled clinical trial with a total of 96 patients. All of the patients received basic treatment with 1000 mg of acetaminophen 4 times daily. The placebo group received a placebo for 7 days. The 3-day ibuprofen group received 600 mg of ibuprofen 3 times daily for the first 3 days and a placebo for the following 4 days. The 7-day ibuprofen group received ibuprofen 3 times daily for 7 days. The primary outcome was the fragment migration for a period of 5 weeks. The secondary outcomes were changes in the wrist's range of motion; Disabilities of the Arm, Shoulder and Hand score; bone mineral density of the injured wrist; changes in serum CrossLaps (Roche Diagnostics) and osteocalcin; and analgesic effects. Analyses were performed according to an intention-to-treat approach. No significant differences in radiological migration or functional, densitometrical, and biochemical effects were established among the treatment groups (.06≤P≤.9). During the first 3 days, the pain score was lower (P=.02) in the ibuprofen groups than in the placebo group. The findings of this study offer an indication for ibuprofen as a bone-safe analgesic treatment after Colles' fracture and may be translated into other fields of cancellous bone fracture treatment. [Orthopedics. 2021;44(2):105-110.].

Geometric semi-automatic analysis of radiographs of Colles' fractures.

Fractures of the wrist are common in Emergency Departments, where some patients are treated with a procedure called Manipulation under Anaesthesia. In some cases, this procedure is unsuccessful and patients need to revisit the hospital where they undergo surgery to treat the fracture. This work describes a geometric semi-automatic image analysis algorithm to analyse and compare the x-rays of healthy controls and patients with dorsally displaced wrist fractures (Colles' fractures) who were treated with Manipulation under Anaesthesia. A series of 161 posterior-anterior radiographs from healthy controls and patients with Colles' fractures were acquired and analysed. The patients' group was further subdivided according to the outcome of the procedure (successful/unsuccessful) and pre- or post-intervention creating five groups in total (healthy, pre-successful, pre-unsuccessful, post-successful, post-unsuccessful). The semi-automatic analysis consisted of manual location of three landmarks (finger, lunate and radial styloid) and automatic processing to generate 32 geometric and texture measurements, which may be related to conditions such as osteoporosis and swelling of the wrist. Statistical differences were found between patients and controls, as well as between pre- and post-intervention, but not between the procedures. The most distinct measurements were those of texture. Although the study includes a relatively low number of cases and measurements, the statistical differences are encouraging.

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.

[Effect of Buyang Huanwu decoction (, BYHWD) on X-ray evaluation of early callus and level of serum alkaline phosphatase in elderly patients with Colles fracture after manual reduction and splint external fixation].

OBJECTIVE: To explore effects of Buyang Huanwu Decoction (, BYHWD) on early callus X-ray evaluation and level of serum alkaline phosphatase in elderly patients with Colles fracture after manual reduction and splint external fixation. METHODS: From October 2016 to October 2018, 60 elderly patients with Colles fractures were treated with manual reduction and splint external fixation and were divided into experimental group and control group. There were 30 patients in control group, including 15 males and 15 females; aged from 56 to 75 years old with an average of (67.81±5.41) years old; bone mineral density was (0.82±0.24) g/cm 2; patients were performed lift shoulders, bend and extend elbow joint, stretch five fingers and make a fist at 3 days after operation, 3 times daily for 1 month, 30 min once a time. There were 30 patients in experimental group, including 13 males and 17 females; aged from 57 to 77 years old with an average of (66.02±5.16) years old; bone mineral density was (0.76±0.23) g/cm2; patients performed rehabilitation exercise as control group and combined with BYHWD, 400 ml per dose, 2 times daily, 7 days as one course, totally 4 courses. RUSS scores at 14 and 28 days after reduction between two groups were compared, serum level of alkaline phosphatase (ALP) and serum calcium concentration were observed at immediately, 14 and 28 days after reduction. RESULTS: The patients between two groups were successfully fixed without re fractures and complications occurred. The patients were followed up for 30 to 35 days with an average of (31.60±1.03) days. RUSS score in experimental group at 14 and 28 days after reduction were 4.58±0.31 and 7.07±0.36, respectively; while in control group were 3.98±0.30 and 6.15±0.35, respectively; RUSS score in experimental group was significantly higher than that of control group. Serum alkaline phosphatase concentrations in experimental group at immediately, 14 and 28 days after reduction were (90.62±12.19) mmol/L ,(105.40±11.63) mmol/L, and (160.86±35.77) mmol/L respectively; while in controlgroup were (91.27±13.52) mmol/L ,(94.60±11.10) mmol/L ,(144.17±26.27) mmol/L respectively; there was no statistically difference between two groups at immediately; and had statistically differences between two groups at 14 and 28 days after reduction. There was no significant difference in serum calcium concentration between two groups at immediately, 14 and 28 days after reduction. CONCLUSION: BYHWD for elderly patients with Colles fracture could promote early formation of callus, effectively increase concentration of serum alkaline phosphatase and promote fracture healing.

Influence of Ibuprofen on Bone Healing After Colles' Fracture: A Randomized Controlled Clinical Trial.

Non-steroidal anti-inflammatory drugs (NSAIDs) may delay bone healing. [Therefore, it is important to establish whether NSAID preparations delay bone healing and what correlations, if any, exist between different bone studies-DEXA-scanning, bone markers, roentgenology controls, and histological examination of newly formed bone]. The purpose of this prospective controlled study was to investigate whether ibuprofen affects bone mineral density, turnover biomarkers, and histomorphometric characteristics of the callus after a Colles' fracture. This study was a single-center, triple-blinded, randomized clinical trial. Ninety-five patients (80 females) with displaced Colles' fracture, median age 65 (range 40-85) years were included in the study and operated on by external fixation from June 2012 through to June 2015. Eighty-nine patients received interventional medicine and 83 completed the 1-year follow-up. The 7-day ibuprofen group received 600 mg of ibuprofen three times a day (N = 29), the 3-day ibuprofen group received ibuprofen for 3 days (N = 30) and a placebo for the following 4 days, and finally, the placebo group received a placebo for 7 days (N = 30). The primary outcome was the difference in bone mineral density between the ultra-distal region of the injured and non-injured radius at 3 months after surgery. The histomorphometric outcomes included the assessment of callus tissue volume and surface fractions at 6 weeks postoperatively. The biomarkers Osteocalcin and CrossLaps were measured at baseline, 1 week, 2 weeks, 6 weeks, 3 months, and 1 year. We included the results of the dropped-out patients in the intention to treat analysis. There was no difference between treatment groups in bone mineral density, histomorphometric estimations, and changes in bone biomarkers. These findings may offer an indication of ibuprofen as a bone-safe analgesic treatment in an acute fracture-phase. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:545-554, 2020.

Radiographic Measurements as a Predictor of Correction Loss in Conservative Treatment of Colles' Fracture.

Dorsal displaced distal radius fracture (Colles' fracture) is very common and could occur from fragility in middle-aged and elderly people. Many Colles' fractures are still treated conservatively in clinics without hospitalization. Internal fixation using a palmar locking plate has been the standard treatment, but some complications have been reported. The aim of this study was to analyze changes in radiographic parameters over time in patients with conservatively treated Colles' fractures, and to establish whether the type of fracture influenced these changes. Prospective data collected included patient characteristics and radiological findings. The study was conducted at two private clinics and included 60 patients (13 men and 47 women; mean age, 72.5 years old; range, 55 to 96 years old) with a Colles' fracture (types of injury: intramedullary [n = 15], anatomical [n = 39], extramedullary [n = 2], and unknown [n = 4]) who were treated conservatively with manipulation and cast immobilization. Conservative, non-surgical treatment with manipulation was performed first, then, cast immobilization continued for 4 weeks. Loss of correction between the time of reduction and the final observation was defined by the following radiographic measurements: palmar tilt, radial inclination, and ulnar variance. The average final follow up period was 4.6 months (1.5-12 months). Immediately after reduction, 11 intramedullary fractures, 42 anatomical fractures and 7 extramedullary fractures were confirmed. Correction loss according to ulnar variance was significantly greater (P = 0.012) during the final observation for patients with an intramedullary injury at reduction than that for patients with extramedullary and anatomical injuries at reduction. We found that the correction loss for ulnar variance from immediately after reduction until the final observation was significantly greater in the intramedullary group, suggesting that an alternative to conservative treatment may be beneficial for patients with intramedullary fractures.

Bootstrap imputation minimized misclassification bias when measuring Colles' fracture prevalence and its associations using health administrative data.

OBJECTIVES: Misclassification bias can result from the incorrect assignment of disease status using inaccurate diagnostic codes in health administrative data. This study quantified misclassification bias in the study of Colles' fracture. STUDY DESIGN AND SETTING: Colles' fracture status was determined in all patients >50 years old seen in the emergency room at a single teaching hospital between 2006 and 2014 by manually reviewing all forearm radiographs. This data set was linked to population-based data capturing all emergency room visits. Reference disease prevalence and its association with covariates were measured. A multivariate model using covariates derived from administrative data was used to impute Colles' fracture status and measure its prevalence and associations using bootstrapping methods. These values were compared with reference values to measure misclassification bias. This was repeated using diagnostic codes to determine Colles' fracture status. RESULTS: Five hundred eighteen thousand, seven hundred forty-four emergency visits were included with 3,538 (0.7%) having a Colles' fracture. Determining disease status using the diagnostic code (sensitivity 69.4%, positive predictive value 79.9%) resulted in significant underestimate of Colles' fracture prevalence (relative difference -13.3%) and biased associations with covariates. The Colles' fracture model accurately determined disease probability (c-statistic 98.9 [95% confidence interval {CI} 98.7-99.1], calibration slope 1.009 [95% CI 1.004-1.013], Nagelkerke's R2 0.71 [95% CI 0.70-0.72]). Using disease probability estimates from this model, bootstrap imputation (BI) resulted in minimal misclassification bias (relative difference in disease prevalence -0.01%). The statistical significance of the association between Colles' fracture and age was accurate in 32.4% and 70.4% of samples when using the code or BI, respectively. CONCLUSION: Misclassification bias in estimating disease prevalence and its associations can be minimized with BI using accurate disease probability estimates.

Fast estimation of Colles' fracture load of the distal section of the radius by homogenized finite element analysis based on HR-pQCT.

Fractures of the distal section of the radius (Colles' fractures) occur earlier in life than other osteoporotic fractures. Therefore, they can be interpreted as a warning signal for later, more deleterious fractures of vertebral bodies or the femoral neck. In the past decade, the advent of HR-pQCT allowed a detailed architectural analysis of the distal radius and an automated but time-consuming estimation of its strength with linear micro-finite element (µFE) analysis. Recently, a second generation of HR-pQCT scanner (XtremeCT II, SCANCO Medical, Switzerland) with a resolution beyond 61 µm became available for even more refined biomechanical investigations in vivo. This raises the question how biomechanical outcome variables compare between the original (LR) and the new (HR) scanner resolution. Accordingly, the aim of this work was to validate experimentally a patient-specific homogenized finite element (hFE) analysis of the distal section of the human radius for the fast prediction of Colles' fracture load based on the last generation HR-pQCT. Fourteen pairs of fresh frozen forearms (mean age = 77.5±9) were scanned intact using the high (61 µm) and the low (82 µm) resolution protocols that correspond to the new and original HR-pQCT systems. From each forearm, the 20mm most distal section of the radius were dissected out, scanned with µCT at 16.4 µm and tested experimentally under compression up to failure for assessment of stiffness and ultimate load. Linear and nonlinear hFE models together with linear micro finite element (µFE) models were then generated based on the µCT and HR-pQCT reconstructions to predict the aforementioned mechanical properties of 24 sections. Precision errors of the short term reproducibility of the FE analyses were measured based on the repeated scans of 12 sections. The calculated failure loads correlated strongly with those measured in the experiments: accounting for donor as a random factor, the nonlinear hFE provided a marginal coefficient of determination (Rm2) of 0.957 for the high resolution (HR) and 0.948 for the low resolution (LR) protocols, the linear hFE with Rm2 of 0.957 for the HR and 0.947 for the LR protocols. Linear µFE predictions of the ultimate load were similar with an Rm2 of 0.950 for the HR and 0.954 for the LR protocols, respectively. Nonlinear hFE strength computation led to precision errors of 2.2 and 2.3% which were higher than the ones calculated based on the linear hFE (1.6 and 1.9%) and linear µFE (1.2 and 1.6%) for the HR and LR protocols respectively. Computation of the fracture load with nonlinear hFE demanded in average 6h of CPU time which was 3 times faster than with linear µFE, while computation with linear hFE took only a few minutes. This study delivers an extensive experimental and numerical validation for the application of an accurate and fast hFE diagnostic tool to help in identifying individuals who may be at risk of an osteoporotic wrist fracture and to follow up pharmacological and other treatments in such patients.

[Quantitative evaluation of Colles' fracture by Multislice CT multiplanner reconstruction: a feasibility study].

OBJECTIVE: To investigate the feasibility and reliability on the quantitative evaluation of Colles' fracture by multislice CT (MSCT) multiplanner reconstruction (MPR). METHODS: A total of 36 patients with Colles' fracture from July 2011 to July 2014 were investigated in this study. There were 11 males and 25 females with a mean age of (42.5 ± 5.4) years old (ranged 35 to 72 years). All the patients underwent anteroposterior and lateral X-ray films and MSCT scans on wrist joints within 2 days after trauma. Images were sent to the workstation through picture archiving and conserving system (PACS). One associate chief physician independently and respectively measured the dorsal intercalation depth of distal fracture block, palmar angle and dislocation degree of wrist articular surface collapse on anteroposterior and lateral X-ray film and MSCT-MPR. The time interval between the two measurements was 2 weeks. All the data between the first and second measurement on X-ray and MPR and the mean value between the X-ray and MPR was examined with paired t-test. The pearson analyzed their correlation. RESULTS: Among the 35 cases, 35 cases of palmar angle, 21 cases of intercalation depth and 16 cases of dislocation of wrist articular surface collapse could be measured on both X-ray and MPR. For the above parameters, the first measurement results were (12.5 ± 3.6)°, (4.5 ± 2.1) mm, (3.7 ± 1.6) mm and the second measurement results were (4.8 ± 2.2)°, (6.4 ± 3.6) mm, (2.5 ± 1.2) mm on X-ray films respectively. The first measurement results on MPR were (14.5 ± 5.3)°, (4.2 ± 1.2) mm, (5.7 ± 2.3) mm, and the results were (13.2 ± 2.6)°, (4.7 ± 2.2) mm, (4.6 ± 2.1) mm for the second measurement respectively. The three parameters between the first and second measurement on plain film had statistical difference and low correlation (r = 0.681, 0.640, 0.345, P < 0.05). The data between the first and second measurement on MPR showed that the dislocation degree of wrist articular surface collapse had statistical difference (P < 0.05) and no statistical significance was found for the other two parameters (P > 0.05), with the moderate correlation (r = 0.954, 0.854, 0.642). The three parameters had low or moderate correlation with each other on X-ray (r = 0.454, 0.532, 0.378, P < 0.05), compared with the mean value on MPR. CONCLUSION: Using MSCT MPR images may carry on the multiple parameter measurement of Colles fracture, to make quantitative evaluation, and repeated measurement is better reliability.

The Effects of Dorsal Cortical Comminution on Radiographic Results following Percutaneous Pinning for Extra-Articular Colles' Fracture.

A number of studies have demonstrated that dorsal cortical comminution (DCC) can predict redisplacement after nonoperative treatment of Colles' fractures; however, the effects of a DCC defect on radiographic outcomes following percutaneous pinning for dorsally displaced extraarticular Colles' fractures are unclear. We, therefore, performed a retrospective study on 85 patients who sustained such fractures treated with percutaneous pinning within 2006-2009. The main outcome measures included four radiographic parameters, including radial height, radial inclination, radial tilt, and ulnar variance. The radiological results showed that all fractures after percutaneous pinning followed the same time series changes and patterns of fracture collapse regardless of the presence of a DCC defect. The use of the pinning construct is to provide support for static loading but not for dynamic loading. Although the final radiographic outcomes were classified as acceptable in fractures with and without DCC, we recommend that a different approach in the management of displaced Colles' fractures might be necessary in consideration of increasing patient expectations of health care.

Stainless steel versus titanium volar multi-axial locking plates for fixation of distal radius fractures: a randomised clinical trial.

BACKGROUND: Distal radius fractures are among the most common fractures seen in the hospital emergency department. Of these, over 40% are considered unstable and require some form of fixation. In recent years with the advent of low profile plating, open reduction and internal fixation (ORIF) using volar plates has become the surgical treatment of choice in many hospitals. However, it is currently unknown which plating system has the lowest complication rate and/or superior clinical and radiological outcomes following surgery. Few studies have compared different types of plates, which may have various features, different plate and screw designs or may be manufactured from different materials (for example, stainless steel or titanium). This study will specifically investigate and compare the clinical and radiological outcomes and complication rates of two commonly used volar plating systems for fixation of distal radius fractures: one made from stainless steel (Trimed™ Volar Plate, Trimed™, California, USA) and the other made from titanium (Medartis® Aptus Volar Plate, Medartis®, Basel, Switzerland). The primary aim of this study is to determine if there is a difference on the Patient Reported Wrist Evaluation six months following ORIF using a volar plate for adult patients with a distal radius fracture. METHODS/DESIGN: This study will implement a randomized prospective clinical trial study design evaluating the outcomes of two different types of volar plates: one plate manufactured from stainless steel (Trimed™ Volar Plate) and one plate manufactured from titanium (Medartis® Aptus Volar Plate). The surgery will be performed at a major trauma hospital in Brisbane, Australia. Outcome measures including function, adverse events, range of movement, strength, disability, radiological findings and health-related quality of life will be collected at 6 weeks, 3, 6, 12 and 24 months following surgery. A parallel economic analysis will also be performed. This randomized clinical trial is due to deliver results in December 2016. DISCUSSION: Results from this trial will contribute to the evidence on operative management of distal radius fractures and plate material type. TRIAL REGISTRATION: ACTRN12612000969864.

A case report of a giant forearm lipoma causing anterior interosseous nerve palsy after fracture of the distal radius.

To the best of our knowledge, there are no previous reports on anterior interosseous nerve palsy (AINP) caused by a soft tissue tumor after fracture of the distal radius. We treated a case of giant forearm lipoma that caused AINP one day after internal fixation of a distal radius fracture.

Changes in length of the radioulnar ligament and distal oblique bundle after Colles' fracture.

The purpose of this study was to investigate changes in length of the radioulnar ligament and distal oblique bundle (DOB) within the distal interosseous membrane after Colles' fracture and correlate the magnitude of the changes in length with clinical features. This study investigated 10 patients with malunion of a Colles' fracture. In three-dimensional computed tomography, the paths of the four limbs of the radioulnar ligament (superficial and deep, dorsal, and palmar limbs) and DOB were modelled and each path length was computed. Differences in length between the affected and contralateral unaffected side were calculated and correlated with the radiographic parameters of deformity on plain X-ray, subluxation of the DRUJ on CT, and limited range of forearm rotation in the clinical examination. In the malunited radius, the superficial and deep dorsal limbs of the radioulnar ligament were significantly elongated and DOB was significantly shortened compared with the contralateral side. These length changes correlated with radiographic radial shortening, subluxation of the DRUJ, and inversely correlated with limited range of forearm pronation. This study suggests that the dorsal radioulnar ligament would be overstretched and disrupted in Colles' fracture with severely increased radial shortening, producing laxity of the distal radioulnar joint that could negate limitation of pronation.

Reliability and reproducibility of classifications for distal radius fractures.

OBJECTIVE: The aim of this study was to evaluate the interobserver reliability and intraobserver reproducibility of the Universal, AO, Fernandez and Frykman classifications for distal radius fractures. METHODS: Fifty standard sets of posteroanterior and lateral roentgenograms of displaced distal radius fractures were classified two times by two groups of evaluators at 2-month intervals. The first group consisted of 10 orthopedic surgeons with a minimum of 5 years of experience. The second group consisted of 10 orthopedic residents in their first two years of practice. Interobserver reliability and intraobserver reproducibility were assessed using Cohen's kappa test. RESULTS: None of the classifications achieved good- very good reliability levels. The Fernandez classification had a moderate and the others had a fair interobserver agreement kappa coefficient. All classifications had fair kappa intraobserver agreement although the Frykman and Fernandez classifications had better results. CONCLUSION: None of the classification systems were superior in terms of reliability and reproducibility. The reliability and reproducibility rates of all four classifications were insufficient.

Treatment of distal radius fractures.

BACKGROUND: In light of the Norwegian Orthopaedic Association's wish to prepare guidelines for treatment of distal radius fractures, we have reviewed the knowledge base for the provision of such treatment. METHOD: The paper is based on systematic reviews of treatment of distal radius fractures from literature search in the following databases: the Cochrane Library, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE Cochrane), the Health Technology Assessment (HTA) database, PreMedline, Medline and Embase. RESULTS: There is evidence for recommending percutaneous pinning of unstable, dorsally displaced distal radius fractures rather than conservative treatment, but which pinning method is best remains uncertain. There is also documentation to support the use of external fixation rather than conservative treatment. There is insufficient documentation available to draw conclusions regarding the relative efficacy of the various methods of external fixation, but external fixation in combination with adjuvant pinning of the fracture fragment enhances the result compared to external fixation alone. The evidence indicates that plates may enhance functional short-term results for unstable distal radius fractures compared to external fixation. INTERPRETATION: There is evidence in support of differentiated treatment of distal radius fractures. However, many questions remain unanswered, and good prospective, randomised multi-centre trials are needed.

[Intra-articular distal radial fracture with lunate fossa rotated, about 4 cases: interest of surgical procedure by volar medial approach]. / Fracture articulaire du radius distal avec fragment de fossette lunarienne retourné, à propos de 4 cas : intérêt du traitement chirurgical par voie antéro-médiale.

INTRODUCTION: Intra-articular distal radial fractures in young subjects occur in severe trauma. Articular reduction needs to be anatomical. We report four cases with the particularity of having a 90° or 180° rotated lunate fossa. Our goal is to bring out the positive aspects of surgical procedure by volar medial approach and to assess long-term functionnal and radiological results. MATERIAL AND METHODS: Our study focused on four men whose average age was 27 (age range from 19 to 43). The fractures were type IV according to Melone's classification. The associated lesions included: one fracture of the base of the ulnar styloid, one fracture of the distal quarter of the ulnar diaphysis and one scapho-lunate diastasis. We used a volar medial approach between the flexors tendons and the ulnar bundle in order to pin the fragment of lunate fossa. The rest of the radial epiphysis was pinned after a 5mm skin incision. In two cases, this pinning was complemented with a brachial-antebrachial-palmar cast and in the other two cases with an external fixator. RESULTS: The follow-up period averaged 68.8 (18 to 115) months, all the patients were clinically examined through antero-posterior, lateral and dynamic X-rays. The objective results assessed according to Green and O'Brien's criteria, later modified by Cooney, were as follows: two very good, one good, one average. The X-rays showed consolidated fractures. According to Knirk and Jupiter's classification of arthritis, we had three grades 0, one of which showed a subchondral sclerosis of the lunate fossa, and one grade 3. DISCUSSION AND CONCLUSION: Imaging with simple radiographs is not sufficient and needs to be complemented with CT scan. Our approach allows for direct access to the fragment of the lunate fossa and easier visualization of the distal radioulnar, compared to Henry's approach, thereby avoiding excessive traction of the median nerve. TYPE D'ÉTUDE: Niveau IV.