Torus fractures - diagnosis and management.

Torus fractures are a common paediatric injury involving the distal radius. Patients typically present following a fall onto the outstretched hand, with wrist pain as their primary complaint. The principal investigation of choice is a plain radiograph of the wrist joint. These fractures should be managed with a soft-bandage and immediate discharge approach and do not require specialist follow-up. Clinicians have historically had differing views regarding optimal management of torus fractures. It is therefore important for hospital clinicians to uniformly understand the most up-to-date management of this condition. This review provides an overview of the epidemiology, anatomy, diagnosis and management, with an aim to improve outcomes.

The association of ICUC trauma score and quick DASH in a distal radius fracture cohort.

BACKGROUND: This study evaluates the association between ICUC trauma and short-form Disabilities of the Arm, Shoulder, and Hand Questionnaire (Quick DASH) scores among patients who underwent surgery for distal radius fractures. METHODS: This research gathered patient-reported outcomes (PROs) from patients registered in the ICUC database at a single trauma center. The study involved 76 adult patients who underwent surgical treatment for distal radius fractures before 2023. These patients received a volar locking plate for their distal radius fracture. The research utilized two different PROs to evaluate the patients' conditions. The ICUC trauma score measures functional impairment and pain through two 5-point scale questions, allowing patients to self-assess these aspects. The Quick DASH, comprising 11 questions, was used to evaluate symptoms and functionality of the upper extremity. RESULTS: For patients aged 55.9 ± 15.3 years and 4.6 ± 3.9 years post-op follow-up, the ICUC trauma score was 0.70 ± 0.95, and Quick DASH was 6.07 ± 10.35. A strong correlation between ICUC and Quick DASH was identified (r = 0.71, P < 0.01). The interaction between the ICUC trauma score and age at the surgery to Quick DASH revealed a significant unstandardized partial regression coefficient of 0.19 (95% confidence interval 0.08-0.31; P < 0.01). CONCLUSION: This study demonstrated a strong correlation between the ICUC trauma score and the Quick DASH among patients, especially the elderly. It was noted that an elevation in the ICUC trauma score is linked to a more marked increase in the Quick DASH score, particularly in older patients. Given its simplicity and efficacy, the ICUC trauma score may be a viable alternative to the Quick DASH for assessing the patient's clinical outcomes.

Adjuvant Arthroscopy Does Not Improve the Functional Outcome of Volar Locking Plate for Distal Radius Fractures: A Randomized Clinical Trial.

PURPOSE: To evaluate the outcomes of adding arthroscopy to osteosynthesis of distal radius fractures (DRF) with volar locking plate (VLP), by Patient-Rated Wrist Evaluation (PRWE) 1 year after surgery. METHODS: In total, 186 functionally independent adult patients who met the inclusion criteria (DRF and a clinical decision for surgery with a VLP) were randomized to arthroscopic assistance or not. Primary outcome was PRWE questionnaire results 1 year after surgery. For the main variable, PRWE, we obtained the minimal clinically important difference based on a distribution-based method. Secondary outcomes included Disabilities of the Arm, Shoulder and Hand and 12-Item Short Form Health Survey questionnaires, range of motion, strength, radiographic measures, and presence of joint step-offs by computed tomography. Data were collected preoperatively and at +1 and +4 weeks, +3 and +6 months, and +1 year after surgery. Complications were recorded throughout the study. RESULTS: In total, 180 patients (mean age: 59.0 ± 14.9 years; 76% women) were analyzed by modified intention to treat. A total of 82% of the fractures were intra-articular (AO type C). No significant difference between arthroscopic (AG) and control (CG) groups in median PRWE was found at +1 year (median AG: 5.0, median CG: 7.5, difference in medians 2.5; 95% confidence interval [CI] -2.0, 7.0, P = .328). The proportion of patients who exceeded the minimal clinically important difference of 12.81 points in the AG and CG was 86.4% vs 85.1%, P = .819, respectively. Percentage of associated injuries and step-offs reduction maneuvers was greater with arthroscopy (mean differences: 17.1 95% CI -0.1, 26.1, P < .001) and 17.4 (95% CI 5.0, 29.7, P = .007). The difference in percentage of residual joint step-offs at the postsurgical computed tomography in radioulnar, radioscaphoid, and radiolunate joints was not significant (P = .990, P = .538, and P = .063). Complications were similar between groups (16.9% vs 20.9%, P = .842). CONCLUSIONS: Adjuvant arthroscopy did not significantly improve PRWE score +1 year after surgery for DRF with VLP, although the statistical power of the study is below the initially estimated to detect the expected difference. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

[Distal radius fracture-tactic and approach]. / Distale Radiusfrakturen ­ Taktik und Zugangswahl.

OBJECTIVE: The aim of surgical treatment is fracture healing with restored alignment, rotation, and joint surface. Stable fixation allows for functional postoperative aftercare. INDICATIONS: Displaced intra- and extra-articular fractures which either could not be adequately reduced or in which a secondary displacement is to expected due to instability criteria. The following factors are considered instability criteria: age > 60 years, female, initial dorsal displacement > 20°, dorsal comminution, radial shortening > 5 mm, palmar displacement. CONTRAINDICATIONS: The only absolute contraindication is if the patient is deemed unfit for surgery due to concerns regarding anesthesia. Old age is a relative contraindication, as it is currently debated whether older patients benefit from the operation. SURGICAL TECHNIQUE: The surgical technique is guided by the fracture pattern. Palmar plating is most commonly performed. If the joint surface needs to be visualized, a dorsal approach (in combination with another approach or alone) or arthroscopically assisted fixation should be chosen. POSTOPERATIVE MANAGEMENT: In general, a functional postoperative regime can be carried out after plate fixation with mobilization without weightbearing. Short-term splinting can provide pain relief. Concomitant ligamentous injuries and fixations, which are not stable enough for functional aftercare (such as k­wires) require a longer period of immobilization. RESULTS: Provided the fracture is reduced correctly, osteosynthesis improves functional outcome. The complication rate ranges between 9 and 15% with the most common complication being tendon irritation/rupture and plate removal. Whether surgical treatment holds the same benefits for patients > 65 years as for younger patients is currently under debate.

Recognizing and Treating Unique Distal Radius Fracture Patterns that are Prone to Displacement.

An unstable distal radius fracture is one that is not capable of resisting displacement after initial closed reduction. The challenge in managing distal radius fractures is identifying which fractures are prone to displacement. Currently, there are no standard criteria for assessing the stability of distal radius fractures. The fracture pattern and patient characteristics should be taken into consideration when treating distal radius fractures. This article discusses how to recognize and manage distal radius fractures that are prone to displacement.

[Terrible triad injuries]. / Terrible-Triad-Verletzungen.

The complex injury pattern of a posterior elbow dislocation with concomitant radial head and coronoid fractures is usually referred to as a terrible triad injury. Due to the concomitant compromise of several osteoligamentous structures of the elbow joint relevant for stability, these injuries pose a particularly major challenge to the treating trauma surgeons. For this reason, a careful preoperative analysis of all relevant injury components is mandatory in order to make an adequate treatment decision. In most cases, surgical treatment addressing all elements relevant for stability is necessary to achieve a stable and congruent elbow joint. Only this enables early functional follow-up treatment and minimizes the complication rate. Delayed or even insufficient treatment with persistent (sub)dislocation must be avoided at all costs, otherwise there is a high risk of serious posttraumatic functional disorders of the elbow with rapid progression of osteoarthritis.

Comparison of Epidemiological Data of Complex Regional Pain Syndrome (CRPS) Patients in Relation to Disease Severity-A Retrospective Single-Center Study.

A retrospective data analysis of 159 complex regional pain syndrome (CRPS) patients (n = 116 women, 73.0%, mean age 60.9 ± 14.4 years; n = 43 men, 27.0%, mean age 52.3 ± 16.7 years) was performed from 2009 to 2020. The right side was affected in 74 patients (46.5%), the left in 84 patients (52.8%), and 1 patient (0.7%) developed a bilateral CRPS. Data were analyzed for the frequency and distribution of symptoms. The number of reduction maneuvers and the number of Budapest criteria were compared in relation to the severity of CRPS. Hand and wrist (n = 107, 67.3%), followed by foot and ankle (n = 36, 22.6%) and other locations (n = 16, 10.1%) were mainly affected by CRPS. The main causes included direct trauma (n = 120, 75.5%), surgery without previous trauma (n = 25, 15.7%), other causes (n = 9, 5.7%), and spontaneous development (n = 3, 1.9%); there was also missing documentation (n = 2, 1.3%). The most common symptoms were difference in temperature (n = 156, 98.1%), limitation of movement (n = 149, 93.7%), and swelling (n = 146, 91.8%). There was no correlation between the number of reduction maneuvers and the number of Budapest criteria. In summary, patients with the following constellation are at increased risk of CRPS: a female, over 60 years old, who has fallen and has sustained a fracture in the hand or wrist with persistent pain and has been immobilized with a cast for approx. 4 weeks.

Self-Efficacy for Managing Injury After Distal Radius Fracture: A Mixed Methods Exploration.

Self-efficacy for managing injury may contribute to variation in clients' support needs after distal radius fracture (DRF). This study aimed to (a) explore associations between self-efficacy for managing injury and self-reported health and (b) compare qualitative descriptions of the self-management process and outcome between high and low self-efficacy groups. In this cross-sectional convergent mixed methods study, 31 adults aged 45 to 72 with a unilateral DRF completed patient-reported outcome measures and a semi-structured interview 2 to 4 weeks after discontinuing full-time wrist immobilization. Higher self-efficacy was moderately associated with better physical, mental, and social health. The High-Self-Efficacy group described self-directed behaviors to manage injury sequelae and more confidence in their ability to use their injured hand. They also described less disruptive physical and emotional symptoms and fewer participation restrictions compared with the Low-Self-Efficacy group. Findings suggest that occupational therapy practitioners should assess and address self-efficacy for managing DRF sequelae to support recovery.

Determinants of Complex Regional Pain Syndrome Type I among Radial Head Fracture Patients with Unilateral Arthroplasty.

OBJECTIVE: This study aims to assess the proportions of complex regional pain syndrome type I (CRPS I) in radial head fracture patients undergoing unilateral arthroplasty and to explore associated factors. METHODS: This is a prospective observational study. From March 2016 to May 2019, a total of 221 adult patients with radial head fracture patients were included in consecutive studies and completed the 1-year follow-up. All patients were treated by unilateral arthroplasty. At each follow-up visit, the visual analogue scale was used to measure patients' pain level. Occurrence of CRPS I, which was diagnosed by Budapest criteria, was the main outcome collected at baseline and the 1-, 3-, 6-, and 9-month follow-ups. The baseline data were collected before surgery and included demographic and clinical data. Independent t-tests and χ2 tests were used as univariate analyses to compare the baseline data of patients with and without CRPS I. Multivariate analysis (Backword-Wald) was used to identify factors independently associated with CRPS I. RESULTS: The proportion of CRPS I cases among radial head fracture patients undergoing unilateral arthroplasty was 11% (n = 24). A total of 19 (79%) patients were diagnosed with CRPS I within 1 month after surgery. Multivariable logistic regression analysis revealed that female gender (odds ratios [OR]: 1.537; 95% confidence interval [CI]: 1.138-2.072), age younger than 60 years (OR: 1.682; 95% CI: 1.246-2.267), moderate and severe Mayo Elbow Performance Score (MEPS) pain (OR: 3.229; 95% CI: 2.392-4.351) and anxiety (OR: 83.346; 95% CI: 61.752-112.320) were independently associated with CRPS I. CONCLUSIONS: This exploratory study reported that the incidence of CRPS I developing after radial head arthroplasty was 11%. Female sex, younger age, moderate and severe MEPS pain and anxiety patients seems more likely to develop CRPS I.

Forearm Fractures: Diagnosis and Contemporary Treatment Strategies.

Diaphyseal forearm fractures represent a spectrum of injury patterns that include isolated radial shaft fractures, isolated ulnar shaft fractures, both-bone forearm fractures, Galeazzi fracture-dislocations, and Monteggia fracture-dislocations. Although less common than distal radius fractures, diaphyseal forearm fractures are still a frequently encountered clinical entity seen by orthopaedic surgeons, both as isolated injuries and in the patient with polytrauma. It is important to review the epidemiology of diaphyseal forearm fractures and the classification systems used to describe them, as well as to discuss the principles of the initial evaluation and management of these fractures. It is important to know the indications for nonsurgical and surgical management, along with the goals of surgical management, options for internal fixation, and surgical approaches to the forearm.

Forecasting effects of "fast-tracks" for surgery in the Swedish national guidelines for distal radius fractures.

BACKGROUND AND PURPOSE: National guidelines for treatment of distal radius fractures (DRFs) were presented in Sweden in 2021. In the guidelines, a fast-track is recommended for 4 subgroups of highly unstable DRFs. Regardless of the results of the closed reduction these are recommended for surgery within 1 week of injury. This study aims to evaluate the potential consequences of the newly presented national guidelines on incidence of surgical interventions. PATIENTS AND METHODS: In all, 1,609 patients (1,635 DRFs) with primary radiographs after a DRF between 2014 and 2017 at two Swedish hospitals were included in a retrospective cohort study. An estimation was made of the percentage of patients in the historical pre-guidelines cohort, that would have been recommended early primary surgery according to the new national guidelines compared to treatment implemented without the support of these guidelines. RESULTS: On a strict radiological basis, 32% (516 out of 1635) of DRFs were classified into one of the 4 defined subgroups. At 9-13 days follow-up, cast treatment was converted into delayed primary surgery in 201 cases. Out of these, 56% (112 out of 201) fulfilled the fast-track criteria and would with the new guidelines have been subject to early primary surgery. INTERPRETATION: The fast-track regimen in the new guidelines, has a high likelihood of identifying the unstable fractures benefitting from early primary surgery. If the proposed Swedish national guidelines for DRF treatment are implemented, a greater proportion of fractures would be treated with early primary surgery, and a delayed surgery avoided in the majority of cases. The potential benefits in relation to possible costs when using the fast-track criteria in every day practice are still unknown.

Distal radius fractures in the superelderly: an observational study of 8486 cases from the Swedish fracture register.

BACKGROUND: The distal radius fracture (DRF) is the most common fracture in adults. With an ageing population, the number of wrist fractures in the superelderly (≥ 80 years) is expected to rise. Optimal treatment for displaced DRFs remains controversial, especially in the superelderly group. In addition, basic knowledge of the outcome after a DRF in this heterogenic group is lacking. The aim of this study was to study injury characteristics, treatment and outcome of DRFs in superelderly patients using data from a large national register. METHODS: We used prospectively collected data from the Swedish Fracture Register. All distal radius fractures registered between April 2012 and December 2018 in patients ≥ 80 years of age were included. Data on epidemiology, fracture type, trauma mechanism and treatment are registered by the physician treating the patient. Patients are also sent a subjective outcome questionnaire including EQ-5D, EQ-VAS and Short Musculoskeletal Function Assessment questionnaire (SMFA-score) at the time of injury and after 12 months. The 12-month questionnaire was sent to those who had completed the questionnaire at the time of injury. A Mann-Whitney U-test was used to assess differences between treatment methods. RESULTS: Mean age for this population was 86 years (80-105 years), a majority of the patients were female (86.7%). The dominating injury mechanism was a simple fall (74.6%) in the patient's residence. The majority of fractures were AO type A (70%) followed by AO type C (20.9%) and type B (8.6%). The incidence of open fractures was significantly higher in females (2.6%) compared to males (1.5%). A majority of the fractures were treated with a cast (87.5%) with volar locking plate as the second most common treatment method (6.6%). Patient-reported outcome measures (PROMs) EQ-5D, EQ-VAS and the Arm Hand Function Index of the SMFA-score deteriorated somewhat one year after injury compared to pre-injury. PROMs did not correlate to treatment with cast or a volar plate. CONCLUSIONS: This nationwide register study provides detailed data on DRFs in the superelderly regarding epidemiology, treatment and self-reported outcome. A good self-reported outcome is possible, but many patients do not recover completely. PROMs did not correlate to type of treatment. The frequency of open fractures was significantly higher in females. The reason for this is unclear but different skin thickness in older males versus females may be one explanation.

Estudio epidemiológico de las fracturas de la extremidad distal de radio en el área sanitaria de Vigo / Epidemiological study of distal radius fractures in the sanitary area of Vigo

Introducción: Las fracturas de la extremidad distal de radio (FEDR) representan una carga cada vez mayor para los recursos sanitarios debido a los cambios demográficos de la población y a las estrategias de gestión, por lo que la comprensión precisa de su epidemiología es esencial. Presentamos un estudio epidemiológico de FEDR y lo comparamos con otras áreas de la península y Europa. Método: Se recogieron todas las FEDR de nuestra área sanitaria registradas en 2017 y 2018 en pacientes mayores de 18años de forma retrospectiva y observacional agrupándolos según la clasificación de AO-OTA. Se analizaron las variables de edad, sexo, época del año, mecanismo de fractura, presencia de lesiones asociadas y tratamiento realizado. Resultados: Registramos 1.121 FEDR en 1.108 pacientes, 903 mujeres (81,5%) y 205 varones (18,5%). En 612 casos se vio afectado el lado izquierdo (54,6%) y en 509 el lado derecho (45,4%). La edad media de la muestra fue de 65,9años (IC95%: 65-66,9años). La tasa de incidencia de FEDR fue de 158,5 fracturas por 100.000 habitantes/año. El 49,2% se clasificaron como tipo A de AO-OTA y se intervinieron quirúrgicamente un 19%. Conclusión: La incidencia de FEDR alcanza un máximo en la sexta década tanto en hombres como en mujeres. Las fracturas de tipo A de la clasificación AO-OTA son las más frecuentes. La mayoría se trataron de forma conservadora. El patrón de paciente tratado quirúrgicamente con más frecuencia es el de una mujer mayor de 50años con FEDR articular compleja.(AU)

Introduction: Distal radius fractures (DRF) are being a bigger burden for health resources as changes continue to happen in our population demography and in management strategies, so a precise epidemiologic comprehension is mandatory. We present a DRF epidemiology study and we compared it with other sanitary areas of the Iberian Peninsula and Europe. Method: Every DRF in our sanitary area registered between 2017 and 2018 in patients older than 18 years old were observational and retrospectively recorded and classified using AO-OTA classification. Age, sex, season of the year, mechanism of injury, presence of associated injuries and type of treatment were analysed. Results: 1,121 DRF in 1,108 patients, 903 women (81.5%) and 205 men (18.5%), were registered. Left side was affected in 612 cases (54.6%) and right side in 509 cases (45.4%). The average age of our sample was 65.9 years old (CI95%: 65-67.9 years old). The incidence rate of DRF in our population was 158.5 fractures per 100,000 people-year; 49.2% were classified as type A of AO-OTA classification and 19% were treated surgically. Conclusion: Incidence of DRF had a maximum during males and women sixth decade of age. Type A fractures of AO-OTA classification were the most frequent. Most part of the fractures were treated non-surgically. The usual patient treated surgically was a woman, over 50 years old with a distal radius intraarticular complex fracture.(AU)

Epidemiological study of distal radius fractures in the sanitary area of Vigo / Estudio epidemiológico de las fracturas de la extremidad distal de radio en el área sanitaria de Vigo

Introduction: Distal radius fractures (DRF) are being a bigger burden for health resources as changes continue to happen in our population demography and in management strategies, so a precise epidemiologic comprehension is mandatory. We present a DRF epidemiology study and we compared it with other sanitary areas of the Iberian Peninsula and Europe. Method: Every DRF in our sanitary area registered between 2017 and 2018 in patients older than 18 years old were observational and retrospectively recorded and classified using AO-OTA classification. Age, sex, season of the year, mechanism of injury, presence of associated injuries and type of treatment were analysed. Results: 1,121 DRF in 1,108 patients, 903 women (81.5%) and 205 men (18.5%), were registered. Left side was affected in 612 cases (54.6%) and right side in 509 cases (45.4%). The average age of our sample was 65.9 years old (CI95%: 65-67.9 years old). The incidence rate of DRF in our population was 158.5 fractures per 100,000 people-year; 49.2% were classified as type A of AO-OTA classification and 19% were treated surgically. Conclusion: Incidence of DRF had a maximum during males and women sixth decade of age. Type A fractures of AO-OTA classification were the most frequent. Most part of the fractures were treated non-surgically. The usual patient treated surgically was a woman, over 50 years old with a distal radius intraarticular complex fracture.(AU)

Introducción: Las fracturas de la extremidad distal de radio (FEDR) representan una carga cada vez mayor para los recursos sanitarios debido a los cambios demográficos de la población y a las estrategias de gestión, por lo que la comprensión precisa de su epidemiología es esencial. Presentamos un estudio epidemiológico de FEDR y lo comparamos con otras áreas de la península y Europa. Método: Se recogieron todas las FEDR de nuestra área sanitaria registradas en 2017 y 2018 en pacientes mayores de 18años de forma retrospectiva y observacional agrupándolos según la clasificación de AO-OTA. Se analizaron las variables de edad, sexo, época del año, mecanismo de fractura, presencia de lesiones asociadas y tratamiento realizado. Resultados: Registramos 1.121 FEDR en 1.108 pacientes, 903 mujeres (81,5%) y 205 varones (18,5%). En 612 casos se vio afectado el lado izquierdo (54,6%) y en 509 el lado derecho (45,4%). La edad media de la muestra fue de 65,9años (IC95%: 65-66,9años). La tasa de incidencia de FEDR fue de 158,5 fracturas por 100.000 habitantes/año. El 49,2% se clasificaron como tipo A de AO-OTA y se intervinieron quirúrgicamente un 19%. Conclusión: La incidencia de FEDR alcanza un máximo en la sexta década tanto en hombres como en mujeres. Las fracturas de tipo A de la clasificación AO-OTA son las más frecuentes. La mayoría se trataron de forma conservadora. El patrón de paciente tratado quirúrgicamente con más frecuencia es el de una mujer mayor de 50años con FEDR articular compleja.(AU)

[Intraosseous foreign body or osteoma : Challenging differential diagnosis after open radius fracture]. / Intraossärer Fremdkörper oder Osteom : Anspruchsvolle Differenzialdiagnose nach offener Radiusfraktur.

Presentation of a 16-year-old male patient due to a cycling accident while mountain biking 14 days after primary treatment after open epiphyseal injury. Metaphyseal intraosseous stones within the anatomically reduced distal radius fracture were misinterpreted as an incidental osteoma.

Treatment of Distal Radius Fracture: Does Early Activity Postinjury Lead to a Lower Incidence of Complex Regional Pain Syndrome?

Background: The optimal treatment for a distal radius fracture (DRF) remains an ongoing discussion. This study observed whether early activity postinjury can lead to the prevention of type 1 complex regional pain syndrome (CRPS-1). Method: Patients who underwent nonoperative treatment for a DRF were invited to participate in this study. Patients followed an exercise program with progressive loading exercises at home immediately after cast removal. After a minimum of 3 months, patients were interviewed by telephone to determine the presence of disproportionate pain. If present, the patients were seen during a clinical consultation to determine whether they had CRPS-1, using the Budapest Diagnostic Criteria. Results: Of the 129 patients included in this study, 12 reported disproportionate pain, and none were diagnosed with CRPS-1. The incidence of CRPS-1 was zero in this study. Conclusion: A more active treatment approach seems to lower the incidence of CRPS-1. A larger randomized study is necessary to strengthen the evidence.

Artificial intelligence to diagnosis distal radius fracture using biplane plain X-rays.

BACKGROUND: Although the automatic diagnosis of fractures using artificial intelligence (AI) has recently been reported to be more accurate than those by orthopedics specialists, big data with at least 1000 images or more are required for deep learning of the convolutional neural network (CNN) to improve diagnostic accuracy. The aim of this study was to develop an AI system capable of diagnosing distal radius fractures with high accuracy even when learning with relatively small data by learning to use bi-planar X-rays images. METHODS: VGG16, a learned image recognition model, was used as the CNN. It was modified into a network with two output layers to identify the fractures in plain X-ray images. We augmented 369 plain X-ray anteroposterior images and 360 lateral images of distal radius fractures, as well as 129 anteroposterior images and 125 lateral images of normal wrists to conduct training and diagnostic tests. Similarly, diagnostic tests for fractures of the styloid process of the ulna were conducted using 189 plain X-ray anteroposterior images of fractures and 302 images of the normal styloid process. The distal radius fracture is determined by entering an anteroposterior image of the wrist for testing into the trained AI. If it identifies a fracture, it is diagnosed as the same. However, if the anteroposterior image is determined as normal, the lateral image of the same patient is entered. If a fracture is identified, the final diagnosis is fracture; if the lateral image is identified as normal, the final diagnosis is normal. RESULTS: The diagnostic accuracy of distal radius fractures and fractures of the styloid process of the ulna were 98.0 ± 1.6% and 91.1 ± 2.5%, respectively. The areas under the receiver operating characteristic curve were 0.991 {n = 540; 95% confidence interval (CI), 0.984-0.999} and 0.956 (n = 450; 95% CI 0.938-0.973). CONCLUSIONS: Our method resulted in a good diagnostic rate, even when using a relatively small amount of data.

Management of Geriatric Elbow Injury.

Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.

Role of the interosseous membrane in post-traumatic forearm instability: instructional review.

PURPOSE: In the last two decades, a strong interest on the interosseous membrane (IOM) has developed. METHODS: The authors present a review of the new concepts regarding the understanding of forearm physiology and pathology, with current trends in the surgical management of these rare and debilitating injuries. RESULTS: Anatomical and biomechanical studies have clarified the anatomy of forearm constrains and their role in forearm longitudinal and transverse stability. The radial pull test, a new intraoperative test, has been developed that might increase the detection on IOM injuries. The forearm is now considered a "functional unit" and, consequently, a new classification has been proposed. Uncommon variants and rare patterns of forearm fracture dislocations have been reported in the literature and could not be classified to those commonly referred to using eponyms (Monteggia, Galeazzi, Essex-Lopresti). The new Artiaco et al. classification includes all injury patterns, thus avoids confusion in the nomenclature, and helps surgeon with detection of lesions and guiding surgical treatment. CONCLUSION: Based on the new classification and after current literature review, authors propose a management flowchart for treatment of forearm instability injuries.

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.