Does circumferential casting prevent fracture redisplacement in reduced distal radius fractures? A retrospective multicentre study.

BACKGROUND: This study evaluates whether a circumferential cast compared to a plaster splint leads to less fracture redisplacement in reduced extra-articular distal radius fractures (DRFs). METHODS: This retrospective multicentre study was performed in four hospitals (two teaching hospitals and two academic hospitals). Adult patients with a displaced extra-articular DRF, treated with closed reduction, were included. Patients were included from a 5-year period (January 2012-January 2017). According to the hospital protocol, fractures were immobilized with a below elbow circumferential cast (CC) or a plaster splint (PS). The primary outcome concerned the difference in the occurrence of fracture redisplacement at one-week follow-up. RESULTS: A total of 500 patients were included in this study (PS n = 184, CC n = 316). At one-week follow-up, fracture redisplacement occurred in 52 patients (17%) treated with a CC compared to 53 patients (29%) treated with a PS. This difference was statistically significant (p = 0.001). CONCLUSION: This study suggests that treatment of reduced DRFs with a circumferential cast might cause less fracture redisplacement at 1-week follow-up compared to treatment with a plaster splint. Level of Evidence Level III, Retrospective study.

Long-term follow-up of distal radius fractures, an evaluation of the current guideline: the relation between malunion, osteoarthritis and functional outcome.

BACKGROUND: Last decades there is an increased tendency of performing surgery on displaced distal radius fractures. However, it is unclear whether this affects the development of osteoarthritis. This study aims to determine the relation between anatomical position, radiological osteoarthritis and functional outcome of the elderly wrist, 10-15 years after a distal radius fracture. PATIENTS AND METHODS: 173 patients between the age of 50 and 70 at time of trauma were included in this retrospective cohort study with a 10-15-year follow-up. Based on the reassessed initial X-rays, the patients were placed into 4 groups (1: anatomical, 2a: acceptable, 2b: current operative indication but treated conservative, 2c: operative indication and operated). Functional outcome was measured, questionnaires were answered, and new bilateral X-rays of the wrist were obtained. Factors influencing osteoarthritis, the difference in osteoarthritis between the groups and the difference between the fractured and non-fractured wrists were studied. RESULTS: Group 2b showed a significantly higher degree of osteoarthritis in comparison with the contralateral wrist. In the other groups, this difference was not observed. We found no significant difference in OA and functional outcomes between the groups. The degree of osteoarthritis of the non-fractured wrist appeared to be highly associated with osteoarthritis of the fractured wrist. CONCLUSION: The results of this study showed that the degree of radiocarpal osteoarthritis is higher in conservatively treated patients that should have been operated on according to current guidelines in comparison with patients without an indication for surgery. This might suggest that our current guidelines can be effective in prevention of posttraumatic osteoarthritis. However, the effect on the functional outcome is very limited. Since the degree of radiocarpal osteoarthritis of the non-fractured wrist appeared to be highly associated with the degree of osteoarthritis of the fractured wrist, future studies should always assess osteoarthritis of both wrists in order to study the real posttraumatic effect of a fracture.

Factors determining outcome of corrective osteotomy for malunited paediatric forearm fractures: a systematic review and meta-analysis.

The aim of this study was to identify predictors of a superior functional outcome after corrective osteotomy for paediatric malunited radius and both-bone forearm fractures. We performed a systematic review and meta-analysis of individual participant data, searching databases up to 1 October 2016. Our primary outcome was the gain in pronosupination seen after corrective osteotomy. Individual participant data of 11 cohort studies were included, concerning 71 participants with a median age of 11 years at trauma. Corrective osteotomy was performed after a median of 12 months after trauma, leading to a mean gain of 77° in pronosupination after a median follow-up of 29 months. Analysis of variance and multiple regression analysis revealed that predictors of superior functional outcome after corrective osteotomy are: an interval between trauma and corrective osteotomy of less than 1 year, an angular deformity of greater than 20° and the use of three-dimensional computer-assisted techniques. LEVEL OF EVIDENCE: II.

Avulsion fracture of the supinator crest as an indication for a sustained posterolateral (sub)luxation of the elbow. A case report, anatomical evaluation and review of the literature.

The treatment of elbow injuries can be challenging because of the complexity of both anatomy and pathology. We present a rare traumatic avulsion fracture of the supinator crest of the ulna in a 37-year-old patient. Conservative treatment in a long arm cast for four weeks led to satisfactory results. Reproduction of the fracture on a cadaveric elbow clarified that the avulsed fragment holds the insertion of the lateral ulnar collateral ligament (LUCL). The mechanism of trauma that causes this fracture is a posterolateral (sub) luxation of the elbow, which usually causes the LUCL to rupture, but in rare cases the insertion of this ligament can be avulsed. A posterolateral (sub) luxation of the elbow can lead to chronic posterolateral rotational instability and therefore the stability of the elbow should be taken into account in the treatment of patients with such a fracture. A review of the literature concluded that this fracture often is associated with other injuries to the elbow and that it is easily missed on conventional AP and lateral radiographs. CT or MRI imaging and a radial head-capitellum view radiograph can be beneficial. Both conservative and operative treatments have been described with good clinical results.

[A man with remarkable clavicles]. / Een man met opvallende claviculae.

A 26-year-old male complained of painful clavicles. His medical history included multiple fractures of both clavicles, all treated conservatively. Conventional radiographs revealed a typical shape of both clavicles, suggesting non-union. His extraordinary medical history and non-union of both clavicles led to the diagnosis: 'congenital pseudarthrosis of both clavicles'.

Risk factors for the displacement of fractures of both bones of the forearm in children.

Forearm fractures in children have a tendency to displace in a cast leading to malunion with reduced functional and cosmetic results. In order to identify risk factors for displacement, a total of 247 conservatively treated fractures of the forearm in 246 children with a mean age of 7.3 years (sd 3.2; 0.9 to 14.9) were included in a prospective multicentre study. Multivariate logistic regression analyses were performed to assess risk factors for displacement of reduced or non-reduced fractures in the cast. Displacement occurred in 73 patients (29.6%), of which 65 (89.0%) were in above-elbow casts. The mean time between the injury and displacement was 22.7 days (0 to 59). The independent factors found to significantly increase the risk of displacement were a fracture of the non-dominant arm (p = 0.024), a complete fracture (p = 0.040), a fracture with translation of the ulna on lateral radiographs (p = 0.014) and shortening of the fracture (p = 0.019). Fractures of both forearm bones in children have a strong tendency to displace even in an above-elbow cast. Severe fractures of the non-dominant arm are at highest risk for displacement. Radiographs at set times during treatment might identify early displacement, which should be treated before malunion occurs, especially in older children with less potential for remodelling.

Supracondylar fractures of the humerus in children. Comparison of results in two treatment periods.

Displaced supracondylar fractures of the humerus in children may be managed with or without Kirschner-wire fixation. The results of treatment of displaced supracondylar fractures of the humerus in children were analyzed, comparing the period before and after an audit of our results in 1997. From 1998 onward a more active policy regarding the use of percutaneous Kirschner-wire fixation was adopted. We treated 33 children between 1991 and 1997 (Period 1) and 49 children between 1998 and 2004 (Period 2). In Period 1, closed reduction and plaster immobilisation was performed in 29 patients. Four received initial Kirschner-wire fixation with plaster immobilisation. Secondary dislocation necessitating re-reduction occurred in 14 patients. In Period 2 initial Kirschner-wire fixation was performed in 41 patients, of whom 23 had open reduction. The other eight had conservative treatment consisting of closed reduction and plaster immobilization, two of them needing re-reduction. This evaluation indicates that a more active policy with regard to (open) reduction with Kirschner-wire fixation in displaced supracondylar humeral fractures in children, results in less need for secondary intervention with comparable functional and cosmetic outcome.