The Amsterdam Wrist Rules: how much money can they save?

PURPOSE: To allow physicians to be more selective in their request for a radiograph of the wrist and to potentially reduce costs, the Amsterdam Wrist Rules (AWR) have been developed, externally validated, and recently also implemented. The aim of this study was to conduct an incremental cost analysis and budget impact analysis of the implementation of the AWR at the emergency department (ED) in the Netherlands. METHODS: A cost-minimisation analysis to determine the expected cost savings for implementation of the Amsterdam Wrist Rules. The incremental difference in costs before and after implementation of the AWR was based on the reduction in costs for radiographs, the cost savings due to reduction of ED consultation times and the costs of a re-evaluation appointment by a physician. RESULTS: In the Netherlands, implementation of the AWR could potentially result in 6% cost savings per patient with a wrist injury. In addition, implementation of the AWR resulted in €203,510 cost savings annually nationwide. In the sensitivity analysis, an increase in physician compliance to 100% substantially increased the potential total amount of annual cost savings to €610,248, which is 6% of total costs before implementation. Variation in time spent at the ED, a decrease and increase in costs and patients presenting annually at the ED did not change the cost savings substantially. CONCLUSION: Implementation of the AWR has been shown to reduce direct and indirect costs and can, therefore, result in considerable savings of healthcare consumption and expenditure.

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

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

The Amsterdam Wrist Rules to reduce the need for radiography after a suspected distal radius fracture: an implementation study.

PURPOSE: While most patients with wrist trauma are routinely referred for radiography, around 50% of these radiographs show no fracture. To avoid unnecessary radiographs, the Amsterdam Wrist Rules (AWR) have previously been developed and validated. The aim of the current study was to evaluate the effect of the implementation of the AWR at the Emergency Department (ED). METHODS: In a before-and-after comparative prospective cohort study, all consecutive adult patients with acute wrist trauma presenting at the ED of four hospitals were included. Primary outcome was the number of wrist radiographs before and after implementation of the AWR. Secondary outcomes were the number of clinically relevant missed fractures, the overall length of stay in the ED, physician compliance regarding the AWR, and patient satisfaction and experience with the care received at the ED. RESULTS: A total of 402 patients were included. The absolute reduction in wrist radiographs after implementation was 15% (p < 0.001). One clinically irrelevant fracture was missed. Non-fracture patients without wrist radiography due to the AWR spent 34 min less time in the ED compared with non-fracture patients who had a wrist radiograph (p = 0.015). The physicians adhered to the AWR in 36% of patients. Of all patients who did not receive a radiographic examination of the wrist, 87% were satisfied. CONCLUSION: Implementation of the AWR safely reduces the amount of wrist radiographs in selected patients and consequently reducing the length of stay in the ED.

Correction to: The Amsterdam Wrist Rules to reduce the need for radiography after a suspected distal radius fracture: an implementation study.

The original version of this article unfortunately contained a mistake. The spelling of the J. Carel Goslings' name was incorrect. The correct information is given above.

Volar Plate Fixation Versus Plaster Immobilization in Acceptably Reduced Extra-Articular Distal Radial Fractures: A Multicenter Randomized Controlled Trial.

BACKGROUND: There is no consensus as to whether displaced extra-articular distal radial fractures should be treated operatively or nonoperatively. We compared the outcomes of open reduction and volar plate fixation with closed reduction and plaster immobilization in adults with an acceptably reduced extra-articular distal radial fracture. METHODS: In this multicenter randomized controlled trial, patients 18 to 75 years old with an acceptably reduced extra-articular distal radial fracture were randomly assigned to open reduction and volar plate fixation or plaster immobilization. The primary outcome was function as measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire after 12 months. Follow-up was conducted at 1, 3, and 6 weeks and at 3, 6, and 12 months. Analyses were performed according to the intention-to-treat principle. RESULTS: Ninety-two patients were randomized, 48 to open reduction and volar plate fixation and 44 to plaster immobilization; 1 patient in each group was excluded for withdrawing informed consent. At all follow-up time points, operatively treated patients had significantly better functional outcomes, as indicated by significantly lower DASH scores, than patients treated nonoperatively (all p values < 0.05). Twelve nonoperatively managed patients (28%) had fracture redisplacement within 6 weeks and underwent subsequent open reduction and internal fixation, and 6 patients (14%) had a symptomatic malunion treated with corrective osteotomy. CONCLUSIONS: Patients with an acceptably reduced extra-articular distal radial fracture treated with open reduction and volar plate fixation have better functional outcomes after 12 months compared with nonoperatively managed patients. Additionally, 42% of nonoperatively managed patients had a subsequent surgical procedure. Open reduction and volar plate fixation should be considered for patients who experience this common injury. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Implementation of the Amsterdam Pediatric Wrist Rules.

BACKGROUND: The Amsterdam Pediatric Wrist Rules have been developed and validated to reduce wrist radiographs following wrist trauma in pediatric patients. However, the actual impact should be evaluated in an implementation study. OBJECTIVE: To evaluate the effect of implementation of the Amsterdam Pediatric Wrist Rules at the emergency department. MATERIALS AND METHODS: A before-and-after comparative prospective cohort study was conducted, including all consecutive patients aged 3 to 18 years presenting at the emergency department with acute wrist trauma. The primary outcome was the difference in the number of wrist radiographs before and after implementation. Secondary outcomes were the number of clinically relevant missed fractures of the distal forearm, the difference in length of stay at the emergency department and physician compliance with the Amsterdam Pediatric Wrist Rules. RESULTS: A total of 408 patients were included. The absolute reduction in radiographs was 19% compared to before implementation (chi-square test, P<0.001). Non-fracture patients who were discharged without a wrist radiograph had a 26-min shorter stay at the emergency department compared to patients who received a wrist radiograph (68 min vs. 94 min; Mann-Whitney U test, P=0.004). Eight fractures were missed following the recommendation of the Amsterdam Pediatric Wrist Rules. However, only four of them were clinically relevant. CONCLUSION: Implementing the Amsterdam Pediatric Wrist Rules resulted in a significant reduction in wrist radiographs and time spent at the emergency department. The Amsterdam Pediatric Wrist Rules were able to correctly identify 98% of all clinically relevant distal forearm fractures.

Prediction of Distal Radius Fracture Redisplacement: A Validation Study.

OBJECTIVE: To externally validate the Edinburgh Wrist Calculator (EWC) in a population of patients with distal radius fractures at risk of loss of threshold alignment. DESIGN: A retrospective cohort study. SETTING: One academic hospital. PATIENTS/PARTICIPANTS: All consecutive adult patients with a displaced distal radius fracture with initial dorsal angulation >10 degree and/or an ulnar variance of >3 mm who were treated with closed reduction and cast immobilization between 2009 and 2014. MAIN OUTCOME MEASUREMENT: The sensitivity and specificity for diagnosis of loss of threshold alignment within 2 weeks of injury was calculated at the 10%, 40%, and the original 70% probability thresholds. The area under receiver operating characteristic curve was calculated using 2 different thresholds for loss of alignment: Mackenney et al and the Dutch consensus standards. RESULTS: The EWC predicted a greater than 70% chance of redisplacement for only 3 fractures. Redisplacement within 2 weeks occurred in 61 of 99 (62%) fractures according to the thresholds of Mackenney et al and in 18 of 99 (18%) fractures according to the Dutch thresholds. The sensitivity increased and the specificity decreased using a lower probability threshold for redisplacement. The area under the receiver operating characteristic curve of the EWC was poor the Mackenney's thresholds [0.47; 95% confidence interval (CI): 0.36-0.59] and adequate for the Dutch thresholds (0.71; 95% CI: 0.58-0.84). CONCLUSIONS: The EWC was a poor predictor of fracture redisplacement greater than threshold in displaced distal radius fractures in our patient population.

Repair of the pronator quadratus after volar plate fixation in distal radius fractures: a systematic review.

To position the volar plate on the distal radius fracture site, the pronator quadratus muscle needs to be detached from its distal and radial side and lifted for optimal exposure to the fracture site. Although the conventional approach involves repair of the pronator quadratus, controversy surrounds the merits of this repair. The purpose of this study was to compare the functional outcomes of patients with distal radius fractures treated with pronator quadratus repair after volar plate fixation versus no pronator quadratus repair. A systematic search was conducted in Medline, EMBASE and the Cochrane Central Register of Controlled Trials, on 23 July 2015. All studies comparing pronator quadratus repair with no pronator quadratus repair in adult patients undergoing volar plate fixation for distal radius fractures were included. The primary outcome was the Disability of the Arm, Shoulder and Hand (DASH) score at 12 months. Secondary outcomes included range of motion, grip strength, post-operative pain and complications. A total of 169 patients were included, of which 95 underwent pronator quadratus repair, while 74 patients underwent no pronator quadratus repair. At 12 months follow-up no statistically significant differences in DASH-scores and range of motion were observed between pronator quadratus repair and no repair. Moreover, post-operative pain and complication rates were similar between both groups. At 12 months of follow-up, we do not see any advantages of pronator quadratus repair after volar plate fixation in the distal radius. However, a definitive conclusion cannot be drawn from this systematic review due to a lack of available evidence.

External validation of clinical decision rules for children with wrist trauma.

BACKGROUND: Clinical decision rules help to avoid potentially unnecessary radiographs of the wrist, reduce waiting times and save costs. OBJECTIVE: The primary aim of this study was to provide an overview of all existing non-validated clinical decision rules for wrist trauma in children and to externally validate these rules in a different cohort of patients. Secondarily, we aimed to compare the performance of these rules with the validated Amsterdam Pediatric Wrist Rules. MATERIALS AND METHODS: We included all studies that proposed a clinical prediction or decision rule in children presenting at the emergency department with acute wrist trauma. We performed external validation within a cohort of 379 children. We also calculated the sensitivity, specificity, negative predictive value and positive predictive value of each decision rule. RESULTS: We included three clinical decision rules. The sensitivity and specificity of all clinical decision rules after external validation were between 94% and 99%, and 11% and 26%, respectively. After external validation 7% to 17% less radiographs would be ordered and 1.4% to 5.7% of all fractures would be missed. Compared to the Amsterdam Pediatric Wrist Rules only one of the three other rules had a higher sensitivity; however both the specificity and the reduction in requested radiographs were lower in the other three rules. CONCLUSION: The sensitivity of the three non-validated clinical decision rules is high. However the specificity and the reduction in number of requested radiographs are low. In contrast, the validated Amsterdam Pediatric Wrist Rules has an acceptable sensitivity and the greatest reduction in radiographs, at 22%, without missing any clinically relevant fractures.

[The Amsterdam wrist rules: the multicenter prospective derivation and external validation of a clinical decision rule for the use of radiography in acute wrist trauma]. / De Amsterdam Wrist Rules: Een klinische beslisregel voor polstrauma op de SEH.

BACKGROUND: Although only 39% of patients with wrist trauma have sustained a fracture, the majority of patients is routinely referred for radiography. The purpose of this study was to derive and externally validate a clinical decision rule that selects patients with acute wrist trauma in the Emergency Department (ED) for radiography. METHOD: This multicenter prospective study consisted of three components: (1) derivation of a clinical prediction model for detecting wrist fractures in patients following wrist trauma; (2) external validation of this model; and (3) design of a clinical decision rule. The study was conducted in the EDs of five Dutch hospitals: one academic hospital (derivation cohort) and four regional hospitals (external validation cohort). We included all adult patients with acute wrist trauma. The main outcome was fracture of the wrist (distal radius, distal ulna or carpal bones) diagnosed on conventional X-rays. RESULTS: A total of 882 patients were analyzed; 487 in the derivation cohort and 395 in the validation cohort. We derived a clinical prediction model with eight variables: age; sex, swelling of the wrist; swelling of the anatomical snuffbox, visible deformation; distal radius tender to palpation; pain on radial deviation and painful axial compression of the thumb. The Area Under the Curve at external validation of this model was 0.81 (95% CI: 0.77-0.85). The sensitivity and specificity of the Amsterdam Wrist Rules (AWR) in the external validation cohort were 98% (95% CI: 95-99%) and 21% (95% CI: 15%-28). The negative predictive value was 90% (95% CI: 81-99%). CONCLUSION: The Amsterdam Wrist Rules is a clinical prediction rule with a high sensitivity and negative predictive value for fractures of the wrist. Although external validation showed low specificity and 100 % sensitivity could not be achieved, the Amsterdam Wrist Rules can provide physicians in the Emergency Department with a useful screening tool to select patients with acute wrist trauma for radiography. The upcoming implementation study will further reveal the impact of the Amsterdam Wrist Rules on the anticipated reduction of X-rays requested, missed fractures, Emergency Department waiting times and health care costs.

Internal plate fixation versus plaster in displaced complete articular distal radius fractures, a randomised controlled trial.

BACKGROUND: Of all distal radius fractures, 25 % are complete articular fractures (AO/OTA type C fractures). Two thirds of those fractures are displaced and require reduction. According to several International Guidelines, adequately reduced intra-articular distal radius fractures are best treated non-operatively with plaster immobilisation, while surgical fixation is suggested only when the articular step exceeds 2 mm after reduction. However, these recommendations are based on studies that did not differentiate between intra- and extra-articular distal radius fractures. Thus, no clear consensus about the best treatment for patients with displaced intra-articular distal radius fractures can be reached. Despite the lack of evidence, an increase in internal fixation of intra-articular distal radius fractures has been observed over the last decade. The aim of this study is to determine the difference in functional outcome following open reduction and plate fixation compared with non-operative treatment with closed reduction and plaster immobilisation in patients with a displaced intra articular distal radius fracture. METHODS/DESIGN: This multicentre randomised controlled trial will randomise between open reduction and internal plate fixation (intervention group) and closed reduction and plaster immobilisation (control group). All consecutive adult patients from 18 to 65 years with a displaced intra-articular distal radius fracture (AO/OTA type C), which has been adequately reduced at the Emergency Department according to the Dutch National Guidelines, are eligible for inclusion in this study. The primary outcome is function and pain of the wrist assessed with the Patient-Rated Wrist Evaluation score (PRWE). Secondary outcomes are the Disability of the Arm, Shoulder and Hand score (DASH), pain, quality of life (SF-36), range of motion, grip strength, radiological parameters, complications, crossovers and cost-effectiveness of both treatments. A total of 90 patients will be included in this study. DISCUSSION: Although displaced intra-articular distal radius fractures are common, there is still no evidence on the optimal treatment for these fractures in patients aged 18 to 65 years. Therefore we aim to determine the difference in functional outcome between open reduction and plate fixation and closed reduction and plaster immobilisation. TRIAL REGISTRATION: This study is registered at ClinicalTrials.gov ( NCT02651779 ) on January 4(th) 2016.

A clinical decision rule for the use of plain radiography in children after acute wrist injury: development and external validation of the Amsterdam Pediatric Wrist Rules.

BACKGROUND: In most hospitals, children with acute wrist trauma are routinely referred for radiography. OBJECTIVE: To develop and validate a clinical decision rule to decide whether radiography in children with wrist trauma is required. MATERIALS AND METHODS: We prospectively developed and validated a clinical decision rule in two study populations. All children who presented in the emergency department of four hospitals with pain following wrist trauma were included and evaluated for 18 clinical variables. The outcome was a wrist fracture diagnosed by plain radiography. RESULTS: Included in the study were 787 children. The prediction model consisted of six variables: age, swelling of the distal radius, visible deformation, distal radius tender to palpation, anatomical snuffbox tender to palpation, and painful or abnormal supination. The model showed an area under the receiver operator characteristics curve of 0.79 (95% CI: 0.76-0.83). The sensitivity and specificity were 95.9% and 37.3%, respectively. The use of this model would have resulted in a 22% absolute reduction of radiographic examinations. In a validation study, 7/170 fractures (4.1%, 95% CI: 1.7-8.3%) would have been missed using the decision model. CONCLUSION: The decision model may be a valuable tool to decide whether radiography in children after wrist trauma is required.

The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review.

Background Unstable distal radius fractures are a popular research subject. However, to appreciate the findings of studies that enrolled patients with unstable distal radius fractures, it should be clear how the authors defined an unstable distal radius fracture. Questions In what percentage of studies involving patients with unstable distal radius fractures did the authors define unstable distal radius fracture? What are the most common descriptions of an unstable distal radius fracture? And is there one preferred evidence-based definition for future authors? Methods A systematic search of literature was performed to identify any type of study with the term unstable distal radius fracture. We assessed whether a definition was provided and determined the level of evidence for the most common definitions. Results The search yielded 2,489 citations, of which 479 were included. In 149 studies, it was explicitly stated that patients with unstable distal radius fractures were enrolled. In 54% (81/149) of these studies, the authors defined an unstable distal radius fracture. Overall, we found 143 different definitions. The seven most common definitions were: displacement following adequate reduction; Lafontaine's definition; irreducibility; an AO type C2 fracture; a volarly displaced fracture; Poigenfürst's criteria; and Cooney's criteria. Only Lafontaine's definition originated from a clinical study (level IIIb). Conclusion In only half of the studies involving patients with an unstable distal radius fracture did the authors defined what they considered an unstable distal radius fracture. None of the definitions stood out as the preferred choice. A general consensus definition could help to standardize future research.

The Amsterdam wrist rules: the multicenter prospective derivation and external validation of a clinical decision rule for the use of radiography in acute wrist trauma.

BACKGROUND: Although only 39 % of patients with wrist trauma have sustained a fracture, the majority of patients is routinely referred for radiography. The purpose of this study was to derive and externally validate a clinical decision rule that selects patients with acute wrist trauma in the Emergency Department (ED) for radiography. METHODS: This multicenter prospective study consisted of three components: (1) derivation of a clinical prediction model for detecting wrist fractures in patients following wrist trauma; (2) external validation of this model; and (3) design of a clinical decision rule. The study was conducted in the EDs of five Dutch hospitals: one academic hospital (derivation cohort) and four regional hospitals (external validation cohort). We included all adult patients with acute wrist trauma. The main outcome was fracture of the wrist (distal radius, distal ulna or carpal bones) diagnosed on conventional X-rays. RESULTS: A total of 882 patients were analyzed; 487 in the derivation cohort and 395 in the validation cohort. We derived a clinical prediction model with eight variables: age; sex, swelling of the wrist; swelling of the anatomical snuffbox, visible deformation; distal radius tender to palpation; pain on radial deviation and painful axial compression of the thumb. The Area Under the Curve at external validation of this model was 0.81 (95 % CI: 0.77-0.85). The sensitivity and specificity of the Amsterdam Wrist Rules (AWR) in the external validation cohort were 98 % (95 % CI: 95-99 %) and 21 % (95 % CI: 15 %-28). The negative predictive value was 90 % (95 % CI: 81-99 %). CONCLUSIONS: The Amsterdam Wrist Rules is a clinical prediction rule with a high sensitivity and negative predictive value for fractures of the wrist. Although external validation showed low specificity and 100 % sensitivity could not be achieved, the Amsterdam Wrist Rules can provide physicians in the Emergency Department with a useful screening tool to select patients with acute wrist trauma for radiography. The upcoming implementation study will further reveal the impact of the Amsterdam Wrist Rules on the anticipated reduction of X-rays requested, missed fractures, Emergency Department waiting times and health care costs. TRIAL REGISTRATION: This study was registered in the Dutch Trial Registry, reference number NTR2544 on October 1(st), 2010.

Mason Type I Fractures of the Radial Head.

Mason type I fractures are the most common fractures of the radial head. The fractures have a benign character and often result in good, pain-free function. Nevertheless, up to 20% of patients with a Mason type I fracture report loss of extension and residual pain. Currently, there is a lack of consensus concerning diagnosis and treatment of these fractures. The goal of this study was to systematically review incidence, diagnosis, classification, treatment, and outcome of Mason type I radial head fractures in adults and establish an evidence-based treatment guideline. A search of the MEDLINE, EMBASE, and Cochrane databases was conducted for English titles without restrictions on publication date. The authors included titles that addressed Mason type I radial head fractures and covered incidence, diagnostics, treatment, or functional or patient-related outcome. Included were randomized controlled trials; case-control studies; comparative cohort studies; case series with more than 10 patients; and expert opinions. Reference lists were cross-checked for additional titles. The search yielded 1734 studies, of which 95 met the inclusion criteria. Seven studies showed that the elbow extension test has a high sensitivity (88.0-97.6) to rule out Mason type I radial head fractures. If radiography is required, antero-posterior and lateral radiographs suffice. For pain relief, hematoma aspiration seems safe and effective. Mason type I fractures are best treated with 48 hours of rest with a sling, followed with active mobilization. Cast immobilization should be avoided. Mobilization should be encouraged and if needed supported by physical therapy.

The Minimum Clinically Important Difference of the Patient-rated Wrist Evaluation Score for Patients With Distal Radius Fractures.

BACKGROUND: The Patient-rated Wrist Evaluation (PRWE) is a commonly used instrument in upper extremity surgery and in research. However, to recognize a treatment effect expressed as a change in PRWE, it is important to be aware of the minimum clinically important difference (MCID) and the minimum detectable change (MDC). The MCID of an outcome tool like the PRWE is defined as the smallest change in a score that is likely to be appreciated by a patient as an important change, while the MDC is defined as the smallest amount of change that can be detected by an outcome measure. A numerical change in score that is less than the MCID, even when statistically significant, does not represent a true clinically relevant change. To our knowledge, the MCID and MDC of the PRWE have not been determined in patients with distal radius fractures. QUESTIONS/PURPOSES: We asked: (1) What is the MCID of the PRWE score for patients with distal radius fractures? (2) What is the MDC of the PRWE? METHODS: Our prospective cohort study included 102 patients with a distal radius fracture and a median age of 59 years (interquartile range [IQR], 48-66 years). All patients completed the PRWE questionnaire during each of two separate visits. At the second visit, patients were asked to indicate the degree of clinical change they appreciated since the previous visit. Accordingly, patients were categorized in two groups: (1) minimally improved or (2) no change. The groups were used to anchor the changes observed in the PRWE score to patients' perspectives of what was clinically important. We determined the MCID using an anchor-based receiver operator characteristic method. In this context, the change in the PRWE score was considered a diagnostic test, and the anchor (minimally improved or no change as noted by the patients from visit to visit) was the gold standard. The optimal receiver operator characteristic cutoff point calculated with the Youden index reflected the value of the MCID. RESULTS: In our study, the MCID of the PRWE was 11.5 points. The area under the curve was 0.54 (95% CI, 0.37-0.70) for the pain subscale and 0.71 (95% CI, 0.57-0.85) for the function subscale. We determined the MDC to be 11.0 points. CONCLUSIONS: We determined the MCID of the PRWE score for patients with distal radius fractures using the anchor-based approach and verified that the MDC of the PRWE was sufficiently small to detect our MCID. CLINICAL RELEVANCE: We recommend using an improvement on the PRWE of more than 11.5 points as the smallest clinically relevant difference when evaluating the effects of treatments and when performing sample-size calculations on studies of distal radius fractures.

Surgery versus conservative treatment in patients with type A distal radius fractures, a randomized controlled trial.

BACKGROUND: Fractures of the distal radius are common and account for an estimated 17% of all fractures diagnosed. Two-thirds of these fractures are displaced and require reduction. Although distal radius fractures, especially extra-articular fractures, are considered to be relatively harmless, inadequate treatment may result in impaired function of the wrist. Initial treatment according to Dutch guidelines consists of closed reduction and plaster immobilisation. If fracture redisplacement occurs, surgical treatment is recommended. Recently, the use of volar locking plates has become more popular. The aim of this study is to compare the functional outcome following surgical reduction and fixation with a volar locking plate with the functional outcome following closed reduction and plaster immobilisation in patients with displaced extra-articular distal radius fractures. DESIGN: This single blinded randomised controlled trial will randomise between open reduction and internal fixation with a volar locking plate (intervention group) and closed reduction followed by plaster immobilisation (control group). The study population will consist of all consecutive adult patients who are diagnosed with a displaced extra-articular distal radius fracture, which has been adequately reduced at the Emergency Department. The primary outcome (functional outcome) will be assessed by means of the Disability Arm Shoulder Hand Score (DASH). Secondary outcomes comprise the Patient-Rated Wrist Evaluation score (PRWE), quality of life, pain, range of motion, radiological parameters, complications and cross-overs. Since the treatment allocated involves a surgical procedure, randomisation status will not be blinded. However, the researcher assessing the outcome at one year will be unaware of the treatment allocation. In total, 90 patients will be included and this trial will require an estimated time of two years to complete and will be conducted in the Academic Medical Centre Amsterdam and its partners of the regional trauma care network. DICUSSION: Ideally, patients would be randomised before any kind of treatment has been commenced. However, we deem it not patient-friendly to approach possible participants before adequate reduction has been obtained. TRIAL REGISTRATION: This study is registered at the Netherlands Trial Register (NTR3113) and was granted permission by the Medical Ethical Review Committee of the Academic Medical Centre on 01-10-2012.

Multiple testing in orthopedic literature: a common problem?

BACKGROUND: Performing multiple tests in primary research is a frequent subject of discussion. This discussion originates from the fact that when multiple tests are performed, it becomes more likely to reject one of the null hypotheses, conditional on that these hypotheses are true and thus commit a type one error. Several correction methods for multiple testing are available. The primary aim of this study was to assess the quantity of articles published in two highly esteemed orthopedic journals in which multiple testing was performed. The secondary aims were to determine in which percentage of these studies a correction was performed and to assess the risk of committing a type one error if no correction was applied. METHODS: The 2010 annals of two orthopedic journals (A and B) were systematically hand searched by two independent investigators. All articles on original research in which statistics were applied were considered. Eligible publications were reviewed for the use of multiple testing with respect to predetermined criteria. RESULTS: A total of 763 titles were screened and 127 articles were identified and included in the analysis. A median of 15 statistical inference results were reported per publication in both journal A and B. Correction for multiple testing was performed in 15% of the articles published in journal A and in 6% from journal B. The estimated median risk of obtaining at least one significant result for uncorrected studies was calculated to be 54% for both journals. CONCLUSION: This study shows that the risk of false significant findings is considerable and that correcting for multiple testing is only performed in a small percentage of all articles published in the orthopedic literature reviewed.