Epidemiology of forearm fractures in women and men in Norway 2008-2019.

The purpose of this paper is to describe rates of forearm fractures in adults in Norway 2008-2019. Incidence rate of distal forearm fractures declined over time in both sexes. Forearm fracture constitute a significant health burden and prevention strategies are needed. PURPOSE: To assess age- and sex-specific incidence rates, and time trends for forearm fractures in Norway, and compare these with incidence rates in other Nordic countries. METHODS: Data on all patients aged 20-107 years with forearm fractures treated in Norwegian hospitals from 2008 to 2019 was retrieved from the Norwegian Patient Registry. Fractures were identified based on International Classification of Disease 10th revision code S52. Age- and sex-specific incidence rates and changes in incidence rates were calculated. RESULTS: We identified 181,784 forearm fractures in 45,628,418 person-years. Mean annual forearm fracture incidence rates per 100,000 person-years were 398 (95% CI 390-407) for all, 565 (95% CI 550-580) for women, and 231 (95% CI 228-234) for men above 20 years. Mean annual number of forearm fractures was 15,148 (95% CI 14,575-15,722). From 2008 to 2019, age-adjusted total incidence rates of forearm fractures S52 diagnoses declined by 3.5% (incidence rate ratio (IRR) of 0.997 (95% CI 0.994-0.999)) in men. The corresponding decline in women was not significant (IRR: 0.999 (95% CI 0.997-1.002)). In the same period, the age-adjusted incidence rates of distal forearm fractures declined by 7.0% in men (IRR = 0.930; 95% CI 0.886-0.965) and 4.7% in women (IRR = 0.953; 95% CI 0.919-0.976). The incidence rates of distal forearm fractures were similar to rates in Sweden and Finland. CONCLUSION: Age-adjusted incidence rates of distal forearm fractures in both sexes declined over time.

Diagnosis of suspected pediatric distal forearm fractures with point-of-care-ultrasound (POCUS) by pediatric orthopedic surgeons after minimal training.

BACKGROUND: Several studies have advocated the use of ultrasound to diagnose distal forearm fractures in children. However, there is limited data on the diagnostic accuracy of ultrasound for distal forearm fractures when conducted by pediatric surgeons or trainees who manage orthopedic injuries in children. The objective of this study was to determine the diagnostic accuracy of point-of-care ultrasound (POCUS) for pediatric distal forearm fractures when conducted by pediatric surgeons and trainees after minimal training. METHODS: This diagnostic study was conducted in a tertiary hospital emergency department in Germany. Participants were children and adolescents under 15 years of age who presented to the emergency department with an acute, suspected, isolated distal forearm fracture requiring imaging. Pediatric surgeons and trainees, after minimal training for sonographic fracture diagnosis, performed 6-view distal forearm POCUS on each participant prior to X-ray imaging. All data was retrospectively collected from the hospital's routine digital patient files. The primary outcome was the diagnostic accuracy of POCUS compared to X-ray as the reference standard. RESULTS: From February to June 2021, 146 children under 15 met all inclusion and exclusion criteria, and 106 data sets were available for analysis. Regarding the presence of a fracture, X-ray and Wrist-POCUS showed the same result in 99.1%, with 83/106 (78.3%) fractures detected in both modalities and one suspected buckle fracture on POCUS not confirmed in the radiographs. Wrist-POCUS had a sensitivity of 100% (95% CI [0.956, 1]) and a specificity of 95.8% (95% CI [0.789, 0.999]) compared to radiographs. In 6 cases, there were minor differences regarding a concomitant ulnar buckle. The amount of prior ultrasound training had no influence on the accuracy of Wrist-POCUS for diagnosing distal forearm fractures. All fractures were reliably diagnosed even when captured POCUS images did not meet all quality criteria. CONCLUSION: Pediatric surgeons and trainees, after minimal training in POCUS, had excellent diagnostic accuracy for distal forearm fractures in children and adolescents using POCUS compared to X-ray.

Health-economic evaluation of orthogeriatric co-management for patients with forearm or humerus fractures: an analysis of insurance claims data from Germany.

Orthogeriatric co-management (OGCM) describes a collaboration of orthopedic surgeons and geriatricians for the treatment of fragility fractures in geriatric patients. While its cost-effectiveness for hip fractures has been widely investigated, research focusing on fractures of the upper extremities is lacking. Thus, we conducted a health economic evaluation of treatment in OGCM hospitals for forearm and humerus fractures.In a retrospective cohort study with nationwide health insurance claims data, we selected the first inpatient stay due to a forearm or humerus fracture in 2014-2018 either treated in hospitals that were able to offer OGCM (OGCM group) or not (non-OGCM group) and applied a 1-year follow-up. We included 31,557 cases with forearm (63.1% OGCM group) and 39,093 cases with humerus fractures (63.9% OGCM group) and balanced relevant covariates using entropy balancing. We investigated costs in different health sectors, length of stay, and cost-effectiveness regarding total cost per life year or fracture-free life year gained.In both fracture cohorts, initial hospital stay, inpatient stay, and total costs were higher in OGCM than in non-OGCM hospitals. For neither cohort nor effectiveness outcome, the probability that treatment in OGCM hospitals was cost-effective exceeded 95% for a willingness-to-pay of up to €150,000.We did not find distinct benefits of treatment in OGCM hospitals. Assigning cases to study groups on hospital-level and using life years and fracture-free life years, which might not adequately reflect the manifold ways these fractures affect the patients' health, as effectiveness outcomes, might have underestimated the effectiveness of treatment in OGCM hospitals.

Opportunistic hand radiographs to screen for low forearm bone mineral density: a prospective and retrospective cohort study.

BACKGROUND: Low bone mineral density affects 53% of women over age 65 in the US, yet many are unaware and remain untreated. Underdiagnosis of forearm osteoporosis and related fragility fractures represent missed warning signs of more deadly, future fractures. This study aimed to determine if hand radiographs could serve as early, simple screening tools for predicting low forearm bone mineral density (BMD). METHODS: We evaluated posterior-anterior (PA) hand radiographs (x-rays) and Dual-energy X-ray absorptiometry (DXA) scans of 43 participants. The ratio of the intramedullary cavity to total cortical diameter of the second metacarpal (second metacarpal cortical percentage (2MCP)) was used as a potential diagnostic marker. Mixed-effects linear regression was performed to determine correlation of 2MCP with BMD from various anatomic regions. Repeated measures ANOVAs were used to compare BMD across sites. An optimal 2MCP cutoff for predicting forearm osteopenia and osteoporosis was found using Receiver Operating Curves. RESULTS: 2MCP is directly correlated with BMD in the forearm. The optimal 2MCP of 48.3% had 80% sensitivity for detecting osteoporosis of the 1/3 distal forearm. An 2MCP cutoff of 50.8% had 84% sensitivity to detect osteoporosis of the most distal forearm. Both 2MCP cutoffs were more sensitive at predicting forearm osteoporosis than femoral neck T-scores. CONCLUSIONS: These findings support the expansion of osteoporosis screening to include low-cost hand x-rays, aiming to increase diagnosis and treatment of low forearm BMD and fractures. Proposed next steps include confirming the optimal 2MCP cutoff at scale and integrating automatic 2MCP measurements into PAC systems.

Trends and projection of forearm fractures including elbow fractures of the Olecranon in Sweden: an analysis of 363 968 fractures using public aggregated data.

BACKGROUND: Forearm and olecranon fractures are a common orthopaedic injury. This study aimed to analyse whether the incidence of forearm injury is changing and identifying trends in the number of forearm and olecranon fractures using public aggregated data in Sweden. METHODS: The number of forearm and olecranon fractures as defined by the number of registered diagnoses with the ICD-10 code of S52 were collected and normalized per 100,000 inhabitants and stratified per sex, age, and month. Age-adjusted incidence for forearm and olecranon fractures were calculated using the direct method. Poisson regression was used to analyse monthly, seasonal and yearly change in forearm and olecranon fracture incidence. Logistical regression was used to predict future trends of forearm and olecranon fractures. RESULTS: The findings revealed a slight decreasing trend in forearm and olecranon fractures. The average incidence rate during the study period was 333 with women having a higher incidence rate than men. More fractures occurred in the winter months. Fluctuations in the number of forearm and olecranon fractures were observed during 2020 which may be influenced by the COVID-19 pandemic. Based on current data, forearm and olecranon fractures are expected to decrease in Sweden by 2035. CONCLUSION: This study describes the trend of forearm and olecranon fractures among individuals according to sex and age in Sweden using easily obtainable data. Trends in forearm and olecranon fractures are dependent on sex and age but generally show a decreasing trend. More precise studies are needed in order to properly quantify the specific incidence of various subtypes of forearm and olecranon fractures and associated risk factors.

Diaphyseal forearm fracture management in adolescent patients from 2011 to 2020: A multicenter study of surgery and regional anesthesia trends.

BACKGROUND: Diaphyseal forearm fractures are common traumatic injuries among children. There has been much debate on the use of intramedullary nailing (IMN) or plate fixation in the adolescent population (10-16 years of age). Furthermore, as ultrasound technology has advanced, the safety and efficacy of ultrasound-guided axillary brachial plexus block for children has dramatically improved. Therefore, anesthesia options for adolescent patients have increased in recent years. This study aimed to investigate recent surgical and regional anesthesia trends of diaphyseal forearm fractures in patients 10 to 16 years of age in Japan through a multicenter epidemiological survey from 2011 to 2020. METHODS: This retrospective, multicenter study included 226 pediatric patients with diaphyseal forearm fracture aged 10-16 years treated from January 2011 to December 2020. We divided the patients into four groups according to the period in which they were treated: early (2011-2013), middle (2014-2016), late (2017-2019), and COVID-19 (2020). Information from medical records was used to investigate the number of surgeries, types of anesthesia administered, and internal fixation methods used for diaphyseal forearm fracture in adolescent patients during each period. RESULTS: The number of surgeries was generally constant in each period but decreased during the COVID-19 period. In the early, middle, late, and COVID-19 periods, the percentages of surgeries performed under regional anesthesia were 67.7, 85.5, 87.0, and 100% respectively (p = 0.003). During the same periods, the percentages of patients receiving IMN were 41.5, 49.3, 58.0, and 66.7%, respectively (p = 0.033). CONCLUSION: The use of IMN and regional anesthesia to treat diaphyseal forearm fracture in patients 10 to 16 years of age steadily increased during the study period from 2011 to 2020. These results indicate that regional anesthesia is safe, effective, and well-tolerated by adolescent patients. The treatment strategy for diaphyseal forearm fractures in adolescents using regional anesthesia in combination with IMN worked well and was effective during COVID-19. Our evidence suggests this trend will continue. We anticipate that our findings can be extrapolated for upper extremity fractures in adolescent patients beyond the Tokai region of Japan where the study was based.

Interlocking intramedullary nail for forearm diaphyseal fractures in adults-A systematic review and meta-analysis of outcomes and complications.

PURPOSE: The purpose of this systematic review is to examine the outcomes, complications, and potential advantages of using anatomical interlocking intramedullary nails (IMN) in the treatment of radius and ulnar shaft diaphyseal fractures in adults. METHODS: Medline, Embase, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched between January 2000 and January 2023. Studies meeting criteria were observational or randomized controlled trials evaluating outcomes in IMN for adult diaphyseal forearm fractures. Standardized data extraction was performed and a quality assessment tool was used to evaluate individual study methodology. Descriptive statistics for interventions, functional outcomes, and complications were reported. Meta-analysis was performed for patient-reported outcome measures and operative time. RESULTS: A total of 29 studies involving 1268 patients were included with 764 (60%) undergoing IMN, 21% open reduction and internal fixation (ORIF), and 9% hybrid fixation. There was no significant difference between groups in DASH and Grace-Eversmann scores. Operative time was significantly shorter in IMN compared with ORIF. The DASH scores were: 13.1 ± 6.04 for IMN, 10.17 ± 3.98 for ORIF, and 15.5 ± 0.63 in hybrids. Mean operative time was 65.3 ± 28.7 in ORIF and 50.8 ± 17.7 in IMN. Complication rates were 16.7% in the IMN group, 14.9% in ORIF, and 6.3% in hybrid constructs. There were 11 cases of extensor pollicis rupture in the IMN group. Average IMN pronation and supination were 78.3° ± 7.9° and 73° ± 5.0°, respectively. Average ORIF pronation and supination was 82.15° ± 1.9° and 79.7° ± 4.5°, respectively. CONCLUSIONS: Similar functional outcomes and complication rates along with shorter operative times can be achieved with IMN compared with ORIF. The use of IMN is promising, however, higher quality evidence is required to assess appropriate indications, subtle differences in range of motion, implant-related complications, and cost-effectiveness. Trail Registration PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42022362353).

Forearm fractures - are we counting them all? An attempt to identify and include the missing fractures treated in primary care.

OBJECTIVE: Norway has a high incidence of forearm fractures, however, the incidence rates based on secondary care registers can be underestimated, as some fractures are treated exclusively in primary care. We estimated the proportion of forearm fracture diagnoses registered exclusively in primary care and assessed the agreement between diagnosis for forearm fractures in primary and secondary care. DESIGN: Quality assurance study combining nationwide data from 2008 to 2019 on forearm fractures registered in primary care (Norwegian Control and Payment of Health Reimbursement) and secondary care (the Norwegian Patient Registry). SETTING AND PATIENTS: Forearm fracture diagnoses in patients aged ≥20 treated in primary care (n = 83,357) were combined with injury diagnoses for in- and outpatients in secondary care (n = 3,294,336). MAIN OUTCOME MEASURES: Proportion of forearm fractures registered exclusively in primary care, and corresponding injury diagnoses for those registered in both primary and secondary care. RESULTS: Of 189,105 forearm fracture registrations in primary and secondary care, 13,948 (7.4%) were registered exclusively in primary care. The proportion ranged from 4.9% to 13.5% on average between counties, but was higher in some municipalities (>30%). Of 66,747 primary care forearm fractures registered with a diagnosis in secondary care, 62% were incident forearm fractures, 28% follow-up controls, and 10% other fractures or non-fracture injuries. CONCLUSION: An overall small proportion of forearm fractures were registered only in primary care, but it was larger in some areas of Norway. Failing to include fractures exclusively treated in primary care could underestimate the incidence rates in these areas.

Norwegian forearm fracture incidence based on secondary care may be underestimated by not including fractures treated exclusively in primary care.The mean proportion of forearm fractures exclusively handled in primary care is 7% and varies from 5% to 14% between counties.Fractures treated in primary care can be considered for more accurate national incidence rates. Correct fracture diagnosis needs further investigation.

Point-of-Care Ultrasound Pronator Quadratus Hematoma Sign for Detection of Clinically Non-Angulated Pediatric Distal Forearm Fractures: A Prospective Cohort Study.

OBJECTIVES: Point-of-care ultrasound (POCUS) diagnosis of distal forearm fractures relies on the identification of buckling or breach of hyperechoic bone cortex. We describe the pronator quadratus hematoma (PQH) formation visualized on POCUS, the PQH sign, as it may aid diagnosis of pediatric distal forearm cortical breach fractures. METHODS: A prospective cohort of children presenting to an emergency department with isolated, clinically non-angulated distal forearm injuries received POCUS by an expert emergency physician sonologist who identified the presence or absence of the PQH sign. They secondarily recorded the difference between the size of the pronator quadratus (PQ) muscle on both the affected and non-affected forearms (PQ delta thickness). Children received an x-ray subsequent to POCUS and were diagnosed based on an x-ray reported by a radiologist masked to POCUS findings. RESULTS: Thirty-eight children were recruited. All 22 patients with cortical breach fracture had PQH sign present (100%; 95%CI: 85-100%), while all 16 patients without cortical breach fracture had PQH sign absent (100%; 95%CI: 79-100%). PQ delta thickness ranged from 2.1 to 10.2 mm in cortical breach fractures, 0.0 to 1.1 mm in buckle fractures, and 0.2 to 0.8 mm in patients without fracture. CONCLUSIONS: The PQH sign correctly distinguished all children with, and without, cortical breach fractures. All PQ delta thicknesses were ≧2.1 mm when cortical breach fracture was present and ≦1.1 mm when cortical breach fracture was absent. The PQH sign and PQ delta thickness are promising measurements to identify pediatric distal forearm cortical breach fractures, and their utility should be confirmed in larger studies with sonologists of different abilities.

Single-bone versus both-bone plating of unstable paediatric both-bone forearm fractures. A randomized controlled clinical trial.

PURPOSE: This clinical trial compares the functional and radiological outcomes of single-bone fixation to both-bone fixation of unstable paediatric both-bone forearm fractures. METHODS: This individually randomized two-group parallel clinical trial was performed following the Consolidated Standards of Reporting Trials (CONSORT) statement at a single academic tertiary medical centre with an established paediatric orthopaedics unit. All children aged between nine and 15 years who presented to the emergency department at Assiut university with unstable diaphyseal, both-bone forearm fractures requiring surgical intervention between November 1, 2018, and February 28, 2020, were screened for eligibility against the inclusion and exclusion criteria. Inclusion criteria were diaphyseal unstable fractures defined as shaft fractures between the distal and proximal metaphyses with an angulation of > 10°, and/or malrotation of > 30°, and/or displacement > 10 mm after attempted closed reduction. Exclusion criteria included open fractures, Galeazzi fractures, Monteggia fractures, radial head fractures, and associated neurovascular injuries. Patients who met the inclusion criteria were randomized to either the single-bone fixation group (intervention) or the both-bone fixation group (control). Primary outcomes were forearm range of motion and fracture union, while secondary outcomes were forearm function (price criteria), radius re-angulation, wrist and elbow range of motion, and surgical time RESULTS: A total of 50 children were included. Out of these 50 children, 25 were randomized to either arm of the study. All children in either group received the treatment assigned by randomization. Fifty (100%) children were available for final follow-up at six months post-operatively. The mean age of single-bone and both-bone fixation groups was 11.48 ± 1.93 and 13 ± 1.75 years, respectively, with a statistically significant difference (p = 0.006). There were no statistically significant differences in gender, laterality, affection of the dominant hand, or mode of trauma between single-bone and both-bone fixation groups. All patients in both groups achieved fracture union. There mean radius re-angulation of the single-bone fixation groups was 5.36 ± 4.39 (0-20) degrees, while there was no radius re-angulation in the both-bone fixation group, with a statistically significant difference (p < 0.001). The time to union in the single-bone group was 6.28 ± 1.51 weeks, while the time to union in the both-bone fixation group was 6.64 ± 1.75 weeks, with no statistically significant difference (p = 0.44). There were no infections or refractures in either group. In the single-bone fixation group, 24 (96%) patients have regained their full forearm ROM (loss of ROM < 15°), while only one (4%) patient lost between 15 and 30° of ROM. In the both-bone fixation group, 23 (92%) patients have regained their full forearm ROM (loss of ROM < 15°), while only two (8%) patients lost between 15 and 30° of ROM. There was no statistically significant difference between groups in loss of forearm ROM (p = 0.55). All patients in both groups regained full ROM of their elbow and wrist joints. On price grading, 24 (96%) and 23 (92%) patients who underwent single bone fixation and both-bone fixation scored excellent, respectively. Only one (4%) patient in the single-bone fixation group and two (8%) patients in the both-bone fixation group scored good, with no statistically significant difference in price score between groups (p = 0.49). The majority of the patients from both groups had no pain on the numerical pain scale; 22 (88%) patients in the single-bone fixation group and 21 (84%) patients in the both-bone fixation groups, with no statistically significant difference between groups (p = 0.38). The single-bone fixation group had a significantly shorter mean operative time in comparison to both-bones plating (43.60 ± 6.21 vs. 88.60 ± 10.56 (min); p < 0.001). CONCLUSION: Single-bone ulna open reduction and plate fixation and casting are safe and had a significantly shorter operative time than both-bone fixation. However, single-bone ORIF had a higher risk radius re-angulation, alas clinically acceptable. Both groups had equally excellent functional outcomes, forearm ROM, and union rates with no complications or refractures. Long-term studies are required.

Epidemiology of distal radius fractures: a detailed survey on a large sample of patients in a suburban area.

BACKGROUND: Literature lacks data on correlations between epidemiology and clinical data of patients with distal radius fractures (DRFs). AIM: The aim of this study was to present a detailed epidemiologic survey of a large consecutive series of patient with DRFs. MATERIALS AND METHODS: This retrospective study included 827 consecutive patients (579 females, 248 men) who sustained a DRFs in the last 5 years. All fractures were radiographically evaluated. DRFs were classified according to Association of Osteosynthesis classification. Data on age, gender, side, period in which fracture occurred, and fracture mechanism were collected. Statistical analysis was performed. RESULTS: The patients' mean age was 60.23 [standard deviation (SD) 16.65] years, with the left side being most frequently involved (56.1%). The mean age of females at the time of fracture was significantly higher than that of males. The most frequent pattern of fracture was the complete articular fracture (64.3%), while the most represented fracture type was 2R3A2.2 (21.5%). Regarding the period in which the fracture occurred, 305 DRFs (37.5%) were observed in the warmer months and 272 (33.4%) in the colder months. Low-energy trauma occurring outside home was found to be the major cause of DRF throughout the year. In both genders, trauma mechanism 2 was more frequent (59.4% F; 31.9% M; p < 0.01). A bimodal distribution of fracture mechanisms was found in males when considering the patient's age with a high-energy mechanism of fracture (3 and 4), identified in 21% (n = 52) of males aged 18-45 years, and a low-energy mechanism (1 and 2) was observed in 39.9% (n = 99) of males aged > 45 years. A significant correlation between all trauma mechanisms (from 1 to 6) and different fracture patterns (complete, partial, and extraarticular) was found (p value < 0.001). The mean age of patients with extraarticular fractures (mean age 61.75 years; SD 18.18 years) was higher than that of those with complete (mean age 59.84 years; SD 15.67 years) and partial fractures (mean age 55.26 years; SD 18.31 years). Furthermore, considering different fracture patterns and patient age groups, a statistically significant difference was found (p < 0.001). CONCLUSIONS: DRFs have a higher prevalence in females, an increase in incidence with older age, and no seasonal predisposition. Low-energy trauma occurring at home is the main cause of fracture among younger males sustaining fractures after sports trauma; Complete articular is the most frequent fracture pattern, while 2R3A2.2 is most frequent fracture type. LEVEL OF EVIDENCE: Level IV; case series; descriptive epidemiology study.

Osteoporotic fractures among foreign-born individuals: a national Swedish study.

In this national study of osteoporotic fractures in foreign-born individuals, we found a lower risk of osteoporotic fractures in general among foreign-born individuals compared with Swedish-born, especially in immigrants from southern Europe. A higher risk was found among some groups, i.e. men and women from Bosnia and Iraq and men from Lebanon. INTRODUCTION: The aim of this study was to analyse risk of osteoporotic fractures in foreign-born individuals compared with Swedish-born individuals. METHODS: This was a nationwide study of individuals 50 years of age and older (N = 2,775,736). Osteoporotic fractures were defined as at least one registered diagnosis of fractures in the hip, humerus, forearm or vertebrae, in the National Patient Register between January 1, 1998, and December 31, 2012. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 99% confidence intervals (CI)) of incident osteoporotic fractures in foreign-born compared with Swedish-born individuals. The Cox regression models were stratified by sex and adjusted for age, comorbidities and sociodemographic status. RESULTS: A total of 362,899 osteoporotic fractures were registered (96,847 among men and 266,052 among women), with hip fractures dominating (54.0% among men, 42.6% among women). Fully adjusted HRs (99% CI) were for all immigrant men 0.75 (99% CI, 0.73-0.78) and women 0.83 (99% CI, 0.81-0.84), with significantly lower HRs among most groups but with higher HRs in certain countries. For the specific fractures, higher HRs were found for lower forearm fractures for men from Asia and for vertebral fractures among women from Asia. CONCLUSIONS: We observed a generally lower risk of osteoporotic fractures among first-generation immigrants, with few exceptions.

Osteoporotic fractures in second-generation immigrants and Swedish natives.

In this national study of osteoporotic fractures in second-generation immigrants in Sweden, we found a similar risk of osteoporotic fractures in general compared to Swedish natives, which suggests that environmental factors are important for the high risk of osteoporotic fractures in Nordic countries. INTRODUCTION: Second generation immigrants may have a similar environment as individuals with two native-born parents. These individuals may be of interest to study concerning whether environmental or hereditary factors could be mostly associated to the risk of osteoporotic fractures. The aim of this study was to analyse the risk of osteoporotic fractures in second-generation immigrants compared to Swedish natives. METHODS: This was a nationwide study of individuals aged 50 years of age and older (N = 1,377,035; 691,750 men and 685,285 women). Osteoporotic fractures were defined as at least one registered diagnosis of fractures in the hip, humerus, forearm or vertebrae, in the National Patient Register between January 1, 1998, and December 31, 2012. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 95% confidence intervals (CI)) of incident osteoporotic fractures in second generation immigrants compared to Swedish natives. The Cox regression models were adjusted for age, comorbidities and for sociodemographic status. RESULTS: A total of 114,505 osteoporotic fractures were registered, 109,622 (8.4%) were among individuals with Swedish-born parents and 4883 (7.5%) among those with foreign-born parents, with distal forearm fractures dominating in general (44.9%). Fully adjusted HRs (95% CI) were for all immigrants 0.95 (95% CI, 0.91-0.99), for men 0.96 (95% CI, 0.89-1.04) and for women 0.95 (95% CI, 0.90-1.00). CONCLUSIONS: We observed a similar risk of osteoporotic fractures among second-generation immigrants as in Swedish natives, which suggests that environmental factors are important for osteoporotic fractures.

Cost-Effectiveness of Titanium Elastic Nail (TEN) in the Treatment of Forearm Fractures in Children.

Background and objectives: There are various methods in the management of forearm fractures in children. Elastic stable intramedullary nailing using Titanium Elastic Nail (TEN) is nowadays employed in diaphysis fractures of children, with clear benefits over other treatment options. However, in the case of TEN versus other treatment methods of forearm fractures in children, cost is an important issue. This report will focus on the cost assessment of using TEN versus other therapeutic means in the treatment of forearm fractures in children. Materials and Methods: We performed a retrospective longitudinal study of 173 consecutive patients with forearm fractures treated in a single institution during 2017. We calculated the cost for each patient by summing up direct costs plus indirect costs, calculated at an aggregate level. Hospital income data were extracted from the Diagnosis Related Groups database. Results: A total of 173 patients with forearm fractures were treated, 44 using TEN, 86 using K-wire, and 46 using closed reduction and cast. There were 66 radius fractures, 1 ulna fracture, and 106 that were both radius and ulna fractures. Mean treatment cost were $632.76 for TEN, $499.50 for K-wire, and $451.30 for closed reduction and cast. Costs for TEN were higher than for K-wire insertion (p = 0.00) and higher than closed reduction and cast ($182.42; p = 0.00). Reimbursement per patient was higher with TEN versus K-wire patients; $497.88 vs. $364.64 /patient (p = 0.00), and higher than for patients treated with closed reduction and cast (p = 0.00). Conclusions: The treatment of upper extremity fractures using TEN was more expensive than the other methods. In Romania, because the reimbursement for TEN is higher as well, there are no differences in the financial burden when treating forearm fractures with TEN versus K-wire. Non-surgical treatment has the lowest cost but also the lowest reimbursement.

Does Mentoring by Orthopedic Surgeons Improve Forearm Fracture Reduction Outcomes by Pediatric Emergency Physicians? Evaluation of a Process Improvement Intervention Program.

BACKGROUND: Forearm fractures are among the most frequently encountered orthopedic injuries in children. The maintenance of satisfactory alignment can be problematic and postreduction displacement with resultant malunion can occur. OBJECTIVES: The objective of the study was to evaluate pediatric emergency medicine (PEM) physicians' performance on forearm fracture reduction to determine the impact of a Process Improvement Intervention Program (PIIP) on postreduction displacement rates after initial reduction. The PIIP was designed to improve our PEM physicians' skills and knowledge in how to properly apply and mold casts to better maintain the alignment of reduced forearm fractures. METHODS: A PIIP was implemented during 2015-2016 when orthopedic surgeons mentored postfellowship-trained PEM physicians. Patient cohorts from pre- and post-PIIP implementation were investigated and compared to evaluate the impact of the PIIP on PEM physicians' initial fracture reduction success rates and postreduction displacement rates. Descriptive and analytical statistics including univariate and multivariate models were tested to understand changes in physicians' performance. RESULTS: Pre- and postcohorts had similar demographic and clinical characteristics and similarly high initial reduction success rates. When distal and midshaft fracture types were combined, there was no significant difference in postreduction displacement rates between the 2 cohorts, but when stratified based on fracture type, the distal radius postcohort showed a statistically significant improvement in postreduction maintenance. CONCLUSIONS: A PIIP by pediatric orthopedic surgeons did not change the PEM physicians' initial fracture reduction success rate, but it did result in a statistically significant improvement in maintenance of reduction rates.

Incidence of distal radius fracture surgery in Finns aged 50 years or more between 1998 and 2016 - too many patients are yet operated on?

BACKGROUND: Although optimal treatment of distal radius fractures is controversial, surgery has gained popularity. The purpose of this study was to evaluate recent trends in the surgical treatment of distal radius fractures in Finns aged 50 years or more. METHODS: A nationwide hospital discharge register-based study was conducted among all patients 50 years of age or older who had a surgically treated distal radius fracture in Finland between 1998 and 2016. The number and rate of different surgical procedures were calculated per 100,000 person-years. RESULTS: Altogether 21,965 surgically treated distal radius fractures were identified. During the study period the rate of percutaneous pinning and external fixation diminished while the rate of plate fixation significantly increased. The rate of operative treatment increased continually from 1998 to 2008 whereupon the peak of the incidence was achieved. After 2008, the rate of operative treatment of distal radius fracture remained quite constant, ranging between 61.1 and 67.8 per 100,000 person-years. CONCLUSIONS: Plate fixation has almost completely replaced both external fixation and percutaneous pinning in the surgical treatment of distal radius fractures in Finland. Despite growing evidence for less invasive treatment options in elderly patients, operative treatment of distal radius fracture is still rather popular today.

Nordic Innovative Trial to Evaluate OsteoPorotic Fractures (NITEP-group): non-operative treatment versus surgery with volar locking plate in the treatment of distal radius fracture in patients aged 65 and over - a study protocol for a prospective, randomized controlled trial.

BACKGROUND: In the literature, there are numerous studies that compare different surgical procedures in the treatment of distal radius fractures (DRF). It is, however, unknown whether operative treatment and better restoration of anatomy with volar locking plate yields a better functional outcome in the elderly population when compared with non-operative treatment. METHODS AND DESIGN: This study is a prospective, randomized, controlled, multi-center trial. The purpose will be to compare the non-operative and operative treatment of initially or early malaligned distal radius fractures in patients aged 65 and older. The primary outcome in this study will be the patient rated wrist evaluation (PRWE) score measured after 1 and 2 years. DISCUSSION: We expect that initial operative treatment of a DRF with volar locking plate will not yield superior results when compared with non-operative treatment with cast immobilization in terms of functional outcome, pain, disability, quality of life, grip strength, and number of complications. TRIAL REGISTRATION: This trial is registered on clinicaltrials.gov , identifier NCT02879656 , registration date 08/17/2016.

Bedside Ultrasound vs X-Ray for the Diagnosis of Forearm Fractures in Children.

BACKGROUND: Painful forearm injuries after a fall occur frequently in children. X-ray study is currently the gold standard investigation. Ultrasound (US) is a potential alternative that avoids exposure to ionizing radiation and may be less painful than x-ray study; and familiarity and skill with US is increasing among emergency physicians. OBJECTIVES: The primary aim of this study was to determine if a cohort of physicians with little or no previous experience with US could, after a short training program, safely exclude forearm fractures in children. Secondary aims were to compare any pain or discomfort associated with clinical examination, US, and x-ray study and to determine the acceptability of US as a diagnostic tool to parents and patients. METHODS: A prospective, nonrandomized, interventional diagnostic study was performed on children between the ages of 0 and 16 years who had a suspected fracture of the forearm. US scanning was performed by a group of physicians, most with little or no previous US experience. RESULTS: After the brief training program, a group of pediatric emergency physicians could diagnose forearm fractures in children with a sensitivity of 91.5% and a specificity of 87.6%. Pain associated with US was no better or worse than pain associated with x-ray study. Patients and parents preferred US over x-ray study as an investigation modality for suspected forearm fractures. CONCLUSION: A group of pediatric emergency physicians with limited previous experience could, after a short training program, diagnose forearm fractures in children. Pain associated with US was no better or worse than pain associated with x-ray study.

Anaesthetic management of forearm fractures using a combination of haematoma block and intravenous regional anaesthesia.

BACKGROUND: Intravenous regional anaesthesia (IVRA) has been successfully used as a sole technique for forearm fractures and has high success rates. However, it is uncomfortable for the patient when the fresh fracture is manipulated for conduct of IVRA. Haematoma block (HB) has also been demonstrated as an effective anaesthetic technique for treatment of radial fractures in the ER. Unfortunately, HB does not provide muscular relaxation and may not be sufficient for operative intervention. METHODS: An observational case series was designed with the hypothesis that a combination of HB and IVRA would overcome the aforementioned drawbacks. A standardized protocol was followed for HB with 0.1 ml/kg of 0.5% bupivacaine preceding the conduct of IVRA, which permitted adequate exsanguination of the extremity (using compression bandage). For IVRA, 0.5% lignocaine at 3 mg/kg was used with an electro-pneumatic tourniquet. Pain scores were noted after the HB, at exsanguination and during surgery. RESULTS: 100 cases were studied. Average time of onset of block after HB was 2 min 18 s. By the time the IVRA procedure was performed, 99% of patients had a pain score of zero. The quality of surgical anaesthesia revealed that 94% of the patients did not have any pain of incision, tourniquet or positioning at any time during surgery. CONCLUSION: The use of dual technique of HB and IVRA improved patient acceptance and compliance, and the safety and efficacy of the IVRA. The combination anaesthesia was found to be easy to administer, effective and safe with no complications.