Distal radius malunion: outcomes following an ulnar shortening osteotomy.

PURPOSE: Positive ulnar variance following a distal radius malunion can lead to ulnar-sided wrist pain, loss of grip strength, and distal radioulnar joint impingement. The primary aim of this study is to describe upper limb-specific functional outcomes following ulnar shortening osteotomy (USO) for ulnar-sided wrist pain associated with malunion of the distal radius. METHODS: We retrospectively identified 40 adult patients from a single centre over a 9-year period that had undergone an USO for symptomatic malunion of the distal radius. The primary outcome was the patient-rated wrist evaluation (PRWE). Secondary outcomes were the QuickDASH, EQ-5D-5L, complications, and net promoter score (NPS). RESULTS: Outcomes were available for 37 patients (93%). The mean age was 56 years and 25 patients were female (68%). At a mean follow-up of 6 years (range 1-10 years) the median PRWE was 11 (IQR 0-29.5), the median QuickDASH 6.8 (IQR 0-29.5), and the median EQ-5D-5L index was 0.88 (IQR 0.71-1). The NPS was 73. Complications occurred in nine patients (24%) and included non-union (n = 4), early loss of fixation requiring revision surgery (n = 1), superficial wound infection (n = 2), neurological injury (n = 1), and further surgery for symptomatic hardware removal (n = 1). CONCLUSIONS: For patients with a symptomatic distal radius malunion where the predominant deformity is ulnar positive variance, this study has demonstrated that despite 1 in 4 patients experiencing a complication, USO can result in excellent patient reported outcomes with high levels of satisfaction. LEVEL OF EVIDENCE: III (Cohort Study).

The Association Between Psychological Factors and Outcomes After Distal Radius Fracture.

PURPOSE: The aim of this study was to identify psychological factors associated with pain intensity and disability following distal radius fracture. METHODS: We prospectively followed 216 adult patients with distal radius fracture for 9 months. Demographics, injury and treatment details, and psychological measures (Hospital Anxiety and Depression Score [HADS], Pain Catastrophizing Scale, Posttraumatic Stress Disorder Checklist-Civilian, Tampa Scale for Kinesiophobia, Illness Perception Questionnaire Brief [IPQB], General Self-Efficacy Scale, and Recovery Locus of Control [RLOC]) were collected at enrollment. Multivariable linear regression was used to identify factors associated with Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) and Likert pain scores. RESULTS: Higher 10-week DASH scores were associated with increased age, the presence of a nerve pathology, increased HADS Depression subscale scores, increased IPQB scores, and lower RLOC scores. Higher 9-month DASH scores were associated with increased age, increased deprivation scores, increased numbers of medical comorbidities, a greater degree of radial shortening, increased HADS Depression subscale scores, and lower RLOC scores. A higher 10-week pain score was associated with increased deprivation and IPQB scores. A higher pain score at 9 months was associated with an increased number of medical comorbidities. CONCLUSIONS: Psychosocial factors measured early after fracture are associated with pain and disability up to 9 months after distal radius fracture. Illness perception is a potentially modifiable psychological construct not previously studied in hand conditions. It may provide a suitable target for psychological interventions that could enhance recovery. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

The rate and associated risk factors for acute carpal tunnel syndrome complicating a fracture of the distal radius.

BACKGROUND: Acute carpal tunnel syndrome (ACTS) is a known complication of distal radius fractures. This study aimed to document the demographics, range of presenting symptoms and risk factors of patients who develop ACTS following a fracture of the distal radius. METHODS: A retrospective review of 1189 patients with an acute distal radius fracture treated in the study centre over a one-year period were identified. Demographic and clinical variables were collected and compared between controls (did not develop ACTS) and those patients who did develop ACTS to identify factors associated with developing ACS. RESULTS: There were 51 (4.3%) distal radius fractures complicated by ACTS. The mean age of patients who developed ACTS was 56 years (range, 16-89) and 73% were female. The median time of onset post-injury was one week (range, 1-12). There was no association between patient background and comorbidities with the development of ACTS. AO-OTA Type C fractures had significantly increased rates of developing ACTS. CONCLUSION: Four percent of distal radius fractures were complicated by ACTS. There was no association between patient background and comorbidities with the development of ACTS. AO-OTA type C complete articular fractures had a significantly higher rate of ACTS. A suggested treatment algorithm for patients presenting with ACTS has been presented. LEVEL OF EVIDENCE: III.

High Risk of Further Surgery After Radial Head Replacement for Unstable Fractures: Longer-term Outcomes at a Minimum Follow-up of 8 Years.

BACKGROUND: The evidence for treating acute, unreconstructable radial head fractures in unstable elbows with radial head replacement predominantly consists of short- to mid-term follow-up studies with a heterogenous mix of implants and operative techniques. Data on longer-term patient-reported outcomes after radial head replacement is lacking. QUESTIONS/PURPOSES: (1) What proportion of patients undergo revision or implant removal after radial head replacement? (2) At a minimum of 8 years follow-up, what are the patient-reported outcomes (QuickDASH, Oxford Elbow Score, and EuroQol-5D)? (3) What factors are associated with a superior long-term patient-reported outcome, according to the QuickDASH? METHODS: Between September 1994 and September 2010, we surgically treated 157 patients for acute radial head fractures. We excluded patients where the radial head was excised (n = 21), internally fixed (n = 15), or replaced as a secondary procedure after failed internal fixation (n = 2). A total of 119 patients who underwent radial head replacement surgery for an acute unreconstructable fracture were included, with a mean age of 50 years (range 15 to 93 ± 19 years), and 53% of patients (63) were women. All but two implants were uncemented, loose-fitting, monopolar prostheses, of which 86% (102) were metallic and 14% (17) were silastic. Implants were only cemented if they appeared unstable within the proximal radius. Silastic implants were used in the earlier series and replaced by metallic implants starting in 2000. We reviewed electronic records to document postoperative complications and prosthesis revision and removal. A member of the local research team (THC, CDC) who was not previously involved in patient care contacted patients to confirm complications, reoperations and to obtain long-term patient-reported outcomes scores. Nineteen patients had died at the point of outcome score collection. Of the remaining 100 patients, 80 were contacted (67% of total cohort), at a median of 11 years (range 8 to 24 years) after injury. The primary outcome measure was the QuickDASH score. RESULTS: Of 119 patients, 25% (30) underwent reoperation, with three patients undergoing revision and 27 patients undergoing prosthesis removal at a median of 7 months (range 0 to 125 months). Twenty-one of 30 procedures (70%) occurred within 1 year after implantation. Kaplan-Meier survivorship analysis demonstrated a cumulative implant survival rate of 71%. In the 80 patients contacted, the mean QuickDASH score was 13 ± 14, the mean Oxford Elbow Score was 43 ± 6, and the median EuroQol-5D score was 0.8 (-0.3 to 1.0). After controlling for covariates, we found that prothesis revision or removal (p = 0.466) and prosthesis type (p = 0.553) were not associated with patient-reported outcome, according to the QuickDASH. CONCLUSIONS: The management of acute unreconstructable fractures of the radial head in unstable elbow injuries with radial head replacement has a high risk of reoperation. Patients must be counselled regarding this risk of secondary intervention, of which the peak risk appears to be within 1 year after implantation. Despite this, patients report low disability according to the QuickDASH at a minimum follow-up of 8 years. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Is Use of a Psychological Workbook Associated With Improved Disabilities of the Arm, Shoulder and Hand Scores in Patients With Distal Radius Fracture?

BACKGROUND: Symptom intensity and magnitude of limitations correlate with stress, distress, and less effective coping strategies. It is unclear if interventions to target these factors can be used to improve outcomes after distal radius fracture in either the short- or longer term. QUESTIONS/PURPOSES: (1) Are there any factors (including the use of a workbook aimed at optimizing psychological response to injury, demographic, radiographic, medical, or psychosocial) associated with improved Disabilities of the Arm, Shoulder and Hand (DASH) and Numerical Rating Scale pain (NRS pain) scores at 6 weeks after management of distal radius fracture? (2) Are any of these factors associated with improved DASH and NRS pain scores at 6 months after management of distal radius fracture? METHODS: We conducted a double-blind randomized controlled trial comparing a workbook designed to optimize rehabilitation by improving psychological response to injury using recognized psychological techniques (the LEARN technique and goal setting) versus a workbook containing details of stretching exercises in the otherwise routine management of distal radius fracture. Patients older than 18 years of age with an isolated distal radius fracture were recruited within 3 weeks of injury from a single academic teaching hospital between March and August 2016. During recruitment, 191 patients who met the inclusion criteria were approached; 52 (27%) declined participation and 139 were enrolled. Eight patients (6%) were lost to followup by 6 weeks. The remaining cohort of 129 patients was included in the analysis. DASH scores and NRS pain scores were recorded at 6 weeks and 6 months after injury. Multivariable regression analysis was used to identify factors associated with outcome scores. RESULTS: At 6 weeks after distal radius fracture, when compared with an information-only workbook, use of a psychologic workbook was not associated with improved DASH (workbook DASH: 38 [range, 21-48]; control DASH: 35 [range, 21-53]; difference of medians: 3; p = 0.949) nor NRS pain scores (workbook NRS: 3 [range, 1-5]; control NRS: 2 [range, 1-4]; difference of medians: 1; p = 0.128). Improved DASH scores were associated with less radial shortening (ß = 0.2, p = 0.009), less dorsal tilt (ß = 0.2, p = 0.035), and nonoperative treatment (ß = 0.2, p = 0.027). Improved NRS pain scores were associated with nonoperative treatment (ß = 0.2, p = 0.021) and no posttraumatic stress disorder (PTSD) (ß = 0.2, p = 0.046). At 6 months, use of a psychologic workbook was not associated with improved DASH (workbook DASH: 11 [range, 5-28]; control DASH: 11 [range, 3-20]; difference of medians: 0; p = 0.367) nor NRS pain scores (workbook NRS: 1 [range, 0-2]; control NRS: 1 [range, 0-2]; difference of medians: 0; p = 0.704). Improved DASH score at 6 months was associated with having fewer medical comorbidities (ß = 0.3, p < 0.001) and lower enrollment PTSD (ß = 0.3, p < 0.011). Lower NRS pain scores at 6 months were associated with having fewer medical comorbidities (ß = 0.2, p = 0.045), lower enrollment PTSD (ß = 0.3, p = 0.008), and lower enrollment Tampa Scale for Kinesiophobia (ß = 0.2, p = 0.042). CONCLUSIONS: Our study demonstrates that there is no benefit from the untargeted use of a psychological workbook based on the LEARN approach and goal-setting strategies in patients with distal radius fracture. Future research should investigate if there is a subgroup of patients with a negative psychological response to injury that benefits from psychological intervention and, if so, how best to identify these patients and intervene. LEVEL OF EVIDENCE: Level II, therapeutic study.

Open ankle fractures: who gets them and why?

Open ankle fractures present a significant clinical challenge. The management and outcome of these injuries has been extensively reported, but there have been no reports of the epidemiology and how this has changed over time. We report 178 adult patients with open ankle fractures presenting to our unit over a twenty-three year period. The study centre is the only hospital receiving adult orthopaedic trauma in the region and has a defined population. The incidence of open ankle fractures was 1.5/10(5)/year, representing 1.5 % of all ankle fractures. The mean age was 55 years (range 16-96), with the highest incidence occurring in women over the age of 90. The most common mechanism was a simple fall with only 26 % of cases due to a motor vehicle collision (MVC). 82 % of cases were isolated injuries. Social deprivation had no significant influence on the incidence, but there was a difference in the mechanism with the majority of injuries in the most deprived quintile caused by MVCs and significantly fewer due to simple falls (p = 0.047). Over the twenty-three years, there was a significant increase in the mean age from 44 to 64 years (p = 0.03). The overall incidence remained constant over the two decades. In common with many traumatic injuries, open ankle fractures are increasingly low-energy insufficiency fractures affecting elderly patients, particularly older women. This has implications for service planning and training as well as the surgical intervention in these patients.

Radial head replacement for acute complex fractures: what are the rate and risks factors for revision or removal?

BACKGROUND: When treating complex radial head fractures, important goals include prevention of elbow or forearm instability, with restoration of radiocapitellar contact essential. When open reduction and internal fixation cannot achieve this, radial head replacement is routinely employed, but the frequency of and risk factors for prosthesis revision or removal are not well defined. QUESTIONS/PURPOSES: We determined (1) the frequency of prosthesis revision or removal after radial head replacement for acute complex unstable radial head fractures, (2) risk factors for revision or removal, and (3) functional outcomes after radial head replacement. METHODS: We identified from our prospective trauma database all patients over a 16-year period managed acutely for unstable complex radial head fractures with primary radial head replacement. Of the 119 patients identified, 105 (88%) met our inclusion criteria; mean age was 50 years (range, 16-93 years) and 57 (54%) were female. All implants were uncemented monopolar prostheses, of which 86% were metallic and 14% silastic. We recorded further procedures for prosthesis revision or removal for any cause, with a minimum followup of 1 year (n = 105). Cox regression analysis was used to determine independent factors associated with revision or removal when controlling for baseline patient (age, sex, comorbidities) and fracture (location, classification, associated injury) characteristics. Short-term functional outcomes (Broberg and Morrey score, ROM) were determined from retrospective review of clinic followup (n = 74), with a minimum followup of 3 months. RESULTS: Twenty-nine patients (28%) underwent prosthesis revision (n = 3) or removal (n = 26) at a mean of 6.7 years (range, 1.8-18 years) after injury. Independent risk factors for removal or revision were silastic implant type and lower age. At a mean of 1.1 years (range, 0.3-5.5 years) after surgery, mean Broberg and Morrey score was 80 out of 100 (range, 40-99). Mean elbow flexion was 133° (range, 90°-159°; SD, 13°), extension 21° (range, 0°-80°; SD, 17°), flexion arc 112° (range, 10°-140°; SD, 25°), pronation 84° (range, 0°-90°; SD, 18°), supination 73° (range, 0°-90°; SD, 28°), and forearm rotation arc 156° (range, 0°-180°; SD, 38°). CONCLUSIONS: We demonstrated a high removal or revision rate after radial head replacement for acute unstable complex fractures, with lower age and silastic implants independent risk factors. Younger patients should be counseled regarding the increased risk of requiring further surgery after radial head replacement. Future work should focus on long-term patient-reported outcomes after these injuries. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Changing epidemiology of adult fractures in Scotland.

BACKGROUND: Fracture epidemiology in adults is changing but there is very little information about the rate of change or whether the change affects males and females equally. METHODS: We have compared fracture incidence in two similar populations 50-60 years apart. A study of fractures in Dundee, Scotland and Oxford, England, in 1954-1958, was compared with a similar cohort of fractures in Edinburgh, Scotland, in 2010-2011. Fracture incidence in patients >35 years was recorded in both time periods. RESULTS: The incidence of fractures increased by 50% between the two time periods, although the increase in males was only 5% compared with 85% in females. The spectrum of fractures has changed considerably, and there has been an increase in the incidence of both fragility and non-fragility fractures. Analysis showed an increased incidence of fall-related fractures in all age groups in both males and females. INTERPRETATION: There has been a substantial change in the incidence of fractures in the last 50-60 years. These have been caused by greater longevity and by considerable social and economic changes.

The spectrum of open fractures of the foot in adults.

BACKGROUND: Open foot fractures are rare, and few surgeons see the whole spectrum of these injuries. There has been no previous study of the epidemiology and severity of open foot fractures. METHODS: A 23-year study of the epidemiology of open fractures was undertaken in a hospital with a catchment area of about 530 000 adults. The results were used to calculate the incidences of open foot fractures and to study their epidemiology and severity. RESULTS: In 23 years, 348 open foot fractures were treated. Analysis showed 3 levels of severity with the least severe fractures being isolated open forefoot fractures, which occurred in 69% of the patients. Patients with multiple forefoot fractures had a higher Injury Severity Score (ISS), prevalence of Gustilo type III fractures, and amputation rate. The most severely injured patients presented with open hindfoot and midfoot fractures. They had an average ISS of 12, and 65.9% had Gustilo type III fractures. In patients with open hindfoot fractures, the amputation rate was 17.1%. This rose to 30% in patients with open midfoot fractures. Open foot fractures tended to occur in younger patients, and only 13% were in patients aged at least 65 years. CONCLUSIONS: Open foot fractures are uncommon. There were 3 levels of injury. Level 1 injuries were isolated fractures of the forefoot. Level 2 injuries were multiple forefoot fractures, and level 3 injuries were open fractures of the midfoot and hindfoot. These were severe injuries with a high amputation rate. They should be treated in level 1 trauma centers. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

The epidemiology of radial head and neck fractures.

PURPOSE: The aim of this study was to define the epidemiological characteristics of proximal radial fractures. METHODS: Using a prospective trauma database of 6,872 patients, we identified all patients who sustained a fracture of the radial head or neck over a 1-year period. Age, sex, socioeconomic status, mechanism of injury, fracture classification, and associated injuries were recorded and analyzed. RESULTS: We identified 285 radial head (n = 199) and neck (n = 86) fractures, with a patient median age of 43 years (range, 13-94 y). The mean age of male patients was younger when compared to female patients for radial head and neck fractures, with no gender predominance seen. Gender did influence the mechanism of injury, with female patients commonly sustaining their fracture following a low-energy fall. Radial head fractures were associated more commonly with complex injuries according to the Mason classification, while associated injuries were related to age, the mechanism of injury, and increasing fracture complexity. CONCLUSIONS: Radial head and neck fractures have distinct epidemiological characteristics, and consideration for osteoporosis in a subset of patients is recommended. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

How useful are meta-analyses in orthopedic trauma?

BACKGROUND: Meta-analysis has become accepted as a methodically rigorous research tool, and as a result, many meta-analyses have been undertaken in orthopedic trauma, the implication being that their conclusions have improved surgeons' knowledge and facilitated improved clinical care. There have been criticisms of the methodology used in a number of meta-analyses; however, there has been no previous study of the clinical usefulness of their conclusions. METHODS: A study of 60 orthopedic trauma meta-analyses published during or after 2000 was undertaken. We divided the conclusions of the meta-analyses into four types depending on their innovation and potential for improving clinical care. We also separated the meta-analyses according to whether they were undertaken by the Cochrane Collaboration or by independent surgeons. RESULTS: Only 4 (6.7%) of the meta-analyses contained new, clinically useful, information, and 22 (36.7%) had no conclusions at all. A further 25 (41.7%) contained conclusions that were already in the standard orthopedic trauma literature. Approximately 70% of the Cochrane Collaborations had no conclusions. CONCLUSIONS: We found considerable variability in the clinical usefulness of orthopedic trauma meta-analyses, and we question the clinical usefulness of this type of research.

Radial head and neck fractures: functional results and predictors of outcome.

BACKGROUND: The purpose of this study was to determine the functional outcomes and predictive factors of radial head and neck fractures. METHODS: Over an 18-month period, we performed a prospective study of 237 consecutive patients with a radiographically confirmed proximal radial fracture (156 radial head and 81 radial neck). Follow-up was carried out over a 1-year period using clinical and radiologic assessment, including the Mayo Elbow Score (MES). Multivariate regression analysis was used to determine significant predictors of outcome according to the MES. RESULTS: Of the 237 patients enrolled in the study, 201 (84.8%) attended for review, with a mean age of 44 years (range, 16-83 years; standard deviation, 17.3). One hundred eighty-seven (93%) patients achieved excellent or good MESs. The mean MES for Mason type-I (n = 103) and type-II (n = 82) fractures was excellent, with only two patients undergoing surgical intervention. For Mason type-III (n = 11) and type-IV (n = 5) fractures, the flexion arc, forearm rotation arc, and MES in the nonoperatively treated patients were not significantly different (all p ≥ 0.05) from those managed operatively. Regression analysis revealed that increasing age, increasing fracture complexity according to the AO-OTA classification, increasing radiographic comminution, and operative treatment choice were independently significant predictors of a poorer outcome (all p < 0.05). CONCLUSIONS: A majority of radial head and neck fractures can be treated nonoperatively, achieving excellent or good results. Age, fracture classification, radiographic comminution, and treatment choice are important factors that determine recovery.

Radial shortening following a fracture of the proximal radius.

BACKGROUND AND PURPOSE: The Essex-Lopresti lesion is thought to be rare, with a varying degree of disruption to forearm stability probable. We describe the range of radial shortening that occurs following a fracture of the proximal radius, as well as the short-term outcome in these patients. PATIENTS AND METHODS: Over an 18-month period, we prospectively assessed all patients with a radiographically confirmed proximal radial fracture. Patients noted to have ipsilateral wrist pain at initial presentation underwent bilateral radiography to determine whether there was disruption of the distal radio-ulnar joint suggestive of an Essex-Lopresti lesion. Outcome was assessed after a mean of 6 (1.5-12) months using clinical and radiographic results, including the Mayo elbow score (MES) and the short musculoskeletal function assessment (SMFA) questionnaire. One patient with a Mason type-I fracture was lost to follow-up after initial presentation. RESULTS: 60 patients had ipsilateral wrist pain at the initial assessment of 237 proximal radial fractures. Radial shortening of ≥ 2mm (range: 2-4mm) was seen in 22 patients (mean age 48 (19-79) years, 16 females). The most frequent mechanism of injury was a fall from standing height (10/22). 21 fractures were classified as being Mason type-I or type-II, all of which were managed nonoperatively. One Mason type-III fracture underwent acute radial head replacement. Functional outcome was assessed in 21 patients. We found an excellent or good MES in 18 of the 20 patients with a Mason type-I or type-II injury. INTERPRETATION: The incidence of the Essex-Lopresti lesion type is possibly under-reported as there is a spectrum of injuries, and subtle disruptions often go unidentified. A full assessment of all patients with a proximal radial fracture is required in order to identify these injuries, and the index of suspicion is raised as the complexity of the fracture increases.

Tibial shaft fractures - to monitor or not? a multi-centre 2 year comparative study assessing the diagnosis of compartment syndrome in patients with tibial diaphyseal fractures.

AIMS: The aim of this study was to compare the outcome in patients who did and did not undergo continuous compartment pressure monitoring (CCPM) following a tibial diaphyseal fracture. PATIENTS AND METHODS: We performed a retrospective cohort study of 287 patients with an acute tibial diaphyseal fractures who presented to three centres over a two-year period. Demographic data, diagnosis, management, wound closure, complications, and subsequent surgeries were recorded. The primary outcome measure was the rate of short-term complications. Secondary outcomes were time to fasciotomy and split-skin grafting rates. RESULTS: Of the 287 patients in the study cohort, 171 patients underwent CCPM (monitored group; MG) and 116 did not (non-monitored group; NMG). There were 21 patients who developed ACS and underwent fasciotomy, with comparable rates in both groups (n=13 in the MG vs n=8 in NMG; p=0.82). There was no difference in the rate of complications between groups (all p>0.05). The mean time from admission to fasciotomy was 22.1hrs, with a mean time of 19.8hrs in the MG and 25.8hrs in the NMG (mean difference, 6hrs; p=0.301). One patient in the NMG required a below-knee amputation. There was a trend towards a reduced requirement for split-skin grafting post decompression in the MG (15% vs 50%; p=0.14). CONCLUSION: This study found no difference in the short-term complication rates in those patients that underwent CCPM and those that did not following a fracture of the tibial diaphysis. CCPM does appear to be safe with no increase in the rate of fasciotomies performed. There was a trend towards a reduced time to fasciotomy and a reduced rate of split skin grafting for wound closure with CCPM. LEVEL OF EVIDENCE: Level III (Diagnostic: Retrospective cohort study).

Diagnosis of Suspected Scaphoid Fractures.

¼: Suspected scaphoid fractures are a diagnostic and therapeutic challenge despite the advances in knowledge regarding these injuries and imaging techniques. The risks and restrictions of routine immobilization as well as the restriction of activities in a young and active population must be weighed against the risks of nonunion that are associated with a missed fracture. ¼: The prevalence of true fractures among suspected fractures is low. This greatly reduces the statistical probability that a positive diagnostic test will correspond with a true fracture, reducing the positive predictive value of an investigation. ¼: There is no consensus reference standard for a true fracture; therefore, alternative statistical methods for calculating sensitivity, specificity, and positive and negative predictive values are required. ¼: Clinical prediction rules that incorporate a set of demographic and clinical factors may allow stratification of secondary imaging, which, in turn, could increase the pretest probability of a scaphoid fracture and improve the diagnostic performance of the sophisticated radiographic investigations that are available. ¼: Machine-learning-derived probability calculators may augment risk stratification and can improve through retraining, although these theoretical benefits need further prospective evaluation. ¼: Convolutional neural networks (CNNs) are a form of artificial intelligence that have demonstrated great promise in the recognition of scaphoid fractures on radiographs. However, in the more challenging diagnostic scenario of a suspected or so-called "clinical" scaphoid fracture, CNNs have not yet proven superior to a diagnosis that has been made by an experienced surgeon.

Patient-reported outcomes after corrective osteotomy for a symptomatic malunion of the distal radius.

AIMS: The primary aim of this study was to describe patient satisfaction and health-related quality of life (HRQoL) following corrective osteotomy for a symptomatic malunion of the distal radius. METHODS: We retrospectively identified 122 adult patients from a single centre over an eight-year period who had undergone corrective osteotomy for a symptomatic malunion of the distal radius. The primary long-term outcome was the Patient-Rated Wrist Evaluation (PRWE) score. Secondary outcomes included the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, the EQ-5D-5L score, complications, and the Net Promoter Score (NPS). Multivariate regression analysis was used to determine factors associated with the PRWE score. RESULTS: Long-term outcomes were available for 89 patients (72%). The mean age was 57 years (SD 15) and 68 were female (76%). The median time from injury to corrective osteotomy was nine months (interquartile range (IQR) 6 to 13). At a mean follow-up of six years (1 to 11) the median PRWE score was 22 (IQR 7 to 40), the median QuickDASH score was 11.4 (IQR 2.3 to 31.8), and the median EQ-5D-5L score was 0.84 (IQR 0.69 to 1). The NPS was 69. Multivariate regression analysis showed that the presence of an associated ulnar styloid fracture was the only significant independent factor associated with a worse PRWE score when adjusting for confounding variables (p = 0.004). CONCLUSION: We found that corrective osteotomy for malunion of the distal radius can result in good functional outcomes and high levels of patient satisfaction. However, the presence of an ulnar styloid fracture may adversely affect function. Level of Evidence: III (cohort study). Cite this article: Bone Joint J 2020;102-B(11):1542-1548.

Effect of Alendronic Acid on Fracture Healing: A Multicenter Randomized Placebo-Controlled Trial.

There is a concern that bisphosphonates may impair fracture healing because of their inhibitory effects on bone turnover. Here we evaluated the effects of early bisphosphonate therapy on fracture healing and functional outcome following a fracture of the distal radius. The fracture and bisphosphonates (FAB) trial was a double-blind, randomized, placebo-controlled trial involving 15 trauma centers in the United Kingdom. We enrolled 421 bisphosphonate-naive patients aged ≥50 years with a radiographically confirmed fracture of the distal radius and randomized them in a 1:1 ratio to receive alendronic acid 70 mg once weekly (n = 215) or placebo (n = 206) within 14 days of the fracture. The primary outcome measure was the proportion of fractures that had radiologically united at 4 weeks as assessed by an observer, blinded to treatment allocation. Secondary outcomes included the Disabilities of the Arm Shoulder and Hand (DASH) questionnaire, range of wrist movement and grip strength, pain and analgesia requirements, and the rate of malunion. The mean ± SD age of participants was 63 ± 8.5 years and 362 (86%) were female. At 4 weeks, 48 of 202 (23.8%) fractures had united in the alendronic acid group compared with 52 of 187 (27.8%) in the placebo group (observed absolute proportion difference 4.0%; 95% CI, -4.7% to 12.8%; p = 0.36). The absolute proportion difference between groups based on imputed data was 4.5% (95% CI, -4.7% to 13.8%; p = 0.30). There was no significant difference in the proportion of fractures that had united at any other time point and no differences in the DASH score, pain at the fracture site, grip strength, or any other clinical outcome. We conclude that among patients aged 50 years and above with a distal radius fracture, early administration of alendronic acid does not adversely affect fracture union or clinical outcome. These findings suggest bisphosphonate therapy can be safely commenced early after fracture if clinically indicated. © 2019 American Society for Bone and Mineral Research.

Nonunions of the proximal humerus: their prevalence and functional outcome.

BACKGROUND: : We present an analysis of the prevalence of proximal humeral nonunions and an assessment of their functional outcome. METHODS: : The results of a study of 11 proximal humeral nonunions taken from a previous prospective study of 1,027 consecutive proximal humeral fractures were analyzed to determine the demography of the patient population, the Constant and Neer scores at 6 weeks, 13 weeks, 26 weeks, and 1 year and the functional outcome of the patients. All patients had been followed for 1 year and standard anteroposterior and modified axial X-rays taken at each assessment. The possible factors associated with proximal nonunion were studied. RESULTS: : The prevalence of proximal humeral nonunion is 1.1%, although it rises to about 8% if metaphyseal comminution is present and 10% if there is between 33% and 100% translation of the surgical neck. The effect of nonunion on function is considerable, even as early as 6 weeks after fracture. Our results show a deterioration of overall glenohumeral function after 6 months compared with patients whose fractures unite. Return to routine activities of daily living is markedly slower in the presence of a nonunion. The nonunions occurred in older patients but the age difference was not statistically significant. CONCLUSIONS: : Our results show that nonunion after nonoperative treatment of proximal humeral fractures is much less than has previously been reported and they suggest that age, metaphyseal comminution and fracture displacement are all factors in the development of nonunion. They also indicate that if operative treatment is required for proximal humeral nonunion it should not be delayed beyond 6 months after fracture and ideally should be performed as soon as the presence of a nonunion has become established this frequently being about 3 months after fracture.

The Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) can measure the impairment, activity limitations and participation restriction constructs from the International Classification of Functioning, Disability and Health (ICF).

BACKGROUND: The International Classification of Functioning, Disability and Health (ICF) model of the consequences of disease identifies three health outcomes, impairment, activity limitations and participation restrictions. However, few orthopaedic health outcome measures were developed with reference to the ICF. This study examined the ability of a valid and frequently used measure of upper limb function, namely the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH), to operationalize the ICF. METHODS: Twenty-four judges used the method of Discriminant Content Validation to allocate the 38 items of the DASH to the theoretical definition of one or more ICF outcome. One-sample t-tests classified each item as measuring, impairment, activity limitations, participation restrictions, or a combination thereof. RESULTS: The DASH contains items able to measure each of the three ICF outcomes with discriminant validity. The DASH contains five pure impairment items, 19 pure activity limitations items and three participation restriction items. In addition, seven items measured both activity limitations and participation restrictions. CONCLUSION: The DASH can measure the three health outcomes identified by the ICF. Consequently the DASH could be used to examine the impact of trauma and subsequent interventions on each health outcome in the absence of measurement confound.