Interest in one of the most common injuries to the musculoskeletal system—the distal radial fracture—has been renewed. Literature over the past two centuries had even led some to believe that the distal radial fracture was a solved problem. In contrast, we are now confronted with a marked swing toward stable internal fixation being touted by some authors as the treatment of choice for all but the most stable, aligned fractures. Instructional courses, symposia, and skills courses worldwide are now oversubscribed, bearing witness to these changing perspectives.

It is surprising that, despite this aggressive push toward internal fixation, there is no convincing evidence that supports this approach in the contemporary literature. To what can we attribute this dramatic shift in the management of the distal radial fracture? In this review, we will attempt to answer this question by looking in depth at a number of contributing factors—changing epidemiologic patterns; a growing understanding of the injury mechanism; the development of enhanced imaging techniques; novel plate designs, especially those featuring …

Management of distal radial fractures.

Volar locking plate fixation via open reduction and internal fixation is an increasingly accepted method for managing displaced distal radius fractures. Volar plating offers biomechanically stable fixation, allows early rehabilitation, and enables fixation of comminuted or osteopenic bone. T

Complications of volar plate fixation for managing distal radius fractures.

The recent development of locking-plate technology has led to a potential revolution in the management of fractures of the distal radius. This review examines the evidence for pursuing anatomical restoration of the distal radius and the possible advantages and pitfalls of using volar locking plates to achieve this goal. The available evidence for adopting volar locking plates is presented and a number of important and, as yet unanswered, questions are highlighted.

A revolution in the management of fractures of the distal radius

Purpose of reviewThe problem of obesity has become a global concern, with increased prevalence reported in the literature. Numerous comorbid conditions are known to be associated with obesity; its relationship with the development and function of the musculoskeletal system in the growing child is po

Musculoskeletal effects of obesity

Background
Obesity is a risk factor for developing slipped capital femoral epiphysis (SCFE). The long-term outcome after SCFE treatment depends on the severity of residual hip deformity and the occurrence of complications, mainly avascular necrosis (AVN). Femoroacetabular impingement (FAI) is associated with SCFE-related deformity and dysfunction in both short and long term.

Slipped capital femoral epiphysis: prevalence, pathogenesis, and natural history.

Rupture of the extensor pollicis longus tendon can occur after volar plate fixation of dorsally comminuted distal radius fractures. We attempted to identify the etiology of extensor pollicis longus tendon injury after volar plate fixation of the distal radius and potential solutions to this problem. After describing two case reports, we examine six cadaveric specimens and retrospectively review 10 selected patients to evaluate possible technique refinements to minimize damage to the extensor pollicis longus tendon during volar plating of the distal radius. We identify specific screw holes in three commercially available volar distal radius plates that direct the drill bit or prominent screw tips into the third extensor compartment. In addition, after reduction and plate fixation, bone fragments or dorsal gapping may predispose the extensor pollicis longus tendon to injury. We recommend either using shorter screw lengths or leaving the implicated plate holes unfilled. In addition, we suggest consideration of an open assessment of the third extensor compartment, if indicated, as performed through a small dorsal incision ulnar to Lister's tubercle.

Two potential causes of EPL rupture after distal radius volar plate fixation.

Purpose The purpose of this study was to identify the incidence of metallic suture anchor pullout after arthroscopic rotator cuff repair and determine the impact of tear size on the risk of pullout. Methods A retrospective review of 269 patients (550 metallic suture anchors) who underwent arthroscopic rotator cuff repair between January 2006 and January 2009 was conducted. Inclusion criteria included patients aged 18 years or older, a minimum of 6 weeks' radiographic follow-up, and the use of 1 or more metallic suture anchors for partial or complete rotator cuff repair. The mean age of the cohort at the time of surgery was 55 years (range, 29 to 86 years), and there were 189 men and 80 women. Results Early anchor pullout occurred in 6 patients (9 anchors). The overall incidence of early metallic suture anchor pullout in this cohort was 2.4% (95% confidence interval, 0.5% to 4.3%). The incidence in rotator cuff tears less than or equal to 3 cm was 0.5%, and the incidence in tears greater than 3 cm was 11%. Patients undergoing arthroscopic rotator cuff repair of a tear greater than 3 cm in size were at a significantly higher risk of having early metallic suture anchor pullout than patients undergoing repair of a smaller tear (relative risk, 22; P = .001). Among the 61 patients undergoing arthroscopic subscapularis repair, no suture anchor failures were observed at the lesser tuberosity. Of the 9 anchors that failed, 8 (89%) pulled out of the posterior aspect of the greater tuberosity. Conclusions There is a minimal risk of suture anchor pullout in small- to medium-sized tears; however, this risk increases with larger tear sizes. We recommend routine radiographic follow-up after use of metallic anchors to ensure identification of early failure by anchor pullout. Level of Evidence Level III, prognostic case series.

The Incidence of Early Metallic Suture Anchor Pullout After Arthroscopic Rotator Cuff Repair

Purpose: Past epidemiological studies demonstrated a nearly fivefold lower incidence of slipped capital femoral epiphysis (SCFE) in New Mexico compared with Connecticut. A recent study demonstrated some regional variability but did not address this earlier finding. We sought to reexamine the incidence of SCFE in New Mexico to improve the understanding of the epidemiology and ultimately the disorder itself. Methods: The discharge databases for the 11 major medical centers in the state were reviewed for the ICD-9 code for SCFE (732.2) for 1995 to 2006. The data were analyzed by comparison with the 2000 New Mexico census data. The incidence data are reported as cases per 100,000 boys aged 10 to 17 years and girls aged 8 to 15 years, as per Kelsey's original article. Results: The incidence of SCFE in New Mexico for the study period was 5.99. This is a doubling of the reported incidence in the 1960s (2.13) and represents a statistically significant change (P < 0.001). More detailed analysis of our data demonstrated a statistically significant increase during 3-year intervals: 1995-1997, 2.27; 1998-2000, 2.75; 2001-2003, 4.73; and 2004-2006, 7.38. The mean age of onset was 12.2 years. There was a male to female ratio of incidence of 1.94:1. Relative frequencies by race were as follows: 4.63x for African Americans, 2.20x for Hispanics, and 2.20x for Native Americans. A preponderance of cases was treated at the state's only tertiary pediatric orthopaedic center: 168 to 15 in the remaining 10 centers. Conclusions: The incidence of SCFE has increased dramatically in New Mexico since Kelsey's epidemiological study in 1970. Obesity is a patient factor that has changed over this same period. According to the National Health and Nutrition Examination Survey Data for 2003/2004, the rates of obesity have tripled since 1971. In New Mexico, 25% of high-school children are estimated to be overweight. However, according to a recent study examining a national database (compiled from 27 states), the national incidence of SCFE remained fairly constant at 10.8 per 100,000. Interestingly, as more patients are seen at a tertiary center for children's orthopaedics, the rate of diagnosis in New Mexico has risen to resemble national trends. In the 1960, that center was located in a remote site and did not provide acute care for children's musculoskeletal issues. Increased obesity in children and improved access to pediatric orthopaedic evaluation may have contributed to a significant increase in reported incidence of SCFE in New Mexico. Level IV Evidence.

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A New Look at the Incidence of Slipped Capital Femoral Epiphysis in New Mexico

Background/Methods
The purpose of this review was to assess the current evidence supporting operative fixation versus casting for acute scaphoid fractures through a systematic review and meta-analysis of the literature.

Eric C. Benson

Papers

Two potential causes of EPL rupture after distal radius volar plate fixation.

The Incidence of Early Metallic Suture Anchor Pullout After Arthroscopic Rotator Cuff Repair

A New Look at the Incidence of Slipped Capital Femoral Epiphysis in New Mexico

Treatment of acute scaphoid fractures: a systematic review and meta-analysis

Distal tibia allograft for glenohumeral instability: does radius of curvature match?