A Systematic Review of Outcomes and Complications of Treating Unstable Distal Radius Fractures in the Elderly
01 May 2011-Journal of Hand Surgery (European Volume) (NIH Public Access)-Vol. 36, Iss: 5, pp 824-835
TL;DR: A systematic review of existing literature for the management of osteoporotic distal radius fractures in patients aged 60 and over with 5 common techniques suggests that despite worse radiographic outcomes associated with CI, functional outcomes were no different from those of surgically treated groups for patients age 60 andover.
Abstract: Purpose As the population in developed countries continues to age, the incidence of osteoporotic distal radius fractures (DRFs) will increase as well. Treatment of DRF in the elderly population is controversial. We systematically reviewed the existing literature for the management of DRFs in patients aged 60 and over with 5 common techniques: the volar locking plate system, nonbridging external fixation, bridging external fixation, percutaneous Kirschner wire fixation, and cast immobilization (CI). Methods We reviewed articles retrieved from MEDLINE, Embase, and CINAHL Plus that met predetermined inclusion and exclusion criteria in 2 literature reviews. Outcomes of interest included wrist arc of motion, grip strength, functional outcome measurements, radiographic parameters, and the number and type of complications. We statistically analyzed the data using weighted means and proportions based on the sample size in each study. Results We identified 2,039 papers and selected 21 papers fitting the inclusion criteria in the primary review of articles with a mean patient age of 60 and older. Statistically significant differences were detected for wrist arc of motion, grip strength, and Disabilities of the Arm, Shoulder, and Hand score, although these findings may not be clinically meaningful. Volar tilt and ulnar variance revealed significant differences among groups, with CI resulting in the worst radiographic outcomes. The complications were significantly different, with CI having the lowest rate of complications, whereas the volar locking plate system had significantly more major complications requiring additional surgical intervention. Conclusions This systematic review suggests that despite worse radiographic outcomes associated with CI, functional outcomes were no different from those of surgically treated groups for patients age 60 and over. Prospective comparative outcomes studies are necessary to evaluate the rate of functional recovery, cost, and outcomes associated with these 5 treatment methods. Type of study/level of evidence Therapeutic III.
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TL;DR: Comparing the outcomes of two methods used for the treatment of displaced and unstable distal radial fractures in patients sixty-five years of age or older found no significant differences between the groups in terms of the range of motion or the level of pain.
Abstract: Background: Despite the recent trend toward the internal fixation of distal radial fractures in older patients, the currently available literature lacks adequate randomized trials examining whether open reduction and internal fixation (ORIF) with a volar locking plate is superior to nonoperative (cast) treatment. The purpose of the present randomized clinical trial was to compare the outcomes of two methods that were used for the treatment of displaced and unstable distal radial fractures in patients sixty-five years of age or older: (1) ORIF with use of a volar locking plate and (2) closed reduction and plaster immobilization (casting).
Methods: A prospective randomized study was performed. Seventy-three patients with a displaced and unstable distal radial fracture were randomized to ORIF with a volar locking plate (n = 36) or closed reduction and cast immobilization (n = 37). The outcome was measured on the basis of the Patient-Rated Wrist Evaluation (PRWE) score; the Disabilities of the Arm, Shoulder and Hand (DASH) score; the pain level; the range of wrist motion; the rate of complications; and radiographic measurements including dorsal radial tilt, radial inclination, and ulnar variance.
Results: There were no significant differences between the groups in terms of the range of motion or the level of pain during the entire follow-up period (p > 0.05). Patients in the operative treatment group had lower DASH and PRWE scores, indicating better wrist function, in the early postoperative time period (p < 0.05), but there were no significant differences between the groups at six and twelve months. Grip strength was significantly better at all times in the operative treatment group (p < 0.05). Dorsal radial tilt, radial inclination, and radial shortening were significantly better in the operative treatment group than in the nonoperative treatment group at the time of the latest follow-up (p < 0.05). The number of complications was significantly higher in the operative treatment group (thirteen compared with five, p < 0.05).
Conclusions: At the twelve-month follow-up examination, the range of motion, the level of pain, and the PRWE and DASH scores were not different between the operative and nonoperative treatment groups. Patients in the operative treatment group had better grip strength through the entire time period. Achieving anatomical reconstruction did not convey any improvement in terms of the range of motion or the ability to perform daily living activities in our cohorts.
Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
429 citations
TL;DR: Findings with respect to mobility, functionality, and quality of life at 12 months provide marginal and inconsistent evidence for the superiority of volar angle-stable plate osteosynthesis over closed reduction and casting in the treatment of intra-articular distal radius fractures.
Abstract: Distal radius fracture is one of the most frequent human injuries. In persons aged 50 and over it is one of the typical fractures indicating underlying osteoporosis (1). The age-adjusted incidence in large population-based studies ranges from 73 to 202 per 100 000 in men and from 309 to 767 per 100 000 in women (2, 3). At the age of 60 years the residual lifetime risk of a distal radius fracture is 15% for women and 2% for men (3). In the year 2012 almost 84 000 persons received inpatient treatment for wrist fractures in Germany. In light of the current epidemic of osteoporosis, further growth of the incidence of distal radius fractures can be expected (4– 6).
The published intervention studies paint an inconsistent picture and are inadequate for the establishment of clear standards of care. The relevant Cochrane Reviews have not been updated since 2008 (7, 8).
Treatment by closed reduction and cast immobilization can be carried out nationwide at low direct cost without admission to hospital, but permits no anatomical reconstruction of bone fragments and joint cartilage. Such reconstruction can be viewed as a necessary, albeit not sufficient, condition for the recovery of joint function. Clinical experience shows that both elderly patients’ perception of age and their level of physical activity have undergone a dramatic transformation in recent years. The treatment of distal radius fractures therefore has to be oriented on the functional expectations of the individual patient. With regard to surgical treatment, volar locking plate fixation (open reduction and internal fixation, ORIF) has become the standard of care.
The authors of a systematic review published in 2011 (21 studies, 2093 patients) concluded that “the available data suggest that in patients over 60 the functional outcome of nonoperative therapy, despite the poorer radiological results, does not differ from that of surgical management” (9). The methods and clinical characteristics (e.g., inclusion criteria and interventions) of the individual studies varied so widely that further interpretation of the data was impossible.
The sole randomized trial to compare volar locking plate fixation with plaster cast treatment included 73 patients (mean age 77 years, proportion of intra-articular fractures 70%) (10). Three months after operation there was a moderate advantage for surgical treatment. At 6 and 12 months, however, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire revealed no significant differences (0.2 and 2.3 points) between the treatment groups. These results were in agreement with those of a previous retrospective study by the same research group (11, 12) and other studies (9, 13).
At present there is no clear answer to the simple question of whether, in multi-fragmentary intra-articular fractures (type C of the Arbeitsgemeinschaft fur Osteosynthese [AO] classification), the benefits of anatomical reconstruction of the wrist joint by open reduction and volar locking plate fixation, coupled with swift attainment of functional stability, outweigh the disadvantages of higher costs and greater risk of complications in the long term.
On the assumption that in future the principal burden of disease will be caused by osteoporosis-related fractures in patients who wish to regain autonomy in looking after themselves and managing their household but are not engaged in sports or other strenuous physical activities, there is an urgent need for direct comparison between outpatient closed reduction with cast immobilization and inpatient volar locking plate fixation. This is also important with regard to strategic planning of inhospital care capacity in the coming years.
The pragmatic randomized multi-center ORCHID study (Open Reduction and Internal Fixation versus Cast Treatment of Highly Comminuted Intra-Articular Fractures of the Distal Radius) is intended to clarify whether open reduction with volar locking plate fixation is superior to nonsurgical treatment in respect of health-related quality of life and functional outcome in the scenario described.
143 citations
TL;DR: The Spanish and European Network of Excellence for the Prevention and Treatment of Osteoporotic Fractures, "Ageing", was created as mentioned in this paper, which integrates three communities, e.g., clinicians, materials scientists and industrial advisors, tackling the same problem from three different points of view.
120 citations
TL;DR: The literature over the past 5 years is reviewed to guide the management regarding the common upper-extremity injury distal radius fracture open reduction and internal fixation.
Abstract: Despite the frequency of distal radius fractures, the optimal treatment remains without consensus opinion. A trend toward increased distal radius fracture open reduction and internal fixation has been identified, with biomechanical and clinical studies suggesting treatment advantages of certain fixation methods over others. Well-controlled patient trials are still missing to lend objective findings to management algorithms. This article reviews the literature over the past 5 years to guide our management regarding this common upper-extremity injury.
118 citations
TL;DR: The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures.
Abstract: Over the past 4 decades, much has been learned about the pathophysiology and treatment of osteoporosis, the prevention of fragility fractures, and the perioperative management of patients who have these debilitating injuries. However, the volume of published literature on this topic is staggering and far too voluminous for any clinician to review and synthesize by him or herself. This manuscript thoroughly summarizes the latest research on fragility fractures and provides the reader with valuable strategies to optimize the prevention and management of these devastating injuries. The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures. As providers begin to gain a better understanding of the principles espoused in this article, it is our hope that they will be able to use this information to optimize the care they provide for elderly patients who are at risk of or who have osteoporotic fractures.
114 citations
References
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TL;DR: A checklist contains specifications for reporting of meta-analyses of observational studies in epidemiology, including background, search strategy, methods, results, discussion, and conclusion should improve the usefulness ofMeta-an analyses for authors, reviewers, editors, readers, and decision makers.
Abstract: ObjectiveBecause of the pressure for timely, informed decisions in public health
and clinical practice and the explosion of information in the scientific literature,
research results must be synthesized. Meta-analyses are increasingly used
to address this problem, and they often evaluate observational studies. A
workshop was held in Atlanta, Ga, in April 1997, to examine the reporting
of meta-analyses of observational studies and to make recommendations to aid
authors, reviewers, editors, and readers.ParticipantsTwenty-seven participants were selected by a steering committee, based
on expertise in clinical practice, trials, statistics, epidemiology, social
sciences, and biomedical editing. Deliberations of the workshop were open
to other interested scientists. Funding for this activity was provided by
the Centers for Disease Control and Prevention.EvidenceWe conducted a systematic review of the published literature on the
conduct and reporting of meta-analyses in observational studies using MEDLINE,
Educational Research Information Center (ERIC), PsycLIT, and the Current Index
to Statistics. We also examined reference lists of the 32 studies retrieved
and contacted experts in the field. Participants were assigned to small-group
discussions on the subjects of bias, searching and abstracting, heterogeneity,
study categorization, and statistical methods.Consensus ProcessFrom the material presented at the workshop, the authors developed a
checklist summarizing recommendations for reporting meta-analyses of observational
studies. The checklist and supporting evidence were circulated to all conference
attendees and additional experts. All suggestions for revisions were addressed.ConclusionsThe proposed checklist contains specifications for reporting of meta-analyses
of observational studies in epidemiology, including background, search strategy,
methods, results, discussion, and conclusion. Use of the checklist should
improve the usefulness of meta-analyses for authors, reviewers, editors, readers,
and decision makers. An evaluation plan is suggested and research areas are
explored.
17,663 citations
TL;DR: In 673 open fractures of long bones treated from 1955 to 1968 at Hennepin County Medical Center, Minneapolis, Minnesota, and analyzed retrospectively and in a prospective study from 1969 to 1973, Sensitivity studies suggested that cephalosporin is currently the prophylactic antibiotic of choice.
Abstract: In 673 open fractures of long bones (tibia and fibula, femur, radius and ulna, and humerus) treated from 1955 to 1968 at Hennepin County Medical Center, Minneapolis, Minnesota, and analyzed retrospectively, the infection rate was 12 per cent from 1955 to 1960 and 5 per cent from 1961 to 1968. In a prospective study from 1969 to 1973, 352 patients were managed as follows: debridement and copious irrigation, primary closure for Type I and II fractures and secondary closure for Type III fractures, no primary internal fixation except in the presence of associated vascular injuries, cultures of all wounds, and oxacillin-ampicillin before surgery and for three days postoperatively. In 158 of the patients in the prospective study the initial wound cultures revealed bacterial growth in 70.3 per cent and the infection rate was 2.5 per cent. Sensitivity studies suggested that cephalosporin is currently the prophylactic antibiotic of choice. For the Type III open fractures (severe soft-tissue injury, segmental fracture, or traumatic amputation), the infection rates were 44 per cent in the retrospective study and 9 per cent in the prospective study.
2,732 citations
TL;DR: Intra-articular fractures of the distal part of the radius in young adults comprise a distinct subgroup of fractures that are difficult to manage and are associated with a high frequency of post-traumatic arthritis.
Abstract: Intra-articular fractures of the distal part of the radius in young adults comprise a distinct subgroup of fractures that are difficult to manage and are associated with a high frequency of post-traumatic arthritis. The effect of residual radiocarpal incongruity after this fracture has not been investigated previously. A retrospective study of forty-three fractures in forty young adults (mean age, 27.6 years) was done to determine the components that are critical to the outcome. Treatment included application of a cast alone in twenty-one fractures, insertion of pins and application of a plaster cast in seventeen, external fixation in two fractures, and open reduction and internal fixation in three fractures. At a mean follow-up of 6.7 years, 26 per cent were rated as excellent; 35 per cent, as good; 33 per cent, as fair; and 6 per cent, as poor. There was radiographic evidence of post-traumatic arthritis in twenty-eight (65 per cent) of the fractures. Accurate articular restoration was the most critical factor in achieving a successful result. Of the twenty-four fractures that healed with residual incongruity of the radiocarpal joint, arthritis was noted in 91 per cent, whereas of the nineteen fractures that healed with a congruous joint, arthritis developed in only 11 per cent. A depressed articular surface (a so-called die-punch fragment) was reduced anatomically by closed means in only 49 per cent and was responsible for residual incongruity in 75 per cent of the incongruous joints at late follow-up. Non-union of the ulnar styloid process adversely affected the results. Restoration and maintenance (extra-articular reduction) of the dorsal tilt and radial length did not prove critical except when severe radial shortening occurred.
1,106 citations
TL;DR: Meta-analysis was applied to the entire applicable literature to generate accurate estimates of the true incidences of ACL tear as a function of gender, sport, and injury-reduction training and found female subjects had a roughly 3 times greater incidence of ACL tears in soccer and basketball versus male subjects.
Abstract: Purpose: The literature has shown that anterior cruciate ligament (ACL) tear rates vary by gender, by sport, and in response to injury-reduction training programs. However, there is no consensus as to the magnitudes of these tear rates or their variations as a function of these variables. For example, the female-male ACL tear ratio has been reported to be as high as 9:1. Our purpose was to apply meta-analysis to the entire applicable literature to generate accurate estimates of the true incidences of ACL tear as a function of gender, sport, and injury-reduction training. Methods: A PubMed literature search was done to identify all studies dealing with ACL tear incidence. Bibliographic cross-referencing was done to identify additional articles. Meta-analytic principles were applied to generate ACL incidences as a function of gender, sport, and prior injury-reduction training. Results: Female-male ACL tear incidences ratios were as follows: basketball, 3.5; soccer, 2.67; lacrosse, 1.18; and Alpine skiing, 1.0. The collegiate soccer tear rate was 0.32 for female subjects and 0.12 for male subjects. For basketball, the rates were 0.29 and 0.08, respectively. The rate for recreational Alpine skiers was 0.63, and that for experts was 0.03, with no gender variance. The two volleyball studies had no ACL tears. Training reduced the ACL tear incidence in soccer by 0.24 but did not reduce it at all in basketball. Conclusions: Female subjects had a roughly 3 times greater incidence of ACL tears in soccer and basketball versus male subjects. Injury-reduction programs were effective for soccer but not basketball. Recreational Alpine skiers had the highest incidences of ACL tear, whereas expert Alpine skiers had the lowest incidences. Volleyball may in fact be a low-risk sport rather than a high-risk sport. Alpine skiers and lacrosse players had no gender difference for ACL tear rate. Year-round female athletes who play soccer and basketball have an ACL tear rate of approximately 5%. Level of Evidence: Level IV, therapeutic case series.
779 citations
TL;DR: This work used population-based data to estimate a woman's lifetime risk of suffering a hip, Colles', or vertebral fracture and her risk of dying of coronary heart disease.
Abstract: • Lifetime risk is a useful way to estimate and compare the risk of various conditions. Hip fractures, Colles' fractures, and coronary heart disease, and breast and endometrial cancers are important conditions in postmenopausal women that might be influenced by the use of hormone replacement therapy. We used population-based data to estimate a woman's lifetime risk of suffering a hip, Colles', or vertebral fracture and her risk of dying of coronary heart disease. A 50-year-old white woman has a 16% risk of suffering a hip fracture, a 15% risk of suffering a Colles' fracture, and a 32% risk of suffering a vertebral fracture during her remaining lifetime. These risks exceed her risk of developing breast or endometrial cancer. She has a 31% risk of dying of coronary heart disease, which is about 10 times greater than her risk of dying of hip fractures or breast cancer. These lifetime risks provide a useful description of the comparative risks of conditions that might be influenced by postmenopausal hormone therapy. ( Arch Intern Med. 1989;149:2445-2448)
675 citations