This monograph is written as a guide for physicians, nurses, therapists, and students interested in ideal care for their patients with fragility fractures. The scope of fragility fractures in the United States is large and will grow over the next 20 years as the population ages. There is much that can be done currently to idealize the outcomes of these patients. Additional research in many areas is needed to further improve the quality of care for these patients. We plan to update this monograph as new information concerning the care of seniors with fragility fractures develops.

https://journals.sagepub.com/doi/pdf/10.1177/2151458510397504

A guide to improving the care of patients with fragility fractures.

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.

https://journals.sagepub.com/doi/pdf/10.1177/2151458515572697

A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2:

Purpose Compared with cast treatment, surgery may expose patients with distal radius fractures to undue risk. Surgical intervention in this cohort may offer less benefit than previously thought and appropriate patient selection is imperative. The modified Frailty Index (mFI) predicts complications after other orthopedic surgeries. We hypothesized that this index would predict, and might ultimately prevent, complications in patients older than 50 years with distal radius fractures. Methods We retrospectively reviewed the American College of Surgeons—National Surgery Quality Improvement Program (ACS-NSQIP) database, including patients older than 50 years who underwent open reduction and internal fixation of a distal radius fracture. A 5-item mFI score was then calculated for each patient. Postoperative complications , readmission and reoperation rates, as well as length of stay (LOS) were recorded. Bivariate and multivariable statistical analysis was then performed. Results We identified 6,494 patients (mean age, 65 years). Compared with patients with mFI of 0, patients with mFI of 2 or greater were nearly 2.5 times as likely to incur a postoperative complication (1.7% vs 7.4%). Specifically, the rates of Clavien-Dindo IV, wound, cardiac, and renal complications were increased significantly in patients with mFI of 2 or greater. In addition, as mFI increased from 0 to 2 or greater, 30-day reoperation rate increased from 0.8% to 2.4%, 30-day readmission from 0.8% to 4.6%, and LOS from 0.5 days to 1.44 days. Frailty was associated with increased complications as well as rates of readmission and reoperation even when controlling for demographic data, LOS, and operative time. Age alone was not significantly associated with postoperative complications, readmission, reoperation, or LOS. Conclusions A state of frailty is highly predictive of postoperative complications, readmission, reoperation, and increased LOS following open reduction and internal fixation of distal radius fractures. Our data suggest that a simple frailty evaluation can help inform surgical decision making in patients older than 50 years with distal radius fractures. Type of study/level of evidence Prognostic II.

Use of a 5-Item Modified Frailty Index for Risk Stratification in Patients Undergoing Surgical Management of Distal Radius Fractures.

Background
Flexor tendon rupture is a rare but major complication associated with volar plate fixation of distal radius fractures.

/pdf/flexor-tendon-injuries-following-plate-fixation-of-distal-2gik98mvxh.pdf

Flexor tendon injuries following plate fixation of distal radius fractures: a systematic review of the literature

Apparatus and methods for bone fracture repair. The apparatus may include a structural support for positioning a first bone segment relative to a second bone segment. The apparatus may include an anchoring substrate. The anchoring substrate may be configured to compress the first bone segment to the second bone segment. The anchoring substrate may transmit tension from a distal bone segment anchor in the first bone segment to a proximal bone segment anchor in the second bone segment. The apparatus may be configured to be deployed percutaneously in an inner cavity of a bone. The apparatus may be installed in an open fracture. The apparatus may be expanded, self-expanding or configured for mechanically actuation. Some embodiments of the apparatus may include a central axis member that may be used in conjunction with expansion of one or both of the structural support and the anchoring substrate to configure the apparatus.

Apparatus and methods for fracture repair

With an incidence of about 2–4 per 1,000 residents per year, the distal radial fracture is the most common fracture in the human skeleton. The introduction of fixed-angle plate systems for extension fractures at the radius was evaluated in a prospective study performed at our hospital after selection and acquisition of a new system. The focus of our interest was whether a secondary loss of reduction can be avoided by this plating system. We reviewed 80 patients treated for unstable distal radius fractures using a volar fixed-angle plate. Postoperative management included immediate finger motion, early functional use of the hand, a wrist splint used for 4 weeks and physiotherapy. Standard radiographic and clinical fracture parameters after 12 months (range 12–14 months) were measured and final functional results where assessed. Bone healing had occurred in all patients at the time of follow-up after 1 year. On X-rays taken at the time of follow-up 60 patients (75%) had no radial shortening, 20 patients (25%) had a mean radial shortening of only 1.8 mm (range 1–3 mm) compared to the contralateral side. The radial tilt was on average 22° (range 14°–36°); the volar tilt was on average 6° (range 0°–18°). Comparing the first postoperative X-rays with those taken at final evaluation showed no measureable loss of reduction in the volar or radial tilt. Castaing’s score, which includes the radiographic results, yielded a perfect outcome in 30 cases, a good outcome in 49 cases and an adequate outcome in one case. The range of motion was on average reduced by 21% during extension/flexion, by 11% during radial/ulnardeviation and by 7% in pronation and supination compared to the contralateral side. Grip strength was 65% that of the contralateral side. The mean DASH score was 25 points. Fixed-angle plate osteosynthesis at the distal radius signifies a significant improvement in the treatment of distal radial fractures in terms of restoration of the shape and function of the wrist. The technically simple palmar access, with a low rate of complications, allows exact anatomical reduction of the fracture. The multidirectional fixed-angle system we used provides solid support for the joint surface even in osteoporotic bone and allows simple subchondral placement of screws with sustained retention of the outcome of reduction. Secondary correction loss can be avoided by this procedure. Early mobilisation can be achieved and is recommended.

Volar fixed-angle plate osteosynthesis of unstable distal radius fractures: 12 months results

Background Because of demographic changes in industrialized countries, signifying a growing population of the aged and a markedly increased life expectancy, the incidence of the distal radius fracture is expected to increase by a further 50% until the year 2030. Osteoporosis characterizes the radius fracture in elderly patients. Primarily weakening metaphyseal bone, osteoporosis renders simple fractures unstable and makes distal bone fixation a challenge. The introduction of fixed-angle plate systems for extension fractures of the radius was evaluated in a prospective study performed at our hospital after selection and acquisition of a new plating system. The focus of our interest was whether a secondary loss of reduction can be prevented by this plating system in the elderly patient. Methods We reviewed 58 patients aged 75 years or older treated for unstable distal radius fractures using a volar fixed-angle plate. Postoperative management included immediate finger motion, early functional use of the hand, wrist splint used for 4 weeks, and physiotherapy. At the time of follow-up, after a mean period of 13 months (range, 12-15 months), standard radiographic and clinical fracture parameters were measured and final functional results were assessed. Results Bone healing had occurred in all patients at the time of follow-up. On X-rays taken at the time of follow-up, 53 patients (91%) had no radial shortening, 5 patients (9%) had a mean radial shortening occurred during follow-up of only 1.3 mm (range, 1-2 mm) compared with the contralateral side. Comparing the first postoperative X-rays with those taken at final evaluation showed no measurable loss of reduction in the volar tilt or radial inclination. Castaing's score yielded a perfect outcome in 25 cases, a good outcome in 30 cases, and an adequate outcome in 3 cases. On an average, the range of motion was reduced by 19% during extension/flexion, by 13% during radial/ulnar deviation, and by 9% in pronation/supination compared with the contralateral side. Grip strength was 55% higher than that of the contralateral side. Eleven patients (19%) reported pain at rest with a mean Visual Analog Pain Scale score of 3.1 (range, 1-6), whereas 30 patients (52%) had pain on load-bearing with a mean Visual Analog Pain Scale score of 3.4 (range, 1-8). The mean disabilities of the arm, shoulder, and hand (DASH) score (Jester A, Harth A, Germann G. J Hand Surg Am. 2005;30:1074.e1-1074.e10) was 28 points. A carpal tunnel syndrome with abnormal nerve conduction velocity was diagnosed in three patients, a rupture of the flexor pollicis longus tendon was seen in one patient. Conclusion Fixed-angle plate osteosynthesis at the distal radius in the elderly patient signifies a significant improvement in the treatment of distal radial fractures in terms of restoration of the shape and function of the wrist associated with a low complication rate. This technique with its simple palmar access, allows exact anatomic reduction of the fracture, allows early return to function, and minimizes morbidity in the elderly patient. Secondary correction loss can be prevented by this procedure.

Unstable Distal Radius Fractures in the Elderly Patient—Volar Fixed-Angle Plate Osteosynthesis Prevents Secondary Loss of Reduction

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Volar fixed-angle plate osteosynthesis of unstable distal radius fractures: 12 months results

Unstable Distal Radius Fractures in the Elderly Patient—Volar Fixed-Angle Plate Osteosynthesis Prevents Secondary Loss of Reduction