18 AAOSNow December2010 ClinicalNewsandViews ClinicalNewsandViews December2010 AAOSNow 19

Howdowetreatwristfracturesintheelderly?

Distalradiusfracture(DRF)pre-dominantlyaffectstheelderlypopulation,withsome80,000fracturessustainedperyear,cost-ingtheU.S.healthcaresystemanestimated$632million.Thesefractureshavetraditionallybeentreatedwithcasting,aconservativeandrelativelyinexpensivetreat-ment.Buttheuseofinternalfixa-tioninelderlypatientsisgrowing,accordingtotheresultsofastudypresentedatthe2010annualmeet-ingoftheAmericanSocietyforSurgeryoftheHand.

Thestudy,presentedbyKevinC.Chung,MD,MS,identified85,924patientsaged65yearsor

olderwhohadreceivedtreatmentwithin2weeksofDRFdiagnosis.Although74percentofpatientsweretreatedwithcasting,17per-centunderwentinternalfixation,7.6percentreceivedpercutaneouspinning,and1.3percentreceivedexternalfixation.Internalfixa-tionhadthehighestrateof90-daymajorcomplications—nearly6percentofcases.

Incomparingpatientdemo-graphics,theresearchersfoundthefollowingsignificantdifferences:•Menwerelesslikelythan

womentoreceiveinternalfixa-tionversusclosedtreatment.

•Menweremorelikelythanwomentoreceiveinternalfixa-tionversuspinningorexternalfixation.

•AfricanAmericanpatientswerelesslikelythanCaucasianpa-tientstoreceiveinternalfixationversusclosedtreatment.Theauthorsattributethese

differencestothereducedriskofosteoporosisinmenandAfricanAmericans.

Comparedtoyoungerpatients,olderpatientswerelesslikelytoreceiveinternalfixationversusothertreatments.Patientswithhighersocioeconomicstatus(SES)weremorelikelytoreceiveinternalfixationversuspinningorexternalfixationthanthoseinthelowestSESgroup.Patientswithcomorbidconditionswerelesslikelythanpatientswithoutcomorbiditiestoreceiveinternalfixationversuspin-

ningorexternalfixation.Handsurgeonsperformedinter-

nalfixationonethirdofthetime,comparedtoorthopaedicsurgeons,whogenerallyusedclosedtreat-ment(71.8percent).Thedifferencecouldbeexplainedbyseverityoffractureandlikelihoodofreferraltoaspecialist,aswellasbyahigh-erawarenessamongspecialistsofnewertechniquesandimplants—specifically,thevolarlockingplat-ingsystemforDRF.

Theuseofinternalfixationfor

DRFintheMedicarepopulationhasbeengrowing,from3percentofcasesin1996to16percentin2005,andislikelytocontinue,notetheauthors.Theyconcludedbycallingforarandomizedmulti-centerclinicaltrialtodeterminewhetherornotthemoneyiswellspent. NOW

CoauthorsincludeMelissaJ.Shauver,MPH;HuiyingYin,MA;andJohnD.Birkmeyer,MD.Theauthorsreportnoconflicts.

0%

10%

20%

30%

40%

50%

60%

70%

80%

Treatment Received by Patient Age Group

Open Treatment Pinning External Fixation Closed Treatment

65–69 70–74 75–79 80+

Fig 1AbreakdownoftreatmentsprovidedtoMedicarebeneficiariesinvariousagegroupswhohavedistalradiusfracturesshowsthatclosedtreatmentisstillthemostpopulartreatmentmode.

Morecomplicationswithsingle-incisionrepair

Patientstreatedwithdouble-incisionrepairusingtransosseousdrillholesforacutedistalbicepsrupturemayseefewercompli-cationsthanthosetreatedwithsingle-incisionrepairusingsutureanchors,accordingtotheresultsofaprospective,randomizedclinicaltrialpresentedbyRuby Grewal, MD, MSc,FRCSC, atthe2010ASSHannualmeeting.

Theresearchersrandomized90malepatientstoreceiveeithersingle-incisionrepair(n=48)ordouble-incisionrepair(n=42).Thetwogroupshadnosignificant

differencesinpatientage,domi-nanthand,ornumberofworkerscompensationcases.OverallmeanAmericanShoulderandElbowSocietypainscoresweresimilarinbothgroupsatallfollow-uppoints(3,6,12,and24months).

At24months,nosignificantdifferenceswerefoundbetweenthetreatmentgroupsinfinalex-tension,pronation,orsupination.Theresearchteamnotedamar-ginaladvantageinmeanisometricflexionstrengthregainedamongparticipantsinthedouble-incisiongroup(double:104percent;single:94percent;p=0.01).

Overall,19of48patientsinthesingle-incisiongrouphadcompli-cations,comparedto3of42inthedouble-incisiongroup(p<0.01)—primarilyduetoahighnumberofearlytransientneuropraxiasinthe

single-incisiongroup.Threeneuro-praxiasinthesingle-incisiongroupremainedsymptomaticafter6months.Theresearchersnotedfourtendonruptures,allofwhichwereduetononcomplianceorreinjuryintheearlypostoperativeperiod.Noneoftheruptureswasrelatedtofixationtechnique.NOW

Dr.Grewal’scoauthorsincludeGeorge S. Athwal MD, FRCSC;JoyC.McDermid,BScPT,MSc,PhD;Kenneth J. Faber, MD, FRCSC;Darren S. Drosdowech, MD, FRCSC;Graham J.W. King, MD, MSc, FRCSC.

Disclosureinformation—Drs.GrewalandMcDermid—nocon-flicts;Dr.Athwal—WrightMedi-calTechnologies,Arthrosurface,ConMedLinvatec,Tornier,Arthrex;

Dr.Faber—TenetMedical,Zimmer;Dr.Drosdowech—DePuy;Dr.King—WrightMedicalTechnol-ogy,Inc.;Tornier;TenetMedical.

BottomlineNooveralldifferencesinfunctionaloutcomeswerefoundbetweendistalbicepsrupturestreatedwitheitherasingleordoubleincisionrepairtechnique;howeverflexionstrengthwasslightlygreaterwithatwo-incisiontechnique.

•Thesingle-incisiongrouphadagreaterincidenceofcomplications.

ASSH 2010AnnuAl Meeting

ASSH 2010AnnuAl Meeting

Bottomline•Despitetheincreasing

useofinternalfixationtechniques,mostelderlypatientswithdistalradiusfracturesarestilltreatedwithclosedtreatment.

•Demographicfactors,suchaspatientgender,raceandage,haveasignificanteffectonthetypeoftreatmentreceived.

Cou

rtes

yof

Kev

inC

.Chu

ng,M

D,M

S

AAOS Now_December 2010.indd 18 11/23/2010 4:14:34 PM