Evidence-Based Antibiotic Prophylaxis in Clean Hand Surgeries: An Educational Intervention to Decrease Use.

PURPOSE: Evidence for the use of prophylactic antibiotics in clean hand surgery is limited, yet surgeons continue to administer antibiotics to prevent postoperative infections. We sought to assess the effect of a program directed at reducing the use of antibiotic prophylaxis in carpal tunnel release surgery and elicit reasons for continued use. METHODS: A surgeon leader implemented a program between September 1, 2018 and September 30, 2019 to reduce antibiotic prophylaxis in clean hand surgeries in a hospital system of 10 medical centers. It consisted of (1) an evidence-based educational session for all participating orthopedic and hand surgeons during which the elimination of the use of antibiotics in clean hand surgeries was requested and (2) a year-long, monthly antibiotic use audit and feedback cycle using carpal tunnel release (CTR) as a proxy for clean hand surgery. The rate of antibiotic use in the year of the intervention was compared to the rate prior to the intervention. Multivariable regression was used to determine patient-related risk factors for receiving antibiotics. Participating surgeons completed a survey to elucidate factors that contributed to continued use. RESULTS: Antibiotic prophylaxis decreased from 1223/2379 (51%) in 2017-2018 to 531/2550 (21%) in 2018-2019. During the last month of evaluation, the rate decreased to 28/208 (14%). Logistic regression revealed a higher rate of antibiotic use during the period after the intervention among patients who had diabetes mellitus or who were operated upon by an older surgeon. The follow-up surgeon survey revealed a strong positive correlation between surgeon willingness to administer antibiotics and patient hemoglobin A1c and body mass index. CONCLUSIONS: The rate of antibiotic use in carpal tunnel release decreased from 51% the year prior to 14% the final month of implementing a surgeon-led program to reduce antibiotic prophylaxis. Multiple barriers to the implementation of evidence-based practice were identified. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Human Amniotic Membrane Wrapping of the Ulnar Nerve During Cubital Tunnel Surgery Reduces Recurrence of Symptoms.

Background: Compare the recurrence rate of paresthesias in patients undergoing primary cubital tunnel surgery in those with and without wrapping of the ulnar nerve with the human amniotic membrane (HAM). Methods: A retrospective investigation of patients undergoing primary cubital tunnel surgery with a minimum 90-day follow-up was performed. Patients were excluded if the nerve was wrapped using another material, associated traumatic injury, simultaneous Guyon's canal release, or revision procedures. Failure was defined as those patients who experienced initial complete resolution of symptoms (paresthesias) but then developed recurrence of paresthesias. Results: A total of 57 controls (CON) and 21 treated with HAM met our inclusion criteria. There was a difference in the mean age of CON (48.4 ± 13.5 years) and HAM (30.6 ± 15) (P< 0.0001). There was no difference in gender mix (P=0.4), the severity of symptoms (P=0.13), and length of follow-up (P=0.084). None of 21 (0%) treated with HAM developed recurrence of symptoms compared to 11 of 57 (19.3%) (P=0.03) (CON). Using a multivariate regression model adjusted for age and procedure type, CON was 24.4 (95% CI=1.26-500, P=0.0348) times higher risk than HAM of developing a recurrence of symptoms. Conclusion: The HAM wrapping used in primary cubital tunnel surgery significantly reduced recurrence rates of paresthesias. Further prospective studies with randomization should be carried out to better understand the role HAM can play in cubital tunnel surgery.

Volar Tilt of the Lunate After Open Reduction Internal Fixation of a Distal Radius Fracture.

The pathophysiology of carpal adaptations after fracture of the distal radius is incompletely understood. We report 5 patients who had normal carpal alignment on injury radiographs that developed marked volar angulation of the lunate during recovery from volar plate fixation of a fracture of the distal radius. There were no signs of alteration of the carpal ligaments. Two patients had similar volar tilt on the contralateral side. The cause and optimal treatment of carpal malalignment after restoration distal radial alignment are unclear.

Giant Cell Tumors of the Upper Extremity: Predictors of Recurrence.

PURPOSE: Giant cell tumors (GCT) of the distal radius are thought to be more aggressive than in other locations. Therefore, the aim of this study was to investigate factors associated with recurrence of GCTs in the upper extremity. METHODS: We retrospectively identified 82 patients who underwent primary surgical treatment for an upper extremity GCT. Tumors were located in the radius (n = 47), humerus (n = 17), ulna (n = 9), and hand (n = 9). Treatment consisted of either wide resection or amputation or intralesional resection with or without adjuvants. A multivariable logistic regression was performed including tumor grade, type of surgery, and tumor location, from which the percentage of contribution to the model of each variable was calculated. RESULTS: The recurrence rate after intralesional resection was 48%; after wide resection or amputation, it was 12%. Two patients developed a pulmonary metastasis (2.4%). In multivariable analysis, intralesional resection was independently associated with recurrence. Intralesional resection had a 77% contribution to predict recurrence and the distal radius location had a 16% contribution in the predictive model. CONCLUSIONS: As expected, intralesional resection was the strongest independent predictor of recurrence after surgical treatment for GCT. The distal radius location contributed to the prediction of giant cell tumor recurrence to a lesser extent. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Complications of Corrective Osteotomies for Extra-Articular Distal Radius Malunion.

PURPOSE: Osteotomy of the distal radius for a fracture malunion is a challenging procedure. The purpose of this study was to review a series of osteotomies to determine the type and risk of complications. METHODS: A retrospective cohort study was performed, including all Kaiser Permanente Southern California patients who were aged 18 years or older between January 1, 2007, and September 25, 2015, and underwent osteotomy for an extra-articular distal radius fracture malunion. Charts were reviewed for demographic data, comorbidities, osteotomy type (hinged vs distraction), implant, and bone graft type. Complications including infection, nonunion, loss of reduction, implant failure, nerve injury, tendon injury, and complex regional pain syndrome were recorded. RESULTS: There were 60 patients who underwent extra-articular osteotomy of the distal radius for malunion during the study period. The mean age was 54 years (range, 21-83 years). There were 24 distraction-type (intervening bone graft) and 36 hinge-type (volar cortical contact maintained) osteotomies. Twenty-five of 60 patients had complications related to the procedure requiring 13 subsequent procedures. There were 7 nonunions and 3 cases of delayed healing at the osteotomy site. One extensor carpi radialis longus tendon laceration resulted from the use of an osteotome. There were 3 delayed extensor pollicis longus (EPL) tendon ruptures after surgery. The distraction-type osteotomy was associated with a greater risk of major complications including nonunion and delayed union. CONCLUSIONS: A complication rate of nearly 50% was observed in distal radius osteotomies. Surgeons should be aware of the risk of injury to, or delayed rupture of the EPL tendon associated with these procedures. The risk of nonunion or delayed union is higher in distraction-type compared with hinge-type osteotomies. Low surgeon volume with this procedure may be a contributing factor to the high rate of complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Complications of Radial Column Plating of the Distal Radius.

Background: Distal radius fractures treated with open reduction and internal fixation are commonly stabilized with a volar locking plate; however, more complex fracture patterns may require supplemental fixation with fragment-specific implants. The objective of this study was to evaluate the outcomes of distal radius fractures treated with radial column plates. Methods: A consecutive series of 61 patients who sustained distal radius fractures underwent radial column plating alone or in conjunction with other implants between August 2006 and January 2014. Thirty-one patients returned for follow-up or returned a mailed questionnaire at an average of 4.1 years. The outcomes measures included Visual Analog Scale (VAS); Disabilities of the Arm, Shoulder and Hand (DASH); and Patient-Rated Wrist Evaluation (PRWE) scores. Results: Sixty-one patients with a mean age of 55 years (range, 20-87) met inclusion criteria and were available for follow-up or chart review at an average of 5.2 years (range, 1.6-9.0 years). Seventeen of 61 (28%) underwent radial column plate removal. Twenty patients returned for final follow-up examination, and 11 completed questionnaires via mail. Subjective scores included a mean postoperative VAS of 0.72, DASH score of 17.2, and PRWE score of 15.7. Hardware sensitivity and wrist stiffness were the most common complications at final follow-up. Conclusions: Radial column plating of the distal radius is a safe treatment modality and a valuable adjunct in the setting of complex distal radius fractures, but patients should be counseled that there is a 28% chance that hardware removal may be required. Our retrospective review found evidence of few complications and objective scores consistent with return to normal function.

The Risk of Dupuytren Diagnosis in Obese Individuals.

PURPOSE: Dupuytren disease is a common benign fibroproliferative disorder causing thickening and shortening of the palmar fascia of the hand. The exact etiology of the disease is unclear but known risk factors such as increased age, male sex, and northern European ethnicity have been established. A link between body mass index (BMI) and Dupuytren disease has not been established previously. The purpose of this study was to test the hypothesis that lower BMI is associated with increased risk for Dupuytren disease diagnosis. METHODS: After we obtained institutional review board approval, we performed a retrospective review using an electronic medical record and an administrative database from Kaiser Permanente Southern California to identify all enrolled patients there between 2007 and 2014 who were diagnosed with Dupuytren disease. Basic demographic data including age, sex, ethnicity, and BMI were collected. Bivariate and multivariable logistical regression analyses were performed to evaluate for associations between Dupuytren disease and BMI. RESULTS: A total of 2,049,803 patients aged 18 years and older were enrolled in Kaiser Permanente Southern California from 2007 to 2014. During that period, 14,844 patients were identified as having Dupuytren disease. The data were consistent with well-defined demographic trends in Dupuytren disease, with increased rates seen in males, Caucasians, and patients aged 50 years and older. In the multivariable analysis, when controlling for age, race, and sex, the risk of Dupuytren disease was inversely proportional to BMI. CONCLUSIONS: The current study showed that higher BMI is associated with decreased odds of having Dupuytren disease. Further work will be required to determine the cause for the apparent relationship between Dupuytren disease and BMI and whether physiologic factors related to obesity may be protective against the development of Dupuytren disease. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Fixation Options for the Volar Lunate Facet Fracture: Thinking Outside the Box.

Background Fractures of the distal radius with small volar ulnar marginal fracture fragments are difficult to stabilize with standard volar locking plates. The purpose of this study is to describe alternative techniques available to stabilize these injuries. Materials and Methods Five patients were identified retrospectively with unstable volar lunate facet fracture fragments treated with supplemental fixation techniques. The demographic data, pre- and postoperative radiographic parameters, and early outcomes data were analyzed. The AO classification, preoperative and final postoperative ulnar variance, articular step-off, volar tilt, radial inclination, and teardrop angle were measured. The lunate subsidence and length of the volar cortex available for fixation were measured from the initial injury films. Description of Technique Lunate facet fixation was based on the morphology of the fragment, and stabilization was achieved with headless compression screws in three patients, a tension band wire construct in one, and two cortical screws in another. Results Five patients with a mean age of 58 years (range: 41-82) were included. There were two AO C3.2 and three B3.3 fractures. Preoperative radiographic measurements including radial inclination, tilt, and ulnar variance all improved after surgery and were maintained within normal limits at 3-month follow-up. There was no change in the teardrop angle at final follow-up (70-64 degrees; p = 0.14). None of the patients had loss of fixation or volar carpal subluxation. The mean visual analog scale pain score at 3 months was 1 (range: 0-2). Conclusions The morphology of volar lunate facet fracture fragments is variable, and fixation must be customized to the particular pattern. Small fragments may preclude the use of plates and screws for fixation. These fractures can be managed successfully with tension band wire constructs and headless screws. These low-profile implants may decrease the risk of tendon irritation that might accompany distally placed plates.

Outcomes of Elbow Arthroscopic Osteocapsular Arthroplasty.

PURPOSE: To evaluate the results of elbow arthroscopic osteocapsular arthroplasty (AOA) and determine which factors influence the outcome in a large group of patients with primary osteoarthritis. METHODS: A consecutive series of 46 patients with elbow osteoarthritis underwent AOA by a single surgeon (N.G.H.) between December 2005 and January 2013. Thirty-one patients returned for a comprehensive physical examination an average of 3.4 years later. The outcomes measures included visual analog scale (VAS), Mayo Elbow Performance Scores (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH), and American Shoulder and Elbow Society (ASES) scores. Preoperative and postoperative continuous variables were compared and a multivariable regression analysis was performed. RESULTS: Thirty-one patients with a mean age of 48 years (range, 19-77 years) returned for final follow-up, including 27 men and 4 women. Statistically significant improvement was observed in extension deficit (24° before surgery to 12° after surgery), flexion (126° before surgery to 135° after surgery), visual analog scale (6.4 before surgery to 1.6 after surgery), and Mayo Elbow Performance Scores (57 [poor] before surgery to 88 [good] after surgery). Subjective scores included a mean postoperative Disabilities of the Arm, Shoulder, and Hand score of 13 and an American Shoulder and Elbow Society pain score of 40. No complications were noted at final follow-up. CONCLUSIONS: Elbow AOA is a safe, efficacious treatment for patients with mild to moderate osteoarthritis. Our retrospective review found significant improvement in elbow motion, pain and clinical outcomes.

Volar plate fixation failure for volar shearing distal radius fractures with small lunate facet fragments.

PURPOSE: To determine the percentage of AO B3 distal radius fractures that lose reduction after operative fixation and to see whether fracture morphology, patient factors, or fixation methods predict failure. We hypothesized that initial fracture displacement, amount of lunate facet available for fixation, plate position, and screw fixation would be significant risk factors for loss of reduction. METHODS: A prospective, observational review was conducted of 51 patients (52 fractures) with AO B3 (volar shearing) distal radius fractures treated operatively between January 2007 and June 2012. We reviewed a prospective distal radius registry to determine demographic data, medical comorbidities, and physical examination findings. Radiographs were evaluated for AO classification, loss of reduction, length of volar cortex available for fixation, and adequacy of stabilization of the lunate facet fragment with a volar plate. Preoperative data were compared between patients who maintained radiographic alignment and those with loss of reduction. A multivariate logistic regression analysis was completed to determine significant predictors of loss of reduction. RESULTS: Volar shearing fractures with separate scaphoid and lunate facet fragments (AO B3.3), preoperative lunate subsidence distance, and length of volar cortex available for fixation were significant predictors for loss of reduction; the latter was significant in multivariate analysis. Plate position and number of screws used to stabilize the lunate facet were not statistically different between groups. CONCLUSIONS: Patients with AO B3.3 fractures with less than 15 mm of lunate facet available for fixation, or greater than 5 mm of initial lunate subsidence, are at risk for failure even if a volar plate is properly placed. In these cases, we recommend additional fixation to maintain reduction of the small volar lunate facet fracture fragments in the form of plate extensions, pins, wires, suture, wire forms, or mini screws. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

The association of hemoglobin A1c with the prevalence of stenosing flexor tenosynovitis.

PURPOSE: Diabetic patients are susceptible to stenosing flexor tenosynovitis (FTS) and may have a diminished response to treatment. The purpose of this study was to determine whether elevated hemoglobin A1c (HbA1c) levels are associated with the development of FTS. METHODS: A review of our diabetic registry identified a cohort of patients with diabetes mellitus. We stratified this cohort to those with and without a diagnosis of FTS during 2008 based on International Classification of Diseases-9 coding (727.00-727.05J). We reviewed charts to confirm the diagnosis. For patients diagnosed with FTS, we used the HbA1c measurement made closest to the date of diagnosis for analysis. We assessed patients without FTS using an average of HbA1c measurements during the same time period and performed subgroup analysis based on specified HbA1c levels (group A, HbA1c level < 7.0%; group B, HbA1c 7.0% to 7.9%; group C, HbA1c 8.0% to 8.9%; group D, HbA1c ≥ 9.0%). Statistical testing consisted of chi-square analysis, odds ratios, and multivariate regression analysis. RESULTS: There were 259,927 patients in 2008 identified with diabetes mellitus, 3,952 of whom were diagnosed with FTS. The period prevalence of FTS in this diabetic population was 1.5%. Multivariate regression analysis revealed that HbA1c greater than 7% was an independent risk factor for FTS (odds ratio/confidence interval: group B, 1.31/1.20-1.42; group C, 1.35/1.21-1.51; group D, 1.23/1.10-1.38). CONCLUSIONS: The prevalence of FTS in this diabetic population was considerably lower than expected and may represent a more accurate assessment given the power of this population-based study. In addition, the development of FTS appears to be associated with higher HbA1c levels. Although further study is necessary, this association may be relevant when evaluating and treating diabetic patients with trigger finger.

Distal radius fracture risk reduction with a comprehensive osteoporosis management program.

PURPOSE: To study risk factors associated with osteoporotic distal radius fractures and evaluate the effectiveness of the screening and treatment components of a comprehensive osteoporosis program. METHODS: We retrospectively identified a cohort of patients aged 60 years or older from a large health maintenance organization. For the period 2002 to 2008, information on age, race, sex, diabetes status, osteoporosis diagnosis, osteoporosis screening activity, medications dispensed, and fracture events, including distal radius, proximal humerus, and hip fractures were recorded. We compared demographic and clinical characteristics for patients with and without distal radius fractures. We estimated multivariable estimates of the associations between pharmacologic treatment, and osteoporosis screening and distal radius fracture risk using Cox proportional hazards methods, and adjusted them for age, sex, race, diabetes status, and prior history of hip or proximal humerus fractures. RESULTS: Overall, 1.7% of the cohort (n = 8,658) of the study population (N = 524,612) sustained a new distal radius fracture during 2002 to 2008. In the multivariable model, we found that patients who received pharmacological intervention were 48% less likely to sustain a distal radius fracture. Similarly, patients who were screened for osteoporosis were 83% less likely to sustain a distal radius fracture. Patients with osteoporosis were 8.9 times more likely to have a distal radius fracture than patients without osteoporosis. White subjects had a 1.6 times higher risk of distal radius fracture than non-whites, and women had a 3.8 times higher risk than men. CONCLUSIONS: White race, female sex, and a diagnosis of osteoporosis are high risks for distal radius fracture. Screening for and pharmacologic management of osteoporosis using a multidisciplinary team approach in a comprehensive osteoporosis management program resulted in a statistically significant decrease in the risk of distal radius fracture. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Clinical quality measures for intraoperative and perioperative management in carpal tunnel surgery.

BACKGROUND: Previous research documents suboptimal preoperative or postoperative care for patients undergoing surgery. However, few existing quality measures directly address the fundamental element of surgical care: intra-operative care processes. This study sought to develop quality measures for intraoperative, preoperative, and postoperative care for carpal tunnel surgery, a common operation in the USA. METHODS: We applied a variation of the well-established RAND/UCLA Appropriateness Method. Adherence to measures developed using this method has been associated with improved patient outcomes in several studies. Hand surgeons and quality measurement experts developed draft measures using guidelines and literature. Subsequently, in a two-round modified-Delphi process, a multidisciplinary panel of 11 national experts in carpal tunnel syndrome (including six surgeons) reviewed structured summaries of the evidence and rated the measures for validity (association with improved patient outcomes) and feasibility (ability to be assessed using medical records). RESULTS: Of 25 draft measures, panelists judged 22 (88%) to be valid and feasible. Nine intraoperative measures addressed the location and extent of surgical dissection, release after wrist trauma, endoscopic release, and four procedures sometimes performed during carpal tunnel surgery. Eleven measures covered preoperative and postoperative evaluation and management. CONCLUSIONS: We have developed several measures that experts, including surgeons, believe to reflect the quality of care processes occurring during carpal tunnel surgery and be assessable using medical records. Although quality measures like these cannot assess a surgeon's skill in handling the instruments, they can assess many important aspects of intraoperative care. Intraoperative measures should be developed for other procedures.

RAND/UCLA Quality-of-Care Measures for Carpal Tunnel Syndrome: Tools for Assessing Quality of Care and Appropriateness of Surgery.

Claims relating to carpal tunnel syndrome (CTS) are common in workers' compensation systems. Given that the human and economic costs related to CTS are considerable, healthcare organizations must be able to offer high-quality care to people affected by this condition. The study on which this article is based is a step toward improving care for CTS. It has produced two unique tools for institutions to use, one for assessing the quality of care received by a population of patients who have or may have CTS, and the other for identifying the appropriateness of surgery for individual patients. Tools that assist in measuring quality of care are fundamental to efforts to improve healthcare quality. Tools that assess the appropriateness of surgery ensure that people who need surgery receive it and, conversely, that people are not subjected to inappropriate operations. Applied in this way, these two tools are likely to improve clinical circumstances and economic outcomes for people with CTS. Together, they can be useful to provider organizations, medical groups, medical certification boards, and other associated decisionmakers attempting to assess, monitor, and provide appropriate care for people with CTS.

Indications for performing carpal tunnel surgery: clinical quality measures.

BACKGROUND: Rates of carpal tunnel surgery vary for unclear reasons. In this study, the authors developed measures determining when surgery is necessary (benefits exceed risks), inappropriate (risks outweigh benefits), or optional. METHODS: Measures were developed using a modified-Delphi panel. Clinical scenarios were defined incorporating symptom severity, symptom duration, clinical probability of carpal tunnel syndrome, electrodiagnostic testing, and nonoperative treatment response. A multidisciplinary panel of 11 carpal tunnel syndrome experts rated appropriateness of surgery for each scenario on a scale ranging from 1 to 9 scale (7 to 9, surgery is necessary; 1 to 3, surgery is inappropriate). RESULTS: Of 90 scenarios (36 for mild, 36 for moderate, and 18 for severe symptoms), panelists judged carpal tunnel surgery as necessary for 16, inappropriate for 37, and optional for 37 scenarios. For mild symptoms, surgery is generally necessary when clinical probability of carpal tunnel syndrome is high, there is a positive electrodiagnostic test, and there has been unsuccessful nonoperative treatment. For moderate symptoms, surgery is generally necessary with a positive electrodiagnostic test involving two or more of the following: high clinical probability, unsuccessful nonoperative treatment, and symptoms lasting longer than 12 months. Surgery is generally inappropriate for mild to moderate symptoms involving two or more of the following: low clinical probability, no electrodiagnostic confirmation, and nonoperative treatment not attempted. For severe symptoms, surgery is generally necessary with a positive electrodiagnostic test or unsuccessful nonoperative treatment. CONCLUSIONS: These are the first formal measures assessing appropriateness of carpal tunnel surgery. Applying these measures can identify underuse (failure to provide necessary care) and overuse (providing inappropriate care), giving insight into variations in receipt of this procedure.

Rate of infection after carpal tunnel release surgery and effect of antibiotic prophylaxis.

PURPOSE: To determine the rate of postoperative wound infection and the association with prophylactic antibiotic use in uncomplicated carpal tunnel release surgery. METHODS: We performed a multicenter, retrospective review of all the carpal tunnel release procedures performed between January 1, 2005, and August 30, 2007. Data reviewed included the use of prophylactic antibiotics, diabetic status, and the occurrence of postoperative wound infection. We determined the overall antibiotic usage rate and analyzed the correlation between antibiotic use and the development of postoperative wound infection. RESULTS: The rate of surgical site infections in the 3003 patients who underwent carpal tunnel release surgery (group A) was 11. Antibiotic usage data were available for 2336 patients (group B). Six patients without prophylactic antibiotics had infection, as did 5 patients with prophylactic antibiotics. This difference was not statistically significant. Of the 11 surgical site infections, 4 were deep (organ/space) and 7 superficial (incisional). The number of patients with diabetes in the overall study population was 546, 3 of whom had infections. This was not statistically different from the nondiabetic population infection rate (8 patients). CONCLUSIONS: The overall infection rate after carpal tunnel release surgery is low. In addition, the deep (organ/space) infection rate is much lower than previously reported. Antibiotic use did not decrease the risk of infection in this study population, including patients with diabetes. The routine use of antibiotic prophylaxis in carpal tunnel release surgery is not indicated. Surgeons should carefully consider the risks and benefits of routinely using prophylactic antibiotics in carpal tunnel release surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

The influence of three-dimensional computed tomography reconstructions on the characterization and treatment of distal radial fractures.

BACKGROUND: Computed tomography identifies important characteristics of distal radial fractures better than plain radiographs do. Our hypothesis was that three-dimensional computed tomography images would further increase the reliability and accuracy of radiographic characterization of distal radial fractures. METHODS: Four independent observers evaluated radiographic images of thirty intra-articular fractures of the distal part of the radius for the presence of a fracture line in the coronal plane, impacted central articular fragments, the presence of comminution (defined as more than three articular fragments), and the number of fracture fragments. A treatment was selected on the basis of the interpretation of the radiographic studies. Three rounds of evaluation were compared: (1) radiographs and two-dimensional computed tomography, (2) radiographs and three-dimensional computed tomography two weeks later, and (3) all three types of images two weeks after that. This cycle was then repeated to assess intraobserver reliability. RESULTS: Three-dimensional computed tomography improved the intraobserver agreement, but not the interobserver agreement, regarding the presence of coronal plane fracture lines and central articular fragment depression. Three-dimensional computed tomography improved both the intraobserver and the interobserver agreement regarding the presence of articular comminution. Interobserver agreement increased when three-dimensional computed tomography was used to determine the exact number of articular fracture fragments. The sensitivity and accuracy of identifying specific fracture characteristics (as compared with intraoperative findings) improved when three-dimensional imaging was used in conjunction with two-dimensional imaging as compared with two-dimensional imaging alone. The addition of three-dimensional computed tomography to two-dimensional computed tomography influenced treatment recommendations, resulting in a significantly greater number of decisions for an open approach (p < 0.05) and combined dorsal and volar exposure (p < 0.001). CONCLUSIONS: Three-dimensional computed tomography improves both the reliability and the accuracy of radiographic characterization of articular fractures of the distal part of the radius and influences treatment decisions. Future studies will be required to determine the impact of these decisions on patient outcome.