Tips and tricks to achieve osteotomy healing and prevent refracture after ulnar shortening osteotomy.

BACKGROUND: Parallel osteotomy is essential for favorable osteotomy reduction and healing and technically challenging during diaphyseal ulnar shortening osteotomy (USO). This study aimed to evaluate the advantages of guided osteotomy for parallel osteotomy and reduction osteotomies, healing over freehand osteotomy. It also aimed to identify surgical factors affecting healing after diaphyseal USO. METHODS: Between June 2005 and March 2016, 136 wrists that had undergone diaphyseal USO for ulnar impaction syndrome (UIS) were evaluated. The wrists were divided into two groups according to the osteotomy technique (group 1: freehand osteotomy, 74 wrists; group 2: guided osteotomy, 62 wrists). The osteotomy reduction gap and time to osteotomy healing (union and consolidation) were compared between the groups. A multiple regression test was performed to identify the surgical factors affecting healing. The cut-off length of the reduction gap to achieve osteotomy union on time and the cut-off period to decide the failure of complete consolidation were statistically calculated. RESULTS: The baseline characteristics did not differ between the two groups. The osteotomy reduction gap and time to osteotomy union, and complete consolidation were shorter in group 2 than in group 1 (p = 0.002, < 0.001, 0.002). The osteotomy reduction gap was a critical surgical factor affecting both time to osteotomy union and complete consolidation (p < 0.001, < 0.001). The use of a dynamic compression plate affected only the time to complete consolidation (p < 0.001). The cut-off length of the osteotomy reduction gap to achieve osteotomy union on time was 0.85 mm. The cut-off period to decide the failure of complete consolidation was 23.5 months after osteotomy. CONCLUSIONS: The minimal osteotomy reduction gap was the most important for timely osteotomy healing in the healthy ulna, and guided osteotomy was beneficial for reducing the osteotomy reduction gap.

Case Report: Prophylactic Plate Fixation for Incomplete Atypical Ulnar Fractures Resulting From the Use of Denosumab for Bone Metastases.

Patients with bone metastases are treated with long-term bone resorption inhibitors such as bisphosphonates and denosumab. However, resorption inhibitors have been known to cause fractures, such as atypical femoral fractures (AFFs). In recent years, there have been an increasing number of reports of atypical ulna fractures (AUFs) caused by bone resorption inhibitor usage. Treatment of AUFs is complicated, especially when they occur in patients with bone metastases, because it is difficult to discontinue bone resorption inhibitor treatment without the risk of aggravating metastatic lesions. Prophylactic surgery is recommended in AFFs when fractures are predicted, but there are few reports of prophylactic surgery for AUFs. Here, we report a case of incomplete AUF in a 74-year-old woman which was surgically treated with prophylactic plate fixation. The patient had been using denosumab for 6 years to treat bone metastases due to thyroid cancer. After surgery, no fractures were observed for 2 years without discontinuing denosumab, and her forearm function was adequate. AUFs are rare and difficult to treat, so oncologists who treat bone metastases need to pay special attention to diagnose this incomplete AUF before the fracture worsens. We believe that detection of a possible fracture and prophylactic surgery can improve prognosis.

Implantes intramedulares enterrados para fracturas de antebrazo pediátricas. ¿Mejora la tasa de refracturas? / Buried intramedullary implants for paediatric forearm fractures. Does the refracture rate improve?

INTRODUCCIÓN: Las fracturas inestables de antebrazo pueden requerir un manejo quirúrgico mediante reducción y osteosíntesis con agujas intramedulares. Esta fijación debe retirarse precozmente si se ha dejado expuesta, pero esto podría aumentar el riesgo de refracturas sobre un hueso en periodo de remodelado. Como alternativa podemos mantener durante más tiempo las agujas, enterradas a nivel subcutáneo, para proteger el callo óseo. OBJETIVO: Valorar si hay diferencias entre utilizar agujas expuestas respecto a enterrarlas en pacientes pediátricos con fracturas de antebrazo. Nuestra hipótesis es que al enterrar las agujas las mantenemos más tiempo reduciendo las refracturas de antebrazo. MATERIAL Y MÉTODOS: Presentamos una cohorte de 75 pacientes pediátricos con fractura de antebrazo entre 2010 y 2016. Se recogieron datos demográficos, técnica quirúrgica, complicaciones y seguimiento del paciente. RESULTADOS: Los implantes se dejaron expuestos en 50 pacientes y 25 de forma enterrada. El tiempo medio de retirada de los implantes expuestos fue de 6,8 semanas, y de 17,6semanas en los enterrados. No se hallaron diferencias significativas en cuanto a consolidación (p = 0,19) ni en tiempo de inmovilización (p = 0,22). Respecto a las refracturas, se observa un mayor número en el grupo de la osteosíntesis expuesta (4pacientes) respecto a solo un caso con osteosíntesis enterrada, pero sin llegar a presentar diferencias significativas (p = 0,49). No se detectaron complicaciones posquirúrgicas y la funcionalidad fue excelente al final del seguimiento en ambos grupos. CONCLUSIÓN: Dejar los implantes enterrados respecto a expuestos a piel no condiciona una disminución en el número de refracturas ni otras complicaciones, con una adecuada funcionalidad del paciente en ambos casos

INTRODUCTION: Unstable forearm fractures may require surgical management by reduction and osteosynthesis with intramedullary needles. This fixation should be removed early if it has been left exposed, but this could increase the risk of refracture in a bone in the period of remodelling. As an alternative we can keep the needles, buried subcutaneously, for a longer time, to protect the bone callus. OBJECTIVE: To assess whether there are differences between using exposed needles with respect to burying them in paediatric patients with forearm fractures. Our hypothesis is that by burying the needles we keep them longer by reducing forearm refractures. MATERIAL AND METHODS: We present a cohort of 75 paediatric patients with a forearm fracture between 2010 and 2016. Demographic data, surgical technique, complications and patient follow-up were collected. RESULTS: The implants were left exposed in 50 patients and 25 buried. The average time of removal of the exposed implants was 6.8 weeks and 17.6weeks in the buried ones. No significant differences were found in terms of consolidation (P=.19) or immobilization time (P=.22). Regarding refractures, a greater number was observed in the exposed osteosynthesis group (4patients) compared to only one case with buried osteosynthesis, but there were no significant differences (P=.49). No postsurgical complications were detected and the functionality was excellent at the end of the follow-up in both groups. CONCLUSION: Leaving implants buried in relation to skin exposed does not cause a decrease in the number of refractures or other complications, with adequate patient functionality in both cases

Buried intramedullary implants for paediatric forearm fractures. Does the refracture rate improve? / Implantes intramedulares enterrados para fracturas de antebrazo pediátricas. ¿Mejora la tasa de refracturas?

INTRODUCTION: Unstable forearm fractures may require surgical management by reduction and osteosynthesis with intramedullary needles. This fixation should be removed early if it has been left exposed, but this could increase the risk of refracture in a bone in the period of remodelling. As an alternative we can keep the needles, buried subcutaneously, for a longer time, to protect the bone callus. OBJECTIVE: To assess whether there are differences between using exposed needles with respect to burying them in paediatric patients with forearm fractures. Our hypothesis is that by burying the needles we keep them longer by reducing forearm refractures. MATERIAL AND METHODS: We present a cohort of 75 paediatric patients with a forearm fracture between 2010 and 2016. Demographic data, surgical technique, complications and patient follow-up were collected. RESULTS: The implants were left exposed in 50 patients and 25 buried. The average time of removal of the exposed implants was 6.8weeks and 17.6weeks in the buried ones. No significant differences were found in terms of consolidation (P=.19) or immobilization time (P=.22). Regarding refractures, a greater number was observed in the exposed osteosynthesis group (4patients) compared to only one case with buried osteosynthesis, but there were no significant differences (P=.49). No postsurgical complications were detected and the functionality was excellent at the end of the follow-up in both groups. CONCLUSION: Leaving implants buried in relation to skin exposed does not cause a decrease in the number of refractures or other complications, with adequate patient functionality in both cases.

Pediatric Orthopedic Hoverboard Injuries: A Prospectively Enrolled Cohort.

Hoverboards pose a significant risk of musculoskeletal injury to pediatric riders. A prospectively enrolled cohort yielded 9 pediatric patients injured while riding hoverboards in 2016. Eight of the injuries involved the upper extremity, and one involved the lower extremity. No riders wore any safety equipment and injury patterns modeled those seen in skateboard riders.

Prevention of re-fractures of both bones of the forearm in children.

PURPOSE: The aim of this study was to observe if the re-fracture rate after forearm both bones was decreased by protecting the forearm with a preventive brace for 6 months following the fracture and by ceasing all physical activities. METHODS: We performed a retrospective study in 75 consecutive cases of diaphyseal fracture of both bone of forearms, in 52 boys and 23 girls aged from 6 months to 11 years. It concerned a first episode of fracture in 84% of cases and a re-fracture in 17%. RESULTS: Re-fracture rate was 0% in the group where a protective brace was worn while it was 20% in the group without brace. CONCLUSIONS: Both the wearing of a protective brace and absence of sport for 6 months may decrease the re-fracture rate to 0%, if the patient is compliant by wearing it and by ceasing all physical activities.

Adherence to osteoporosis drugs and fracture prevention: no evidence of healthy adherer bias in a frail cohort of seniors.

UNLABELLED: We examined new users of osteoporosis drugs among seniors in Pennsylvania and found no evidence of healthy adherer bias on observed associations between adherence to treatment and non-vertebral fracture risk; we document fracture reduction with better adherence to bisphosphonates, yet no fracture reduction with better adherence to calcitonin or raloxifene. INTRODUCTION: We examined the potential for "healthy adherer bias" when studying the effects of adherence to osteoporosis pharmacotherapy on fracture risk. Based on clinical trial evidence, bisphosphonates, calcitonin, and raloxifene reduce vertebral fracture risk; yet only bisphosphonates are documented to reduce non-vertebral fracture risk. METHODS: This is a cohort study of older women in Pennsylvania who initiated osteoporosis drugs between 1995 and 2005. We included new users of bisphosphonates, calcitonin, and raloxifene. Adherence was categorized based on a measure of compliance as high [proportion of days covered (PDC) ≥ 80%], intermediate (50% < PDC < 80%), or low (PDC ≤ 50%) according to a 180-day ascertainment period. Non-vertebral fracture rates within 365 days after the ascertainment period were compared between adherence categories (reference = low) using Cox proportional hazard models and adjusting for fracture risk factors. Primary and secondary prevention cohorts were examined separately. Adherence to calcitonin and raloxifene were control analyses. RESULTS: We found little difference in fracture rates between levels of adherence to calcitonin, bisphosphonates for primary prevention, or raloxifene for secondary prevention. We document lower fracture rates among high versus low adherent bisphosphonate users for secondary prevention (HR = 0.53, 95%CI = 0.38-0.74) and higher fracture rates among high versus low adherent raloxifene users for primary prevention (HR = 2.01, 95%CI = 1.04-3.87). CONCLUSIONS: We document little evidence of healthy adherer bias when studying the association between better adherence to osteoporosis drugs and fracture risk reduction, with only better adherence to bisphosphonates reducing fracture risk. The higher fracture risk among highly adherent raloxifene users for primary prevention is likely due to residual confounding.

[Application of guidelines for secondary prevention of fracture and the FRAX index in patients with fragility fracture]. / Aplicación de las guías de prevención secundaria de fractura osteoporótica y del índice FRAX en una cohorte de pacientes con fractura por fragilidad.

BACKGROUND AND OBJECTIVES: There are different guidelines for secondary prevention of fractures related with osteoporosis. Our aim is to analyse the appliance of such guidelines in a sample of patients with fragility fracture PATIENTS AND METHODS: Adult patients older than 50 years attended in the emergency department with a fragility fracture were invited to participate in a study for secondary prevention. Clinical data and densitometry for the FRAX index were recorded. Current guidelines were employed to calculate the number of patients who needed secondary prevention. RESULTS: With the appliance of current guidelines to 380 patients, 54-100% of women and 26-81% of men were candidates for treatment. For hip fractures the percentage was 81-100% and for forearm fractures 36-93%. FRAX index for hip fracture was ≥3% in 35% of patients. The National Institute for Health and Clinical Excellence and the National Osteoporosis Foundation 2009 were the most restrictive guidelines (54% and 57% respectively). On the other hand the National Guideline Clearinghouse (87%) and the National Osteoporosis Guideline Group (93%). CONCLUSION: There are high differences in the percentage of patients who need treatment to prevent new fractures according to the guidelines. Fewer patients require treatment when the FRAX index is included in a guideline.

Impact of a community-based osteoporosis and fall prevention program on fracture incidence.

Associations between a 10-year community-based osteoporosis and fall prevention program and fracture incidence amongst middle-aged and elderly residents in an intervention community are studied, and comparisons are made with a control community. A health-education program was provided to all residents in the intervention community, which addressed dietary intake, physical activity, smoking habits and environmental risk factors for osteoporosis and falls. Both communities are small, semi-rural and situated in Ostergotland County in southern Sweden. The analysis is based on incidences of forearm fractures in the population 40 years of age or older, and hip fractures in the population 50 years of age or older. Data for three 5-year periods (pre-, early and late intervention) are accumulated and compared. In the intervention community, forearm fracture incidence decreased in women. There are also tendencies towards decreasing forearm fracture incidence in men, and towards decreasing trochanteric hip fracture incidences in women and in men in the late intervention period. No such changes in fracture incidences are found in the control community. Cervical hip fracture incidence did not change in the intervention and the control communities. Although the reported numbers of fractures are small (a total of 451 forearm and 357 hip fractures), the numbers are based on total community populations and thus represent a true difference. The decrease in forearm fracture incidence among women, and the tendency towards decreasing trochanteric hip fractures, in contrast to the absence of change in cervical hip fractures, might be mainly due to a more rapid effect of fall preventive measures than an increase in bone strength in the population. For the younger age groups an expected time lag between intervention and effect might invalidate the short follow-up period for outcome measurements. Thus, the effect of the 10-year intervention program on fracture incidence should be followed during an extended post-intervention period.

Reducing the risk for distal forearm fracture: preserve bone mass, slow down, and don't fall!

A case-control study of 1,150 female and male distal forearm cases and 2,331 controls of age 45 years and older was undertaken from 1996-2001 in five Northern California Kaiser Permanente Medical Centers. Most information on possible risk factors was obtained by an interviewer-administered questionnaire, supplemented by a few tests of lower extremity neurological function. Previous fractures since 45 years of age, a rough marker of osteoporosis, were associated with an increased risk (adjusted odds ratio [OR] [95% confidence interval] = 1.48 [1.20-1.84 ] per previous fracture). Several factors thought to protect against low bone mass were associated with a reduced risk, including current use of menopausal hormone therapy (adjusted OR = 0.60 [0.49-0.74]), ever used thiazide diuretics or water pills for at least 1 year (adjusted OR = 0.79 [0.64-0.97]), high body mass index (weight in kg/height in m2) (adjusted OR = 0.96 [0.89-1.04] per 5 unit increase), and high dietary calcium intake (adjusted OR = 0.88 [0.75-1.03] per 500 mg/day). Falls in the past year and conditions associated with falling, such as epilepsy and/or use of seizure medication (adjusted OR = 2.07 [1.35-3.17]) and a history of practitioner-diagnosed depression (adjusted OR = 1.40 [1.13-1.73]), were associated with increased risks. Having difficulty performing physical functions and all lower-extremity problems measured in this study were associated with reduced risks. The results from this and other studies indicate that distal forearm fractures tend to occur in people with low bone mass who are otherwise in relatively good health and are physically active, but who are somewhat prone to falling (particularly on an outstretched hand), and whose movements are not slowed by lower extremity problems and other debilities. Thus, measures to decrease fall frequency and to slow down the pace of relatively healthy people with low bone mass should lead to a lower frequency of distal forearm fracture.

Are current playground safety standards adequate for preventing arm fractures?

OBJECTIVE: To assess compliance with current standards of playgrounds where children have sustained a fall-related arm fracture. DESIGN, SETTING AND PARTICIPANTS: Between October 2000 and December 2002, a consecutive prospective series of 402 children aged under 13 years who fell from playground equipment and sustained an arm fracture was identified by emergency department staff in five Victorian hospitals. Trained field testers measured playground equipment height, surface type and depth, and surface impact attenuation factors to determine compliance with safety standards. MAIN OUTCOME MEASURES: Playground compliance with current Australian safety standards. RESULTS: Ninety-eight percent of playgrounds had a recommended type of surface material. The mean surface depth was 11.1 cm (SD, 5.0 cm) and the mean equipment height was 2.04 m (SD, 0.43 m). Although over 85% of playgrounds complied with recommended maximum equipment height and surface impact attenuation characteristics, only 4.7% complied with recommended surface depth. CONCLUSION: Playgrounds where children have sustained an arm fracture generally comply with all important safety recommendations except surface depth. Playground fall-related arm fracture requires specific countermeasures for prevention, distinct from head injury prevention guidelines.

Refractures of the radius and ulna in children.

Seven hundred and sixty-eight children with displaced forearm fractures requiring reduction were studied retrospectively. Of 38 refractures (incidence 4.9%), 34 occurred within nine months at the original fracture site. The median time to refracture was eight weeks after discontinuing cast immobilisation. Diaphyseal fractures were eight times more likely to refracture than metaphyseal fractures. The risk of refracture was inversely proportional to the duration of cast immobilisation. Cast immobilisation for a minimum of six weeks reduces the risk of refracture by a factor of between four and six. Midshaft forearm fractures are at risk of refracture for sixteen weeks from cast removal.

Milk, dietary calcium, and bone fractures in women: a 12-year prospective study.

OBJECTIVES: This study examined whether higher intakes of milk and other calcium-rich foods during adult years can reduce the risk of osteoporotic fractures. METHODS: This was a 12-year prospective study among 77761 women, aged 34 through 59 years in 1980, who had never used calcium supplements. Dietary intake was assessed with a food-frequency questionnaire in 1980, 1984, and 1986. Fractures of the proximal femur (n = 133) and distal radius (n = 1046) from low or moderate trauma were self-reported on biennial questionnaires. RESULTS: We found no evidence that higher intakes of milk or calcium from food sources reduce fracture incidence. Women who drank two or more glasses of milk per day had relative risks of 1.45 for hip fracture (95% confidence interval [CI] = 0.87, 2.43) and 1.05 for forearm fracture (95% CI = 0.88, 1.25) when compared with women consuming one glass or less per week. Likewise, higher intakes of total dietary calcium or calcium from dairy foods were not associated with decreased risk of hip or forearm fracture. CONCLUSIONS: These data do not support the hypothesis that higher consumption of milk or other food sources of calcium by adult women protects against hip or forearm fractures.

Bilateral distal radius and ulnar fractures in adolescent weight lifters.

Two cases of bilateral radius and ulnar fractures in adolescent weight lifters are described. The fractures healed without complications. However, the authors stress that these injuries can be prevented if coaches, trainers, and sports medicine physicians are aware of their occurrence and undertake necessary preventative measures. Adequate supervision with spotters at the end of each bar, appropriate foot wear, and, above all, the maximum level of concentration are key factors in preventing these injuries.