Distal radius fractures in the elderly population

We found no clear evidence of the clinical superiority of distal radius fracture surgery among older adults at one year.Surgical treatment, however, may yield a faster recovery to previous level of activity in elderly patients.With operative treatment, hardware-based problems may warrant secondary operations and implant removal, whereas in non-operative treatment, symptomatic loss of alignment and malunion can occur.In elderly patients, non-operative treatment can be considered to be the gold standard.Peer reviewe

Two casting methods compared in patients with Colles' fracture: A pragmatic, randomized controlled trial

Background: Distal radius fractures are common fractures and the cornerstone of treatment remains immobilization of the wrist in a cast. At present, there is a scarcity of studies that compare different cast immobilization methods. The objective of the study was therefore to compare volar-flexion and ulnar deviation cast to functional cast position in the treatment of dorsally displaced distal radius fracture among elderly patients. Methods and findings: We performed a pragmatic, randomized, controlled trial in three emergency centers in Finland. After closed reduction of the fracture, the wrist was placed in either volar-flexion and ulnar deviation cast or functional cast position. The follow-up was 12 months. The primary outcome was patient-rated wrist evaluation (PRWE) score at 12 months. The secondary outcomes were Quick-DASH score, grip strength, health-related quality of life (15D), and pain catastrophizing scale. The number of complications was also recorded. In total, 105 participants were included in the study. Of these, 88% were female and the mean age was 73.5 (range 65-94) years. In the primary analysis, the mean difference in patient-rated wrist evaluation measure between groups was -4.9 (95% CI: -13.1.- 3.4., p = .24) in favor of the functional cast position. Operative treatment due to loss of reduction of fracture was performed for four patients (8%) in the FC group and for seven patients (13%) in the volar-flexion and ulnar deviation cast group (OR: 0.63, 95% CI: 0.16-2.1). Conclusion: In this study, the data were consistent with a wide range of treatment effects when comparing two different cast positions in the treatment of distal radius fracture among elderly patients at 12-month follow-up. However, the functional cast is more likely to be superior when compared to volar-flexion and ulnar deviation cast.Peer reviewe

Long-term subjective results and radiologic prognosis of a distal radius fracture in working-aged patients : a prognostic cohort study of 201 patients

Objective: To investigate long-term outcomes associated with distal radius fracture (DRF) in working-aged patients. The authors hypothesized that the majority of patients experience no permanent loss of function when measured with patient-rated wrist evaluation (PRWE). Methods: This was a retrospective cohort study of patients with a DRF aged between 18 and 65 years. The primary outcome measure was PRWE score at a minimum of 4 years after DRF. Secondary outcome measures were pain catastrophizing scale (PCS) and radiographic measurements. Results: Of 201 patients included, 179 were primarily treated non-operatively with a 5-week cast treatment and 22 were primarily operated. The mean follow-up duration was 5 years. The mean PRWE score was 10.9 (95% confidence interval 8.4, 13.4) and median PRWE was 3.5 (interquartile range, 0.0–13.0). There was minor correlation between PCS and PRWE score (correlation coefficient [CC] 0.3), and between PRWE score and dorsal angulation of the fracture measured after closed reduction (CC 0.2) and in one-week follow-up radiographs (CC 0.2). Conclusions: Working-aged patients seem to gain nearly normal wrist function after DRF in longer follow-up. Pain catastrophizing appears to correlate with long-term treatment outcome.publishedVersionPeer reviewe

Sick leave length and the costs of operatively and conservatively treated distal radius fractures in the working age population: a retrospective cohort study

Abstract Background Among the working population, a transient loss of working ability due to distal radius fracture (DRF) has a societal impact in terms of sick leave. Non-operative cast immobilization is the most common treatment option for DRF. However, these fractures are increasingly treated operatively. This retrospective cohort study of patients aged 20–64 with DRF compares the effects of different treatment strategies on sick leave length and overall cost of treatment. Methods Multivariable regression analysis was used with treatment modality as an exposure and sick leave length as an outcome. Sick leave data were obtained from a national register. Costs were evaluated by adding the direct cost of the treatment modality to the mean cost of sick leave per patient in different treatment groups. Results Of 614 working-age patients with a DRF who were treated at a tertiary hospital in Finland between January 2013 and December 2014, 521 were primarily treated non-operatively with cast immobilization and 93 were primarily operated. Of the primarily non-operatively treated patients, 48 were operated during follow-up. The mean follow-up was 5 years. The median time lost from work after DRF was 55 days (7.9 weeks), and the separated medians by treatment modality were 49 (7 weeks) and 70 days (10 weeks) for conservative and operative treatment, respectively. Multivariable linear regression analyses were performed for those patients who had sick leave (n = 292). Regression analysis also showed that operative treatment correlates with longer sick leave. Conclusions Operative treatment of distal radius fracture led more often to longer time lost from work than conservative treatment. Moreover, due to longer sick leave and the costs of the operation itself, operative treatment is over two times more expensive than conservative treatment. Trial registration retrospectively registered

Resuscitative endovascular balloon occlusion of the aorta (REBOA) may also have a place outside major trauma centers - A case report from a Finnish rural hospital

The recent adoption of endovascular and hybrid methods in the management of massive bleeding following trauma to the torso and junctional areas has been a major advance in trauma care. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is one tool to tackle immediate exsanguination in such cases. To take advantage of such methods, rapid femoral artery access is crucial.In rural hospitals a trauma surgeon, vascular surgeon and interventional radiologist may not be in the hospital during on-call hours. Furthermore, gaining femoral arterial access is an infrequent procedure for a trauma surgeon working outside major trauma centers. Therefore, it might be difficult to acquire and maintain the requisite skills. However, a consultant anesthesiologist is a member of the trauma team and always on call in our hospital. An experienced anesthesiologist is a valuable asset in ultrasound guided arterial punctures and in inserting intravascular introducer sheaths, as was the case in our patient. To our knowledge, anesthesiologists do not commonly participate in the actual placement of arterial introducer sheaths for REBOA catheters in trauma teams. We wish to bring to notice this hidden asset when a team that does not routinely include a vascular surgeon or an interventional radiologist is treating a seriously injured trauma patient.We report on a patient who had sustained a shrapnel injury to the groin with massive blood loss. To stop further bleeding and to stabilize hemodynamics, we used REBOA to gain proximal control of the bleeding. As a result, the patient avoided surgical retroperitoneal exposure and a dry surgical field was created. We conclude that REBOA may also have a place in rural hospitals, and that, if necessary, trauma team members may adopt novel roles in the treatment of hemorrhage

Incidence of distal radius fracture surgery in Finns aged 50 years or more between 1998 and 2016 – too many patients are yet operated on?

Abstract Background Although optimal treatment of distal radius fractures is controversial, surgery has gained popularity. The purpose of this study was to evaluate recent trends in the surgical treatment of distal radius fractures in Finns aged 50 years or more. Methods A nationwide hospital discharge register-based study was conducted among all patients 50 years of age or older who had a surgically treated distal radius fracture in Finland between 1998 and 2016. The number and rate of different surgical procedures were calculated per 100,000 person-years. Results Altogether 21,965 surgically treated distal radius fractures were identified. During the study period the rate of percutaneous pinning and external fixation diminished while the rate of plate fixation significantly increased. The rate of operative treatment increased continually from 1998 to 2008 whereupon the peak of the incidence was achieved. After 2008, the rate of operative treatment of distal radius fracture remained quite constant, ranging between 61.1 and 67.8 per 100,000 person-years. Conclusions Plate fixation has almost completely replaced both external fixation and percutaneous pinning in the surgical treatment of distal radius fractures in Finland. Despite growing evidence for less invasive treatment options in elderly patients, operative treatment of distal radius fracture is still rather popular today

Trends in acute abdominal pain visits to EDs and rate of abdominal surgeries during the COVID-19 pandemic in Finland : A retrospective register study

publishedVersionPeer reviewe

The effect of national lockdown due to COVID-19 on emergency department visits

Background: COVID-19 outbreak lead to nationwide lockdown in Finland on the March 16th, 2020. Previous data regarding to the patient load in the emergency departments during pandemics is scarce. Our aim is to describe the effect of national lockdown and social distancing on the number and reasons for emergency department (ED) visits and inpatient admissions in three large volume hospitals prior to and after the outbreak of the COVID-19 epidemic in Finland. Methods: Data for this register-based retrospective cohort study were collected from three large ED’s in Finland, covering 1/6 of the Finnish population. All patients visiting ED’s six weeks before and six weeks after the lockdown were included. Pediatric and gynecological patients were excluded. Numbers and reasons for ED visits and inpatient admissions were collected. Corresponding time period in 2019 was used as reference. Results: A total of 40,653 ED visits and 12,226 inpatient admissions were analyzed. The total number of ED visits decreased 16% after the lockdown, whereas the number of inpatient admissions decreased 15% (p < 0.001). This change in inpatient admissions was similar in all participating hospitals. Visits due to back or limb pain decreased 31% and infectious diseases 28%. The visit rate and inpatient admissions due to acute myocardial infarction and strokes remained stable throughout the study period. Interestingly, the rate of inpatient admissions due to psychiatric diagnoses remained unchanged, although the ED visit rate decreased by 19%. The number of ED visits (n = 282) and inpatient admissions (n = 55) due to COVID-19 remained low in the participating hospitals. Conclusions: Changes in ED visits and inpatient admissions prior to and during the early phase of the COVID-19 outbreak were unpredictable, and our results may help hospitals and especially ED’s focus their resources better. Surprisingly, there was a major decrease in the rate of ED visits due to back or limb pain and not so surprisingly in infectious diseases. Rates of acute myocardial infarctions and cerebral strokes remained stable. In summary, stabile resources for the treatment of patients with severe diseases will be needed in hospitals and ED’s.publishedVersionPeer reviewe

A comparison of the functional results and costs of functional cast and volar-flexion ulnar deviation cast at 2-year follow-up in 105 patients aged 65 and older with dorsally displaced distal radius fracture: A randomized controlled trial

Background and purpose Non-operative treatment is the most common treatment option for older patients with distal radius fracture (DRF). Traditionally, wrists have been placed in volar-flexion and ulnar deviation position (VFUDC). In recent years, there has been a trend towards using a functional position cast (FC). However, long-term results for these different casting positions are lacking. Patients and methods This randomized, controlled, prospective study evaluates the functional results and costs of the 2 casting positions in patients 65 and older with DRF. Primary end point in this study was Patient-Reported Wrist Evaluation (PRWE) at 24 months, and secondary end points were cost-effectiveness of treatment, health-related quality of life measurement (15D), short version of Disabilities of arm, shoulder and hand score (QuickDASH), and VAS at 24 months. The trial was registered in ClinicalTrials.gov (NCT02894983, https://clinicaltrials.gov/ct2/show/NCT02894983). Results We enrolled 105 patients, of which 81 (77%) continued until 24-month follow-up. 8 patients (18%) were operated in the VFUDC group and 4 (11%) in the FC group. Patients in the VFUDC group also received more frequent physical therapy. The difference in PRWE score between the VFUDC and FC groups at 24 months was -4.31. The difference in the cost of treatment per patient was €590. Both findings favored FC. Interpretation We found a slight, but consistent difference in the functional results between groups. These results suggest that VFUDC is not superior to FC when treating Colles’ type DRF. Cost analysis revealed overall costs in the VFUDC group are nearly double those in the FC group, mostly due to more physical therapy, additional visits to hospital, and additional examinations. Therefore, we recommend FC in older patients with Colles’ type DRF

A comparison of the functional results and costs of functional cast and volar-flexion ulnar deviation cast at 2-year follow-up in 105 patients aged 65 and older with dorsally displaced distal radius fracture : A randomized controlled trial

Background and purposeNon-operative treatment is the most common treatment option for older patients with distal radius fracture (DRF). Traditionally, wrists have been placed in volar-flexion and ulnar deviation position (VFUDC). In recent years, there has been a trend towards using a functional position cast (FC). However, long-term results for these different casting positions are lacking.Patients and methodsThis randomized, controlled, prospective study evaluates the functional results and costs of the 2 casting positions in patients 65 and older with DRF. Primary end point in this study was Patient-Reported Wrist Evaluation (PRWE) at 24 months, and secondary end points were cost-effectiveness of treatment, health-related quality of life measurement (15D), short version of Disabilities of arm, shoulder and hand score (QuickDASH), and VAS at 24 months. The trial was registered in ClinicalTrials.gov (NCT02894983, ).ResultsWe enrolled 105 patients, of which 81 (77%) continued until 24-month follow-up. 8 patients (18%) were operated in the VFUDC group and 4 (11%) in the FC group. Patients in the VFUDC group also received more frequent physical therapy. The difference in PRWE score between the VFUDC and FC groups at 24 months was -4.31. The difference in the cost of treatment per patient was euro590. Both findings favored FC.InterpretationWe found a slight, but consistent difference in the functional results between groups. These results suggest that VFUDC is not superior to FC when treating Colles' type DRF. Cost analysis revealed overall costs in the VFUDC group are nearly double those in the FC group, mostly due to more physical therapy, additional visits to hospital, and additional examinations. Therefore, we recommend FC in older patients with Colles' type DRF.Peer reviewe