Secondary Logo

Journal Logo

First Place Award

A radiographic analysis of closed reduction and casting of distal radial fractures with consideration of candidacy

Trouw, Arie G. MDa,b; Mulchandani, Neil B. MDa,c; Kelly, John J. MSa,d; Eldib, Ahmed M. MDa; Shah, Neil V. MD, MSa; Banning, George K. MD, MPHa; Chatterjee, Dipal MDa; Scollan, Joseph P. BSa; Yang, Andrew MDa; Kapadia, Bhaveen H. MDa; Diebo, Bassel G. MDa; Illical, Emmanuel M. MD, FRCSCa; Urban, William P. MDa

doi: 10.1097/BCO.0000000000000779
Special Focus: Resident Research Award
Free

Background: Distal radial fractures (DRF) are treated by internal fixation or closed reduction and casting (CRC). Over the years, various DRF classification systems and radiographic thresholds have been developed to guide management for orthopaedic surgeons, yet no gold standard has been established. This study sought to identify patients who presented with DRF and received treatment with CRC and determine if the process of selecting CRC-managed patients had improved by analyzing radiographic maintenance of reduction through final bone union.

Methods: Retrospective review of a single-site database from 2012-2015 identified CRC-managed DRF with pre-CRC, post-CRC, and final-union radiographs. Outcomes compared included radial height (RH), radial inclination (RI), volar tilt (VT), teardrop angle (TDA), and ulnar variance (UV).

Results: Post-CRC RH increased (7.5 to 10.4 mm, P<0.01) and regressed by 1.3 mm by union. RI increased (14.4 to 19.4 degrees, P<0.01) and returned to 17.3 degrees by union. Mean VT changed from −9.9 to 7.9 degrees (P<0.01) and to 1.1 degrees by union (P<0.05). TDA increased by union (34.1 to 44.5 degrees, P<0.01). UV changed from 1.2 to −0.2 mm (P<0.02) to 1.2 mm by union (P<0.01). At presentation the following parameters had differences when considering established favorable and unfavorable values at final-union: RH (9.58 vs. 5.26 mm), RI (16.9 vs. 8.1 degrees), and UV (0.4 vs. 3.9 mm) (all P<0.0005).

Conclusions: Current literature demonstrated substantial variation in DRF management and expectations after CRC. This study revealed that RH greater than 9.5 mm and UV less than 3.8 mm at presentation were associated with successful reductions without functional deficit.

aDepartment of Orthopaedic Surgery, State University of New York (SUNY), Downstate Medical Center, Brooklyn, NY

bDepartment of Orthopaedic Surgery, University of Connecticut Health, Farmington, CT

cDepartment of Orthopaedic Surgery, Northwell-Lenox Hill Hospital, New York, NY

dSchool of Medicine, SUNY Upstate Medical University, Syracuse, NY

Financial Disclosure: Dr. Illical discloses a financial relationship outside this work with Biocomposite and Skeletal Dynamics. The authors report no conflicts of interest.

Correspondence to Neil V. Shah, MD, MS, Department of Orthopaedic Surgery, SUNY Downstate Medical Center, 450 Clarkson Ave, MSC 30, Brooklyn, NY 11203S Tel: (718)-221-5270; fax: (718)-270-8769; e-mail: neilvshahmd@gmail.com.

Back to Top | Article Outline

INTRODUCTION

Distal radial fractures (DRF) are commonly encountered orthopaedic injuries, occurring mostly with a bimodal age distribution within boys and postmenopausal women.1,2 Multiple studies have reported an increasing incidence of DRF, which has been attributed to an increased amount of high-energy traumas and an aging population.3,4 A number of factors, including patient demographics, hand dominance, and baseline activity level, determine management decisions for DRF. However, the degree of fracture stability often dictates whether operative management is necessary. Radiographic parameters of unstable fractures include intraarticular involvement, radial shortening greater than 5 mm, dorsal angulation greater than 20 degrees, metaphyseal comminution, or displacement of the radius in either direction by more than two thirds the width of the shaft.5,6 Unstable fracture patterns have a higher risk of failing conservative management with closed reduction and casting (CRC).7 In these cases, operative strategies include open reduction and internal fixation (ORIF), percutaneous pinning, and external fixation.8 Failing to provide proper and timely treatment may result in complications, such as complex regional pain syndrome, malunion, infection, or tenosynovitis.9 Thus, accurate radiographic assessment and interpretation of a DRF is crucial, as current definitions of fracture instability are structured around radiographic measurements.10

Closed reduction and casting has been the mainstay treatment of DRF for decades. More recently, surgeons have shown an increased preference toward managing active patients with ORIF due to evidence suggesting that this strategy has improved functional outcomes.11,12 Despite conflicting evidence in regards to functional outcomes in the elderly population, management of DRF in this population is also following the trend.13,14 Rates of CRC in Medicare patients have decreased from 83% to 74% between 1997 and 2007; meanwhile, ORIF rates have risen from 1% to 17% during this same time frame.15 Although management tendencies of DRF are trending away from CRC, there is no evidence in the literature indicating that surgeons have become better at selecting candidates for CRC. Between 1996 and 2004, three studies evaluated over 350 CRC-managed DRF and found that up to 88% of the injuries had secondarily displaced, as determined by radiographic assessment.16–18 CRC achievement of satisfactory functional results is considered the standard for determining whether optimal care was delivered; moreover, reductions that are closest to native anatomy appear to correlate with better wrist function. As DRF rates continue to rise and management trends further adapt, there is a need to evaluate the management decision-making process to determine if patients are receiving optimal care.

Over the years, various DRF classification systems and radiographic measurement guidelines have been developed to assist orthopaedic surgeons in selecting better management plans.10,19 These systems, in addition to implant advancements, specifically, the introduction of volar locking plates in 2000, have led to a decrease in the number of conservatively treated DRF.20 Therefore, the purpose of the present study was to identify patients who presented with DRF and received treatment with CRC and determine if the process of selecting CRC-managed patients has improved by analyzing radiographic maintenance of reduction through final bone union. Specifically, we measured radial height (RH), radial inclination (RI), ulnar variance (UV) volar tilt (VT), and teardrop angles (TDA) and compared these measurements at presentation, after CRC, and at final bone union.

Back to Top | Article Outline

MATERIALS AND METHODS

Data Source

Radiographs performed during emergency department visits at a single-institution and which diagnosed a DRF, were identified between July 2012 and March 2015. Institutional review board approval was obtained to conduct this retrospective study.

Back to Top | Article Outline

Study Population

This study evaluated all patients who had documentation of a distal radial fracture and subsequently received CRC management. Patients were only included in the analysis if they had the following three wrist radiographs: (1) prereduction radiograph at initial presentation, (2) postreduction radiograph following CRC, and (3) a radiograph after final bone union, were identified. Final bone union radiographs were dated a mean of 6.4 mo (range, 2 to 51 mo) from the initial injury.

Back to Top | Article Outline

Radiographic Assessment

Five radiographic parameters were measured using the institution’s picture archiving and communication system (PACS), at each of the three radiographic periods by two of the authors (Figure 1). Coronal plane measurements included radial height (RH), radial inclination (RI), and ulnar variance (UV). Sagittal plane measurements included volar tilt (VT), and teardrop angle (TDA).

FIGURE 1

FIGURE 1

Radial inclination was represented by the angle formed by drawing a line perpendicular to the radius’ longitudinal axis and a tangential line connecting the styloid tip of the radius to the ulnar edge of the lunate facet (Figure 2A). Radial height was measured by the distance between two parallel lines that were perpendicular to the long axis of the radius; one line was drawn at styloid process tip of the distal radius, and the other line was drawn across the articular surface of the radius (Figure 2B). Ulnar variance was measured by comparing the relative lengths of the articular surfaces of the distal radius and ulna. The TDA correlated to the arc of the curvature between the lunate and the articular margin of the radius (Figure 3A). Volar tilt referred to the angle between a line perpendicular to the radius’ longitudinal axis from the margin of the joint and another that ran tangentially along the radius’ distal articular surface in the dorsal to volar direction (Figure 3B).10

FIGURE 2

FIGURE 2

FIGURE 3

FIGURE 3

Back to Top | Article Outline

Data Analysis

Data analysis was performed using SPSS version 24.0 (IBM Corp, Armonk, NY). Analysis included one-way ANOVA tests, and a P-value of<0.05 was interpreted to be statistically significant. Cohen’s kappa scores were calculated for interrater reliability for all radiographic parameters. Data was organized, and tables were constructed using Microsoft Excel 2010 (Microsoft Corporation; Redmond, WA).

Back to Top | Article Outline

Consideration of Candidacy

The most studied radiographic parameters used to predict functional outcomes in DRF managed with CRC include RH, VT, RI, and UV. Most of the data support RH as being the strongest predictor of functional outcomes, especially among elderly patients,10,21 but VT10,14,21,22 also has been found to predict outcomes to a lesser degree. In general, at final bone union, a RH greater than 9.3 mm or VT greater than 3 degrees has correlated with better functional outcomes in conservatively managed patients, and despite little evidence correlating RI with functional outcomes, a RI greater than 15 degrees has been postulated as a management goal.21,23 Similarly, conservatively treated patients with a UV less than 3 mm has been reported by Kodama et al.14 to have superior Mayo wrist scores (MWS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Thus, using these values as a cutoff to determine whether CRC management was successful or not, the prereduction means of successfully managed fractures were compared against the prereduction means of unsuccessfully managed fractures using a Student t-test, and a P-value of<0.05 denoted statistical significance.

Back to Top | Article Outline

RESULTS

Patient Demographics

The present study identified 42 patients, 31 of whom were women, with a mean age of 58.98 yr (range, 23 to 100 yr) (Table 1).

TABLE 1

TABLE 1

Back to Top | Article Outline

Radial Height, Radial Inclination, and Ulnar Variance

The mean RH was significantly restored after CRC (7.5 to 10.4 mm; P<0.01), regressing only slightly by 1.3 mm after final union. Mean RH was not significantly different between postreduction and final union measurements or prereduction and final union measurements. A similar pattern of significant change was observed with RI, which increased from 14.4 to 19.4 degrees (P<0.01) following CRC and returned to 17.3 degrees after final bone union (Table 2). Prereduction UV decreased at postreduction CRC (1.2 to −0.2 mm, P<0.02), and UV was restored by final bone union (1.2 mm, P<0.01). There was no difference in UV between pre-CRC and final union.

TABLE 2

TABLE 2

Back to Top | Article Outline

Volar Tilt and Teardrop Angle

The mean VT angle significantly changed at each radiographic period, from −9.9 degrees at initial presentation to 7.9 degrees after CRC (P<0.01) to 1.1 degrees after union (P<0.05). The mean TDA also significantly increased following CRC (34.1 to 49.9 degrees, P<0.01) and did not deviate significantly from this measurement through final bone union (Table 2).

Back to Top | Article Outline

Candidacy Analysis

The mean prereduction RH in patients who achieved a favorable final bone RH was significantly higher than the mean prereduction RH in those who failed to achieve a satisfactory RH (9.58 vs. 5.26 mm, P=0.0002). A similar pattern was appreciated with respect to RI (16.92 vs. 8.08 degrees, P=0.0006) and UV (0.41 vs. 3.88 mm, P<0.01); however, no significant difference was found between mean prereduction VT values (Table 3).

TABLE 3

TABLE 3

Back to Top | Article Outline

Interrater Reliability

Between the two surgeons who performed radiographic measurements, the Cohen’s kappa scores for interrater reliability for all radiographic parameters were >0.892, indicating a strong level of agreement.24

Back to Top | Article Outline

DISCUSSION

Radiographic measurements have been described in various ways in the literature, which results in significant interobserver variability. However, the literature appears to agree that the majority of DRF managed with CRC undergo secondary displacement at some time prior to final bone union.18 Furthermore, the literature trends show that a distal radial malunion in younger patients is associated with poorer functional outcomes.25 For the elderly, secondary displacement occurs at higher rates.18 However, the correlation between malunion and poorer functional outcomes has not been made in this population.13,26,27 Between 1996 and 2004, the rates of internal fixation across all age groups nearly doubled, reflecting the recent introduction of volar locking plates and some literature showing improved functional outcomes for operatively treated DRF.28,29

Many studies have sought to analyze radiographic measurements in conservatively managed DRF, but most of these studies were conducted before or during the time that trends were shifting toward increased management with internal fixation. The present study, which evaluated DRF treated with CRC between 2012 and 2015, determined that all radiographic measurements significantly improved after CRC, and acceptable RH, RI, and VT values were maintained through union. On the other hand, TDA, despite improving significantly after CRC, never attained normal values. However, this measurement is relatively new to the literature, and normal postreduction values have not been reported elsewhere. Additionally, the present study found that patients with a RH less than 9.5 mm and UV of greater than 3.8 mm at time of presentation may be at significant risk for having suboptimal functional outcomes if treated conservatively. This is based on the present study’s radiographic findings in the context of previous studies that have evaluated correlations between radiographic parameters and functional outcomes.

Radial height is normally 9 to 12 mm in length.23 Shortening of this measurement below 9 mm results from comminution and impaction of fracture fragments, and shortening of 5 mm or more compared to the contralateral distal radius is a marker of fracture instability.23 Similar to the present study, Azzopardi et al.30 between 1997 and 2000 and Wong et al.31 between 2006 and 2007 demonstrated RH improvement after CRC, achieving postreduction values of 10 mm and 10.7 mm, respectively. However, after final bone union, both studies reported that CRC-managed patients had a mean RH that regressed below prereduction values (4.2–5.0 mm), possibly suggesting that these patients were poor candidates for conservative management.30,31 Similarly, Bagul et al.32 found statistically significant improvement in the mean RH of 15 DRF following CRC (6.1 to 7.9 mm, P<0.001). However, this postreduction RH was outside what is considered “normal,” suggesting that either the patients of this study were poor candidates for CRC, or that there was poor technique used to reduce fractures in this study. Many other studies dating from 1990 to 2015 failed to achieve acceptable final union RH values.8,27,33 A 2015 study by Cai et al.21 demonstrated that RH was the most important radiographic determinant of final function and that loss of RH was associated with poor functional outcomes, evidenced by a strong correlation between a final union RH>9.3 mm and a Mayo Wrist Score (MWS) of 80 or higher. Using this 9.3-mm cutoff for RH at final union, the present study found that patients who achieved this measurement goal had a mean RH of 9.5 mm at the time of injury. Similarly, Kodama et al.14 demonstrated that among patients treated conservatively, those with UV of less than 3 mm at final examination had superior MWS and DASH scores. Using this 3-mm cutoff at final union, the present study found that patients who achieved this measurement goal had a mean UV of 0.4 mm. Therefore, the authors of this study believe that patients initially presenting with a RH less than 9.5 mm or UV greater than 3.8 mm at time of injury may benefit from consideration of nonconservative treatment, given the potential for poor functional outcomes based on RH and UV values at union.

The normal range of RI is 19 to 29 degrees, but in the event of a DRF, improvement of inclination to greater than 15 degrees is considered acceptable.23 Loss of radial inclination in DRF shifts the load distribution more to the lunate fossa and less to the scaphoid fossa, resulting in abnormal wrist joint mechanics.34 Altering wrist joint mechanics can predispose the wrist to posttraumatic arthritis. Wong et al.31 examined pre and post-CRC, and final union radiographs in 30 patients with DRF, and reported comparable mean RI measurements to the present study (13 degees at initial presentation, 23 degrees after CRC, and 16 degrees after bone union). Other studies have shown similar findings, although in these studies, the RI was within a normal range at initial presentation as well.13,30 Multiple other studies agree that an acceptable RI can be achieved with CRC by time of bone union.27,33,35,36 However, it should be noted that reduction technique influences postreduction radiographic parameters. Wichlas et al.37 reported substantially higher RI values when reduction was preceded by 15 min of hanging traction. Overall, the literature suggests that RI can be restored and maintained to normal values with CRC management, contrary to varying results pertaining to radial height. The present study found a significant difference between mean RI at time of presentation based on the achievement or lack of achievement of a final union RI of 15 degrees. However, most studies have demonstrated appropriate restoration of RI, and there is little evidence to support RI as a predictor of functional outcomes in RI, making little significance of this finding.

A negative VT indicates dorsal angulation of the distal radial articular surface. Although normal values range from 0 to 22 degrees, an acceptable value after reduction of a DRF is any value within 20 degrees of the contralateral distal radius.23 Loss of VT greater than 10 degrees has been shown to markedly decrease the radioscaphoid and radiolunate articular contact areas, leading to significant increases in pressure load to the dorsal aspect of the radiocarpal joint and predisposing the wrist to dorsal radiocarpal instability.38 Studies have shown significant reductions in dorsal angulation after CRC in DRF patients.18,30 Although multiple studies have reported acceptable VT values at time of bone union after CRC comparable to this study, these studies did not report prereduction or postreduction measurements, making it hard to draw definitive conclusions.8,27,35 Other studies have refuted CRC success by reporting that dorsal angulation persisted in the long-term.39 For example, Egol et al.33 reported that, the mean VT decreased from -1.1 to -5.8 degrees between 3 and 12 mo after reduction, but the study failed to report any normalized VT values, making it uncertain whether acceptable values were attained immediately after reduction. Largely, there is a lack of convincing evidence in the current literature to determine if restoration of VT is more achievable with CRC now than in the past. To the best of the authors’ knowledge, no previous study has reported prereduction or postreduction VT measurements in CRC-managed patients. Additionally, some studies have supported the fact that restoration of VT has a positive influence on functional outcomes.14 Cai et al.21 suggested a goal value for final union VT to be greater than 3 degrees, at which point the MWS was likely to be 80 or higher. The present study found that patients on either side of this cutoff did not significantly differ in terms of mean VT at presentation; thus, despite correlation between VT and functional outcomes, we were unable to predict which patient might achieve an acceptable reduction with restoration of VT with CRC therapy based on prereduction VT.

The normal TDA of 68 to 70 degrees was first described by Medoff in 2005.10 After reduction, a depression of this angle may be an indicator that articular incongruity remains despite restoration of radial inclination and volar tilt.10,40 There is a significant paucity of data regarding TDA in the literature, especially as it relates to CRC. In 2011, Forward et al.41 published the only other study to date that analyzed prereduction, postreduction, and final union TDA values, finding that the TDA significantly improved after CRC (47 to 58 degrees, P<0.0001) and was maintained through final union (56 degrees). No study to date, including those that have evaluated TDA outcomes after surgical management, has achieved successful restoration of the TDA in the normal reported range.

The retrospective nature of the present study poses certain limitations. The size of the cohort included is one major limitation; these patients were included, as they met all inclusion criteria and had full radiograph sets. Nevertheless, there is a downward trend in conservative management of distal radial fractures and a paucity of literature on acceptable parameters at presentation for conservative management.28 Moreover, this cohort size is similar to several related studies.8,42,43 Additionally, the mean age of the study population was 58.98 yr; while this may indicate a relatively younger cohort, the study population actually had a bimodal age distribution (46 and 67 yr). Although age has been determined to effect reduction outcomes, our study population, though small, represented both relatively younger and elderly patients.18 In addition, the study cohort varied in patient demographic data, and fracture classification and severity were not recorded.

In conclusion, most of the current literature on the topic of radiographic outcomes of CRC-managed DRF is underpowered, and few studies have reported analyzing radiographs at initial presentation, postreduction, or after final union. With the literature that does exist, follow-up timelines vary, and marked inconsistencies in results have been reported. Also, little attempt has been made to assess the predictive value of various radiographic measurements on functional outcomes. This supports the fact that management decisions for DRF with CRC remain subjective. Results from the present study underscore the importance of developing standardized guidelines to properly assess radiographs in DRF patients. Additionally, using predetermined final union goals, this study found that patients with a RH greater than 9.5 mm and UV less than 3.8 mm at time of injury would be likely to achieve successful reduction without functional deficit. Establishment of guidelines would offer surgeons the ability to make better management decisions that are both evidence-based and will correlate better with radiographic and functional outcomes.

Back to Top | Article Outline

REFERENCES

1. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001; 26:908–915.
2. Nellans KW, Kowalski E, Chung KC. The epidemiology of distal radius fractures. Hand Clin. 2012; 28:113–125.
3. Meena S, Sambharia AK, Sharma P, et al. Fractures of distal radius: an overview. J Fam Med Prim Care. 2014; 3:326.
4. Jupiter JB. Fractures of the distal end of the radius. J Bone Joint Surg Am. 1991; 73:461–469.
5. Altissimi M, Mancini GB, Azzarà A, et al. Early and late displacement of fractures of the distal radius. The prediction of instability. Int Orthop. 1994; 18:61–65.
6. Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury. 1989; 20:208–210.
7. Jung H-W, Hong H, Jung HJ, et al. Redisplacement of distal radius fracture after initial closed reduction: analysis of prognostic factors. Clin Orthop Surg. 2015; 7:377–382.
8. Venkatesh RB, Maranna GK, Narayanappa RKB. A comparative study between closed reduction and cast application versus percutaneous K-wire fixation for extra-articular fracture distal end of radius. J Clin Diagn Res. 2016; 10:RC05–RC09.
9. Mathews AL, Chung KC. Management of complications of distal radius fractures. Hand Clin. 2015; 31:205–215.
10. Batra S, Gupta A. The effect of fracture-related factors on the functional outcome at 1 year in distal radius fractures. Injury. 2002; 33:499–502.
11. Koenig KM, Davis GC, Grove MR, et al. Is early internal fixation preferred to cast treatment for well-reduced unstable distal radial fractures? J Bone Joint Surg Am. 2009; 91:2086–2093.
12. Rozental TD, Blazar PE, Franko OI, et al. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial. J Bone Joint Surg Am. 2009; 91:1837–1846.
13. Arora R, Gabl M, Gschwentner M, et al. A comparative study of clinical and radiologic outcomes of unstable Colles type distal radius fractures in patients older than 70 years: nonoperative treatment versus volar locking plating. J Orthop Trauma. 2009; 23:237–242.
14. Kodama N, Takemura Y, Ueba H, et al. Acceptable parameters for alignment of distal radius fracture with conservative treatment in elderly patients. J Orthop Sci. 2014; 19:292–297.
15. Shauver MJ, Yin H, Banerjee M, et al. Current and future national costs to medicare for the treatment of distal radius fracture in the elderly. J Hand Surg Am. 2011; 36:1282–1287.
16. Beumer A, McQueen MM. Fractures of the distal radius in low-demand elderly patients: closed reduction of no value in 53 of 60 wrists. Acta Orthop Scand. 2003; 74:98–100.
17. Earnshaw SA, Aladin A, Surendran S, et al. Closed reduction of Colles fractures: comparison of manual manipulation and finger-trap traction: a prospective, randomized study. J Bone Joint Surg Am. 2002; 84-A:354–358.
18. Makhni EC, Ewald TJ, Kelly S, et al. Effect of patient age on the radiographic outcomes of distal radius fractures subject to nonoperative treatment. J Hand Surg Am. 2008; 33:1301–1308.
19. Solgaard S. Classification of distal radius fractures. Acta Orthop Scand. 1985; 56:249–252.
20. Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg Am. 2002; 27:205–215.
21. Cai L, Zhu S, Du S, et al. The relationship between radiographic parameters and clinical outcome of distal radius fractures in elderly patients. Orthop Traumatol Surg Res. 2015; 101:827–831.
22. Tsukazaki T, Takagi K, Iwasaki K. Poor correlation between functional results and radiographic findings in Colles’ fracture. J Hand Surg Br. 1993; 18:588–591.
23. Wheeless CRWheeless CR, Nunley JA, Urbaniak JR. Wheeless’ Textbook of Orthopaedics. Duke University Medical Center’s Division of Orthopaedic Surgery, in conjunction with Data. Durham, North Carolina: Trace Internet Publishing, LLC; 2004.
24. McHugh ML. Interrater reliability: the kappa statistic. Biochem Medica. 2012; 22:276–282.
25. McQueen M, Caspers J. Colles fracture: does the anatomical result affect the final function? J Bone Joint Surg Br. 1988; 70:649–651.
26. Barton T, Chambers C, Bannister G. A comparison between subjective outcome score and moderate radial shortening following a fractured distal radius in patients of mean age 69 years. J Hand Surg Eur Vol. 2007; 32:165–169.
27. Young BT, Rayan GM. Outcome following nonoperative treatment of displaced distal radius fractures in low-demand patients older than 60 years. J Hand Surg Am. 2000; 25:19–28.
28. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment of distal radial fractures in the elderly. J Bone Joint Surg Am. 2009; 91:1868–1873.
29. Fanuele J, Koval KJ, Lurie J, et al. Distal radial fracture treatment: what you get may depend on your age and address. J Bone Joint Surg Am. 2009; 91:1313–1319.
30. Azzopardi T, Ehrendorfer S, Coulton T, et al. Unstable extra-articular fractures of the distal radius: a prospective, randomised study of immobilisation in a cast versus supplementary percutaneous pinning. J Bone Joint Surg Br. 2005; 87:837–840.
31. Wong TC, Chiu Y, Tsang WL, et al. Casting versus percutaneous pinning for extra-articular fractures of the distal radius in an elderly Chinese population: a prospective randomised controlled trial. J Hand Surg Eur Vol. 2010; 35:202–208.
32. Bagul R, Deshmukh A, Salgia A, et al. Comparative evaluation in the measurement of the radial height, radial inclination, and ulnar variance in fracture distal end radius treated conservatively by closed reduction and cast and closed reduction, Kirschner wire and cast. Med J Dr DY Patil Univ. 2014; 7:590.
33. Egol KA, Walsh M, Romo-Cardoso S, et al. Distal radial fractures in the elderly: operative compared with nonoperative treatment. J Bone Joint Surg Am. 2010; 92:1851–1857.
34. Pogue DJ, Viegas SF, Patterson RM, et al. Effects of distal radius fracture malunion on wrist joint mechanics. J Hand Surg Am. 1990; 15:721–727.
35. Forward DP, Davis TRC, Sithole JS. Do young patients with malunited fractures of the distal radius inevitably develop symptomatic post-traumatic osteoarthritis? J Bone Joint Surg Br. 2008; 90:629–637.
36. Kilic A, Ozkaya U, Kabukcuoglu Y, et al. [The results of non-surgical treatment for unstable distal radius fractures in elderly patients]. Acta Orthop Traumatol Turc. 2009; 43:229–234.
37. Wichlas F, Haas NP, Lindner T, et al. Closed reduction of distal radius fractures: does instability mean irreducibility? Arch Orthop Trauma Surg. 2013; 133:1073–1078.
38. Wang X, Zhong S, Zhao W, et al. Palmar tilt changes due to distal radius fractures and radiocarpal instability: a biomechanical study. Di Yi Jun Yi Da Xue Xue Bao. 2003; 23:352–354.
39. Földhazy Z, Törnkvist H, Elmstedt E, et al. Long-term outcome of nonsurgically treated distal radius fractures. J Hand Surg Am. 2007; 32:1374–1384.
40. Fujitani R, Omokawa S, Iida A, et al. Reliability and clinical importance of teardrop angle measurement in intra-articular distal radius fracture. J Hand Surg Am. 2012; 37:454–459.
41. Forward D, Davis T. The teardrop angle and AP distance in fractures of the distal radius. Orthop Proc. 2011; 93-B(suppl):6.
42. Walenkamp MMJ, Mulders MAM, van Hilst J, et al. Prediction of distal radius fracture redisplacement: a validation study. J Orthop Trauma. 2018; 32:e92–e96.
43. Brogren E, Petranek M, Atroshi I. Cast-treated distal radius fractures: a prospective cohort study of radiological outcomes and their association with impaired calcaneal bone mineral density. Arch Orthop Trauma Surg. 2015; 135:927–933.
Keywords:

distal radius; fracture; closed reduction; casting; radiographic parameters; patient selection

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved