Background: Traditionally, distal radial fractures in the elderly have been treated nonoperatively with casting.

Purpose As the population in developed countries continues to age, the incidence of osteoporotic distal radius fractures (DRFs) will increase as well. Treatment of DRF in the elderly population is controversial. We systematically reviewed the existing literature for the management of DRFs in patients 60 and over with five common techniques: volar locking plate system (VLPS), non-bridging external fixation (non-BrEF), bridging external fixation (BrEF), percutaneous Kirschner-wire fixation (PKF), and cast immobilization (CI). Methods Articles retrieved from MEDLINE, Embase and CINAHL Plus that met predetermined inclusion and exclusion criteria were reviewed in two literature reviews. Outcomes of interest included wrist arc of motion, grip strength, functional outcome measurements, radiographic parameters, and the number and type of complications. The data were statistically analyzed using weighted means and proportions based on the sample size in each study. Results 2,039 papers were identified, and 21 papers fitting the inclusion criteria were selected in the primary review of articles with mean patient age of 60 and over. Statistically significant differences were detected for wrist arc of motion, grip strength, and DASH score, although these findings may not be clinically meaningful. Volar tilt and ulnar variance revealed significant differences amongst the groups, with CI resulting in the worst radiographic outcomes. The complications were significantly different, with CI having the lowest rate of complications, whereas VLPS had significantly more major complications requiring additional surgical intervention. Conclusions This systematic review suggests that despite worse radiographic outcomes associated with CI, functional outcomes were no different than surgically treated groups for patients 60 and over. Prospective comparative outcomes studies are necessary to evaluate the rate of functional recovery, cost, and outcomes associated with these 5 treatment methods. Level of Evidence Therapeutic, Level III

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Background Needle aponeurotomy and collagenase injection are alternative treatments of Dupuytren's contracture to open partial fasciectomy; however, reported data are difficult to interpret without a formal systematic review. Methods A Medline, EMBASE, and Cochrane database search was performed, and 277 articles were identified. Articles were stratified by level of evidence, and those of the highest level for each technique were included. Evidence available for needle aponeurotomy was of low quality so only cohorts larger than 100 patients were included. Results The sample size of patients for open partial fasciectomy ranged from 37-261. The recurrence rate ranged from 12-39%, with mean follow-up time of 1.5-7.3 years. The complication rate ranged from 14-67%. Complications included nerve division (2-5%), infection (4-12%), neurapraxia (0.4-52%), and regional pain syndrome (2-13%). For needle aponeurotomy the sample size ranged from 117-211. The recurrence rate ranged from 50-58%, with mean follow-up time of 3-5 years. With regard to collagenase injection, the sample size ranged from 13-204. The recurrence rate ranged from 10-31%, with mean follow-up time of 120 days to 4 years. For the two latter procedures, adverse effects consisted primarily of skin tears (9-25%). Kruskal-Wallis testing demonstrated that the recurrence rate was significantly higher for needle aponeurotomy than for open partial fasciectomy (p=0.001), and the recurrence rate was significantly higher for open partial fasciectomy than for collagenase injection (p=0.001). Conclusions The recurrence rates and types of complications differ between open partial fasciectomy and needle aponeurotomy or collagenase injection. Long-term outcomes have not been well reported.

Background Arthritis of the PIP joint is a debilitating condition commonly treated with arthroplasty. The pyrolytic carbon (pyrocarbon) implant has been developed for PIP joint arthroplasty in these patients. This prospective outcomes study will evaluate the outcomes and complications of the pyrocarbon implant for the PIP joint. Methods Consecutive candidates for PIP joint arthroplasty with pyrocarbon implant were prospectively evaluated. Functional measurements and the Michigan Hand Outcomes Questionnaire (MHQ) were administered pre-operatively and at 3, 6 and 12 months postoperatively. Pre-operative means and 12-month post-operative means for all functional measures were compared using paired t-tests and nonparametric Wilcoxon signed-rank sum test, and effect size was reported for MHQ. Results Fourteen patients treated with 21 implants enrolled in the study. At the 12-month follow-up period, mean active arc of motion (AAM) was 38°, decreasing slightly from the pre-operative value. Mean grip strength improved from 11.3 kg to 15.1 kg, although the difference was not statistically significant. Mean key pinch values improved significantly from 6.6 kg pre-operatively to 9.2 kg at the 12-month follow-up time (p=0.03). Jebsen-Taylor test scores showed improvement, although not significantly. Changes in all MHQ domains showed high effect size. Complications were minimal. Three patients experienced squeaking of the implant and three patients experienced dislocation of the pyrocarbon joint. Conclusions The pyrocarbon implant for PIP joint arthroplasty shows encouraging results, primarily in patient satisfaction and pain relief, but is associated with complications related to implant dislocations, which required prolonged treatment with external fixators.

Purpose To determine the change in score required in various domains of the Michigan Hand Outcomes Questionnaire (MHQ) to indicate meaningful patient improvement, or the minimal clinically important difference (MCID), for three common hand conditions: rheumatoid arthritis (RA), carpal tunnel syndrome (CTS) and distal radius fracture (DRF). Methods The MHQ was administered to patients at two time-points. Patient satisfaction was defined as a satisfaction score equal to or greater than 80% of the standard deviation of that patient sample. The minimal change in score in specific MHQ domains that corresponded with patient satisfaction was determined using receiver operating characteristic (ROC) curves. Results For CTS patients, MCIDs of 23, 13 and 8 were identified for the Pain, Function and Work domains, respectively. For RA patients, Pain and Function were also identified as having discriminative ability, with MCIDs of 11 and 13, respectively. An MCID of 3 was identified for the Activities of Daily Living domain. For DRF patients, no MHQ domains showed discriminative ability due to the ceiling effect at the 3 month assessment period. Conclusions Individual domains of the MHQ can be used to discriminate between patients who are satisfied and those who are not after either carpal tunnel release or silicone arthroplasty of the metacarpophalangeal joints for RA. Pain and Function are the domains of the MHQ that are best able to discriminate between patients who are satisfied and those who are not. The identical Function MCID for both RA patients and CTS patients, despite markedly different pre-operative values, indicates that a standard amount of functional change may indicate patient satisfaction. High post-operative satisfaction, even only 3 months after surgery, prevented any domains from showing discriminative ability for the DRF patients.

The use of internal fixation for the treatment of a distal radial fracture differs widely among geographical regions and patient populations. Such variations highlight the need for improved comparative-effectiveness data to guide the treatment of this fracture.