Research Projects

Distal Forearm Workshop: A Summary

Written by Amy
Tuesday, 05 April 2005

ISFR-IOF Workshop on Osteoporotic Fractures of the Distal Forearm
Bologna, 6-7th November 2004

Sixteen orthopaedic surgeons and six scientists from twelve countries convened in Bologna on November 6th-7th last year for a 24hr distal forearm fractures workshop. The Fractures Working Group, a collaboration between the International Society for Fracture Repair (ISFR) and the International Osteoporosis Foundation (IOF) took the lead in organizing this event. Various representatives from our industrial partners were also in attendance including: DePuy, Wyeth, Orthofix, Stryker, Wright Medical, Orthologics and AO Research. This three-part workshop, chaired by David Marsh (Queen’s University, Musgrave Park Hospital, Belfast, UK), featured short papers with discussion on basic musculoskeletal issues, strengths and weaknesses of current surgical approaches and the burden of the disease.

Roger Francis (Bone Clinic, University of Newcastle-upon-Tyne, UK) said that wrist fracture patients over the age of 65 should always be scanned for osteoporosis. The ideal place in terms of practicality and usefulness for BMD assessment is the fracture clinic. He says that if indeed a peripheral dual energy x-ray absorptiometry (pDXA) service can be introduced into a fracture service, then emphasis should be placed on the ability to determine bone quality prior to surgery. This could be beneficial for the surgical indication and consequently treatment outcome.

Angel Ferreres (University of Barcelona, Spain) emphasized that most wrist injuries are extra-articular. Although extra-articular injuries are often easier to treat than intra-articular injuries which usually require surgical reduction, all types of wrist injuries can lead to malunion. Low trauma injuries generally involve extra-articular fractures with a dorsal defect that reduces the wrist flexion arc. The challenge lies in measuring dorsal lines which correlate with long-term malalignment and whose severity is often underestimated. Malunion may result in pain, forearm shortening, and eventual disuse by the patient. Furthermore, grip strength accompanied by pain because of malalignment and arthritis make a significant difference to the patient. Nonunion is much rarer and may instead reflect the loss of mobility or operative fixation in a distracted position.

Margaret McQueen (Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Scotland) emphasized the importance of the relationship between anatomy and function, which is often ignored in the orthopaedic community. M McQueen said that with wrist fractures, if the surgical treatment is carried out correctly, the failure rate is minimal. She also claimed that achieving optimal anatomical reduction is less important for the elderly. These patients are more concerned with pain and function than with perfect wrist alignment. M McQueen also noted that with intra-articular fractures, bridging external fixation is useful for reducing the malunion rate but non-bridging fixators are a better indication for extra-articular fractures.

Shohei Iwabu (Japan) says that open reduction and internal fixation in addition to external fixation from either the dorsal or the volar side can achieve good reduction and stability. In particular, the development of plates fixed with locking screws has improved the outcome for osteoporotic fractures. The use of screws which lock to the plate is now being applied to the distal radius. Iwabu believes that better results can be obtained with this type of implant as opposed to standard types.

David Marsh (Queen’s University, Belfast) says that younger patients with widely displaced fractures are more likely to have stout cortices, which can be re-aligned, whereas older osteoporotic patients will have a large bone void after reduction of the fracture where the osteoporotic bone has been compressed. A significant feature is the crushing of cancellous bone, which leads to void formation, especially dorsally, when deformity is corrected. The void may fill with bone naturally if the fracture can be stabilised for a sufficient period of time. However, there are cases in which calcium phosphate cement should be recommended.

Amy Ladd (Stanford University School of Medicine, USA) presented several surgical techniques to treat wrist fractures. She claimed that if good fixation is obtained, there is no need to fill the gap with calcium phosphate cements. She was happy with the implants already available and recommends internal fixation in a variety of fracture types to restore wrist alignment correctly.

Thomas Gausepohl (St. Vinzenz-Hospital, Cologne, Germany) said that there are zones which offer optimal screw purchase, whereas in other areas, the bone is simply non-existent. Since bone quality varies from patient to patient and radiological analysis does not seem to provide adequate information, we need to investigate how best to assess bone quality. A better understanding of the bone density along the wrist would be useful for evaluating screw purchase.

Olof Johnell (University of Lund Malmö, Sweden) said that if distal radius fractures remain untreated, the quality of life for the patient concerned is significantly affected. While the loss of QOL following low-trauma distal forearm fractures is less than in other injuries, i.e. hip, spine, shoulder, the number of people affected is large; this will in turn have a high social and economic impact. In addition, patients with wrist fractures have an increased risk of a secondary fracture; a wrist fracture doubles the risk of a hip fracture, further affecting QOL. Therefore, wrist fractures are an opportunity for secondary fracture prevention that orthopaedic surgeons should not miss.

Aenor Sawyer (Private practice, California, USA) said that every patient with wrist fixation should undergo physical therapy. This is to optimize the return to previous functional levels regardless of the surgical treatment decision. She also mentioned how therapy can be useful for preventing fractures in the osteoporotic population.

Antonio Moroni (Rizzoli Orthopaedic Institute, Bologna University, Italy), disagrees with M Mcqueen, and states that osteoporotic wrist fracture patients do not tolerate inadequate reductions. Because of this, surgical treatment is the direction we should take in the vast majority of cases. Unfortunately, in osteoporotic bone, there is a significant incidence of fixation failure because of the inability of implants to achieve and maintain adequate stability. Moroni believes that there are effective fixation augmentation techniques such as augmentation with calcium phosphate cements or the use of implants coated with calcium-phosphates. These implants have an optimal osteointegration ability even in osteoporotic bone. However, the missing factor is how the surgeon should take the decision whether or not to use fixation augmentation techniques. Moroni says that because of this background, a better understanding of bone quality in elderly wrist fracture patients is greatly needed. He proposes to develop a tool to measure bone quality intraoperatively.

Amy Hoang-Kim (Rizzoli Orthopaedic Institute, Bologna, Italy) said that as mechanical and biological factors are important for fracture healing, future research should focus on these two aspects. Implant design and coatings (eg. HA-coated screws which yield better outcomes in osteoporotic bone) are crucial and can be further improved. In addition, drugs (alendronate), growth factors (BMP), stem cells, cements and physical stimulation (CEMP, ultrasound) have yet to establish a secure role in positive bone remodelling, maintenance of fixation stability and reduction of wrist deformity in osteoporotic patients. Problems relating to distal radius fractures should be overcome using a multi-factorial approach, which will lead to better overall clinical outcomes.

Elisabeth Venturelli (Orthofix srl, Verona, Italy) said that since the introduction of fixation augmentation techniques such as HA-coated pins, there has been a sharp increase in products for wrist fracture treatment.

Andreas Spietling and Monique Günther (Stryker) agreed on the need to develop a tool for measuring intra-operative bone density and expressed a commitment on behalf of the company to develop this tool.

Jim Ryaby (Orthologics) expressed his support for growth factors saying that they played a fundamental role in wrist fracture treatment and that future research should address this.

The integration of clinical practice with evidence-based analysis involving multi-centric studies could create a large database of patient information concerning osteoporosis. However, the standardization of data outcomes should be examined so that orthopaedic surgeons can examine results from different countries. M McQueen and J Goldhahn (Zurich, Switzerland) suggested that there is a problem in standardizing outcomes and that it is difficult to compare outcome papers because of different measurements. In addition, M McQueen noted a resistance in the orthopaedic community to change. D Marsh urged for the use of registries of different low trauma fracture types and outcomes. N Fazzalari suggested cooperation in creating a classification system for fractures in order to determine treatment techniques.

Last Updated ( Tuesday, 17 May 2005 )