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A Brief overview of the Distal Forearm Workshop held in Rome

Written by Amy Hoang-Kim
Wednesday, 26 July 2006

"As new agents are introduced, it is desirable to develop simple yet sensitive non-invasive methods for detecting early changes in the fracture repair process"
Harry Genant, MD

A variety of approved and investigational agents have been evaluated for their effect on accelerating fracture healing. Exogenous and endogenous growth factors, such as low intensity pulsed ultrasound and bone morphogenic protein allow for manipulation of the fracture site to achieve successful union of the bone ends without additional surgery. While conventional radiography remains the mainstay of routine fracture assessment, it may not be sensitive enough. CT with volumetric reconstruction appears to offer the best balance between convenience, cost, availability and ability to quantify soft and calcified tissue changes, according to H. Genant (University of California).

"Age is not a good indicator of functional needs or activity level. Activity level can be objectively rated for decision making and outcome assessment"
Jesse Jupiter, MD

C Day (Boston, US) tested whether age-based discrepancies exist in both treatments employed and accepted radiographic results. Patients included in the study were divided into four groups: young, middle, retired, and elderly. He found that radiographic parameters measured were comparable in all four age groups (p > 0.05). Similarly, initial treatment modality and operative intervention rates were not significantly different between age groups. Patients who received cast only treatment in the ER had 42.6% radiographic failures after first treatment. Closed reduction had a failure rate of 76.8%; when this rate was analyzed by age group, the young had a 50.0% failure rate compared to 92.9% failure in the elderly (p < 0.05). When healed, 13.5% of young patients had radiographic failures as compared to 42.3% for the elderly patients (p < 0.05). He concluded a significantly higher percentage of distal radius radiographic failures were accepted in the elderly group. However, he found no statistically significant discrepancy in the treatment of distal radius fractures with respect to age. Closed reduction treatment led to high rates of radiographic failure, especially in the elderly group. This study suggests considering changes in the present treatment algorithm for the elderly, either in the radiographic failure criteria used or in the treatment rendered.

Many burning issues were discussed amongst which A. Goodship (Royal Veterinary College and University College London, UK) asked whether assessment of bone quality deficiencies in strength could be improved, whether site-specific changes were related to fracture risk and whether bone matrix deficiencies were evident in elderly adults and could be identified in the developing skeleton. He further discussed a novel method to assess the molecular architecture of collagen through RAMAN spectroscopy. Transcutaneous assessment of bone may be feasible at specific sites, this may allow both prediction and monitoring of risk for fragility fractures in the clinic.

V. Kuhn (Germany) believed that biomechanical testing might determine the structural strength of bone which in turn could be correlated with various densitometric parameters. Biomechanical testing conditions may vary considerably from study to study with 3-point bending (shaft), axial compression (metaphysical), and fall simulations being some of the techniques used. Geometry-based parameters of cortical bone are also good predictors but have not been shown to offer significant advantages over measurement of bone mass. Microstructural finite element modelling appears to give the most accurate prediction of distal radius fractures, despite appearing to be patient-specific.

In the aftermath, some of the compelling issues that arose in the surgical treatment of osteoporotic wrist fractures were published in Orthopaedics Today (US) and Orthopaedics International in March 2006. In this year’s American Academy of Orthopaedic Surgeon, the OFC boasts its first symposium "Management of Osteoporotic Wrist Fractures" organized with DFW faculty members. Hot topics included: Conservative Treatment, When I use it (T Axelrod, Toronto, Canada); Internal Fixation: Is this the new gold standard (A Ladd, Stanford, US); Contemporary Perspectives on the role of stable internal fixation (J Jupiter, Boston, US); Minimally-Invasive Open Treatment (C Melone, New York, US) and Fixation Augmentation Techniques: When and How (A Moroni, Bologna, Italy).

"These workshops are distinctive to ISFR. The opportunity to meet with a small group of world leaders in their field to explore new and novel perspectives to fracture treatment and repair is unique."
Nick Fazzalari, PhD

Workshops for the OFC represent a highly-focused group who tackle burning questions and address future directions. Here are some of your questions:

1. Is there a need to include osteoporosis in the classification of distal radius fractures?
2. Post operative management can you avoid casts?
3. When will a density test be developed which accurately reflects upper limb osteoporosis, as compared to osteoporosis of the hip and spine?
4. Can newly developed bone substitutes replace the need for bone grafts in distal radius fractures?

The first two parts of the workshop aimed to generate new insights that may lead to improved methods of treating patients with osteoporotic wrist fractures. The final part of the workshop dealt instead with defining how such new methods could have their superiority demonstrated in reliable clinical studies.

"There are many perceived difficulties of performing randomized, controlled studies in surgery and the coordination between centers needs to achieve adequate power"
David Marsh, MD, FRCS

Finally, we would like to thank all the participants and industrial sponsors who have helped us gather such scientific insight. And we have most definitely realized that there are many roads that lead to Rome but not many taxis to take us out! We are looking forward to carrying out our next venture in Monte Carlo December 1-3, 2006 to resolve issues on patients with osteoporotic hips.

Last Updated ( Wednesday, 26 July 2006 )