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Fractures of the distal radius: Factors related to radiographic evaluation, conservative treatment and fracture healing
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Distal radius fractures (DRFs) are one of the most common injuries encountered in orthopaedic practise. Such fractures are most often treated conservatively, but surgical treatment has become increasingly common. This trend is not entirely scientifically based

The aims of this thesis were threefold: to increase measurement precision in dorsal angulation (DA) on radiographs and computer tomographies (CTs); to assess the results after shortened plaster cast fixation time in reduced DRFs; and to evaluate the feasibility and safety of applying Augment® (rhPDGF-BB/β-TCP) in DRFs.

In Paper I and Appendix 1 and 2, a semi-automatic CT-based three-dimensional method was developed to measure change in DA over time in DRFs. This approach proved to be a better (more sensitive) method than radiography in determining changes in DA in fractures of the distal radius.

In Paper II, a CT model was used to simulate lateral radiographic views of different radial directions in relation to the X-ray. Using an alternative reference point on the distal radius, precision and accuracy in measuring DA was increased.

Paper III and IV are based on a prospective and randomised clinical study (the GitRa trial) that compares clinical and radiographic outcomes after plaster cast removal at 10 days versus 1 month in 109 reduced DRFs. Three patients in the early mobilised group were excluded because of fracture dislocation (n=2) or a feeling of fracture instability (n=1). For the remaining patients in the early mobilised group (51/54) a limited but temporary gain in range of motion, but a slight increase in radiographic displacement were observed. Our results suggest that plaster cast removal at 10 days after reduction of DRFs is not feasible.

Paper V is based on a prospective, randomised clinical study (the GEM trial) in which 40 externally fixated DRFs were randomised to rhPDGF-BB/β-TCP into the fracture gap or to the control group. Augment® proved to be convenient and safe during follow-up (24 weeks). However, because of the nature of the study design, the effect on fracture healing could not be determined. A decrease in pin infections was seen in the Augment® group, a finding we could not explain.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2017. , p. 124
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1290
National Category
Orthopaedics
Identifiers
URN: urn:nbn:se:uu:diva-312931ISBN: 978-91-554-9796-5 (print)OAI: oai:DiVA.org:uu-312931DiVA, id: diva2:1065374
Public defence
2017-03-03, Rosénsalen, Ing 95/96, Akademiska Sjukhuset, Uppsala, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2017-02-09 Created: 2017-01-15 Last updated: 2018-01-13
List of papers
1. Comparison of 2D radiography and a semi-automatic CT-based 3D method for measuring change in dorsal angulation over time in distal radius fractures
Open this publication in new window or tab >>Comparison of 2D radiography and a semi-automatic CT-based 3D method for measuring change in dorsal angulation over time in distal radius fractures
Show others...
2016 (English)In: Skeletal Radiology, ISSN 0364-2348, E-ISSN 1432-2161, Vol. 45, no 6, p. 763-769Article in journal (Refereed) Published
Abstract [en]

Objective The aim of the present study was to compare the reliability and agreement between a computer tomography-based method (CT) and digitalised 2D radiographs (XR) when measuring change in dorsal angulation over time in distal radius fractures. Materials and methods Radiographs from 33 distal radius fractures treated with external fixation were retrospectively analysed. All fractures had been examined using both XR and CT at six times over 6 months postoperatively. The changes in dorsal angulation between the first reference images and the following examinations in every patient were calculated from 133 follow-up measurements by two assessors and repeated at two different time points. The measurements were analysed using Bland-Altman plots, comparing intra- and inter-observer agreement within and between XR and CT. Results The mean differences in intra- and inter-observer measurements for XR, CT, and between XR and CT were close to zero, implying equal validity. The average intra- and inter-observer limits of agreement for XR, CT, and between XR and CT were +/- 4.4 degrees, +/- 1.9 degrees and +/- 6.8 degrees respectively. Conclusions For scientific purpose, the reliability of XR seems unacceptably low when measuring changes in dorsal angulation in distal radius fractures, whereas the reliability for the semi-automatic CT-based method was higher and is therefore preferable when a more precise method is requested.

National Category
Orthopaedics Medical Image Processing
Research subject
Computerized Image Processing
Identifiers
urn:nbn:se:uu:diva-297776 (URN)10.1007/s00256-016-2350-6 (DOI)000374476200003 ()26922189 (PubMedID)
Available from: 2016-02-27 Created: 2016-06-28 Last updated: 2018-05-14Bibliographically approved
2. Increased precision in the measurement of dorsal angulation in distal radius fractures using the dorsal-ulnar cornaer as the reference point versus Lister’s tubercle
Open this publication in new window or tab >>Increased precision in the measurement of dorsal angulation in distal radius fractures using the dorsal-ulnar cornaer as the reference point versus Lister’s tubercle
(English)Manuscript (preprint) (Other academic)
National Category
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-312929 (URN)
Available from: 2017-01-15 Created: 2017-01-15 Last updated: 2018-01-13
3. Radiographic results after plaster cast fixation for 10 days versus 1 month in reduced distal radius fractures: a prospective randomised study
Open this publication in new window or tab >>Radiographic results after plaster cast fixation for 10 days versus 1 month in reduced distal radius fractures: a prospective randomised study
2016 (English)In: Journal of Orthopaedic Surgery and Research, ISSN 1749-799X, E-ISSN 1749-799X, Vol. 11, article id 145Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The aim of this study was to examine whether reduced distal radius fractures can be treated with early mobilisation without affecting the radiographic results.

METHODS: In a prospective randomised study, 109 patients (mean age 65.8 (range 50-92)) with moderately displaced distal radius fractures were treated with closed reduction and plaster cast fixation for about 10 days (range 8-13 days) followed by randomisation to one of two groups: early mobilisation (n = 54, active group) or continued plaster cast fixation for another 3 weeks (n = 55, control group).

RESULTS: For three patients in the active group (6%), treatment proved unsuccessful because of severe displacement of the fracture (n = 2) or perceived instability (n = 1). From 10 days to 1 month, i.e. the only period when the treatment differed between the two groups, the active group displaced significantly more in dorsal angulation (4.5°, p < 0.001), radial angulation (2.0°, p < 0.001) and axial compression (0.5 mm, p = 0.01) compared with the control group. However, during the entire study period (i.e. from admission to 12 months), the active group displaced significantly more than the controls only in radial angulation (3.2°, p = 0.002) and axial compression (0.7 mm, p = 0.02).

CONCLUSIONS: Early mobilisation 10 days after reduction of moderately displaced distal radius fractures resulted in both an increased number of treatment failures and increased displacement in radial angulation and axial compression as compared with the control group. Mobilisation 10 days after reduction cannot be recommended for the routine treatment of reduced distal radius fractures.

TRIAL REGISTRATION: ClinicalTrail.gov, NCT02798614 . Retrospectively registered 16 June 2016.

National Category
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-312927 (URN)10.1186/s13018-016-0478-7 (DOI)000391332600001 ()27871284 (PubMedID)
Available from: 2017-01-15 Created: 2017-01-15 Last updated: 2018-01-13Bibliographically approved
4. Clinical outcome after plaster cast fixation for 10 days versus 1 month in reduced distal radius fractures: A prospective randomized study.
Open this publication in new window or tab >>Clinical outcome after plaster cast fixation for 10 days versus 1 month in reduced distal radius fractures: A prospective randomized study.
(English)Manuscript (preprint) (Other academic)
National Category
Medical and Health Sciences Orthopaedics
Identifiers
urn:nbn:se:uu:diva-312928 (URN)
Available from: 2017-01-15 Created: 2017-01-15 Last updated: 2018-01-13
5. Prospective randomized feasibility trial to assess the use of rhPDGF-BB in treatment of distal radius fractures
Open this publication in new window or tab >>Prospective randomized feasibility trial to assess the use of rhPDGF-BB in treatment of distal radius fractures
2015 (English)In: Journal of Orthopaedic Surgery and Research, ISSN 1749-799X, E-ISSN 1749-799X, Vol. 10, article id 37Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Recombinant human platelet-derived growth factor BB (rhPDGF-BB) combined with an osteoconductive scaffold (β-TCP) has been demonstrated to increase bone formation, but rhPDGF-BB has not been studied in human fractures. The purpose of this study was to evaluate the safety and potential use of locally administered rhPDGF-BB/β-TCP (Augment®) in acute wrist fractures.

METHODS: Forty patients with unstable distal radial fracture were randomized to closed reduction and external fixation alone (n = 20) or combined with injection of rhPDGF-BB/β-TCP (Augment®) into the fracture (n = 20). All patients were followed for 24 weeks. Outcome was based on adverse events, fracture displacement on radiographs, fracture healing, range of motion, grip strength, pain, and the disability of the arm, shoulder and hand (DASH) score.

RESULTS: There were no serious adverse events in the study, but the pin tract infection rate was significantly lower in the Augment® group. There was no difference between the groups in fracture healing time, based on number of healed cortices or fracture displacement. The Augment® group had an early temporary significant decrease in wrist flexion, but no difference in range of motion at 24 weeks. There were no differences between the two treatment groups for any other outcome variables.

CONCLUSION: rhPDGF-BB/β-TCP (Augment®) is safe and convenient for local administration into wrist fractures. In this pilot study, we could not detect any reduced healing time in the Augment® group although potential efficacy should be addressed in larger studies.

CLINICAL TRIAL REGISTRATION NUMBER: The clinical trial registration number for the study protocol is BMPI-2014-02-E.

Keywords
Distal radius fracture; External fixation; PDGF; Calcium phosphate; Radiographic evaluation; Clinical evaluation; Prospective; Randomized
National Category
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-266609 (URN)10.1186/s13018-015-0174-z (DOI)000369737900001 ()25888774 (PubMedID)
Available from: 2015-11-10 Created: 2015-11-10 Last updated: 2018-01-10Bibliographically approved

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