Ice and pulsed electromagnetic field to reduce pain and swelling after distal radius fractures

Objective: To examine the relative effectiveness of ice therapy and/or pulsed electromagnetic field in reducing pain and swelling after the immobilization period following a distal radius fracture.Methods: A total of 83 subjects were randomly allocated to receive 30 minutes of either ice plus pulsed electromagnetic field (group A); ice plus sham pulsed electromagnetic field (group B); pulsed electromagnetic field alone (group C), or sham pulsed electromagnetic field treatment for 5 consecutive days (group D). All subjects received a standard home exercise programme. A visual analogue scale was used for recording pain; volumetric displacement for measuring the swelling of the forearm; and a hand-held goniometer for measuring the range of wrist motions before treatment on days 1, 3 and 5.Results: At day 5, a significantly greater cumulative reduction in the visual analogue scores as well as ulnar deviation range of motion was found in group A than the other 3 groups. For volumetric measurement and pronation, participants in group A performed better than subjects in group D but not those in group B.Conclusion: The addition of pulsed electromagnetic field to ice therapy produces better overall treatment outcomes than ice alone, or pulsed electromagnetic field alone in pain reduction and range of joint motion in ulnar deviation and flexion for a distal radius fracture after an immobilization period of 6 weeks.

Interobserver reliability of radial head fracture classification : two-dimensional compared with three-dimensional CT

Background: The Broberg and Morrey modification of the Mason classification of radial head fractures has substantial interobserver variation. This study used a large web-based collaborative of experienced orthopaedic surgeons to test the hypothesis that three-dimensional reconstructions of computed tomography (CT) scans improve the interobserver reliability of the classification of radial head fractures according to the Broberg and Morrey modification of the Mason classification.

Methods: Eighty-five orthopaedic surgeons evaluated twelve radial head fractures. They were randomly assigned to review either radiographs and two-dimensional CT scans or radiographs and three-dimensional CT images to determine the fracture classification, fracture characteristics, and treatment recommendations. The kappa multirater measure (κ) was calculated to estimate agreement between observers.

Results: Three-dimensional CT had moderate agreement and two-dimensional CT had fair agreement among observers for the Broberg and Morrey modification of the Mason classification, a difference that was significant. Observers assessed seven fracture characteristics, including fracture line, comminution, articular surface involvement, articular step or gap of ≥2 mm, central impaction, recognition of more than three fracture fragments, and fracture fragments too small to repair. There was a significant difference in kappa values between three-dimensional CT and two-dimensional CT for fracture fragments too small to repair, recognition of three fracture fragments, and central impaction. The difference between the other four fracture characteristics was not significant. Among treatment recommendations, there was fair agreement for both three-dimensional CT and two-dimensional CT.

Conclusions: Although three-dimensional CT led to some small but significant decreases in interobserver variation, there is still considerable disagreement regarding classification and characterization of radial head fractures. Three-dimensional CT may be insufficient to optimize interobserver agreement.

Overweight children have poor bone strength relative to body weight, placing them at greater risk for forearm fractures

Introduction: Obesity is thought to be a protective factor for bones in adults but not in children based on the evidence of the greater incidence of forearm fractures in obese children. Our objective was to investigate the effect of adiposity on bone strength in relation to the mechanical challenge placed onto the forearm bones in case of a fall.

Methods: Cross sectional areas (CSA) were obtained at the mid- and distal radius by peripheral quantitative computed tomography in 486 children (241 boys), mean age 8.3 years (range 6.9–9.7), participating in the LOOK Project. The following parameters were measured: bone mass and bone CSA (both sites), and muscle and fat CSA (mid-forearm only). Bone strength indices combining bone size and total volumetric density were calculated at each site.

Results/Discussion: Overweight children (BMI > percentile equivalent to 25 kg/m² in adults) have higher bone parameters than normal-weight peers (Z-scores +0.6 to +0.9SD, p < 0.0001). These differences disappear after adjustment for muscle CSA. Adiposity (fat CSA/muscle CSA) was negatively correlated with bone mass, size and strength at the distal radius only (r = −0.1, p < 0.05). After adjustment for body weight (estimate of the load during a fall), the negative correlations were stronger and observed at both the mid- and distal radius (r = −0.37 to −0.55, p < 0.0001).

Conclusion. Overweight children have stronger bones due to greater muscle size. However, children with high fat mass relative to muscle mass (increased adiposity) have poorer bone strength, independent of weight, which may contribute to the increased risk of fracture in obese children.

Short-term and long-term site-specific effects of tennis playing on trabecular and cortical bone at the distal radius

Mechanical loading during growth magnifies the normal increase in bone diameter occurring in long bone shafts, but the response to loading in long bone ends remains unclear. The aim of the study was to investigate the effects of tennis playing during growth at the distal radius, comparing the bone response at trabecular and cortical skeletal sites. The influence of training duration was examined by studying bone response in short-term (children) and long-term (young adults) perspectives. Bone area, bone mineral content (BMC), and bone mineral density (BMD) of the radius were measured by DXA in 28 young (11.6 ± 1.4 years old) and 47 adult tennis players (22.3 ± 2.7 years old), and 70 age-matched controls (12 children, 58 adults) at three sites: the ultradistal region (trabecular), the mid-distal region, and the third-distal region (cortical). At the ultradistal radius, young and adult tennis players displayed similar side-to-side differences, the asymmetry in BMC reaching 16.3% and 13.8%, respectively (P < 0.0001). At the mid- and third-distal radius, the asymmetry was much greater in adults than in children (P < 0.0001) for all the bone parameters (mid-distal radius, +6.6% versus +15.6%; third-distal radius, +6.9% versus +13.3%, for BMC). Epiphyseal bone enduring longitudinal growth showed a great capacity to respond to mechanical loading in children. Prolonging tennis playing into adulthood was associated with further increase in bone mineralization at diaphyseal skeletal sites. These findings illustrate the benefits of practicing impact-loading sports during growth and maintaining physical activity into adulthood to enhance bone mass accrual and prevent fractures later in life.

The exclusion of high trauma fractures may underestimate the prevalence of bone fragility fractures in the community : the Geelong Osteoporosis Study

Fractures associated with severe trauma are generally excluded from estimates of the prevalence of osteoporotic fractures in the community. Because the degree of trauma is difficult to quantitate, low bone mass may contribute to fractures following severe trauma. We ascertained all fractures in a defined population and compared the bone mineral density (BMD) of women who sustained fractures in either 'low' or 'high' trauma events with the BMD of a random sample of women from the same population. BMD was measured by dual-energy X-ray absorptiometry and expressed as a standardized deviation (Z score) adjusted for age. The BMD Z scores (mean ± SEM) were reduced in both the low and high trauma groups, respectively: spine-posterior-anterior (- 0.50 ± 0.05 and -0.21 ± 0.08), spine-lateral (-0.28 ± 0.06 and -0.19 ± 0.10), femoral neck (-0.42 ± 0.04 and -0.26 ± 0.09), Ward's triangle (- 0.44 ± 0.04 and -0.28 ± 0.08), trochanter (-0.44 ± 0.05 and -0.32 ± 0.08), total body (-0.46 ± 0.06 and -0.32 ± 0.08), ultradistal radius (- 0.47 ± 0.05 and -0.42 ± 0.07), and midradius (-0.52 ± 0.06 and -0.33 ± 0.09). Except at the PA spine, the deficits were no smaller in the high trauma group. Compared with the population, the age-adjusted odds ratio for osteoporosis (t-score < -2.5) at one or more scanning sites was 3.1 (95% confidence interval 1.9, 5.0) in the high trauma group and 2.7 (1.9, 3.8) in the low trauma group. The data suggest that the exclusion of high trauma fractures in women over 50 years of age may result in underestimation of the contribution of osteoporosis to fractures in the community. Bone density measurement of women over 50 years of age who sustain fractures may be warranted irrespective of the classification of trauma.

Forearm bone mineral density and incidence of hip fractures in Swedish urban and rural men 1987-2002

Background: It is not known whether the recently described break in the trend in hip fracture incidence in many settings applies in both women and men, depends on changes in bone mineral density (BMD) or changes in other risk factors, or whether it is apparent in both urban and rural settings. Methods: We evaluated changes in annual hip fracture incidence from 1987 to 2002 in Swedish men aged ≥60 years in one urban (n=25,491) and one rural population (n=16,432) and also secular differences in BMD, measured by single-photon absorptiometry at the distal radius and multiple other risk factors for hip fracture in a population-based sub-sample of the urban and the rural men aged 60–80 years in 1988/89 (n=202 vs. 121) and in 1998/99 (n=79 vs. 69). Results: No statistically significant changes in the annual age-adjusted hip fracture incidence per 10,000 were apparent from 1987 to 2002 in urban (0.38 per year, 95% CI-0.12 to 0.88) or rural men (-0.05 per year, 95% CI -0.63 to 0.53). BMD was similar in 1988/89 and 1998/99 when examining both urban (-19.6 mg/cm², 95% CI -42.6 to 3.5) and rural (-23.0 mg/cm², 95% CI -52.1 to 6.1) men. Conclusions: Since no secular change in age-adjusted hip fracture incidence was found during the study period, a levelling off in hip fracture incidence is present also in Swedish men. Because BMD on a group level was similar in 1988/89 and 1998/99, changes in other risk factors ought to be either of minor importance or counteracted by changes in different risk factors.

Surgical treatment of lateral clavicle fractures associated with complete coracoclavicular ligament disruption: clinico-radiological outcomes of acromioclavicular joint sparing and spanning implants

Distal clavicle fracture associated with complete coracoclavicular ligament disruption represents an unstable injury, and osteosynthesis is recommended. This study was performed (1) to retrospectively analyse the clinico-radiological outcomes of two internal fixation techniques, and (2) to identify and analyse radiographic fracture patterns of fracture that are associated with this injury. Conclusions: Internal fixation of this fracture pattern is associated with a high union rate and favorable clinical outcomes with both techniques. A combination of distal radius plate and ligament reconstruction device resulted in stable fixation and significantly lower reoperation rates, and should be used when fracture geometry permits (Types 1 and 2).

Inter-observer variation in the diagnosis of coronal articular fracture lines in the lunate facet of the distal radius

Background: Several studies support the use of CT for diagnosing coronal fractures of the distal radius but the inter-observer reliability of these observations is less well studied. We tested the null hypothesis that radiographs alone and the combination of radiographs and two-dimensional computed tomography scans (2DCT) have the same inter-observer variation for the diagnosis of coronal articular fracture lines in the distal radius. Methods: Using a web-based survey, 63 surgeons were randomized to evaluate 16 fractures of the distal radius on radiographs alone or radiographs and 2DCT for the presence or absence of a coronal fracture line of the lunate facet and, if present, the stability of the fracture. The kappa multirater measure was calculated to estimate agreement between observers. Results: The inter-observer variation in diagnosis of a coronal fracture line was fair with both radiographs and 2DCT, as was the diagnosis of instability of the volar lunate facet fracture when present. Conclusion: Two-dimensional computed tomography does not improve observer agreement on the diagnosis of coronal plane articular fracture lines in the lunate facet of the distal radius. © 2012 American Association for Hand Surgery.

Application of bending under tension test to determine the effect of tool radius and the contact pressure on the coefficient of friction in sheet metal forming

To quantify the frictional behaviour in sheet forming operations, several laboratory experiments which simulate the real forming conditions are performed. The Bending Under Tension Test is one such experiment which is often used to represent the frictional flow of sheet material around a die or a punch radius. Different mathematical representations are used to determine the coefficient of friction in the Bending Under Tension Test. In general the change in the strip thickness in passing over the die radius is neglected and the radius of curvature to thickness ratio is assumed to be constant in these equations. However, the effect of roller radius, sheet thickness and the surface pressure are also omitted in some of these equations. This work quantitatively determined the effect of roller radius and the tooling pressure on the coefficient of friction. The Bending Under Tension Test was performed using rollers with different radii and also lubricants with different properties. The tool radii were found to have a direct influence in the contact pressure. The effect of roller radius on friction was considerable and it was observed that there is a clear relationship between the contact pressure and the coefficient of friction.

Use of calcium or calcuim in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis

Background:  Whether calcium supplementation can reduce osteoporotic fractures is uncertain. We did a meta-analysis to include all the randomised trials in which calcium, or calcium in combination with vitamin D, was used to prevent fracture and osteoporotic bone loss.

Methods:  We identified 29 randomised trials (n=63 897) using electronic databases, supplemented by a hand-search of reference lists, review articles, and conference abstracts. All randomised trials that recruited people aged 50 years or older were eligible. The main outcomes were fractures of all types and percentage change of bone-mineral density from baseline. Data were pooled by use of a random-effect model.

Findings:  In trials that reported fracture as an outcome (17 trials, n=52 625), treatment was associated with a 12% risk reduction in fractures of all types (risk ratio 0·88, 95% CI 0·83–0·95; p=0·0004). In trials that reported bone-mineral density as an outcome (23 trials, n=41 419), the treatment was associated with a reduced rate of bone loss of 0·54% (0·35–0·73; p<0·0001) at the hip and 1·19% (0·76–1·61%; p<0·0001) in the spine. The fracture risk reduction was significantly greater (24%) in trials in which the compliance rate was high (p<0·0001). The treatment effect was better with calcium doses of 1200 mg or more than with doses less than 1200 mg (0·80 vs 0·94; p=0·006), and with vitamin D doses of 800 IU or more than with doses less than 800 IU (0·84 vs 0·87; p=0·03).

Interpretation:  Evidence supports the use of calcium, or calcium in combination with vitamin D supplementation, in the preventive treatment of osteoporosis in people aged 50 years or older. For best therapeutic effect, we recommend minimum doses of 1200 mg of calcium, and 800 IU of vitamin D (for combined calcium plus vitamin D supplementation).

The evidence that exercise during growth or adulthood reduces the risk of fragility fractures is weak

There has never been, and will never be, a randomized double-blind placebo-controlled trial demonstrating that exercise in youth, adulthood or old age reduces fragility or osteoporosis-related fractures in old age. The next level of evidence, a randomized, controlled but unblinded study with fractures as an end-point is feasible but has never been done. The basis for the belief that exercise reduces fractures is derived from lower levels of ‘evidence’, namely, retrospective and prospective observation cohort studies and case–control studies. These studies are at best hypothesis generating, never hypothesis testing. They are all subject to many systematic biases and should be interpreted with extreme scepticism. Surrogate measures of anti-fracture efficacy are the next level of evidence, such as the demonstration of a reduction in risk factors for falls, a reduction in falls, a reduction in fractures due to falls, an increase in peak bone size and mass, prevention of bone loss in midlife and restoration of bone mass and structure in old age.