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Abstract Background Currently, non- or minimally displaced distal radius fractures are treated by 3 to 5 weeks of cast immobilisation. Many patients with a distal radius fracture suffer from long-term functional restrictions, which might be related to stiffness due to cast immobilisation. Current literature indicates that 1 week of immobilisation might be safe; however, no level 1 evidence is available. This trial aims to compare 1 week of brace immobilisation with 3 weeks of cast immobilisation in patients with distal radius fractures that do not need reduction. Methods The aim of this trial is to evaluate the non-inferiority of 1 week of brace immobilisation in patients with non- or minimally displaced distal radius fractures. A two-armed single blinded multicentre randomised clinical trial will be conducted in three hospitals. Adult patients, between 18 and 50 years old, independent for activities of daily living, with a non- or minimally displaced distal radius fracture can be included in this study. The intervention group is treated with 1 week of brace immobilisation, and the control group with 3 weeks of cast immobilisation. Primary outcome is the patient-reported outcome measured by the Patient-Related Wrist Evaluation score (PRWE) at 6 months. Secondary outcomes are patient-reported outcome measured by the Quick Disabilities of the Arm, Shoulder and Hand score at 6 weeks and 6 months, PRWE at 6 weeks, range of motion, patient-reported pain score measured by VAS score, radiological outcome (dorsal/volar tilt, radial height, ulnar variance, presence of intra-articular step off), complications and cost-effectiveness measured by the EuroQol 5 Dimension questionnaire, Medical Consumption Questionnaire and Productivity Cost Questionnaire. Discussion This study will provide evidence on the optimal period of immobilisation in non-operatively treated displaced and reduced distal radius fractures. Both treatment options are accepted treatment protocols and both treatment options have a low risk of complications. Follow-up will be according to the current treatment protocol. This study will provide level 1 evidence on the optimal period and way of immobilisation for non- or minimally displaced distal radius fractures in adult patients. Trial registration ABR 81638 | NL81638.029.22 | www.toetsingonline.nl . 18th of October 2023

Abstract Background There is no consensus concerning the optimal casting technique for displaced distal radius fractures (DRFs) following closed reduction. This study evaluates whether a splint or a circumferential cast is most optimal to prevent fracture redisplacement in adult patients with a reduced DRF. Additionally, the cost-effectiveness of both cast types will be calculated. Methods/design This multicenter cluster randomized controlled trial will compare initial immobilization with a circumferential below-elbow cast versus a below-elbow plaster splint in reduced DRFs. Randomization will take place on hospital-level (cluster, n = 10) with a cross-over point halfway the inclusion of the needed number of patients per hospital. Inclusion criteria comprise adult patients (≥ 18 years) with a primary displaced DRF which is treated conservatively after closed reduction. Multiple trauma patients (Injury Severity Score ≥ 16), concomitant ulnar fractures (except styloid process fractures) and patients with concomitant injury on the ipsilateral arm or inability to complete study forms will be excluded. Primary study outcome is fracture redisplacement of the initial reduced DRF. Secondary outcomes are patient-reported outcomes assessed with the Disability Arm Shoulder Hand score (DASH) and Patient-Rated Wrist Evaluation score (PRWE), comfort of the cast, quality of life assessed with the EQ-5D-5L questionnaire, analgesics use, cost-effectiveness and (serious) adverse events occurence. In total, 560 patients will be included and followed for 1 year. The estimated time required for inclusion will be 18 months. Discussion The CAST study will provide evidence whether the type of cast immobilization is of influence on fracture redisplacement in distal radius fractures. Extensive follow-up during one year concerning radiographic, functional and patient reported outcomes will give a broad view on DRF recovery. Trial registration Registered in the Dutch Trial Registry on January 14th 2020. Registration number: NL8311 .

Abstract Background In the past several years, an increase in open reduction and internal fixation (ORIF) for intra-articular distal radius fractures has been observed. This technique leads to a quicker recovery of function compared to non-operative treatment. However, some patients continue to have a painful and stiff wrist postoperatively. Arthroscopically assisted removal of intra-articular fracture haematoma and debris may improve the functional outcomes following operative treatment of intra-articular distal radius fractures. The purpose of this randomised controlled trial is to determine the difference in functional outcome, assessed with the Patient-Rated Wrist Evaluation (PRWE) score, after ORIF with and without an additional wrist arthroscopy in adult patients with displaced complete articular distal radius fractures. Methods In this multicentre trial, adult patients with a displaced complete articular distal radius fracture are randomised between ORIF with an additional wrist arthroscopy to remove fracture haematoma and debris (intervention group) and conventional fluoroscopic-assisted ORIF (control group). The primary outcome is functional outcome assessed with the PRWE score after three months. Secondary outcomes are wrist function assessed with the Disability of the Arm, Shoulder and Hand (DASH) score, postoperative pain, range of motion, grip strength, complications and cost-effectiveness. Additionally, in the intervention group, the quality of reduction, associated ligamentous injuries and cartilage damage will be assessed. A total of 50 patients will be included in this study. Discussion Although ORIF of intra-articular distal radius fractures leads to a quicker resume of function compared to non-operative treatment, some patients continue to have a painful and stiff wrist postoperatively. We hypothesise that, due to the removal of fracture haematoma and debris by an additional arthroscopy, functional outcomes will be better compared to the non-arthroscopically treated group. Trial registration ClinicalTrials.gov, NCT02660515. Registered on 13 January 2016.

Introduction: Distal radius fractures in patients over 80 years old are traditionally treated non-operatively. The aim of this study is to evaluate patient-reported outcome in octogenarians treated non-operatively for a distal radius fracture. Methods: Retrospective case study of all consecutive patients over 80 years old, treated non-operatively for a distal radius fracture after 1 year. The primary outcome was evaluated by the patient-rated wrist evaluation (PRWE) and quick disability of the arm, shoulder, and hand (qDASH) questionnaire, which were collected prospectively. Secondary outcomes were radiographic characteristics. Results: A total of 124 patients were included, male/female: 4/120, median age of 85 years. Fracture types were mainly Type A and C. The median follow-up was 1.3 years, 18 patients died and 6 patients were lost to follow-up for other reasons. The median PRWE score after follow-up was 3.25. Median qDASH score was 6.82. Only redisplacement after 1 week was associated with poorer outcome. Conclusion: The overall long-term patient-reported outcome of octogenarians with non-operatively treated distal radius fractures with or without deformity is excellent.

Validation study using data from a multicenter, randomized, clinical trial (RCT).To evaluate the reliability, validity, responsiveness, and minimal important change (MIC) of the Dutch version of the Oxford Elbow Score (OES) and the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) in patients with a simple elbow dislocation.Patient-reported outcome measures are increasingly important for assessing outcome following elbow injuries, both in daily practice and in clinical research. However measurement properties of the OES and Quick-DASH in these patients are not fully known.OES and Quick-DASH were completed four times until one year after trauma. Mayo Elbow Performance Index, pain (VAS), Short Form-36, and EuroQol-5D were completed for comparison. Data of a multicenter RCT (n = 100) were used. Internal consistency was determined using Cronbach's alpha. Construct and longitudinal validity were assessed by determining hypothesized strength of correlation between scores or changes in scores, respectively, of (sub)scales. Finally, floor and ceiling effects, MIC, and smallest detectable change (SDC) were determined.OES and Quick-DASH demonstrated adequate internal consistency (Cronbach α, 0.882 and 0.886, respectively). Construct validity and longitudinal validity of both scales were supported by >75% correctly hypothesized correlations. MIC and SDC were 8.2 and 12.0 point for OES, respectively. For Quick-DASH, these values were 11.7 and 25.0, respectively.OES and Quick-DASH are reliable, valid, and responsive instruments for evaluating elbow-related quality of life. The anchor-based MIC was 8.2 points for OES and 11.7 for Quick-DASH.

Background Traumatic elbow injuries in children occur frequently and are among the most common traumatic injuries seen in the emergency department (ED) and in general practice. The use of a validated decision rule to enhance selective radiography in paediatric patients with possible elbow fractures may reduce unnecessary exposure to radiation in children.Method and analysis This study is designed as a multicentre prospective cohort study. An expert panel of orthopaedic elbow surgeons, paediatric orthopaedic surgeons and trauma surgeons will initially determine clinical parameters that provide a possible predictive value for elbow fractures. Four hundred children between the ages of 2 and 17 years visiting the ED with pain following elbow trauma will then be included. The clinical parameters will be collected via patient history and physical examination. Elbow radiographs will be obtained in all patients to identify fractures. The data will be processed in a multivariable logistic regression analysis to determine which clinical parameters predict the presence of an elbow fracture. Only the clinical parameters that predict a fracture will be used to formulate the new decision rule: the paediatric elbow trauma (PET) rules. Internal validation of the prediction model will take place after inclusion is complete and by means of a bootstrap analysis on the acquired data. A calculation will be made to determine how many radiographs can potentially be reduced by applying the PET rules and a cost analysis will be performed.Ethics and dissemination The study will be conducted according to the principles of the Declaration of Helsinki and in accordance with the Medical Research Involving Human Subjects Act. The Medical Research Ethics Committees United stated on 16 May 2022 that The Medical Research Involving Human Act (WMO) does not apply to this study and an official approval by the committee is not required, reference number; project W22.086.

Abstract Background Elective implant removal (IR) after fracture fixation is one of the most common procedures within (orthopedic) trauma surgery. The rate of surgical site infections (SSIs) in this procedure is quite high, especially below the level of the knee. Antibiotic prophylaxis is not routinely prescribed, even though it has proved to lower SSI rates in other (orthopedic) trauma surgical procedures. The primary objective is to study the effectiveness of a single intravenous dose of 2 g of cefazolin on SSIs after IR following fixation of foot, ankle and/or lower leg fractures. Methods This is a multicenter, double-blind placebo controlled trial with a superiority design, including adult patients undergoing elective implant removal after fixation of a fracture of foot, ankle, lower leg or patella. Exclusion criteria are: an active infection, current antibiotic treatment, or a medical condition contraindicating prophylaxis with cefazolin including allergy. Patients are randomized to receive a single preoperative intravenous dose of either 2 g of cefazolin or a placebo (NaCl). The primary analysis will be an intention-to-treat comparison of the proportion of patients with a SSI at 90 days after IR in both groups. Discussion If 2 g of prophylactic cefazolin proves to be both effective and cost-effective in preventing SSI, this would have implications for current guidelines. Combined with the high infection rate of IR which previous studies have shown, it would be sufficiently substantiated for guidelines to suggest protocolled use of prophylactic antibiotics in IR of foot, ankle, lower leg or patella. Trial registration Nederlands Trial Register (NTR): NL8284, registered on 9th of January 2020, https://www.trialregister.nl/trial/8284

Background and purpose — It has been hypothesized that hospitals and surgeons with high caseloads of hip fracture patients have better outcomes, but empirical studies have reported contradictory results. This systematic review and meta-analysis evaluates the volume–outcome relationship among patients with hip fracture patients. Methods — A search of different databases was performed up to February 2018. Selection of relevant studies, data extraction, and critical appraisal of the methodological quality was performed by 2 independent reviewers. A random-effects meta-analysis using studies with comparative cut-offs was performed to estimate the effect of hospital and surgeon volume on outcome, defined as in-hospital mortality and postoperative complications. Results — 24 studies comprising 2,023,469 patients were included. Overall, the quality was reasonable. 11 studies reported better health outcomes in high-volume centers and 2 studies reported better health outcomes in low-volume centers. In the meta-analysis of 11 studies there was a statistically non-significant association between higher hospital volume and both lower in-hospital mortality (adjusted odds ratio (aOR) 0.87, 95% confidence interval (CI) 0.73–1.04) and fewer postoperative complications (aOR 0.87, CI 0.75–1.02). Four studies on surgeon volume were included in the meta-analysis and showed a minor association between higher surgeon volume and in-hospital mortality (aOR 0.92, CI 0.76–1.12). Interpretation — This systematic review and meta-analysis did not find an evident effect of hospital or surgeon volume on health outcomes. Future research without volume cut-offs is needed to examine whether a true volume–outcome relationship exists.

Background and purpose — The lower extremity functional scale (LEFS) is a well-known and validated instrument for measurement of lower extremity function. The LEFS was developed in a group of patients with various musculoskeletal disorders, and no reference data for the healthy population are available. Here we provide normative data for the LEFS. Methods — Healthy visitors and staff at 4 hospitals were requested to participate. A minimum of 250 volunteers had to be included at each hospital. Participants were excluded if they had undergone lower extremity surgery within 1 year of filling out the questionnaire, or were scheduled for lower extremity surgery. Normative values for the LEFS for the population as a whole were calculated. Furthermore, the influence of sex, age, type of employment, socioeconomic status, and history of lower extremity surgery on the LEFS were investigated. Results — 1,014 individuals fulfilled the inclusion criteria and were included in the study. The median score for the LEFS for the whole population was 77 (out of a maximum of 80). Men and women had similar median scores (78 and 76, respectively), and younger individuals had better scores. Participants who were unfit for work had worse scores. There were no statistically significant correlations between socioeconomic status and type of employment on the one hand and LEFS score on the other. A history of lower extremity surgery was associated with a lower LEFS score. Interpretation — High scores were observed for the LEFS throughout the whole population, although they did decrease with age. Men had a slightly higher score than women. There was no statistically significant correlation between socioeconomic status and LEFS score, but people who were unfit for work had a significantly worse LEFS score.