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Objectives: To determine the relative influence of mindset and fracture severity on 9-month recovery trajectories of pain and capability after upper extremity fractures., Design: Secondary use of longitudinal data., Setting: Single Level-1 trauma center in Oxford, United Kingdom., Patient Selection: English-speaking adults with isolated proximal humerus, elbow, or distal radius fracture managed operatively or nonoperatively were included, and those with multiple fractures or cognitive deficit were excluded., Outcome Measures and Comparisons: Incapability (Quick-DASH) and pain intensity (11-point rating scale) were measured at baseline, 2-4 weeks, and 6-9 months after injury. Cluster analysis was used to identify statistical groupings of mindset (PROMIS Depression and Anxiety, Pain Catastrophizing Scale, and Tampa Scale for Kinesiophobia) and fracture severity (low/moderate/high based on OTA/AO classification). The recovery trajectories of incapability and pain intensity for each mindset grouping were assessed, accounting for various fracture-related aspects., Results: Among 703 included patients (age 59 ± 21 years, 66% women, 16% high-energy injury), 4 statistical groupings with escalating levels of distress and unhelpful thoughts were identified (fracture severity was omitted considering it had no differentiating effect). Groups with less healthy mindset had a worse baseline incapability (group 2: β = 4.1, 3: β = 7.5, and 4: β = 17) and pain intensity (group 3: β = 0.70 and 4: β = 1.4) (P < 0.01). Higher fracture severity (β = 4.5), high-energy injury (β = 4.0), and nerve palsy (β = 8.1) were associated with worse baseline incapability (P < 0.01), and high-energy injury (β = 0.62) and nerve palsy (β = 0.76) with worse baseline pain intensity (P < 0.01). Groups 3 and 4 had a prolonged rate of recovery of incapability (β = 1.3, β = 7.0) and pain intensity (β = 0.19, β = 1.1) (P < 0.02)., Conclusions: Patients with higher levels of unhelpful thinking and feelings of distress regarding symptoms experienced worse recovery of pain and incapability, with a higher effect size than fracture location, fracture severity, high-energy injury, and nerve palsy. These findings underline the importance of anticipating and addressing mental health concerns during recovery from injury., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Through an international survey, we assessed whether deciding to operatively treat an intra-articular distal radius fracture (DRF) is guided by identifiable patient and surgeon factors. In addition, we compared surgeons' treatment decisions with the American Academy of Orthopaedic Surgeons' Appropriate Use Criteria (AUC) treatment recommendations., Methods: This cross-sectional survey asked 224 surgeons to operatively or nonoperatively treat 28 hypothetical patients with radiographs of an intra-articular DRF. We randomized patient age (50/70 years), gender, mechanism of injury, activity level, and OTA/AO fracture type. We classified 6 fractures as "nonclinically significant displacement" and 22 as "potentially clinically significant displacement." Multilevel logistic regression analysis was performed. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported. Statistical significance was P < 0.05., Results: Patient factors independently associated with surgery included younger age (OR 6.7, P = 0.003), clinically significant fracture displacement (type B: OR 122, CI, 20-739, P < 0.001; type C: OR 59, CI, 12-300, P < 0.001), normal activity level (OR 5.0, P < 0.001), and high-energy mechanisms (OR 1.3, P = 0.002). Surgeon factors associated with recommending surgery included practicing outside the United States (Europe: OR 2.6, P < 0.001; "other": OR 4.8, P < 0.001). Hand surgeons most often selected surgery, as compared to orthopaedic trauma surgeons (OR 2.3, P = 0.001) and "other orthopaedists" (OR 2.2, P = 0.022). Thirty-seven percent of treatment decisions for patients with normal activity levels were rated by AUC recommendations as "rarely appropriate," which included 91% disagreement for 70-year-olds with nonclinically significant displacement., Conclusions: Surgeons use patient age and fracture displacement to make treatment recommendations for intra-articular DRF. We recommend that the AUC be updated to include these clinical factors as essential components in its algorithm., Level of Evidence: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Objectives: Despite advanced imaging techniques, classic measurements of fracture reduction have not been revisited to date. The purpose of this study was to evaluate the reliability of innovative measurement techniques to quantify operative fragment reduction of posterior malleolar fractures by quantification of three-dimensional computed tomography (Q3DCT)., Methods: Twenty-eight ankle fractures including a posterior malleolar fragment (AO/OTA type 44) were evaluated using 2DCT and Q3DCT to postoperatively quantify fragment reduction. "Classic" maximum gap and step-off of the posterior fragment were measured on 2DCT and Q3DCT. In addition, 2 innovative Q3DCT parameters were introduced and their reliability was tested using intraclass correlations (ICCs): gap surface (mm) and multidirectional 3D-displacement (mm)., Results: "Classic" measurements showed a median maximum step-off of 1.1 mm [interquartile range (IQR) 0.0-1.8 mm] on 2DCT versus a median step-off of 0.6 mm (IQR 0.0-1.1) on Q3DCT. Median maximum gap was 1.2 mm (IQR 0.0-3.8) on 2DCT, and its equivalent on Q3DCT showed no median displacement. Q3DCT measurements revealed a median gap surface of 14.5 mm (IQR 4.7-30.0) and a median multidirectional 3D-displacement of 0.7 mm (IQR 0.0-1.1). Interrater reliability of these new Q3DCT parameters of displacement was excellent (ICC 0.92, 95% CI 0.79-0.98) for gap surface and good (ICC 0.64, 95% CI 0.28-0.88) for 3D-displacement., Conclusions: Q3DCT is a reliable and promising technique for postoperative evaluation of fracture fragment reduction. In addition to "classic" gap and step-off measurements, we propose to explore total gap surface and 3D-displacement as innovative radiographic measurements in future clinical studies., Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To determine if closed reduction is worthwhile for the subset of patients who choose operative treatment before attempted reduction of their distal radius fracture. We hypothesize that there are no differences in (1) adverse events and (2) subsequent surgeries between patients treated with manipulative reduction compared with those that were splinted without reduction., Design: Retrospective cohort study., Setting: Three affiliated urban hospitals in a single city in the United States., Patients/participants: One thousand five hundred eleven consecutive adult patients who underwent open reduction and internal fixation of their distal radius fracture between January 1, 2007, and December 31, 2012, of whom 102 (7%) were not reduced before surgery., Intervention: Manipulative reduction compared with splinting without reduction., Main Outcome Measurements: Adverse events were defined as any infections, hematomas treated operatively, disproportionate finger stiffness, (transient) neuropathology after surgery, delayed carpal tunnel release, malunion, reoperation for loss of alignment, hardware removal, and tendon ruptures within 1 year after surgery. Outcome measures were grouped to determine the overall adverse event rate and subsequent surgery rate., Results: We found no difference in specific adverse events between unreduced and reduced fractures. After adjusting for possible confounding variables by logistic regression, we found no difference in overall rates of adverse events (adjusted odds ratio unreduced fractures 1.2, 95% confidence interval 0.67-2.0) and subsequent surgeries (adjusted odds ratio unreduced fractures 0.65, 95% confidence interval 0.23-1.8)., Conclusions: Leaving the fracture unreduced before surgery was not associated with increased adverse events or subsequent surgeries. For patients who make an informed decision to undergo operative treatment for their closed neurovascular intact displaced distal radius fracture, manipulative reduction may not be helpful.

Objectives: To identify demographic, injury-related, or psychologic factors associated with finger stiffness at suture removal and 6 weeks after distal radius fracture surgery. We hypothesize that there are no factors associated with distance to palmar crease at suture removal., Design: Prospective cohort study., Setting: Level I Academic Urban Trauma Center., Patients: One hundred sixteen adult patients underwent open reduction and internal fixation of their distal radius fractures; 96 of whom were also available 6 weeks after surgery., Intervention: None., Main Outcome Measurements: At suture removal, we recorded patients' demographics, AO fracture type, carpal tunnel release at the time of surgery, pain catastrophizing scale, Whiteley Index, Patient Health Questionnaire-9, and disabilities of the arm, shoulder, and hand questionnaire, 11-point ordinal measure of pain intensity, distance to palmar crease, and active flexion of the thumb through the small finger. At 6 weeks after surgery, we measured motion, disabilities of the arm, shoulder, and hand, and pain intensity. Prereduction and postsurgery radiographic fracture characteristics were assessed., Results: Female sex, being married, specific surgeons, carpal tunnel release, AO type C fractures, and greater catastrophic thinking were associated with increased distance to palmar crease at suture removal. At 6 weeks, greater catastrophic thinking was the only factor associated with increased distance to palmar crease., Conclusions: Catastrophic thinking was a consistent and major determinant of finger stiffness at suture removal and 6 weeks after injury. Future research should assess if treatments that ameliorate catastrophic thinking can facilitate recovery of finger motion after operative treatment of a distal radius fracture., Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.