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Background: Radial head stress fractures (RHSFs) and capitellar osteochondritis dissecans (COCD) are rare but may be seen in gymnasts. The purpose of this study was to compare the clinical and radiographic characteristics and the outcomes of RHSF and COCD in pediatric and adolescent gymnastic athletes., Methods: Classical gymnasts and competitive tumblers ≤18 years of age presenting with RHSF or COCD over a 5-year period were reviewed. Radiographic characteristics, clinical characteristics, and patient-reported outcomes were compared., Results: Fifty-eight elbows (39 with COCD and 19 with RHSF) were studied; the mean patient age was 11.6 years. Gymnastic athletes with RHSF competed at a higher level; of the athletes who competed at level ≥7, the rate was 95% of elbows in the RHSF group and 67% of elbows in the COCD group. The RHSF group presented more acutely with more valgus stress pain than those with COCD (p < 0.01) and demonstrated increased mean valgus angulation (and standard deviation) of the radial neck-shaft angle (13° ± 3.8° for the RHSF group and 9.3° ± 2.8° for the COCD group; p < 0.01) and decreased mean proximal radial epiphyseal height (3.7 ± 0.6 mm for the RHSF group and 4.2 ± 1.5 mm for the COCD group; p < 0.01). At a minimum of 2 years (range, 2.0 to 6.3 years), the RHSF group reported fewer symptoms; the QuickDASH (abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire) score was 1.75 ± 3.84 points for the RHSF group and 7.45 ± 7.54 points for the COCD group (p < 0.01). Those at a high level (≥7) were more likely to return to gymnastics independent of pathology, with the RHSF group reporting higher final activity levels with the mean Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) score at 26.0 ± 7.5 points compared with the COCD group at 23.6 ± 5.7 points (p < 0.05). Of the 9 patients with bilateral COCD, only 3 (33%) returned to gymnastics., Conclusions: RHSF with features similar to the more familiar COCD lesion may present in gymnastic athletes. Those with RHSF may present more acutely with a high competitive level and may have a better prognosis for return to competitive gymnastics than those with COCD., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G582)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Although screening for and treating osteoporosis can prevent subsequent fractures, the rates of such interventions are low following a distal radial fracture. One potential method for identifying metabolic bone disease is via Hounsfield unit (HU) measurements from diagnostic computed tomography (CT) scans. We hypothesized that HU values of the distal aspect of the radius could be used to assess local bone quality and would be predictive of distal radial fracture risk, thereby allowing the identification of patients in need of further management., Methods: Measurements of bone mineral density (BMD) were made for 100 patients on the basis of HU values of cancellous portions of the distal aspect of the radius, the ulnar head, and the capitate. The HU values in twenty-five male and twenty-five female patients with an acute distal radial fracture documented on CT were compared with those of age and sex-matched control patients who had a CT scan obtained for other indications., Results: Among the control patients, HU values decreased as age increased. When assessed on the basis of sex, both male and female patients with a distal radial fracture had significantly lower regional BMD compared with nonfracture control patients. A distal radial HU value of 218 for females and 246 for males optimized sensitivity and specificity; values below this threshold were associated with an increased risk of distal radial fracture., Conclusions: HU measurements can be obtained from any diagnostic CT scan using modern software programs and can be obtained by physicians in the office setting with minimal effort and at no additional cost or radiation exposure to the patient. Regardless of imaging indications, we suggest that patients with HU values below the identified thresholds be considered for further metabolic bone disease work-up, such as additional imaging, laboratory assessments, the initiation of osteoporosis treatment, or appropriate referral., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Decreased physical performance has been associated with an increased risk of falls and fragility hip fractures. The purpose of our study was to compare physical performance measures and fall risk factors in middle-aged and elderly patients with recent distal radial fractures relative to age-matched control patients., Methods: We prospectively recruited forty postmenopausal women over fifty years of age who sustained a distal radial fracture due to a fall and forty age-matched controls without a recent history of falls. We excluded those patients with cognitive impairment, neuromuscular diseases, or other chronic conditions affecting muscle function. We compared the two groups for the level of physical performance and other risk factors of a fall. Other known risk factors assessed were low body mass index; osteoarthritis; arrhythmia; depression; visual disturbance; hypotension; use of antihypertensive drugs, sedatives, hypnotics, or antidepressants; and use of four or more medications., Results: There was no significant difference in the Short Physical Performance Battery summary score between the two groups. However, when patients with distal radial fracture were compared with control patients, significantly lower scores were observed for chair stand (p = 0.034) and grip strength (adjusted for hand dominance) (p = 0.038)., Conclusions: This study suggests that overall physical performance level is not different between women with a distal radial fracture and those without a distal radial fracture. Differences in chair stand test scores and grip strength may imply an early subtle decrease in physical performance level in patients with distal radial fracture.

Background: Bisphosphonates can adversely affect fracture-healing because they inhibit osteoclastic bone resorption. It is unclear whether bisphosphonates can be initiated safely for patients who have sustained an acute distal radial fracture. The purpose of this randomized study was to determine whether the early use of bisphosphonate affects healing and outcomes of osteoporotic distal radial fractures treated with volar locking plate fixation., Methods: Fifty women older than fifty years of age who had undergone volar locking plate fixation of a distal radial fracture and had been diagnosed with osteoporosis were randomized to Group I (n = 24, initiation of bisphosphonate treatment at two weeks after the operation) or Group II (n = 26, initiation of bisphosphonate treatment at three months). Patients were assessed for radiographic union and other radiographic parameters (radial inclination, radial length, and volar tilt) at two, six, ten, sixteen, and twenty-four weeks, and for clinical outcomes that included Disabilities of the Arm, Shoulder and Hand (DASH) scores, wrist motion, and grip strength at twenty-four weeks. The two groups were compared with regard to the time to radiographic union, the radiographic parameters, and the clinical outcomes., Results: No significant differences were observed between the two groups with respect to radiographic or clinical outcomes after volar locking plate fixation. All patients obtained fracture union, and the mean times to radiographic union in Groups I and II were similar (6.7 and 6.8 weeks, respectively; p = 0.65). Furthermore, the time to radiographic union was not related to osteoporosis severity or fracture type., Conclusions: In patients with an osteoporotic distal radial fracture treated with volar locking plate fixation, the early initiation of bisphosphonate treatment did not affect fracture-healing or clinical outcomes., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: Distal radial fractures occur earlier in life than hip and spinal fractures and may be the first sign of osteoporosis. The aims of this case-control study were to compare the prevalence of osteopenia and osteoporosis between female and male patients with low-energy distal radial fractures and matched controls and to investigate whether observed differences in bone mineral density between patients and controls could be explained by potential confounders., Methods: Six hundred and sixty-four female and eighty-five male patients who sustained a distal radial fracture, and 554 female and fifty-four male controls, were included in the study. All distal radial fractures were radiographically confirmed. Bone mineral density was assessed with use of dual x-ray absorptiometry at the femoral neck, total hip (femoral neck, trochanter, and intertrochanteric area), and lumbar spine (L2-L4). A self-administered questionnaire provided information on health and lifestyle factors., Results: The prevalence of osteoporosis was 34% in female patients and 10% in female controls. The corresponding values were 17% in male patients and 13% in male controls. In the age group of fifty to fifty-nine years, 18% of female patients and 5% of female controls had osteoporosis. In the age group of sixty to sixty-nine years, the corresponding values were 25% and 7%, respectively. In adjusted conditional logistic regression analyses, osteopenia and osteoporosis were significantly associated with distal radial fractures in women. Osteoporosis was significantly associated with distal radial fractures in men., Conclusions: The prevalence of osteoporosis in patients with distal radial fractures is high compared with that in control subjects, and osteoporosis is a risk factor for distal radial fractures in both women and men. Thus, patients of both sexes with an age of fifty years or older who have a distal radial fracture should be evaluated with bone densitometry for the possible treatment of osteoporosis.

Background: In the past, radial head resection was the surgical treatment of choice for radial head fractures that could not be internally fixed. More recently, radial head implant arthroplasty has gained popularity for the treatment of isolated radial head fractures. The purpose of the present study was to review the long-term results of radial head resection after radial head fractures not associated with elbow instability in patients younger than forty years of age., Methods: Twenty-six patients younger than forty years of age who had sustained an isolated fracture of the radial head (including six patients who had sustained a Mason type-II fracture and twenty who had sustained a Mason type-III fracture) that had been treated with primary radial head resection were reviewed retrospectively at a minimum of fifteen years (mean, twenty-five years). Outcomes were evaluated according to the Mayo Elbow Performance Score and the Disabilities of the Arm, Shoulder and Hand score. Radiographic assessment of osteoarthritic changes and the carrying angle was also performed., Results: Twenty-one patients (81%) had no elbow pain, three had mild pain, and two had moderate pain. The mean arc of motion was from 9 degrees to 139 degrees of flexion. All but one patient had a functional arc of motion. The mean pronation was 84 degrees, and the mean supination was 85 degrees. Nineteen elbows had normal strength in comparison with the unaffected side. The mean Mayo Elbow Performance Score was 95 points; the score was classified as good or excellent for twenty-four elbows (92%) and as fair for two. The mean Disabilities of the Arm, Shoulder and Hand score was 6 points. Three patients complained of wrist pain, which was mild in two patients and moderate in one. In four patients, some degree of elbow instability could be detected on physical examination. The mean carrying angle of the involved elbow was significantly greater than that of the uninjured elbow (21 degrees compared with 10 degrees). Radiographic changes of arthritis were considered mild in seventeen elbows and moderate in nine. We could not detect significant differences in functional outcome on the basis of the degree of radiographic change., Conclusions: Radial head resection in young patients with isolated fractures without instability yields long-term satisfactory results in >90% of cases. Osteoarthritic changes are uniformly present but typically are not associated with functional impairment.

Background: Medical treatment of women with established osteoporosis may decrease the incidence of future fractures. Postmenopausal women who have sustained a distal radial fracture have decreased bone-mineral density and nearly twice the risk of a future hip fracture. The purpose of this study was to evaluate the adequacy of diagnosis and treatment of osteoporosis in postmenopausal women following an acute fracture of the distal part of the radius., Methods: A retrospective cohort study was performed with use of a claims database that includes more than three million patients, from thirty states, enrolled in multiple health plans. All women, fifty-five years of age or older, who sustained a distal radial fracture between July 1, 1994, and June 30, 1997, were identified in the database. Only patients with at least six months of continuous and complete medical and pharmaceutical health-care coverage from the date of the fracture were enrolled, to ensure that all health-care claims would be captured in the database. This cohort of patients was then evaluated to determine the proportion who had undergone either a diagnostic bone-density scan or treatment with any recommended medication for established osteoporosis (estrogen, a bisphosphonate, or calcitonin) within six months following the fracture., Results: A search of the database identified 1,162 women, fifty-five years of age or older, who had a distal radial fracture. Of these 1,162 patients, thirty-three (2.8 percent) underwent a bone-density scan and 266 (22.9 percent) were treated with at least one of the medications approved for treatment of established osteoporosis. Twenty women had both a bone-density scan and drug treatment. Therefore, only 279 (24.0 percent) of the 1,162 women who sustained a distal radial fracture underwent either diagnostic evaluation or treatment of osteoporosis. There was a significant decrease in the rate of treatment of osteoporosis with increasing patient age at the time of the fracture (p < 0.0001)., Conclusions: Current physician practice may be inadequate for the diagnosis and treatment of osteoporosis in postmenopausal women who have sustained a distal radial fracture.

Background: Osteocutaneous radial forearm free flaps have fallen from favor due to pathological fractures of the radius. The purposes of this study were to propose a means to decrease the rate of pathological fracture by prophylactic fixation of the donor-site defect and to evaluate this technique biomechanically., Methods: Two groups of ten matched pairs of fresh-frozen cadaveric radii were harvested. In Group 1, an eight-centimeter length of radius comprising 50 percent of the cross-sectional area of the bone was removed to simulate an osteocutaneous radial forearm donor-site defect. This defect was created in one member of each pair, with the other bone in the pair left intact. In Group 2, both members of the ten matched pairs of radii had identical defects created as previously described. However, one radius in each pair had a twelve-hole, 3.5-millimeter dynamic compression plate placed across the segmental defect. In each group, five matched pairs were tested to failure in torsion and five matched pairs were tested to failure in four-point bending., Results: In Group 1, the intact radius was a mean of 5.7 times stronger in torsion and 4.2 times stronger in four-point bending than the radius with the segmental resection. In Group 2, the radius that was ostectomized and fixed with a plate was a mean of 4.0 times stronger in torsion and 2.7 times stronger in four-point bending than the ostectomized radius., Conclusions: Removal of an eight-centimeter segment from the radius dramatically decreased both torsion and bending strength. Application of a plate over the defect in the radius significantly restored the strength of the radius (p = 0.01).

Forty-nine Monteggia and forty-seven Galeazzi lesions were treated over a twenty-five-year period. I used Bado's criteria to evaluate the results in the Monteggia lesions. In all of the children in the series either closed or open reduction yielded good results, while the results of treatment of the Monteggia fractures in the adults in the study varied. The best results were obtained in Type-I lesions treated by open anatomical reduction, internal stabilization of the ulnar fracture, and closed reduction of the radial head. Factors leading to poor results in Type-I lesions were failure to obtain anatomical reduction of the ulna, heterotopic ossification including synostosis of the proximal parts of the radius and ulna, and persistence or recurrence of dislocation of the radial head. In patients in whom the radial head could not be reduced by closed methods, the radial head was buttonholed through the joint capsule and the annular ligament was displaced but not ruptured. I have not found that reconstruction of the annular ligament is necessary in the treatment of acute Monteggia fractures. In the Type-II, III, and IV lesions in this series, fair results were the rule. The results of closed reduction of the classic Galeazzi fractures in the adults in this series were not good, due to malunion of the radius and persistent derangement of the distal radio-ulnar joint. The seventeen patients who were treated with accurate reduction and internal fixation of the fractured radius and immobilization of the forearm in full supination for six to eight weeks obtained good results.

Four cases of an unusual angulation deformity of the radial head were seen in juvenile baseball players, with or without associated lesions of osteochondritis in the contiguous capitellum of the humerus and loose-body formation. The established deformity did not show a tendency toward anatomical restitution. In each case, symptoms produced by this deformity were noted to appear in association with athletic activity.