Abstract
Objectives A lack of conclusive evidence on the treatment of acute median neuropathy (AMN) in patients with distal radius fractures has led to inconsistent surgical guidelines and recommendations regarding AMN in distal radius fractures. There is a wide variation in surgical decision-making. We aimed to evaluate international differences between surgical considerations and practices related to carpal tunnel release (CTR) in the setting of distal radius fractures.
Methods We approached surgeons who were a member of the Orthopaedic Trauma Association (United States) or of the Dutch Trauma Society (the Netherlands) and asked them to provide sociodemographic information and information on their surgical practice regarding CTR in the setting of distal radius fractures. After applying our exclusion criteria, our final cohort consisted of 127 respondents.
Results Compared with Dutch surgeons, surgeons from the United States are more of the opinion that displaced distal radius fractures are at risk of developing acute carpal tunnel syndrome (ACTS), consider persistent paresthesia in the median nerve distribution after closed reduction to be a surgical emergency less often, and are more likely to perform a CTR if there are signs of ACTS in the setting of a distal radius fracture.
Conclusion A lack of conclusive evidence has led to international differences in surgical practice regarding the treatment of ACTS in the setting of distal radius fractures. Future research should guide surgeons in making appropriate evidence-based decisions when performing CTR in the setting of distal radius fractures.
Level of Evidence This is a Level V study.
Keywords: distal radius fractures, carpal tunnel release, median nerve
Acute median neuropathy (AMN) is a well-acknowledged condition occurring in the setting of distal radius fractures, with reported incidence rates varying from 0.2 to 21.3%. 1 Although often interpreted as carpal tunnel syndrome (CTS), median neuropathy after distal radius fractures can be the consequence of a variety of diagnosis, such as compartment syndrome or more direct compression of the median nerve by bone fragments, local edema, or hematoma. 2 3 4 Clinical examination is a valuable tool in differentiating between nerve contusion and progressive median neurapraxia after a distal radius fracture: normal median nerve examination with a progressive loss of two-point discrimination is an indication for acute CTS (ACTS), whereas nerve contusions are characterized by nonprogressive dysesthesia. 1 Nevertheless, one must bear in mind that the median neuropathy may be preexisting to the trauma and that diagnostic criteria of different causes of AMN may overlap. 5 Lateral radiographs demonstrating fracture translation at the carpal tunnel region may increase the clinician's index of suspicion for ACTS. 6 Patients with progressive median nerve symptoms due to increased pressure in the carpal tunnel benefit from urgent decompression of the carpal tunnel, 2 but if the compression is proximal to the carpal tunnel, a proximal exploration and release of the median nerve may be more appropriate. 3 Concurrent carpal tunnel release (CTR) may not always be beneficial for wrist trauma patients if there are no signs of progressive median nerve dysfunction. 7 8 9 Multiple case series have shown that delayed CTR may lead to irrevocable loss of median nerve function, 10 11 12 but consensus regarding the recommended timeframe and indications for CTR in the setting of ACTS in distal radius fractures is yet to be established. 13 The combination of a lack of a reference standard for correctly diagnosing the type of median nerve pathology in the setting of distal radius fractures and the shortcomings of the current evidence regarding traumatic median neuropathy makes AMN in patients with distal radius fractures a challenging problem for surgeons who treat such fractures. 4 This lack of conclusive evidence regarding the treatment of median nerve dysfunction in the setting of distal radius fractures has led to differences in both local and international surgical guidelines regarding the management of AMN in distal radius fractures. For example, the distal radius fracture guideline of the American Academy of Orthopaedic Surgeons (AAOS) states that there are no qualified studies to address any recommendation either for or against nerve decompression surgery in patients with distal radius fractures experiencing postreduction median nerve dysfunction, and the Dutch Surgical Society does not mention median nerve complaints in their distal radius fracture guideline at all. 14 15
In light of these differences, the purpose of this study was to evaluate differences between surgical considerations and practices related to release CTR in the setting of distal radius fractures. A better understanding of practice variation regarding the role of CTR during open reduction and internal fixation (ORIF) of distal radius fractures may aid in the clinical guidance for decision-making in the setting of AMN in distal radius fractures.
We tested the primary null hypothesis that there are no differences in the risk assessment of fracture displacement on the development of ACTS in patients with distal radius fractures between surgeons from the Netherlands and surgeons from the United States of America.
Furthermore, in comparing these two sets of surgeons, we tested the secondary null hypotheses that there are no differences in the following:
The risk assessment of fracture displacement on the development of median nerve paresthesias after closed reduction of the distal radius fracture.
Surgical practice or risk assessment in the setting of distal radius fractures.
Patient-, injury-, median nerve assessment-, or logistics-related considerations influencing the likeliness of CTR in the setting of distal radius fractures.
The likelihood of receiving a CTR at the time of distal radius ORIF.
Methods
Study Design
Our Institutional Review Board determined that this study met the criteria for exemption. We then approached eligible surgeons for participation in this cross-sectional study from October 2016 to January 2017. We distributed our survey questionnaire ( Supplementary material [ Appendix A ]) to the following: (1) active members of the Orthopaedic Trauma Association (OTA) on the research section of their Web site ( https://ota.org/research/research-surveys ) and by distributing a QR-code linked to the survey at the 32nd annual OTA meeting ( n = 637), (2) members of the Dutch Trauma Society (DTS) who were approached through e-mail ( n = 540), and (3) physicians attending the 44th annual meeting of the New England Hand Society (NEHS), who were presented a paper version of the questionnaire ( n = 82). Our inclusion criteria were (1) medical practice in the United States or in the Netherlands and (2) practicing orthopaedic, trauma, or hand and wrist surgeons. In total, 94 participants responded through the OTA (15%), 29 responded to the e-mail received from the DTS (5.4%), and 23 filled out the survey at the NEHS annual meeting (28%). After excluding nine (6.2%) participants who did not complete the survey, nine (6.2%) participants who were not from the Netherlands or the United States, and one (0.68%) participant who was a rehabilitation specialist and not a surgeon, our final cohort consisted of 127 respondents.
Questionnaire and Likelihood of Receiving a CTR during Distal Radius ORIF
Participants provided sociodemographic information and completed our online questionnaires by using the REDCap (Research Electronic Data Capture) data management software, 16 assessing their surgical practice regarding CTR in the setting of distal radius fractures. The sociodemographic variables consisted of age, sex, years in practice since board qualification, country and region where residency training was completed, country of practice, position, supervising surgeon or not, surgical specialty, and work status.
The questionnaire that we used was constructed by the senior authors, who together have more than 40 years of cumulative surgical experience, and was based on their observations, questions, clinical experiences, and expert discussions related to median neuropathy in the setting of fractures of the distal radius. More specifically, the survey is based on fracture displacement, effectiveness of closed reduction on median nerve paresthesias, surgical routine, open or closed fractures, contiguous fractures of the carpus and the distal radius, fracture mechanism, the patient's age, and the patient's sex.
To evaluate the likelihood of receiving a CTR during distal radius ORIF, we assigned a score to each of the variables possibly influencing the surgeon's likelihood of performing a CTR during distal radius ORIF. We assigned a score of 0 to each answer stating that the presence of a characteristic has no influence, a score of 1 to each answer stating that the presence of a characteristic makes it more likely, and a score of –1 to each answer stating that the presence of a characteristic makes it less likely that the surgeon would perform a CTR at the same time as distal radius ORIF.
Statistical Analysis
A posthoc power analysis demonstrated that 26 Dutch surgeons and 101 surgeons from the United States provided us with 95% statistical power (two-tailed α : 0.05) to detect an absolute difference in proportions of surgeons who consider displacement of the distal radius fracture to be a risk factor for ACTS with an effect size of 0.22. We presented categorical data as frequencies with percentages, and continuous data as means with their standard deviations (SDs). The demographic differences between the surgeons were assessed through bivariate analysis: Fisher's exact test was used to compare the distribution of categorical data, and the two-sample Student's t -test with equal variance was used for the continuous variables. The differences in surgical practice and risk assessment between the surgeons and the differences in surgical decision-making regarding CTR in the setting of distal radius fractures were all assessed using Fisher's exact test.
Surgeon Characteristics
Our sample comprised 127 surgeons, 117 men (92%) and 10 women (7.9%), with a mean age of 50 (SD: 11) years. Twenty percent of the surgeons ( n = 26) were from the Netherlands and 80% ( n = 101) were from the United States. Nearly all participants had their surgical residency in the same country where they practice medicine (98%) and were working full-time (93%; Table 1 ). Compared with the surgeons from the United States, the Dutch surgeons were younger ( p = 0.0091), had worked fewer years since board certification ( p = 0.0033), and worked in level I trauma centers more often ( p = 0.001). Compared with the Dutch surgeons, the group of surgeons from the United States consisted of more hand surgeons ( p < 0.001; Table 1 ) and worked in a practice where ORIF of distal radius fractures is a day surgery procedure more often.
Table 1. Characteristics of the participating surgeon.
| Characteristic | All surgeons ( n = 127) |
Country | p- Value | |
|---|---|---|---|---|
| NL ( n = 26) | United States ( n = 101) | |||
| Age, mean ± SD, years | 50 ± 11 | 46 ± 7.9 | 52 ± 11 | 0.0091 a |
| Sex, n (%) | 0.43 b | |||
| Men | 117 (92) | 23 (88) | 94 (93) | |
| Women | 10 (7.9) | 3 (12) | 7 (6.9) | |
| Residency in the same country as medical practice, n (%) | 124 (98) | 25 (96) | 99 (98) | 0.50 b |
| Type of institution, n (%) | 0.001 b | |||
| Level I trauma center | 54 (43) | 13 (50) | 41 (41) | |
| Community hospital/nonlevel I trauma center | 39 (31) | 13 (50) | 26 (26) | |
| Private practice | 29 (23) | 0 (0) | 29 (29) | |
| More than one type of institution | 5 (3.9) | 0 (0) | 5 (5) | |
| Work status n (%) | >0.99 b | |||
| Full time | 118 (93) | 24 (92) | 94 (93) | |
| Part time | 5 (3.9) | 1 (3.9) | 4 (4) | |
| Retired | 4 (3.2) | 1 (3.9) | 3 (3) | |
| Position, n (%) | 0.57 b | |||
| Surgeon | 125 (98) | 25 (96) | 100 (99) | |
| Fellow | 1 (0.79) | 0 (0) | 1 (0.99) | |
| Other | 1 (0.79) | 1 (3.9) | 0 (0) | |
| Supervising surgeon, n (%) | 87 (69) | 22 (85) | 65 (64) | 0.059 b |
| Specialty, n (%) | <0.001 b | |||
| General orthopaedic surgery | 9 (7.1) | 0 (0) | 9 (8.9) | |
| Orthopaedic traumatology | 45 (35) | 23 (88) | 22 (22) | |
| Hand and wrist surgery | 73 (57) | 3 (12) | 70 (69) | |
| Years in practice since board certification, mean ± SD, years | 16 ± 11 | 11 ± 7.5 | 18 ± 11 | 0.0033 a |
Abbreviations: NL, the Netherlands; SD, standard deviation.
Student's t -test.
Fisher's exact test.
Note: Values in bold represent statistically significant values.
Results
Bivariate analysis showed that compared with Dutch surgeons, more surgeons from the United States are of the opinion that patients with displacement of their distal radius fracture are at a risk of developing an ACTS ( P < 0.001). In contrast, more surgeons from the Netherlands consider persistent paresthesia in the median nerve distribution after closed reduction of the distal radius fracture to be a surgical emergency ( p = 0.007; Table 2 ). Surgeons from the United States perform elective open CTR in patients with CTS as part of their practice more often ( p = 0.005), have more recent experience (in the past 4 weeks prior to answering the questionnaire) with releasing a carpal tunnel ( p = 0.008), and have more experience with treating a patient with a displaced distal radius fracture who developed preoperative ACTS ( p = 0.016).
Table 2. Differences in surgical practice and risk assessment regarding CTR in the setting of DRFs between surgeons from the NL and surgeons from the United States.
| Variable, n (%) | Country of surgical practice | ||
|---|---|---|---|
| NL ( n = 26) | United States ( n = 101) | p- Value | |
| Surgical practice | |||
| Performed elective open CTR in patients with CTS as part of his/her practice | 13 (50) | 81 (80) | 0.005 |
| Released a carpal tunnel, for any reason, in the past 4 wk | 12 (46) | 76 (75) | 0.008 |
| Working in practice where ORIF of DRFs is a day procedure | 20 (77) | 99 (98) | 0.001 |
| Has ever treated a patient with a displaced DRFs who also developed preoperative acute CTS | 22 (85) | 99 (98) | 0.016 |
| Has ever treated a patient with a displaced DRFs who also developed postoperative acute CTS | 16 (62) | 76 (75) | 0.22 |
| Has (institutional) clinical or radiographic guidelines to determine which DRFs are at a risk of CTS | 0 (0) | 8 (7.9) | 0.21 |
| Performs routinely (>50% of the time) CTR at the same time as distal radius ORIF | 1 (3.9) | 9 (8.9) | 0.69 |
| Has ever returned to the operating room with a patient after distal radius ORIF for subsequent CTR | 11 (42) | 64 (63) | 0.073 |
| Changes the postoperative rehabilitation if there was concurrent CTR during ORIF of the distal radius | 2 (7.7) | 11 (11) | >0.99 |
| Routinely allows for preoperative peripheral nerve block placement for DRFs requiring surgery | 15 (58) | 73 (72) | 0.16 |
| Risk factor assessment | |||
| Believes that displaced DRFs are at risk of acute CTS | 20 (77) | 100 (99) | <0.001 |
| Considers persistent paresthesia in the median nerve distribution after closed reduction of DRFs to be a surgical emergency | 13 (50) | 22 (22) | 0.007 |
Abbreviations: CTR, carpal tunnel release; CTS, carpal tunnel syndrome; DRFs, distal radius fractures; : NL, the Netherlands; ORIF, open reduction and internal fixation.
Note: Values in bold represent statistically significant values.
Radiographic displacement of the distal radius fracture would lead to a higher probability of performing a CTR during distal radius ORIF in 12% of the Dutch surgeons, whereas this was the case with 18% of the surgeons from the United States ( p = 0.028). Furthermore, there was a larger proportion of U.S. surgeons than Dutch surgeons who would not consider contiguous fractures of the carpus and the distal radius fracture as an influencing factor in the surgical decision-making regarding CTR during ORIF of the distal radius fracture ( p = 0.05; Table 3 ). Apart from these two injury-related characteristics, there were no patient-, median nerve-, or logistics-related factors that showed differences between these groups regarding surgical decision-making on CTR at the time of distal radius ORIF ( Table 3 ).
Table 3. Differences in surgical decision-making regarding CTR in the setting of distal radius fractures between surgeons from the NL and surgeons from the United States.
| Variable influencing the likeliness of CTR at the same time as distal radius ORIF, n (%) | Country of surgical practice | p- Value | |
|---|---|---|---|
| NL ( n = 26) | United States ( n = 101) | ||
| Patient characteristics | |||
| Age > 55 y old (reference: <55 y old) | 0.59 | ||
| More likely | 0 (0) | 3 (3) | |
| Less likely | 3 (12) | 7 (6.9) | |
| No influence on the surgeon's decision-making | 23 (88) | 91 (90) | |
| Female sex (reference: male sex) | 0.54 | ||
| More likely | 0 (0) | 2 (2) | |
| Less likely | 2 (7.7) | 3 (3) | |
| No influence on the surgeon's decision–making | 24 (92) | 96 (95) | |
| Comorbidities such as diabetes or end-stage renal disease | 0.12 | ||
| (reference: no comorbidities) | |||
| More likely | 2 (7.7) | 21 (21) | |
| Less likely | 1 (3.9) | 1 (0.99) | |
| No influence on the surgeon's decision–making | 23 (88) | 79 (78) | |
| Injury characteristics | |||
| Radiographic displacement of the distal radius fracture | 0.028 | ||
| (reference: no radiographic displacement) | |||
| More likely | 3 (12) | 18 (18) | |
| Less likely | 4 (15) | 2 (2) | |
| No influence on the surgeon's decision-making | 19 (73) | 81 (80) | |
| Open fracture (reference: closed fracture) | 0.098 | ||
| More likely | 8 (31) | 32 (32) | |
| Less likely | 3 (12) | 2 (2) | |
| No influence on the surgeon's decision-making | 15 (58) | 67 (66) | |
| Contiguous fractures of the carpus and distal radius (reference: no contiguous fractures) | 0.05 | ||
| More likely | 12 (46) | 46 (46) | |
| Less likely | 2 (7.7) | 0 (0) | |
| No influence on the surgeon's decision-making | 12 (46) | 55 (54) | |
| High-energy distal radius fracture (reference: low-energy fracture) | 0.28 | ||
| More likely | 18 (69) | 70 (69) | |
| Less likely | 1 (3.9) | 0 (0) | |
| No influence on the surgeon's decision-making | 7 (27) | 31 (31) | |
| Median nerve paresthesias | |||
| Resolving median nerve paresthesias following closed reduction of a fracture indicated for ORIF | 0.56 | ||
| Would perform a CTR at the same time as ORIF of the distal radius | 3 (12) | 18 (18) | |
| Would not perform a CTR at the same time as ORIF of the distal radius | 23 (88) | 83 (82) | |
| Unresolving median nerve paresthesias following closed reduction of a fracture indicated for ORIF | 0.58 | ||
| Would perform a CTR at the same time as ORIF of the distal radius | 26 (100) | 96 (95) | |
| Would not perform a CTR at the same time as ORIF of the distal radius |
0 (0) | 5 (5) | |
| Logistical considerations | |||
| Day of the week being a Friday (reference: Monday to Thursday) | 0.19 | ||
| More likely | 0 (0) | 1 (0.99) | |
| Less likely | 2 (7.7) | 1 (0.99) | |
| No influence on the surgeon's decision-making | 24 (92) | 99 (98) | |
Abbreviations: CTR, carpal tunnel release; NL, the Netherlands; ORIF, open reduction and internal fixation.
Note: Values in bold represent statistically significant values.
Based on the mean summative scores that were assigned to the surgeon's decision-making, surgeons from the United States are more likely to perform a CTR at the same time as distal radius ORIF (mean: 1.8 [SD: 1.6], range: –3 to 6) when compared with surgeons from the Netherlands (mean: 0.96 [SD: 2.4], range: –6 to 4; p = 0.044).
Discussion
The lack of conclusive evidence regarding the treatment of median nerve dysfunction in the setting of distal radius fractures has led to differences in surgical guidelines regarding the management of AMN. We aimed to evaluate the differences between surgeons in their decision-making regarding CTR in the setting of distal radius fractures.
Our study should be interpreted in light of its strengths and limitations. First, we do not have accurate data on the number of incorrect or unavailable contact information. In addition, it is possible that the e-mails that were sent to prospective respondents were wrongly identified as spam e-mails, which may have reduced the response rate, which, in turn, affected our reported response rate. Our response rate could also be affected by the fact that medical specialists show a high variability in response rates. 17 Second, because of feasibility reasons, the results of this study are based on surgeons from the Netherlands and the United States, and assessing the differences between surgeons from other countries could possibly lead to different outcomes. Third, there was a difference in age and, consequently, years in practice between the two groups. It is likely that this only had a limited influence on our outcomes, as prior studies have shown that the influence of surgical experience on both assessment and treatment of distal radius fractures is limited. 18 19 The observation that surgical experience only accounts for 1% of the variability in treatment recommendation of wrist fractures supports this. 19 Furthermore, the Dutch group of surgeons consisted of fewer hand surgeons than the U.S. group. This is not surprising, as hand and upper extremity surgery is not a separate specialty in the Netherlands, and there are no set criteria by which an individual can be classified as a hand surgeon. In the Netherlands, hand and upper extremity surgery is practiced by orthopaedic surgeons, trauma surgeons, and plastic surgeons. The treatment of distal radius fractures is, however, mainly the domain of the orthopaedic trauma surgeons, as Dutch hand surgeons primarily focus on (trauma of) the hand. The differences in (sub)specialty between the groups in this study therefore are unlikely to imply differences in treatment domains. Additionally, the effect of surgical specialty on operative treatment recommendation is not clear as it has not been reported with consistent results. 19 20 Lastly, this study is a cross-sectional survey and not a data-driven study. This means that we assessed expert opinions on hypothetical statements rather than observing behavior in actual clinical settings. It could be that our respondent's practice would not be in line with the answers they provided. However, this is a typical characteristic of survey studies assessing medical practices, and expert opinions of surgeons are a good indication of the need and development of surgical guidelines. 21 22 23
With regard to the strengths of this study, our extensive literature search did not reveal any preexisting data assessing AMN in distal radius fractures with a study design similar to ours, and we anticipate that this study will be able to facilitate the establishment of guidelines for the management of this injury. Other strengths are the representative sample, a sample size allowing us to perform a statistical analysis rather than providing descriptive results only, and a wide reach of exposure to eligible participants through the involvement of the respective national trauma associations.
Our results show that compared with Dutch surgeons, surgeons from the United States are more of the opinion that patients with displacement of their distal radius fractures are at a risk of developing ACTS. Although a matched case–control study identified fracture translation as a risk factor for ACTS, 6 there is still insufficient evidence to advise for or against CTR in the setting of distal radius fractures based on radiographic characteristics alone. 4
Compared with Dutch surgeons, surgeons from the United States perform elective open CTR more often and have more experience in the treatment of patients with displaced distal radius fractures who developed preoperative ACTS. Elective open CTR is a procedure that is performed by multiple surgical specialties in the Netherlands, whereas CTR in the setting of ACTS is mainly the domain of the Dutch trauma surgeon. Therefore, the difference between our groups in the proportion of surgeons who perform elective CTR may be because we approached Dutch trauma surgeons through the DTS and focused on Dutch trauma surgeons primarily. ORIF of a distal radius fracture was a day procedure in the institutions of Dutch surgeons less often compared with those from the United States. It must be noted that none of the Dutch surgeons worked in private practice and that this is likely a consequence of the differences in national health care systems between the countries of the participating surgeons.
There were no differences in patient-, logistics-, or median nerve assessment related factors associated with the likelihood of receiving CTR during ORIF of the distal radius fracture. Although radiographic displacement had no influence on the surgical decision-making regarding CTR during ORIF in the majority of both groups, there were relatively more Dutch surgeons than U.S. surgeons who were less likely to perform a CTR during ORIF based on fracture displacement. This is in line with our finding that surgeons from the United States consider fracture displacement a risk factor for developing ACTS more often.
Surgeons from the United States had higher summative likelihood scores than the Dutch surgeons, indicating that, overall, U.S. surgeons are more likely to perform a CTR in patients with median neuropathy who receive operative treatment for their distal radius fracture. This is in line with our finding that U.S. surgeons had more and more recent experience with CTR more often. While the Dutch guideline on treatment of distal radius fracture has no mention of median nerve release, 14 the AAOS treatment guideline on distal radius fractures does not advise for or against nerve decompression in persisting median neuropathy after reduction, although it must be mentioned that this recommendation does not concern simultaneous CTR during ORIF of the distal radius specifically. 15
There are limited published data on ACTS and CTR in distal radius fractures. The rapidly progressive nature of the symptoms may aid differentiating between ACTS and other AMN pathologies with overlapping diagnostic criteria such as median nerve contusion or neurapraxia, forearm compartment syndrome, or exacerbation of a preexisting CTS. 4 5 A study that assessed CTR in patients with volar Barton fractures and median nerve symptoms advised that the median nerve should not be decompressed during ORIF using buttress plating and screws if there are no signs of median neuropathy. 9 Another study concluded that a CTR during ORIF in patients with no median neuropathy signs may lead to more complications than not performing a CTR. 8 This CTR was, however, not a typical CTR: the incision of a volar Henry approach was extended to the ulnar side of the thenar compartment. It is important to note that not all median neuropathies associated with distal radius fractures will benefit from a CTR, as it could also be that progressive AMN is caused by a local median nerve injury. In some of those cases, the symptoms may resolve over time, even without a concomitant CTR. However, in this group, it is difficult to accurately predict which patients may improve clinically without a CTR. Therefore, it may be a more prudent option to perform a concomitant CTR to reduce the likelihood of any compression that may impede neural recovery in patients with a direct injury to the median nerve and to perform a more proximal exploration and release of the median nerve if the injury to the nerve is proximal to the carpal tunnel. 3
Our data suggest that there are differences in surgical practices among first-world countries. We speculate that this is due to a lack of solid evidence regarding CTR during ORIF of distal radius fractures. Patients with median nerve symptoms after a distal radius fracture are more likely to receive a concomitant CTR during ORIF of their distal radius fractures in the United States than in the Netherlands, which may or may not be facilitated by differences in surgical guidelines. Identifying differences in surgeon's views and practices may contribute to the discussion regarding the role of CTR during ORIF of distal radius fractures. It is still difficult to identify which patients will benefit from a CTR during ORIF of distal radius fractures, and future research should guide surgeons in making appropriate evidence-based decisions when performing CTR in the setting of distal radius fractures and will, hopefully, reduce surgeon-to-surgeon variability in the treatment of this injury.
Funding Statement
Funding Departmental.
Conflict of Interest None declared.
Author Contributions
This study represents a great deal of effort, resources, and dedication on the part of the authors in reviewing and reconstructing all cases, reviewing the literature, and performing statistical analyses. All authors have participated in a material way. S. Ö., C. M., F. B., M. H., B. E., and C. W. contributed to the study design, S. Ö., B. E., and C. W. contributed to data collection, S. Ö., C. M., and F. B. contributed to data analysis, S. Ö., B. E., C. M., F. B., and M. H. contributed to the initial draft, S. Ö., C. M., F. B., M. H., and C. W. contributed to data accuracy.
Note
The work was performed at the Hand and Upper Extremity Service, Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
Ethical Review Committee Statement
The Institutional Review Board determined that this study met the formal criteria for exemption.
Supplementary Material
References
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