Cast-treated distal radius fractures: a prospective cohort study of radiological outcomes and their association with impaired calcaneal bone mineral density

If at first you don't succeed, should you try again? The efficacy of repeated closed reductions of distal radius fractures

INTRODUCTION

A repeated closed reduction ("re-reduction") of a displaced distal radius fracture is a common procedure performed to obtain satisfactory alignment and avoid surgery when the initial reduction is deemed unsatisfactory. However, the efficacy of re-reduction is unclear. Compared to a single closed reduction, does a re-reduction of a displaced distal radius fracture: (1) improve radiographic alignment at the time of fracture union and, (2) decrease the rate of operative intervention?

MATERIALS AND METHODS

Retrospective cohort analysis of 99 adults aged 20-99 years with extra-articular or minimally displaced intra-articular, dorsally angulated, displaced distal radius fracture with or without an associated ulnar styloid fracture who underwent a re-reduction, compared against 99 adults matched for age and sex who were managed with a single reduction. Exclusion criteria were skeletal immaturity, fracture-dislocation and articular displacement greater than 2 mm. Outcome measures included radiographic alignment at fracture union and rate of surgical intervention.

RESULTS

At 6-8 weeks follow-up, the single reduction group had greater radial height (p = 0.045, CI 0.04 to 3.57), and less ulnar variance (p < 0.001, CI - 3.08 to - 1.00) compared to the re-reduction group. Immediately following re-reduction, 49.5% of patients met radiographic non-operative criteria, but by 6-8 weeks follow-up, only 17.5% of patients continued to meet these criteria. Patients in the re-reduction group were treated with surgery 34.3% of the time, compared to 14.1% of the time for patients in the single reduction group (p = 0.001). In patients aged under 65 years, 49.0% of those who underwent a re-reduction were managed with surgery, compared to 21.0% of those who had a single reduction (p = 0.004).

CONCLUSION

A re-reduction performed to improve radiographic alignment and avoid surgical management in this subset of distal radius fractures had minimal value. Alternative treatment options should be considered before attempting a re-reduction.

Residual dorsal displacement following surgery in distal radial fractures: A cause for trouble?

PURPOSE

Distal radius fractures have great impact on activities of daily living of affected patients. Repeatedly, a non-anatomic restoration of the volar tilt can be observed in a minimum of 20% in postoperative X-ray control examinations. Hence, the question arises whether the achieved reduction is functionally acceptable, or whether a further attempt should be made to improve the surgical outcome.

METHODS

The data presented here originate from a prospective analysis including three therapy studies on surgical treatment options for fractures of the distal radius between 2004 and 2011. For this study, the participants were divided into two groups: The first group represents the cases with non-anatomical restoration of the volar tilt with - 5° to 5°. The second group contains patients with an anatomical volar tilt between 6° and 15°.

RESULTS

A total of 624 patients were screened according to the inclusion criteria. Radiological evaluation showed consolidation of all fractures. The mean volar tilt as measured in standard x-rays of the wrist was 0° and 8°, respectively. The range of wrist motion in relation of the healthy opposite side was comparable in all directions (for example comparison group 1: Ext/Flex 94/94%; group 2: Ext/Flex 93/93%). Functional assessment of postoperative midterm results employing the Castaing and Gartland & Werley scores 2.3 years after surgery did not reveal significant differences between both groups.

CONCLUSION

According to the available data, a volar tilt in the range of - 5° to 5° can be tolerated intraoperatively without any risk of loss of function regarding the patient's manual abilities.

Magnitude, Direction, Temporal Patterns, and Frequency of Loss of Distal Radius Fracture Reduction in Women 50 Years and Older

PURPOSE

To determine the magnitude, direction, temporal patterns, and frequency of reduction loss following nonsurgical, closed treatment of distal radius fractures in women 50 years and older and correlate these observations with bone mineral density and age.

METHODS

We reviewed registry data on 1,148 patients 50 years and older with distal radius fractures managed by closed reduction and cast immobilization. Radial inclination (RI), ulnar variance (UV), and radial tilt (RT) were measured immediately and at 1, 2, 3, 6, 9, and 12 weeks after reduction. Magnitude, direction, frequency, and patterns of change were compared at each time point and correlated with bone mineral density T-scores and age using paired t tests in a mixed effects model.

RESULTS

Over 12 weeks, RI decreased by 3° ± 5°, the majority occurring in the first 2 weeks and significantly correlated with bone mineral density T-score and age. Unexpectedly, RI increased over time in 5% of patients. Ulnar variance increased by 2.3 ± 1.7 mm, the majority occurring in the first 3 weeks and correlated with age. Radial tilt changed by 7° ± 11° in those displacing dorsally and 8° ± 12° in those displacing volarly at 12 weeks, with the majority occurring in the first 3 weeks and significantly correlating with age. Ulnar variance and RT continued to change by small increments between weeks 3 and 6. Nearly 90% of our cohort experienced measurable loss of reduction and 50% changed at least 5° RI, 11° RT, and 2 mm UV.

CONCLUSIONS

Most distal radius fracture managed with closed reduction and casting have some loss of reduction, the majority occurring in the first 3 weeks and correlated with increased age and osteoporosis. This guides clinicians in informing patients about expected reduction loss, frequency of clinical and radiographic follow-up, and timing of discussions regarding the need for surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

The Requirement for Closed Reduction of Dorsally Displaced Unstable Distal Radius Fractures Before Operative Treatment

BACKGROUND

Dorsally displaced distal radius fractures are generally treated with closed reduction followed by casting. Current evidence suggests that fracture reduction is of no benefit before either conservative or surgical treatment. It has not been studied to date whether the degree of pain suffered by the patient during preoperative casting is any different if the fracture is reduced beforehand.

METHODS

In a prospective, randomized trial, dorsally displaced unstable distal radius fractures were treated surgically, either with or without prior closed reduction (22 and 25 patients, respectively). The primary endpoint was the difference between the pain score (on the Visual Analog Scale) on day 1 after treatment and the initial pain score on presentation. The secondary endpoints included the clinical and radiological outcome and any damage to the median nerve. Moreover, the Krimmer score (strength, mobility, pain, and function of the wrist joint) an the DASH score (Disability of the Arm, Shoulder and Hand) were determined 3 and 12 months after treatment. This trial has been registered with the number DRKS00010570.

RESULTS

With regard to the primary endpoint on day 1 after treatment, there was a statistically significant non-inferiority of the group without reduction, compared to the group with reduction. Sensory disturbances appeared at similar frequencies in the two groups four to six weeks after treatment (9.5% with reduction, 9.1% without). At 12 months, the Krimmer and DASH scores of patients whose fractures had not been reduced were no worse than those of patients whose fractures had been reduced (96 and 7 versus 96.5 and 4.5, respectively; p-values for non-inferiority, 0.004 and 0.008).

CONCLUSION

This trial shows that dispensing with closed reduction before casting as a preliminary to planned surgery yields no disadvantage. Thus, in the authors' view, routine reduction is not warranted.

Efficacy of non-bridging external fixation in treating distal radius fractures

Objective

To investigate the efficacy of non‐bridging external fixation in treating distal radius fractures (DRF) and its effect on wrist joint function.

Methods

The medical records of 207 patients who were treated for DRF between May 2008 and April 2017 in our hospital (age, 18.0–70.0 years; 99 males and 108 females) were retrospectively analyzed. All patients had evident wrist trauma and the diagnosis of DRF was confirmed by imaging tests. A total of 101 patients received bridging external fixation (control group), whereas another 106 received non‐bridging external fixation (study group). At 12 weeks after the procedure, the treatment effect was measured using the Dienst scoring system (rating scale: ≤3 points, excellent; 4–7 points, good; 8–11 points, fair; >12 points, poor), and the wrist joint function was evaluated by Gartland and Werley classification (rating scale: 0–2 points, excellent; 3–8 points, good; 9–20 points, fair; >21 points, poor); meanwhile, the radial length, radial inclination, and palmar tilt were examined by X‐ray. Follow‐up visits were conducted once every 2 weeks for 6 months, and the incidences of complications in the two groups within 6 months after operation were recorded, including incision infection, Kirschner wire loosening, delayed fracture healing, and arthritis.

Results

There were no differences in the sex ratio, mean age, mean injury period, Arbeitsgemeinschaft fur osteosynthesefragen classification, and cause of fracture between the two groups (all P > 0.05). In terms of the treatment effects, the study group had a higher percentage of excellent results (P < 0.001) and lower percentages of fair and poor results (P = 0.002, P = 0.001) than the control group 12 weeks after treatment, while both groups had similar percentages of good results (P = 0.109). In terms of the score of the wrist joint function, the study group had a higher proportion of excellent result than the control group 12 weeks after treatment (P = 0.029), whereas no intergroup differences in the proportion of good, fair, and poor results were observed (all P > 0.05). After follow‐up for 6 months, the incidences of incision infection, Kirschner wire loosening, delayed fracture healing, and arthritis, as well as the total complication rate were found to be similar between the two groups (all P > 0.05).

Conclusions

Using non‐bridging external fixation for treating DRF allows some level of wrist movement during the early stage of fixation, effectively maintains the radial length, radial inclination, and palmar tilt, and achieves better outcomes than bridging external fixation.

Necessity of acceptable radiologic alignment by preoperative closed reduction for unstable distal radius fractures treated with volar locking plates

PURPOSE

The purpose of this study was to demonstrate the necessity of achieving acceptable radiographic alignment by preoperative closed reduction in unstable distal radius fractures (DRFs) to improve preoperative pain and obtain satisfactory outcomes after surgery.

METHODS

From 2013 to 2016, patients who received volar locking plates for DRFs were retrospectively reviewed. Patients were classified into acceptable and non-acceptable reduction groups based on immediate post-reduction radiographs. To avoid potential bias, a matched-pair analysis was performed, and paired patients were categorized into non-acceptable reduction (group A) and acceptable reduction (group B) groups. Preoperative pain level, mean length of stay, operation time, postoperative complications, and surgical outcomes were analysed. The preoperative pain level and functional results were assessed by the visual analogue scale (VAS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores.

RESULTS

Of the 239 patients, 80 had non-acceptable and 159 had acceptable reductions. Among these patients, 201 (66 in group A vs. 135 in group B) were matched in a 1:2 matched ratio. Although the radiological parameters after closed reduction were better in group B, there were no significant differences in the preoperative pain VAS score, mean length of stay, operation time, and postoperative complications between the groups. In addition, radiologic parameters and the DASH score at a 1-year follow-up were also not significantly different between the groups.

CONCLUSION

Our results suggest that obtaining acceptable radiologic alignment by closed reduction is not necessary for patients who make an informed decision to undergo volar plating for unstable DRFs.

Pain Perception following Initial Closed Reduction in the Preoperative Care of Unstable, Dorsally Displaced Distal Radius Fractures

Introduction Closed reduction and cast immobilization is a common practice as initial treatment for distal radius fractures. This study examines the pain perception that accompanies this approach. Materials and Methods Thirty dorsally displaced distal radius fractures were reduced and casted under finger-trap traction with intravenous analgesics. Patients rated their pain perception on visual analog scale prior to presentation, during reduction, during casting, and for every day until surgery. Closed reduction improved palmar tilt from -26.3 to -10.8 degrees. Surgery improved palmar tilt from -10.8 to +6.1 degrees. Closed reduction improved radial inclination from 15.5 to 19.1 degrees. Surgery improved radial inclination from 19.1 to 21.6 degrees. Mean pain perception was 5.8 at presentation. Reduction increased pain to 7.5 ( p < 0.001), whereas casting was less painful (3.7; p < 0.001). At the evening following casting and the following days until surgery, mean pain was still as high as 4.1, 4.2, 4.1, 3.6, 3.9, 2.8, 3.0, and 3.0, with some patients experiencing more pain than initially. Conclusion Reduction generates significant pain with only minor relief during cast immobilization. The indication for closed reduction prior to cast application is therefore questionable.

Wrist Fractures and Osteoporosis

Distal radial fractures account for up to 18% of all fractures in patients over 65 years of age, and osteoporosis is a predominant factor in these fractures. Fracture treatment may include closed reduction and casting/splinting, external fixation, and open reduction and internal fixation.

Repeated closed reduction attempts of distal radius fractures in the emergency department

INTRODUCTION

Repeated attempts of closed reduction of distal radius fractures (DRF) are performed in the emergency department setting to optimize fracture alignment and avoid surgery. The additional manipulation of the fracture may, however, increase dorsal comminution and lead to loss of reduction in the cast. This retrospective cohort study has investigated the effect of second reduction attempt on fracture alignment and comminution.

MATERIALS AND METHODS

Six-hundred-eighteen patients with DRF were treated in the medical center in 2007-2010. Seventy-six (12.3%) DRF who underwent two reductions were included in the study. Radiographs taken after the first and second reduction attempts were reviewed for changes in fracture alignment parameters (radial height, radial inclination, volar tilt) and dorsal comminution length. Patients were also followed retrospectively to determine the rates of secondary displacement in a cast.

RESULTS

A second closed reduction attempt improved mean radial height by 1.43 mm, mean radial inclination by 1.62° and mean volar tilt by 8.75°. Mean dorsal comminution length increased by 1.6 mm. Of the 19 (25%) patients with acceptable alignments after two reduction attempts, follow-up radiographs were available for 12, which showed successful reduction in four cases (33.3 or 5.2% of total 76 patients).

CONCLUSIONS

A second closed reduction attempt improved immediate fracture alignment, but also worsened dorsal comminution. Only 5.2% of patients who underwent two reduction attempts had an acceptable final alignment and did not require surgery. Increased dorsal comminution may further compromise fracture stability, complicate surgery and have negative effect on the postoperative course.