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Defining displacement thresholds for surgical intervention for distal radius fractures - A Delphi study.

ABSTRACT: Distal radius fractures are very common yet controversy exists regarding which require treatment and is reflected by significant variation in surgical intervention rate. Evidence regarding which fractures would benefit from intervention is varied and largely poor quality. This study had three aims; identify which radiographic parameters are clinically important; quantify the threshold of displacement at which intervention should occur and investigate which patient factors influence the decision to intervene. A modified three round Delphi study was carried out and responses were qualitatively analysed. The Delphi panel was composed of three groups of national and international expert surgeons: hand and wrist surgeons, trauma surgeons, and international researchers. 46 participants initially agreed to take part. 43 completed the first round and all then completed three rounds. Participants were asked questions based around case vignettes in patients of three ages (38, 58, 75 years). For all age groups ulnar variance was ranked as the most important extra-articular parameter, step was ranked as the most important intra-articular parameter. Agreed thresholds were the same for all parameters for patients aged 38 and 58. Surgeons would intervene with +2 mm ulnar variance, 10 degrees dorsal tilt, 2mm step and 3mm gap. In patients aged 75 the agreed thresholds were 20 degrees dorsal tilt, 3mm step and 4mm gap, consensus was not achieved for ulnar variance. Mental capacity, pre-injury functional level and medical co-morbidities were ranked as the most important factors influencing the decision to intervene. Qualitative analysis suggested that pre-injury function was the main theme within these factors. Our findings provide useful advice about which parameters should be measured and radiographic thresholds for intervention. These thresholds may then be modified depending on important patient factors. This information can help guide clinicians with management decisions and reduce variation.

SUBMITTER: Johnson N

PROVIDER: S-EPMC6324814 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Defining displacement thresholds for surgical intervention for distal radius fractures - A Delphi study.

Johnson Nick N Leighton Paul P Pailthorpe Charles C Dias Joseph J

PloS one 20190108 1

Distal radius fractures are very common yet controversy exists regarding which require treatment and is reflected by significant variation in surgical intervention rate. Evidence regarding which fractures would benefit from intervention is varied and largely poor quality. This study had three aims; identify which radiographic parameters are clinically important; quantify the threshold of displacement at which intervention should occur and investigate which patient factors influence the decision ...[more]

PMID: 30620763

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Project description:BackgroundDistal radius fractures are the most common fracture of childhood, occurring in ∼1 per 100 children annually. Given the high incidence of these fractures, we explored feasibility of a bundled payment model. We determined the total treatment costs for each child and identified components of fracture management that contributed to variations in cost.MethodsWe retrospectively reviewed all hospital and physician costs related to the treatment of closed distal radius fractures at a large academic children's hospital. We included all children age 2 to 15 years treated by an orthopaedic surgeon for an isolated closed distal radius fracture between 2013 and 2015. We compared total treatment costs by fracture management approach. We then estimated the contribution of each component of fracture management to total treatment costs using linear regression.ResultsWe identified 5640 children meeting the inclusion criteria, of which 4602 (81.6%) received closed treatment without manipulation, 922 (16.3%) underwent closed reduction in the clinic, emergency department, or radiology procedure suite, and 116 (2.1%) underwent treatment in the operating room. The median cost for closed treatment without manipulation was $1390 [interquartile range (IQR) 1029 to 1801], compared with $4263 (IQR, 3740 to 4832) for closed reduction and $9389 (IQR, 8272 to 11,119) for closed reduction and percutaneous pinning (P<0.001). In multivariable regression analysis, fracture management approach and use of the operating room environment were the largest cost drivers (P<0.001, R=0.88). Closed reduction in the clinic or emergency department added $894 (95% confidence interval, 819-969) to treatment costs, while closed reduction in the operating room added $5568 (95% confidence interval, 5224-6297). Location of the initial clinical evaluation, number of radiographic imaging series obtained, and number of orthopaedic clinic visits also contributed to total costs.ConclusionsClosed pediatric distal radius fractures treated without manipulation show small variations in treatment costs, making them well suited for bundled payment. Bundled payments for these fractures could reduce costs by encouraging adoption of existing evidence-based practices.Level of evidenceLevel III-therapeutic.

Project description:Instability of the distal radioulnar joint (DRUJ) is a complication that can occur following distal radius fracture or malunion. We have observed that residual radial translation of the distal radius, relative to the radial shaft, may be a causal factor of DRUJ instability, even once the traditional radiographic parameters (volar tilt, radial inclination, and ulnar variance) have been restored. Residual radial translation of the distal fragment may cause detensioning of the distal interosseous membrane (IOM) and pronator quadratus with poor apposition between the ulnar head and sigmoid notch. This may potentially lead to persistent instability of the ulnar head following internal fixation. Residual radial translation deformity is at risk of being overlooked by the wrist surgeon as there is no existing radiographic parameter that accurately measures this deformity.In this study, 100 normal wrist radiographs were reviewed by three fellowship-trained orthopedic surgeons to develop a simple and reproducible technique to measure radial translation.Utilizing the method described, the point of intersection between the ulnar cortex of the shaft of the radius and the lunate left a mean average of 45.48% (range 25–73.68%) of the lunate remaining on the radial side. In the majority of cases more of the lunate resided ulnar to this line. High levels of agreement with inter-rater (intraclass coefficients = 0.967) and intra-rater (intraclass coefficients = 0.79) reliability was observed.The results of this study can be used to define a normal standard against which residual radial translation can be measured to assess the reduction of distal radius fractures. This new parameter aids in the development of surgical techniques to correct residual radial translation deformity. In addition, awareness and correction of this potential malreduction at the time of surgery may decrease the need for other procedures on the ulnar side of the wrist to improve DRUJ stability, such as ulnar styloid fixation, TFCC repair, or ligamentous grafting [corrected].

Project description:IntroductionOptimal management of distal radius fractures in adults remains controversial. Previous evidence and current clinical guidelines tell us that, if a closed reduction of a dorsally displaced fracture is possible, Kirschner wires (K-wires) are the preferred form of surgical fixation. However, the question remains whether there is any need to perform surgical fixation following a successful closed reduction, or is a simple plaster cast as effective? This is the protocol for a randomised controlled trial of manipulation and surgical fixation with K-wires versus manipulation and casting in the treatment of dorsally displaced distal radius fractures.Methods and analysisAdult patients with an acute dorsally displaced fracture of the distal radius are potentially eligible to take part. Prior to surgery, baseline demographic data, radiographs, data on pain/function using the Patient-Rated Wrist Evaluation Score (PRWE) and health-related quality of life (HRQoL) using the EuroQoL 5-dimension 5-level (EQ-5D-5L) will be collected. A randomisation sequence, stratified by centre, intra-articular extension of the fracture and age, will be administered via a secure web-based service. Each patient will be randomly allocated to either 'manipulation and surgical fixation with K-wires' or 'manipulation and plaster casting'. A clinical assessment, radiographs and records of early complications will be recorded at 6 weeks. PRWE and HRQoL outcome data will be collected at 3, 6 and 12 months post-randomisation. Further information will be requested with regard to healthcare resource use and any complications.Ethics and disseminationThe National Research Ethic Committee approved this study on 6 October 2016 (16/SC/0462).The National Institute for Health Research Health Technology Assessment monograph and a manuscript to a peer-reviewed journal will be submitted on completion of the trial. The results of this trial will substantially inform clinical practice on the clinical and cost-effectiveness of the treatment of this injury.Trial registration numberISRCTN11980540; Pre-results.

Project description:ImportanceThe burden of injury and costs of wrist fractures are substantial. Surgical treatment became popular without strong supporting evidence.ObjectiveTo assess whether current surgical treatment for displaced distal radius fractures provided better patient-reported wrist pain and function than nonsurgical treatment in patients 60 years and older.Design, setting, and participantsIn this multicenter randomized clinical trial and parallel observational study, 300 eligible patients were screened from 19 centers in Australia and New Zealand from December 1, 2016, until December 31, 2018. A total of 166 participants were randomized to surgical or nonsurgical treatment and followed up at 3 and 12 months by blinded assessors. Those 134 individuals who declined randomization were included in a parallel observational cohort with the same treatment options and follow-up. The primary analysis was intention to treat; sensitivity analyses included as-treated and per-protocol analyses.InterventionSurgical treatment was open reduction and internal fixation using a volar-locking plate (VLP). Nonsurgical treatment was closed reduction and cast immobilization (CR).Main outcomes and measuresThe primary outcome was the Patient-Rated Wrist Evaluation score at 12 months. Secondary outcomes were Disabilities of Arm, Shoulder, and Hand questionnaire score, health-related quality of life, pain, major complications, patient-reported treatment success, bother with appearance, and therapy use.ResultsIn the 300 study participants (mean [SD] age, 71.2 [7.5] years; 269 [90%] female; 166 [81 VLP and 85 CR] in the randomized clinical trial sample and 134 [32 VLP and 102 CR] in the observational sample), no clinically important between-group difference in 12-month Patient-Rated Wrist Evaluation scores (mean [SD] score of 19.8 [21.1] for VLP and 21.5 [24.3] for CR; mean difference, 1.7 points; 95% CI -5.4 to 8.8) was observed. No clinically important differences were found in quality of life, wrist pain, or bother at 3 and 12 months. No significant difference was found in total complications between groups (12 of 84 [14%] for the CR group vs 6 of 80 [8%] for the VLP group; risk ratio [RR], 0.53; 95% CI, 0.21-1.33). Patient-reported treatment success favored the VLP group at 12 months (very successful or successful: 70 [89%] vs 57 [70%]; RR, 1.26; 95% CI, 1.07-1.48; P = .005). There was greater use of postoperative physical therapy in the VLP group (56 [72%] vs 44 [54%]; RR, 1.32; 95% CI, 1.04-1.69; P = 0.02).Conclusions and relevanceThis randomized clinical trial found no between-group differences in improvement in wrist pain or function at 12 months from VLP fixation over CR for displaced distal radius fractures in older people.Trial registrationhttp://anzctr.org.au identifier: ACTRN12616000969460.

Project description:BACKGROUND:Distal radial fractures are common traumatic injuries, but their management remains controversial also in case of conservative treatment regarding the type of immobilisation. Hence, we conducted a two-arm, parallel-group, prospective randomised trial to compare the capacity of long casts (above-elbow) and short casts (below-elbow) to maintain the reduction of extra-articular distal radius fractures with dorsal displacement (AO/OTA classification: 2R3A2.2). METHODS:Seventy-four eligible patients with AO/OTA 2R3A2.2 fractures treated with closed reduction and cast immobilisation were randomised to the long cast group (n°= 37) or to the short cast group (n°= 37). Baseline radiological parameters, radial inclination (RI), radial height (RH), ulnar variance (UV) and palmar tilt (PT) were taken, and compared with clinical (DASH, Mayo Wrist and Mayo Elbow) and radiological scores taken at 7-10 days, 4 weeks and 12 weeks. Furthermore, to evaluate correlations between radiological parameters and functional outcomes, patients were divided into two groups according to whether or not their radiological parameters at Follow-ups 2 and 3 were acceptable, i.e. within the range 11-12 mm for RH, 16°-28° for RI, - 4-+ 2 mm for UV and 0°-22° for PT. RESULTS:Patient demographic and baseline radiological parameters were similar between groups. At follow-up, there were no statistically significant differences between the two types of cast in terms of RI, RH, UV or PT, or Mayo wrist or DASH scores. Short cast group patients displayed better Mayo elbow score at follow-up 2 (4 weeks), but this difference was no longer statistically significant at follow-up 3 (12 weeks). No statistically significant differences in clinical outcomes were found between patients who presented acceptable radiographic parameters at follow-up and those who did not. CONCLUSION:As there were no significant differences between short casts and long casts in terms of fracture reduction maintenance or clinical outcomes, short casts are an effective method of post-reduction immobilisation in AO/OTA 2R3A2.2 fracture of the radius. Radiological parameters outside the range conventionally considered acceptable do not preclude a satisfactory clinical outcome. TRIAL REGISTRATION:ClinicalTrials.gov PRS, NCT04062110. Registred 20 August 2019.

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Defining displacement thresholds for surgical intervention for distal radius fractures - A Delphi study.

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Defining displacement thresholds for surgical intervention for distal radius fractures - A Delphi study.

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