A common fracture, but research on effective treatments is lacking

Fractures of the distal end of the radius account for nearly one in every six fractures that are treated in emergency departments in the United States. The incidence of these injuries demonstrates two peaks when plotted against age—one in young adults who sustain complex articular fractures after substantial trauma and the other peak in the elderly who have compromised bone quality and experience a trivial fall, leading to a “fragility fracture.”

Since the first description of this injury by Abraham Colles in 1814, many different treatment methods have been used. An abundance of articles can be found in the orthopaedic literature reporting successful treatment of radius fractures with various individual treatment options, but very little evidence exists to support one treatment over another.

Several questions about distal radius fractures remain unanswered, including the following:

• Does the type of cast applied after reduction matter?
• Does surgical treatment offer any advantage over closed treatment techniques, especially in those older than age 55?
• Is any single surgical method superior to the others?
• Is wrist arthroscopy necessary when evaluating intra-articular fractures?
• When should wrist motion be started after treatment? Is routine supervised therapy helpful?

To answer these and other questions, the AAOS has begun developing evidence-based clinical practice guidelines (CPG). The most recent guideline, approved by the AAOS Board of Directors at its December 2009 meeting, addresses issues relating to the evaluation, treatment, and rehabilitation of distal radius fractures (DRF). The full guideline can be found at www.aaos.org/guidelines

Grading the recommendations
Intended for use by orthopaedic surgeons and other qualified practitioners who treat patients with distal radius fractures, the DRF CPG includes 29 specific recommendations addressing treatment options for the fracture itself; management of associated injuries such as nerve injuries, ligament disruptions, and ulnar styloid fractures; postoperative therapy; and complications such as pain syndrome.

The CPG Workgroup graded each recommendation based on the total body of evidence available to support or dispute the intervention. None of the recommendations was graded “strong,” because of a lack of Level I studies that addressed the question raised. Five recommendations were categorized as “moderate” based on supporting Level II or Level III evidence from more than one study with consistent findings, or Level I evidence from a single study recommending for or against the intervention. Seven recommendations were “weak” because the supporting evidence was mainly Level IV or Level V.

Fourteen recommendations were deemed “inconclusive” due to conflicting evidence or lack of supporting evidence to recommend for or against the intervention. The Workgroup created three recommendations by “consensus” when no supporting evidence could be found regarding critical issues of clinical importance. Consensus recommendations were based on the clinical opinion of the group members after due consideration of the known harms and benefits associated with the intervention.

What we know
The following recommendations have adequate evidence to support a moderately strong endorsement:

• We suggest rigid immobilization in preference to removable splints when using nonoperative treatment for the management of displaced distal radius fractures.
• We suggest that all patients with distal radius fractures receive a postreduction true lateral X-ray of the carpus to assess distal radial ulnar joint alignment.
• We suggest operative fixation as opposed to cast fixation for fractures with postreduction radial shortening greater than 3 mm, dorsal tilt greater than 10 degrees, or intra-articular displacement or step-off greater than 2 mm.
• We suggest that patients do not need to begin early wrist motion routinely following stable fracture fixation.
• We suggest adjuvant treatment of distal radius fractures with vitamin C for the prevention of disproportionate pain.

The available evidence does not allow for recommendation of any one specific surgical method over another. The guidelines also cannot recommend for or against casting as the definitive treatment after initial adequate reduction.

A call for research
The overall lack of strong recommendations reflects the need for more research into treatment of this common injury. The members of this Workgroup felt that authors should limit bias in treatment options by proper randomization and adequate blinding of investigators, patients, and/or evaluators wherever possible.

Future studies should also include a priori power analyses to ensure that the clinically important improvements measured are the ones that matter to patients rather than rely on radiographic outcomes alone. These studies should utilize validated patient-oriented outcome measures that are anatomic region specific (Disabilities of the Arm, Shoulder, and Hand), disease specific (Patient-Rated Wrist Evaluation), and, if possible, general health specific (Short Form-36).

The guidelines section on “Future Research” outlines current limitations and possible areas for further study. These include prospective randomized clinical studies examining the following key issues:

• Surgical treatment versus nonsurgical treatment, separating articular and nonarticular fractures, and separating older, infirm, low-demand patients from younger, active patients
• Surgical treatment versus nonsurgical treatment to determine the preferable treatment of elderly and sedentary patients with displaced fractures
• Effectiveness of various forms of surgical treatment, separating articular and nonarticular fractures, and separating older, low-demand patients from younger ones
• Effect of nonsurgical adjuvant modalities such as vitamins and minerals (such as vitamin C or calcium), physical therapy, and mechanical adjuvants such as bone stimulators
• Surgical or expectant treatment of concomitant median or ulnar neuropathy
• The effect of adjuvant bone grafts or substitutes with concurrent surgical fixation

A summary of the recommendations can be found on the AAOS Web site. The Workgroup strongly recommends that practitioners not rely solely on the summary, but that they also consult the full guideline and evidence report. Treatment decisions for an individual patient depend on all of the circumstances presented by that patient and mutual communication between the patient and the treating practitioner.

Randy R. Bindra, MD, FRCS, served as the vice-chair of the CPG DRF Workgroup.

View Table 1

Guideline development
The Clinical Practice Guideline for the Treatment of Distal Radius Fractures, adopted by the AAOS Board of Directors at their December 2009 meeting, was developed by a volunteer workgroup that included David M. Lichtman, MD, chair; Randipsingh R. Bindra, MD, FRCS, vice-chair; Martin I. Boyer, MD; Matthew D. Putnam, MD; David C. Ring, MD, PhD; Joseph F. Slade III, MD; David Joseph Slutsky, MD; John S. Taras, MD; William C. Watters III, MD, chair, Guidelines and Technology Oversight Committee (GTOC); Michael J. Goldberg, MD, vice-chair, Michael W. Keith, MD, chair, Evidence-Based Practice Committee; Robert H. Haralson III, MD, MBA; Charles M. Turkelson, PhD, AAOS director of research and scientific affairs; and Janet L. Wies, MPH, AAOS clinical practice guideline manager.

Funding was provided by the AAOS. The guideline is based on a systematic review of the current scientific and clinical information on accepted approaches to treatment and/or diagnosis. The entire process included a review panel of internal and external committees, public commentaries, and final approval by the AAOS Board of Directors.

The methods used to prepare the guideline were rigorous, employed to minimize bias and to develop a set of reliable, transparent, and accurate clinical recommendations for treating distal radius fractures. These methods are detailed in the full guideline.