Dr. Cooney: What does the new evidence-based clinical practice guideline tell you and how will it affect or change your treatment of distal radius fractures?
Dr. Gelberman: It tells me that if you are looking for evidence on which to base management of distal radius fractures, you are not going to find many credible studies. Even procedures that we commonly perform aren’t supported by the evidence. This effort has informed us that much of our current treatment is based on experience, that we haven’t performed the rigorous clinical assessments necessary to confirm our management decisions. Although I believe we have some effective techniques for treating fractures of the distal radius, the current literature doesn’t support them with Level I or Level II evidence.
As a result, the guideline probably won’t change my treatment methods, aside from making me aware that the evidence for much of what we do just isn’t there.
Dr. Benson: I think that doctors tend to treat patients based on their personal experiences and opinions. When you make an effort to find objective, scientifically sound evidence, it’s amazing how little exists. This guideline is an effort to improve that situation, but until we have more support to back many of our commonly accepted ideas, I don’t think it’s going to change my practice.
Dr. Gelberman: It’s very difficult to conduct prospective randomized clinical trials in a surgical discipline. Although better studies have been conducted in recent years, we’re still a long way from practicing evidenced-based orthopaedic surgery.
Dr. Cooney: What should we tell residents and fellows about treating unstable distal radius fractures?
Dr. Weiland: Not all fractures of the distal radius have to be treated with open reduction and internal fixation. Maybe 10 percent to 15 percent of cases seen in emergency departments can be casted if we follow them weekly to ensure there is no displacement. Cast treatment still has a role.
Dr. Gelberman: A 60-year-old patient who undergoes closed reduction has a 50 percent chance of losing that reduction at day 0. According to a 2004 study, if satisfactory position is maintained for 1 week, the chance of losing the reduction decreases to 25 percent. At 2 weeks, the chances of losing the reduction are small. Therefore, taking weekly radiographs for 2 or 3 weeks following closed reduction is mandatory.
Dr. Cooney: If the patient loses reduction, what are the next steps?
Dr. Gelberman: In most cases, efforts to regain and maintain satisfactory alignment are warranted. Patients of an advanced age with low activity levels, however, may tolerate deformity of the distal radius well.
Dr. Benson: I think it’s appropriate to be a bit more aggressive in the younger age populations, because they are going to put a lot more miles on that wrist. With some elderly patients, it’s difficult to predict how much of a reduction loss is going to produce symptoms and they may have less functional demand. You need to know about the patient’s personality, lifestyle, and preferences and to engage the patient to help you make a decision. This is, for me, the most difficult element. As much as we try to create some guidelines, a lot of the evidence isn’t really there, and no matter how good a guideline you create, you can’t remove that element of judgment.
Dr. Weiland: I don’t distinguish between older and younger patients; I essentially treat both of them the same. If the patient has a fracture with significant deformity, I don’t hesitate to recommend outpatient surgery with a regional anesthetic. It wasn’t that way 10 or 15 years ago, but locking plates and regional anesthesia make it possible now.
Dr. Cooney: With the healthcare reform debate and the lack of evidence-based Level I and II studies, can we justify operative treatment in the elderly patient?
Dr. Cooney: If we agree that plate fixation is the wave of the future, what are your thoughts about dorsal versus locking plate fixation?
Dr. Weiland: I use the dorsal plate for the very distal dorsal marginal fractures but with the advent of locking plates, dorsal plates will not be used as frequently as in the past.
Dr. Benson: I pretty much agree; the number of times that I’ve approached the fracture dorsally has diminished dramatically. Occasionally fractures that involve the dorsal medial corner of the distal radius are hard to approach from the palmer side; if that contributes to distal radius joint instability or wrist subluxation, I may use a plate to hold that marginal cortical fracture fragment. But 90 percent of the time, that isn’t necessary.
Dr. Cooney: Is there any role for closed reduction and external fixation or percutaneous pin fixation?
Dr. Weiland: I don’t use external fixation very often; it’s a hassle to the patient with respect to pin care and the reductions aren’t as good as we get with volar locking plates. Although percutaneous pin fixation is cost effective, if you reduce the fracture anatomically, no matter what method you use, the results are pretty much going to be the same. But patient demand for early return of function makes me favor open reduction and internal fixation.
Dr. Cooney: In the past, bone grafting—both allografts and autografts—has been recommended for distal radial fractures with dorsal communition and instability. Do you commonly use bone grafts, and if so, what are the indications?
Dr. Benson: I use bone grafts occasionally. I think the indications would include specific situations such as the presence of a large metaphyseal void or a severe dorsal communition where the fracture would have a tendency to subside and reassume dorsal angulation or tilt of the distal radius. For a standard distal radius fracture, I don’t automatically use bone grafts.
Dr. Gelberman: The AAOS distal radius fracture guideline is inconclusive on using bone grafts or bone graft substitutes. I use bone grafts for malunions or nonunions—the indications are specific.
Dr. Cooney: Let’s talk a bit about complications, beginning with the most common—median neuropathy. What are your indications for operative release of carpal tunnel with median neuropathy associated with distal radius fractures and what do the AAOS guidelines tell us?
Dr. Benson: Occasionally I have a patient with a distal radius fracture whom I know has had trouble with the carpal tunnel, which might be a consideration to release the carpal tunnel at the same time. I typically do not do that unless the patient has some unusual distal radius fracture pattern that puts the median nerve at risk. If median nerve symptoms are the primary complaint or if the patient had a high-energy injury that includes median neuropathy, I think carefully about doing a carpal tunnel release at the time of surgery, but that might be 5 percent to 8 percent of my distal radius fracture cases. The AAOS guidelines, however, do not provide specific guidance in decision making related to median nerve symptoms and reasons for surgical intervention.
Dr. Gelberman: One absolute indication for carpal tunnel release is loss of sensibility as detected by increased 2-point discrimination. Although direct measurement of interstitial pressure is generally useful, I’d proceed directly with carpal tunnel release at 72 hours.
Dr. Weiland: I agree that if carpal tunnel syndrome develops 72 hours after injury or following surgery and sensibility is decreasing, carpal tunnel release is needed. The downside of not releasing it is that a complex regional pain syndrome (CRPS) will develop, the hand will swell, pain will increase, and the patient will need an additional 3 to 6 months of rehabilitation.
Dr. Cooney: One of the fracture treatment guidelines at the moderate level was the use of vitamin C to prevent CRPS. What are your thoughts on that?
Dr. Benson: I think that it’s important to consider pain dystrophy early and take a multifactorial approach. I will see the patient more in the office to measure progress, get the patient involved with the occupational therapist, try and get the patient moving, reduce the swelling, and perhaps involve an anesthesiologist or pain clinic person. The key is to recognize it early to prevent both physical and psychological issues.
Dr. Weiland: When I used an external fixation device, I really didn’t see any significant amount of complex regional pain syndrome, partly because we sent all those patients to therapy right away and got them moving. I wasn’t really aware that vitamin C was effective.
Dr. Benson: Can I mention one thing? I think that if we effectively treat the median nerve, we can virtually eliminate CRPS. I don’t have a specific approach to managing the patient with pain, stiffness, and swelling associated with CRPS. I assess the median nerve, and if I find evidence of carpal tunnel syndrome, then I just release it.
Dr. Cooney: Let’s talk about physical therapy. Is physical therapy routinely necessary—or can we let patients mobilize on their own?
Dr. Gelberman: If the reduction is stable, a custom splint can be applied at a week or 10 days and the patient proceeds with active motion rehabilitation. Typically, I have a therapist meet with the patient once or twice; I then monitor progress and use more therapy as needed on a case-by-case basis.
Dr. Benson: I generally have the patient see the therapist one time between days 3 and 7. At least half the patients in my practice will see the therapist once or twice a week for 2 to 4 weeks. The supervision encourages them to keep going, but it’s a rare situation for a patient to need therapy for more than a month. I think that the patients can actually proceed pretty much on their own; therapy focuses on getting them to be less anxious and to encourage movement.
Dr. Cooney: What about a distal radius fracture in a woman older than age 75? Do you think that the underlying osteoporosis might represent a pathologic type of fracture that requires treatment of the underlying disease?
Dr. Weiland: I think most women older than age 40 are going to have some degree of osteoporosis. We send these patients to our osteoporosis clinic for treatment, but unfortunately many don’t follow up and neither do their treating physicians or private medical doctors, so I think this remains a problem.
Dr. Gelberman: Because I practice at Washington University, I send them to our bone and mineral disease clinic for assessment and treatment. I neither undertake nor supervise treatment myself.
Dr. Cooney: In closing, let’s return to the guidelines. What advice would you provide to readers regarding evidence-based studies as we try to judge what the best treatment of distal radius fractures would be?
Dr. Weiland: I think it’s a wake-up call that we can do better. The studies conducted when we were in training were largely retrospective case reviews and not sufficient for determining whether or not any specific treatment works. I think the challenge is to take this on and provide evidence for our management. The fundamental problem, however, is the issue of randomized operative trials and potential litigation. If I am going to treat distal radial fractures with external fixation or a dorsal plate, will I be open to possible litigation if the patients who receive one treatment don’t do as well as those who receive the other?
Dr. Benson: I think the Academy is making a good attempt to create practice guidelines. I think that, to some degree, it is incumbent on those of us in practice to help contribute to the data.
Dr. Gelberman: I agree. It is telling that, given this body of work—which I think is very well presented—it hasn’t influenced our opinions regarding treatment. We are still relying on our expert judgment, our own personal experience, and the evidence that we do have. We have been unable, at the present time, to accrue the Level I and Level II studies necessary to answer these questions.
Editor’s Note: The latest clinical practice guidelines focus on the treatment of distal radial fractures (see “New AAOS guideline addresses distal radial fractures.”). Because so little Level I evidence exists, AAOS Now assembled a distinguished panel of surgeons of the upper extremity—including William B. Cooney III, MD (moderator); Richard H. Gelberman, MD; Andrew J. Weiland, MD; and Leon S. Benson, MD—to discuss specific treatment questions.
AAOS Guideline on Treatment of Distal Radial Fractures
Nesbitt KS, Failla JM, Les C: Assessment of instability factors in adult distal radius fractures. J Hand Surg Am 2004;Nov;29(6):1128-1138.
Grewal R, MacDermid JC: The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients. J Hand Surg Am 2007;Sep;32(7):962-970.