Distal radius fractures are common orthopaedic injuries, accounting for about one in six fractures seen in the emergency department (ED). Treatment is based on the type of fracture, and is often tailored to the individual patient’s needs and lifestyle. As a result, there is no general consensus that supports one treatment over another.

During a combined Specialty Day session of the Orthopaedic Trauma Association and the American Society for Surgery of the Hand (OTA/ASSH), Andrew Jawa, MD, of Boston University Medical Center and the New England Baptist Hospital, and Eric P. Hofmeister, MD, of Naval Medical Center San Diego, debated whether or not angulated distal radius fractures should be treated with reduction and casting in the ED or with a splint.

Reduce and cast
According to Dr. Jawa, treating angulated distal radius fractures—excluding open, high-energy, multitrauma, and volar shear fractures—with closed reduction and casting in the ED can be very effective. “We know it can work, we’ve all seen it, and the literature supports it,” he said.

The initial reduction determines treatment, Dr. Jawa pointed out. “If the reduction is unacceptable, the surgeon can move the patient to surgery quicker. This can be especially beneficial for older patients with medical issues. If the reduction is acceptable, the loss of reduction can quickly be determined, enabling the surgeon to provide the patient with a clear treatment plan.”

Dr. Jawa added that earlier reductions are easier to perform. Hematoma blocks are more effective when the fracture is fresh, and callus develops quickly. “Ultimately, delay may lead to unnecessary surgery,” he said.

Earlier reduction also makes sense logistically for both patients and surgeons, Dr. Jawa said. Many patients, especially the elderly, have difficulty making and keeping follow-up appointments. “Surgeons should reduce the fracture in the ED and give patients the opportunity to be casted there. From the surgeon’s standpoint, most orthopaedic offices don’t have the necessary resources—they are not set up for finger traps or casting. Good reductions also take time,” he said.

Importantly, he added, early reduction reduces the risk of development of acute carpal tunnel syndrome that can be associated with distal radius fractures.

“Ultimately, I ask myself, ‘What if my mother was across the country and broke her wrist? Would I advise her to have it reduced in the ED?’ Yes, I would,” Dr. Jawa said. “Then, when she returned home, we could see how effective the reduction was and whether any other treatment was needed.”

Splint for comfort
Dr. Hofmeister argued against reducing angulated distal radius fractures in favor of splinting. He explained that in addition to being time-consuming, invasive, and expensive, reduction provides no clinical benefit in many cases.

“Many European countries neither reduce nor operate on these fractures, and many studies show no functional benefit to reduction,” Dr. Hofmeister said.

He cited two studies that evaluated nonsurgical versus surgical treatment of distal radius fractures in elderly patients. “Both concluded that anatomic reduction appears to have no effect on range of motion or subjective or objective function in patients aged 65 years or older,” he said.

Dr. Hofmeister also pointed out that, in some cases, reduction can actually lead to worse outcomes. He gave the example of a 65-year-old man with a 35-degree dorsally angulated distal radius fracture. The patient reported to the ED the morning after the injury and waited 7 hours to be treated with closed reduction and a bivalved cast, obtaining neutral angulation.

“At 10-day follow-up, the fracture was 10 degrees dorsally angulated. At 4 weeks follow-up, dorsal angulation was 35 degrees. So, with this invasive procedure, the patient was back to where he started from a month earlier,” Dr. Hofmeister said.

He concluded, “In my opinion, there is little evidence—especially in the elderly population—to support reduction of distal radius fractures. In most cases, we are lacking good evidence to prove this is helpful in the management of these fractures.”

Disclosure information: Drs. Jawa and Hofmeister report no conflicts.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

References

1. Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M: A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am 2011;93(23):2146-2153.
2. Egol, KA, Walsh M, Romo-Cardoso S, Dorsky S, Paksima N: Distal radial fractures in the elderly: Operative compared with nonoperative treatment. J Bone Joint Surg Am 2010;92(9):1851-1857.