Distal radius fractures (DRFs) are among the most common injuries in orthopaedic practice and account for up to 20 percent of the fractures treated in the emergency department (ED). In tertiary care centers and academic institutions, the first provider to see a patient after an emergency physician’s evaluation is usually not an orthopaedic surgery attending. It can be a physician’s assistant (PA), a nurse practitioner, a resident, or an ED attending. Although these providers are more than capable of temporarily stabilizing such injuries in the acute setting, they do not usually decide definitive treatment. Thus, the resident or PA who saw the patient in the ED often is not equipped to participate in shared decision-making with the patient. The decision to advance to surgery depends on many factors, such as the type of fracture, patient age, fracture displacement at two-week follow-up, the orthopaedic attending’s practice norms, and the patient’s preferences.

The incidence of DRFs has been on the rise, and presentation of the injury has become more heterogeneous. In the past, DRFs could be broadly classified into high-energy injuries in young adults and low-energy injuries in elderly patients with osteoporosis. This classification has become outdated and no longer applies to current patient populations because older adults strive to remain more active, childhood obesity is on the rise, more women work in urban areas, and other lifestyle and cultural changes have increased the incidence of DRFs in all age groups. These factors have greatly complicated the treatment paradigm, making DRFs difficult to triage for orthopaedic surgery residents and other advanced practice providers in the ED.

In 2013, AAOS developed appropriate use criteria (AUC) for DRFs to help orthopaedic providers determine treatment of specific distal radius injury patterns. The criteria were developed with a combination of the best available evidence and clinical expertise. The AAOS AUC for DRFs are a valuable tool that can greatly simplify residents’ decision-making process in the ED and improve patient satisfaction. The AUC can be used to guide patient counseling after DRF reduction and prevent miscommunication regarding the treatment plan—whether surgical or nonsurgical.

AUC simplify decision-making

I have encountered many DRFs as an orthopaedic resident while on trauma call and have found that no two DRFs are identical. Although a displaced DRF should be reduced as quickly as clinically possible, certain challenges do arise.

The biggest challenge I have encountered is weighing the risks and benefits of performing multiple reduction attempts to achieve anatomic alignment. Although it is important to achieve good reduction, multiple attempts to do so can put elderly patients at risk for skin tears and put pediatric patients at risk of acute compartment syndrome due to repeated soft-tissue injury. Although acute compartment syndrome is a rare complication of DRFs, it has been shown to occur in greater than 1 percent of all DRFs. It has been noted in cases after closed reduction and cast immobilization.

For example, Fig. 1 shows radiographic images of a 26-year-old female who presented to the ED as a Level II trauma status following a motor vehicle collision. Based on the history and imaging, it was obvious that she sustained a high-energy DRF. I entered the fracture pattern (AO type C3), energy mechanism, patient’s activity level, and associated injuries on the AAOS AUC website (www.aaos.org/auc). Based on the DRF AUC recommendations, I determined that regardless of anatomic reduction, the patient likely needed surgical fixation.

Courtesy of Sravya Vajapey, MD

This guided my approach to reduction to improve fracture alignment and provide pain relief with as little soft-tissue injury as possible. Based on the guidelines, it was likely the patient would not benefit from multiple, aggressive reduction attempts in the quest to achieve perfect anatomic alignment. It would not have reduced the need for surgical stabilization, and it could have increased her risk of skin compromise, swelling, fracture blisters, and other complications. So the DRF AUC was helpful in formulating the treatment plan for this complex injury; the patient received a provisional reduction for comfort and then surgical fixation and did well postoperatively. Fig. 2 shows the patient’s radiographs after reduction.

Courtesy of Sravya Vajapey, MD

AUC guide patient counseling, prevent miscommunication, and improve satisfaction

The most common question patients ask after DRF reduction is, “Will I need surgery?” The answer is challenging, because no one can guarantee that a reduced fracture will not displace at two weeks and require surgery. However, using the AUC, orthopaedic providers can share with their patients some reliable information on the probability of that happening.

Fig. 3 shows a wrist radiograph of a 93-year-old female who presented to the ED after falling onto her outstretched arm. From the clinical examination and imaging, it was evident that she had a low-energy injury and sustained an AO type A3 fracture. After entering the patient information onto the AUC website, I found at least seven articles in the literature (Level I or II evidence) suggesting this fracture pattern could be treated definitively and achieve a good outcome with reduction and immobilization. I therefore counseled the patient that if anatomic reduction were achieved, she would likely not need surgery. Even if it took multiple attempts, I asked the patient to bear with me as I tried to achieve anatomic reduction to avoid surgery. She complied happily and was not upset when I attempted reduction a second time to get better alignment, because she understood that a well-reduced fracture could improve her outcomes. In this case, patient counseling prior to treatment greatly increased the patient’s satisfaction while improving the shared decision-making process. AUC can help providers set expectations for patients in the acute setting and counsel them regarding definitive treatment.

Courtesy of Sravya Vajapey, MD

Experienced orthopaedic surgeons often have a gut feeling on how to engage patients in healthcare decisions (see sidebar). Other providers and those in training often can benefit from this additional tool when discussing potential outcomes with patients. Increased awareness about the utility of AUC for residents and advanced practice providers has great potential to prevent miscommunication with patients and streamline the triage and treatment process.

Pediatric hand surgeon shares perspective on AUC

As an attending surgeon, it is a privilege to work with talented residents. The ones I enjoy working with the most are the residents who are aware of the multiple clinical practice guidelines and AUC available online. I’ve found that the residents and advanced practice providers who use them in their decision-making greatly improve not only patient care but also patient satisfaction.

I think we, as educators, could do a better job of directing our trainees to these wonderful resources and provide positive feedback whenever they are utilized.
—Julie Balch Samora, MD, PhD

Sravya Vajapey, MD, is an orthopaedic surgery resident at The Ohio State University and a member of the Gold Humanism Honor Society. She also is concurrently pursuing an MBA from Fisher College of Business. She can be reached at sravya.vajapey@osumc.edu.

References

1. Nellans KW, Kowalski E, Chung KC: The epidemiology of distal radius fractures. Hand Clin. 2012;28:113-25.
2. Oren TW, Wolf JM: Soft-tissue complications associated with distal radius fractures. Operative Techniques in Orthopaedics. 2009;19(2):100-6. Available at https://www.sciencedirect.com/science/article/pii/S1048666609000834​.
3. American Academy of Orthopaedic Surgeons: Appropriate use criteria for treatment of distal radius fractures. 2013. Available at https://www.aaos.org/research/Appropriate_Use/DRF_AUC.pdf.
4. Meena S, Sharma Pankaj, Sambharia AK, et al: Fractures of distal radius: an overview. J Family Med Prim Care. 2014;3:325-32.
5. Jerrhag D, Englund M, Karlsson MK, et al: Epidemiology and time trends of distal forearm fractures in adults—a study of 11.2 million person-years in Sweden. BMC Musculoskelet Disord. 2017;18:240.