“Appropriate” Management of Distal Radial Fractures Improves Outcomes, Lowers Cost
Many surgeons realize that to improve value, we must improve the quality of care while decreasing its cost. Clinical Practice Guidelines (CPGs) developed by the AAOS and other medical societies are designed to help improve the quality of care and safety for patients, while also reducing inappropriate care and decreasing cost. Unfortunately, the evidence used for the development of CPGs is often of mixed quality. It is therefore crucial that studies evaluate patient outcomes when clinicians do and do not adhere to CPGs, so we can ensure that the guidelines are achieving their objective of improving care.
In the October 16, 2019 issue of The Journal of Bone and Joint Surgery, Giladi et al. hypothesize that adhering to Recommendation 3 of the AAOS CPG regarding radiographic indications for operative management of distal radial fractures would yield improved patient outcomes and cost benefits. Recommendation 3 of the CPG suggests that fractures with post-reduction radial shortening of >3 mm, dorsal tilt of >10°, or intra-articular displacement or step-off of >2 mm should be operatively treated. The authors retrospectively reviewed 266 patients, 145 of whom were treated operatively and 121 of whom were treated nonoperatively. Based on the guideline recommendation, only 6 patients were determined to have undergone inappropriate operative fixation, but 68 patients in the nonoperative cohort received inappropriate treatment; many of those had higher-grade fractures that, per the guideline, should have been surgically treated.
Using QuickDASH outcome scores at 4 time points up to 1 year and 1-year direct cost data, the authors compared the appropriately treated operative cohort to both the appropriate and inappropriate nonoperative groups. They also compared the appropriate and inappropriate nonoperative groups to each other. QuickDASH outcomes for appropriate nonoperative treatment were better than those for inappropriate nonoperative treatment at 1 year. In addition, inappropriate nonoperative treatment cost 60% more than appropriate nonoperative treatment. Although this cost comparison did not reach statistical significance, (p=0.23), it does suggest a cost savings with adherence to the CPGs. Appropriately treated operative patients reported less disability than the inappropriately nonoperative group.
As we continue to work at increasing health-care value, it is critical that we review CPGs in action, as Giladi et al. have done in this study. A potential next step would be to investigate whether the modest improvements in QuickDASH scores noted between appropriate operative treatment and inappropriate nonoperative treatment justify the 6-fold higher cost of operative treatment.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Plate–Tendon Contact: How Important Is It?
There are few things more discouraging for an orthopaedic surgeon than a late postoperative complication after what was an otherwise successful surgery. One such scenario occurs when patients who have undergone open reduction/internal fixation (ORIF) for a distal radial fracture subsequently experience a flexor pollicis longus (FPL) tendon rupture. While previous literature has suggested that plate positioning plays a role in that complication, no studies have evaluated whether newer plate designs decrease contact with the FPL tendon and therefore reduce the risk of rupture.
With that question in mind, Stepan et al. evaluated two cohorts of patients who had undergone ORIF for a distal radial fracture. In the September 4, 2019 issue of JBJS, they report on findings from 40 patients, 20 of whom received a standard distal radial volar locking plate, and 20 of whom received a plate designed with a distal cutout to afford the FPL more room to traverse.
Ultrasound analysis revealed that similar percentages of patients in each group had FPL–plate contact (65% in the FPL-plate group and 79% in the standard-plate group), and there were no differences between groups in terms of FPL tendon degeneration as seen on ultrasound. However, patients who received the FPL plate had significantly less of the tendon come in contact with the plate at 0° and 45° of wrist extension. The authors noted, however, that this difference may have been influenced by the fact that patients with the FPL-specific plate also had significantly lower volar tilt than patients with the standard locking plate. It is therefore not possible to determine whether it was the plate design or the bone position (or both) that led to these results.
It is also noteworthy that the two senior authors of this study work as consultants for the company that manufactures the plates that were evaluated. It is also important to note that because all the patients in this study were asymptomatic, further research is needed to determine the clinical importance of reduced tendon–plate contact area. We should temper our excitement about specially designed volar plates until we have more clinical data supporting their success in avoiding the problem for which they were designed.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
How Many X-Rays Does It Take to Treat a Distal Radial Fracture?
We orthopaedists obtain radiographs for many reasons—to diagnose an unknown problem, to determine the progress of healing, and occasionally because we follow X-ray “dogma” acquired over time. That last reason prompted van Gerven et al. to undertake a multicenter, prospective, randomized controlled trial, the findings of which appear in the August 7, 2019 issue of The Journal.
The authors set out to evaluate the clinical utility of radiographs taken after a distal radial fracture in >300 patients. Some of those fractures were treated nonoperatively, while others underwent operative fixation. Surgeons of the patients randomized to the “usual-care” pathway were instructed to obtain radiographs at 1, 2, 6, and 12 weeks following the injury/surgery. Surgeons of patients in the “reduced-imaging” arm did not obtain radiographs beyond 2 weeks after the injury/surgery unless there was a specific clinical reason for doing so.
The authors found no significant differences between groups in any of the 6 patient-reported outcomes measured in the study, including the DASH score. Furthermore, the complication rates were almost identical between the usual-care (11.4%) and reduced-imaging (11.3%) groups. Not surprisingly, patients in the reduced-imaging group had fewer radiographs obtained (median 3 vs 4) and were exposed to a lower overall dose of ionizing radiation than those in the usual-care group.
Probably because the study was conducted in the Netherlands, it did not address the widespread practice of “defensive medicine” in the US—the unnecessary overuse of medical tests and procedures to reduce the risk of a malpractice claim. While that may limit the external validity of these findings among orthopaedists in the United States, this relatively simple yet well-designed study should remind us that it is important to have a definite clinical purpose when ordering a test of any type. A picture may be worth a thousand words, but sometimes it takes only 2 pictures to tell the full story of a healing distal radial fracture.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
New Minute-Commentary Video
See what JBJS Deputy Editor for Social Media Chad Krueger, MD thinks about the just-published Level-I trial comparing nonoperative treatment to volar locking plate fixation among 140 elderly patients with dorsally displaced distal radial fractures.
What’s New in Hand Surgery 2019
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in one of 13 subspecialties. Click here for a collection of all OrthoBuzz subspecialty summaries.
This month, Christopher J. Dy, MD, MPH, author of the March 20, 2019 “What’s New in Hand Surgery,” selected the five most compelling findings from among the 47 noteworthy studies summarized in the article.
Distal Radial Fractures
—A randomized trial comparing volar plate fixation to cast management in patients >60 years of age who had AO type-C distal radial fractures1 found that the volar plating group had better Patient-Rated Wrist Evaluation scores than the casting group after a minimum 24 months of follow-up. Maintenance of reduction was also better in the volar plating group. These findings are contrary to those of a similar randomized trial published in 2011, suggesting that there are patient-level and surgeon-level differences between the 2 environments in which the studies were conducted.
—Among 175 elderly patients with distal radial fractures treated nonoperatively and who showed acceptable radiographic reduction at 1 to 2 weeks, 28% had late displacement or malunion at the 3-month follow-up.2 Relative to cases in which reduction was maintained, cases with late displacement or malunion had lower grip strength and loss of the total wrist range of motion. However, there was no between-group difference in patient-reported functional measures, and the incidence of the most common complication—carpal tunnel syndrome—was the same in both groups.
Scaphoid Fractures
—Findings from a biomechanical study with cadavers suggest that 50% cortical healing of a scaphoid fracture after open reduction and internal fixation with a compression screw is sufficient to allow unrestricted activity.3 Constructs with a 50% osteotomy and compression screw showed the same load to failure as intact scaphoids, but load to failure in a group with a 75% osteotomy and compression screw was lower than that in the intact scaphoid group.
—Traditionally, surgeons have emphasized proximal pole vascularity in cases of scaphoid nonunion. However, a study of 35 scaphoid nonunions treated with nonvascularized bone grafting and a headless compression screw4 found that 33 fractures went on to union, despite evidence of compromised proximal pole vascularity in 14 of 32 patients who had histopathological data available.
Carpal Tunnel Syndrome
—A cross-sectional study analyzing data from 367 patients who presented for evaluation of carpal tunnel syndrome (CTS)5 found that those with the poorest socioeconomic status had worse PROMIS scores for physical function, pain interference, depression, and anxiety, compared with those in the least-deprived quartile. Deprived patients were also more likely to have a higher comorbidity burden and to use tobacco, both of which may influence outcomes after CTS treatment.
References
- Martinez-Mendez D, Lizaur-Utrilla A, de-Juan-Herrero J. Intra-articular distal radius fractures in elderly patients: a randomized prospective study of casting versus volar plating. J Hand Surg Eur Vol.2018 Feb;43(2):142-7. Epub 2017 Sep 4
- Wadsten MÅ, Sjödén GO, Buttazzoni GG, Buttazzoni C, Englund E, Sayed-Noor AS. The influence of late displacement in distal radius fractures on function, grip strength, range of motion and quality of life. J Hand Surg Eur Vol.2018 Feb;43(2):131-6. Epub 2017 Jul 31.
- Guss MS, Mitgang JT, Sapienza A. Scaphoid healing required for unrestricted activity: a biomechanical cadaver model. J Hand Surg Am.2018 Feb;43(2):134-8. Epub 2017 Nov 7.
- Rancy SK, Swanstrom MM, DiCarlo EF, Sneag DB, Lee SK, Wolfe SW; Scaphoid Nonunion Consortium. Success of scaphoid nonunion surgery is independent of proximal pole vascularity. J Hand Surg Eur Vol.2018 Jan;43(1):32-40. Epub 2017 Sep 24.
- Wright MA, Beleckas CM, Calfee RP. Mental and physical health disparities in patients with carpal tunnel syndrome living with high levels of social deprivation. J Hand Surg Am.2018 Jun 23. [Epub ahead of print].
What’s New in Pediatric Orthopaedics 2019
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in one of 13 subspecialties. Click here for a collection of all OrthoBuzz subspecialty summaries.
This month, Kelly L. VanderHave, MD, co-author of the February 20, 2019 “What’s New in Pediatric Orthopaedics,” selected the five most compelling findings from among the more than 50 noteworthy studies summarized in the article.
Pediatric Trauma
—A before-and-after comparison found that, after implementation of a dedicated, weekday operating room reserved for pediatric trauma, length of stay for 5 common pediatric orthopaedic fractures was reduced by >5 hours. In addition, cost was reduced by about $1,200 per patient; complication rates improved slightly; frequency of after-hours surgery decreased by 48%; and wait times for surgery were significantly reduced.
—Forty-two patients with a distal radial buckle fracture received a removable wrist brace during an initial clinic visit, along with instructions to wear it for 3 to 4 weeks. No follow-up was scheduled, but the family was contacted at 1 week and at 5 to 10 months following treatment. No complications or refractures occurred; 100% of respondents said they would select the same treatment.1
Pediatric Sports Medicine
—Among a continuous cohort of 85 patients (mean age 13.9 years) who underwent primary ACL reconstruction (77% with open physes at time of surgery) and who were followed for a minimum of 2 years, overall prevalence of a second ACL surgery was 32%, including 16 ACL graft ruptures and 11 contralateral ACL tears. A slower return to sport was found to be protective against a second ACL injury.
Infection and Scoliosis Surgery
—A preliminary study of 36 pediatric patients who underwent a total of 191 procedures for early-onset scoliosis found that the use of vancomycin powder during closure significantly decreased the rate of surgical site infection (13.8% per procedure in the control group versus 4.8% per procedure in the vancomycin group).
Clubfoot
—A retrospective review of >1,100 clubfeet that were presumed to be idiopathic upon presentation found that the condition in 112 feet (8.9%) was later determined to be associated with neurological, syndromic, chromosomal, or spinal abnormalities—and therefore nonidiopathic.2 The nonidiopathic group was less likely to have a good result at the 2- and 5-year follow-up, and more likely to require surgery. The authors conclude, however, that surgery is avoidable for most patients with nonidiopathic clubfoot.
References
- Kuba MHM, Izuka BH. One brace: one visit: treatment of pediatric distal radius fractures with a removable wrist brace and no follow-up visit. J Pediatr Orthop.2018 Jul;38(6):e338-42.
- Richards BS, Faulks S. Clubfoot infants initially thought to be idiopathic, but later found not to be. How do they do with nonoperative treatment?J Pediatr Orthop. 2017 Apr 10. [Epub ahead of print].
Immobilization after Fixation of Distal Radial Fractures
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew Herring, MD, in response to a recent study in JBJS.
Postoperative immobilization after internal fixation of fractures is common practice. However, immobilization after locked volar plate fixation of distal radial fractures may actually thwart our patients’ rehabilitation—at least in the short term. So suggest the findings from Watson et al. in the July 5, 2018 issue of JBJS.
The authors randomized 133 patients who underwent locked volar plate fixation of distal radial fractures to 1, 3, or 6 weeks of postoperative immobilization. All patients were placed into volar splints postoperatively. After 1 week, splints were removed entirely or converted to short-arm circumferential casts based on the patient’s allocation. All patients started physical therapy within 3 days of definitive splint or cast removal.
Outcomes were evaluated at 6, 12, and 26 weeks and included patient-reported measures (PRWE, VAS pain scores, and DASH), active wrist range of motion, and postoperative complications. Six weeks following surgery, the results favored 1 or 3 weeks of immobilization over 6 weeks of casting in terms of improved patient-reported outcomes and objective wrist range of motion. However, those between-group differences disappeared at 12 and 26 weeks of follow-up. No significant differences were found in complication rates between the 3 groups.
For me, the primary message of this article is that early mobilization after distal radial fracture fixation offers improved short-term outcomes with little or no risk of adverse effects. For most patients, a major goal of fracture treatment is to restore normal function as quickly as possible. With early mobilization, patients reported less pain and less disability, and they demonstrated greater range of motion at 6 weeks.
However, the quick restoration of function must be done safely and without complications. In this cohort, 6 patients lost fracture reduction—5 in the 1-week immobilization group and 1 in the 6-week group. While that difference was not statistically significant, the study was not sufficiently powered to detect that difference. A quick power analysis, assuming an anticipated 11% loss-of-reduction rate as seen in the 1-week group and a 2% rate as seen in the 6-week group, estimates that 234 patients would be needed to confidently avoid a type II error when analyzing loss of reduction.
Translating findings like these into practice constitutes the art of medicine. It is probably safe, and perhaps even beneficial, to allow early mobilization of distal radial fractures treated with volar locking plates. However, there is probably a subset of patients who are at risk for losing reduction, and therefore it may be prudent to have a low threshold for keeping certain patients casted for a longer duration. The orthopaedist who extends cast immobilization beyond 3 weeks can take comfort in the findings that reported outcomes and range of motion in the 6-week-immobilization group quickly caught up with the results of the early-mobilization cohorts by 12 weeks after surgery.
Matthew Herring, MD is a fellow in orthopaedic trauma at the University of California, San Francisco and a member of the JBJS Social Media Advisory Board.
Fixation Costs for Distal Radial Fracture
There is no consensus on the optimal fixation method for patients who require a surgical procedure for distal radial fractures. We used cost-effectiveness analyses to determine which of 3 modalities offers the best value. https://goo.gl/mos4dc #JBJS #JBJSInfographics
What’s New in Pediatric Orthopaedics
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, Derek Kelly, MD, co-author of the February 15, 2017 Specialty Update on Pediatric Orthopaedics, selected the five most clinically compelling findings from among the 60 studies summarized in the Specialty Update.
Upper-Extremity Trauma
—A systematic review of eight randomized studies comparing splinting with casting for distal radial buckle fractures confirmed that splinting was superior in function, cost, and convenience, without an increased complication rate.1
Lower-Extremity Trauma
—A review of the treatment of 361 pediatric diaphyseal femoral fractures before and after the 2009 publication of AAOS clinical guidelines for treating such fractures revealed that the guidance had little impact on the treatment algorithm in one pediatric hospital.
Spine
—Bracing remains an integral part of managing adolescent idiopathic scoliosis, but patient compliance with brace wear is variable. A prospective study of 220 patients demonstrated that physician counseling based on compliance-monitoring data from sensors embedded in the brace improved patients’ average daily orthotic use.
Hip
—AAOS-published evidence-based guidelines on the detection and nonoperative management of developmental dysplasia of the hip (DDH) in infants from birth to 6 months of age determined that only two of nine recommendations gleaned from evidence in existing literature could be rated as “moderate” in strength:
- Universal DDH screening of all newborn infants is not supported.
- Imaging before 6 months is supported if the infant has one or more of three listed risk factors.
Seven additional recommendations received only “limited” strength of support.
—A study of the utility of inserting an intraoperative intracranial pressure (ICP) monitor during closed reduction and pinning for slipped capital femoral epiphysis (SCFE) found that 6 of 15 unstable hips had no perfusion according to ICP monitoring. However, all 6 hips were subsequently reperfused with percutaneous capsular decompression, and no osteonecrosis developed over the next 2 years.
Reference
- Hill CE, Masters JP, Perry DC. A systematic review of alternative splinting versus complete plaster casts for the management of childhood buckle fractures of the wrist. J Pediatr Orthop B. 2016 ;25(2):183–90.
What’s New in Orthopaedic Trauma
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, David Teague, MD, co-author of the July 7, 2016 Specialty Update on orthopaedic trauma, selected the eight most clinically compelling findings from among the 35 studies summarized in the Specialty Update.
Shoulder
–The randomized PROFHER trial found that surgical treatment of acute displaced proximal humeral fractures (with either ORIF or hemiarthroplasty) yielded no difference in patient outcomes compared with nonsurgical sling treatment at time points up to 2 years. Surgery was also significantly more expensive.1
Wrist
–A randomized trial of 461 patients with an acute dorsally displaced distal radial fracture found no difference at one year in primary or secondary outcomes between a group that received ORIF and a group that received Kirschner-wire fixation. K-wire fixation was also more cost-effective.2
Tibia
–A retrospective study of 137 type-III open tibial fractures concluded that both antibiotic prophylaxis and definitive wound coverage should occur as soon as possible for severe open tibial fractures. Prehospital antibiotic administration should be considered when transport is expected to take longer than one hour. 3
Ankle
–A randomized trial of 214 patients who received either supervised physical therapy or engaged in self-directed home exercise after six weeks of immobilization treatment for an ankle fracture found no difference in activity and quality-of-life outcomes at 1, 3, and 6 months.4
Managing Thromboembolism
–A registry study examining the incidence of deep venous thrombosis (DVT)/pulmonary embolism (PE) after surgery for a fracture distal to the knee identified the following risk factors for a thromboembolic event: previous DVT or PE, oral contraceptive use, and obesity.
Wound Care
–A randomized controlled trial of 2,447 patients compared irrigation with normal saline solution at various pressures to castile soap irrigation. Saline was superior in terms of reoperation rates after 12 months but irrigation pressure did not influence the reoperation rate.5
–A retrospective cohort study involving 104 patients who required a fasciotomy found that hospital stays were shorter among patients who underwent delayed primary closure (DPC) or a split-thickness skin graft on the first post-fasciotomy surgery. The authors noted limited utility of repeat surgeries to achieve DPT if fasciotomy wounds were not closed primarily on the first return trip.6
Obesity
–A prospective observational study of 376 trauma patients requiring orthopaedic surgery found that those with a BMI of >30 kg/m2 had an overall complication rate of 38% and had longer hospital stays, longer delays to definitive fixation, and higher infection rates than nonobese patients.7
References
- Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, Goodchild L, Chuang LH, Hewitt C,Torgerson D; PROFHER Trial Collaborators. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015 Mar 10;313(10):1037-47.
- Costa ML, Achten J, Plant C, Parsons NR, Rangan A, Tubeuf S, Yu G, Lamb SEUK. UK DRAFFT: a randomised controlled trial of percutaneous fixation with Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius. Health Technol Assess.2015 Feb;19(17):1-124: v-vi
- Lack WD, Karunakar MA, Angerame MR, Seymour RB, Sims S, Kellam JF, Bosse MJ. Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. J Orthop Trauma. 2015 Jan;29(1):1-6.
- Moseley AM, Beckenkamp PR, Haas M, Herbert RD, Lin CW; EXACT Team. Rehabilitation after immobilization for ankle fracture: the EXACT randomized clinical trial. JAMA. 2015 Oct 6;314(13):1376-85.
- Bhandari M, Jeray KJ, Petrisor BA, Devereaux PJ, Heels-Ansdell D, Schemitsch EH, Anglen J, Della RoccaGJ, Jones C, Kreder H, Liew S, McKay P, Papp S, Sancheti P, Sprague S, Stone TB, Sun X, Tanner SL,Tornetta P 3rd., Tufescu T, Walter S, Guyatt GH; FLOW Investigators. A trial of wound irrigation in the initial management of open fracture wounds. N Engl J Med. 2015 Dec 31;373(27):2629-41. Epub 2015 Oct 8.
- Weaver MJ, Owen TM, Morgan JH, Harris MB. Delayed primary closure of fasciotomy incisions in the lower leg: do we need to change our strategy? J Orthop Trauma. 2015 Jul;29(7):308-11.
- Childs BR, Nahm NJ, Dolenc AJ, Vallier HA. Obesity is associated with more complications and longer hospital stays after orthopaedic trauma. J Orthop Trauma. 2015 Nov;29(11):504-9.
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