April 24, 2014

Distal Radial Fractures

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It’s one of the most common fractures we see in the ED, but how important is it to get a perfect reduction? Is it even worthwhile to try?

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There are two sides to every story…

PROS: Accurate reduction

  • Anecdotally, pain is improved when a severely displaced fracture is reduced and immobilized.
  • The ED has sedation capabilities that the orthopedist’s office does not. If we can get good anatomic alignment in the ED and save a trip to the OR, we’ve benefitted the patient
  • You are treating the patient for their presenting complaint

CONS:

  • A significant portion of reduced fractures will fall out of reduction
  • They are a huge time and resource sink. Time to reach NPO status keeps a bed occupied. The sedation and splinting involve multiple staff members. A nurse is taken away from other ED patients for as long as the patient needs close monitoring
  • Many of these patients may not actually benefit from reduction.

Bottom Line…

Do you like to reduce Colles fractures? If so, have at it. They’re one of my favorite procedures and I rarely pass up the chance. But there is no fault in splinting and referring to the orthopedist as long as the skin and neurovascular exam are intact. You just need to explain to the patient/family why you’re not fixing a deformed wrist.

Written Summary:  Justin Arambasick MD  Akron General  Medical Center

Curbside Consult with Hans Moller, MD

Does a mild to moderate (< 35˚) nonarticular fracture of the distal radius haveto be reduced?

  • Not necessarily. Many countries in Europe do no perform surgery or reduction on these, and a variety of low powered studies have not shown functional benefit in doing so.

Is there a benefit to doing an ED reduction?

  • Yes, patients whom have had a reduction in the ED and show up in the orthopaedic follow up clinic have in general better pain control and less skin changes.

When should a patient follow up with orthopedics after an ED reduction?

  • 7-10days

Does intraarticular involvement necessitate a trip to the OR?

  • Not necessarily.  These fractures are at higher risk for subsequent arthritis, which can be mitigated by surgery (but not completely prevented). The problem with these is that the pieces of the fracture tend to drift apart, increasing the chance of an unfavorable outcome.

What is radial shortening?

  • This refers to the length of the radius comparing the carpal articular surface of the ulna and the lunate fossa of the radius. A line drawn across the end of the ulna should be at the same level as the radial lunate fossa. If the lunate fossa is behind (proximal to) this line, the radius is shortened.
Radial length

Radial length

Radial Shortening (yellow arrow)

Radial Shortening (yellow arrow)

What is the purpose of finger traps?

  • To elongate the shortened radius. Hans prefers placing the thumb and index finger in the trap and separating them by a 3 inch roll of Webril, thus elongating the radius and providing ulnar deviation.
  • Place splint on while still in trap.

What are the hallmarks of an adequate fracture reduction?

  • <2mm articular step off
  • <20 degrees of volar angulation
  • <3mm of radial shortening
  • With these parameters, the functional outcome should be the same as someone who has had surgery.  Surgery has quicker return to full function than casting.Further Reading
  • Neidenbach P, Audigé L, Wilhelmi-Mock M, Hanson B, De Boer P.  The efficacy of closed reduction in displaced distal radius fractures. Injury. 2010 Jun;41(6):592-8. Epub 2009 Dec 2. [PMID 19959165]
  • 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 Aug 4;92(9):1851-7. [PMID 20686059]
  • Download the podcast AUDIO
  • Eponymous Orthopedic Fractures

 

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About Rob Orman

Deceptively tall.
Podcaster to the stars, father of many, lover of few

Comments

  1. Thanks for this!
    Just one note:
    The problem with looking at the ulnar fossa to measure radial shortening is that not all patients have neutral variance, some have positive ulnar variance.

    A question, does it mean we can attempt to reduce Dorsal-type Barton’s?

    Thanks.

    • Great point about ulnar variance. Not everyone has a nice level line across the ulnar and radio-lunate fossa. Sometimes it’s a case of ‘use your best judgment’ and it’s but one piece of the puzzle when deciding if a reduction was successful. I recently had a case with positive radial variance. The reduction looked great but the radius was several mm distal to the ulna. “What have I done?!?!” was my gut reaction when looking at the post reduct xray. To your point, not all wrists follow the rules of anatomic relationships.

      Regarding the Barton fracture… This is a matter of personal choice. The success rate is going to be less than for a Colles because of the flexor forces working agaisnt you. I usually call the orthopods on these since they’ll occasionally take the to the OR straight away, but they usually ask us to give a try at reduction in the ED. I’m about 50% successful, which is way less than a Colles, but can occasionally save a patient surgery if it’s a solid alignment.

  2. Dean Burns says:

    Hi Rob

    I really enjoyed this podcast on distal radius fractures. I was wondering if Dr Moller had any thoughts on attempted closed reduction of Smith’s fractures in the ED and whether it’s worth a shot.

    Ortho are often keen for an attempt to be made but I’ve often been reluctant to try given the tendency of these fractures to be unstable.

    I’d love to hear his thoughts.

    Dean

    • Rob Orman says:

      The orthopods in our hospital are a mixed bag. Since these are unstable fractures, many just take them to the OR, while others ask us to reduce them. I have found the Smith fracture much harder to reduce and keep in place than Colles’.

  3. I just saw a question on this topic in the boardvitals.com emergency medicine questions while I was studying for boards, great topic!

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  1. [...] up with ZDoggMD and bounced back this month and taken out top spot with a brilliant podcast on the truth about distal radial fractures. Rob answer’s the tough questions on how important is it to get a perfect reduction? Is it [...]

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