Displaced distal radius fractures

What?

A 65yo woman comes into your Emergency Department (ED) presenting with right wrist pain, swelling and deformity following a fall onto an outstretched hand (FOOSH). An x-ray reveals a dorsally angulated and displaced distal radius fracture. It is suggested this type of fracture requires reduction and cast immobilisation, so how do you make the decision on when to perform closed reduction and which anaesthetic technique is most appropriate……

So What?

Distal radius fractures are the most common fractures treated in the UK ED’s. They comprise 16% of all fractures and are particularly prevalent in the young and elderly. It is widely believed that accurate reduction to restore anatomy produces superior radiographic outcome which is essential to maximise functional outcome (BMJ, 2016). NICE advise the consideration of closed reduction in adults with dorsally displaced distal radius fractures and recommend considering Intravenous Regional Anaesthesia (IVRA) aka Bier’s Block to achieve this (NICE Guideline 38, 2016). However, it has been observed that practice varies between clinicians and the evidence upon which these clinical decisions are based is not clear (Sprot et al., 2013).

In 2003 the Cochrane Collaboration concluded there was insufficient evidence to determine the most appropriate method of conservative treatment for distal radius fractures in adults, advising further research is necessary to determine whether moderately displaced fractures should be manipulated back into position (Handoll et al., 2003). They also concluded there was insufficient evidence to establish the effectiveness of methods of anaesthesia used in this treatment, but with some indication that haematoma block provides less analgesia than IVRA, which could therefore compromise reduction (Handoll et al., 2002).

Despite this guidance there is substantial variation in clinical practice around the UK. A 2013 survey of 105 ED’s in England and Wales shows the most frequently used anaesthetic types were haematoma block (50%), conscious sedation (20%) and IVRA (17%) (Sprot et al., 2013).

A systematic review of the evidence after the Cochrane review, from 2003 to 2017 carried out by this author demonstrated:

  • If radial displacement is less than 5mm and angulation less than 15° then closed reduction is not indicated and cast immobilisation alone is sufficient in the emergency department.
  • Initial complete displacement or radial shortening of greater than 5mm has a high risk of re-displacement after reduction and should be referred for a surgical opinion.
  • There is no benefit in closed reduction of severely displaced distal radius fractures in the emergency department, these should be simply immobilised and managed surgically.
  • Leaving a fracture unreduced before surgery is not associated with any adverse events.
  • Inadequate radiological outcome parameters are unrelated to functional outcomes in older patients.
  • Teaching of closed reduction and casting techniques needs to be improved in the emergency department.
  • Haematoma block should be the treatment of choice in emergency departments for closed reduction of displaced distal radius fractures based on cost, ease of technique and safety profile.

The table below shows the costs involved in the most commonly used anaesthetic approaches in emergency departments in the UK:

 

Procedure

 

HCP Needed

 

Time Spent

 

HCP Time Costs

 

Anaesthetic / Equipment Costs

 

Total Cost

 

Conscious Sedation

 

2 x Clinician

1 x Nurse

 

240 minutes (120 minutes with patient)

 

£153.50

 

£1.97

 

£155.47

 

IVRA

 

2 x Clinician 1 x Nurse

 

45 mins

+

60 Mins Observation (Nurse Only)

 

£119.50

 

£5.92

 

£125.42

 

Haematoma Block

 

1 x Clinician

1 x Nurse

 

45 Mins

 

£55.50

 

£3.86

 

£59.36

(Adapted from Nice Guideline 38, 2016)

Now What?

In the 15 years since the Cochrane reviews there remains insufficient evidence on which to base clinical decisions to manage displaced distal radius fractures in the emergency department. NICE recommendations to consider IVRA is based on older literature with the more recent literature supporting haematoma block. However, recent evidence is of low to moderate quality, being mostly retrospective cohort studies with a high risk of bias due to a lack of blinding. Randomised controlled trials are necessary to directly compare anaesthetic techniques.

 

Nathan Humphries

 

 

 

References

Bentohami, A., Bijlsma, T., Goslings, J., de Reuver, P., Kaufmann, L., Schep, N. (2013) Radiological criteria for acceptable reduction of extra-articular distal radial fractures are not predictive for patient-reported functional outcome. Journal of Hand Surgery: European Volume. 38(5):524.

Beumer, A., McQueen, M. (2003) Fractures of the distal radius in low-demand elderly patients: closed reduction of no value in 53 of 60 wrists. Acta Orthop Scand. 74(1):98-100.

Bhattacharyya, R., Morgan, B., Mukherjee, P., Royston, S. (2014) Distal radial fractures: the significance of the number of instability markers in management and outcome. Iowa Orthop J. 34:118-22.

BMJ Best Practice. (2016) Wrist Fractures. [online] Available from http://bestpractice.bmj.com/best-practice/monograph/392.html (Accessed 16th January 2017).

Cowie, J., Anakwe, R., McQueen, M. (2015) Factors associated with one-year outcome after distal radial fracture treatment. J Orthop Surg (Hong Kong). 23(1):24-8.

Dixon, S., Allen, P., Bannister, G. (2005) Which Colles’ fractures should be manipulated? Injury. 36(1):81-3.

Egan, C., Egan, R., Curran, P., Bryan, K., Fleming, P. (2013) Development of a model for teaching manipulation of a distal radial fracture. Journal of Bone & Joint Surgery – American Volume. 95(5):433-8.

Gluck, J., Chhabra, A. (2013) Loss of alignment after closed reduction of distal radius fractures. [Review] Journal of Hand Surgery – American Volume. 38(4):782-3.

Guay, J. (2009) Adverse events associated with intravenous regional anaesthesia (Bier block): a systematic review of complications. Journal of clinical anaesthesia, 21(8):585-594.

Handoll, H., Madhok, R. (2003) Conservative interventions for treating distal radial fractures in adults. Cochrane Database of Systematic Reviews. 2: CD000314

Handoll, H., Madhok, R., Dodds, C. (2002) Anaesthesia for treating distal radial fracture in adults. Cochrane Database of Systematic Reviews. 3:CD003320.

Jakeman, N., Kaye, P., Hayward, J., Watson, D., Turner, S. (2013) Is lidocaine Bier’s block safe? Emergency Medicine Journal. 30(3):214.

Jaremko, J., Lambert, R., Rowe, B., Johnson, J., Majumdar, S. (2007) Do radiographic indices of distal radius fracture reduction predict outcomes in older adults receiving conservative treatment? Clinical Radiology. 62(1):65-72.

Jung, H., Hong, H., Jung, H., Kim, J., Park, H., Bae, K., Jeon, I. (2015) Re-displacement of Distal Radius Fracture after Initial Closed Reduction: Analysis of Prognostic Factors. Clinics in Orthopaedic Surgery. 7(3):377-82.

Jordan, R., Naeem, R., Jadoon, S., Srinivas, K., Shyamalan, G. (2016) The value of manipulation of displaced distal radius fractures in the emergency department.  Acta Orthop. Belg. 82:203-209.

LaMartina, J., Jawa, A., Stucken, C., Merlin, G., Tornetta, P. (2015) Predicting alignment after closed reduction and casting of distal radius fractures. J Hand Surg Am. 40(5):934-9.

Myderrizi, N., Mema, B. (2011) The hematoma block an effective alternative for fracture reduction in distal radius fractures. Medicinski Arhiv. 65(4):239.

Neidenbach, P., Audige, L., Wilhelmi-Mock, M., Hanson, B., De Boer, P. (2010) The efficacy of closed reduction in displaced distal radius fractures. Injury. 41(6):592-8.

NICE guideline (2016) Fractures (non-complex): assessment and management [online] Available from: nice.org.uk/guidance/ng38 (Accessed 16th January 2017).

Ogunlade, S., Omololu, A., Alonge, T., Salawu, S., Bamgboye, E. (2002) Haematoma block in reduction of distal radial fractures. West African Journal of Medicine. 21(4):282.

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Ramoutar, D., Silk, R., Rodrigues, J., Hatton, M. (2014) Quality of Plaster Moulding for Distal Radius Fractures Is Improved Through Focused Tuition of Junior Surgeons. J Orthop Trauma. 28(8):e180-5.

Sprot, H., Metcalfe, A., Odutola, A., Palan, J., White, S. (2013) Management of distal radius fractures in emergency departments in England and Wales. Emerg Med J. 30(3):211-3.

Synn, A., Makhni, E., Makhni, M., Rozental, T., Day, C. (2009) Distal radius fractures in older patients: is anatomic reduction necessary? Clinical Orthopaedics & Related Research. 467(6):1612-20.

Teunis, T., Mulder, F., Nota, S., Milne, L., Dyer, G., Ring, D. (2015) No Difference in Adverse Events Between Surgically Treated Reduced and Unreduced Distal Radius Fractures. Journal of Orthopaedic Trauma. 29(11):521-5.

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Wichlas, F., Haas, N., Lindner, T., Tsitsilonis, S. (2013) Closed reduction of distal radius fractures: does instability mean irreducibility? Archives of Orthopaedic & Trauma Surgery. 133(8):1073-8.

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