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Reading List: Treatment of distal radial fractures by Ms Sue Fullilove
Five papers dealing with the current management of fractures involving the wrist 1. Downing ND, Karantana A. A revolution in the management of fractures of the distal radius. J Bone Joint Surg [Br] 2008;90-B:1271-5.
I would highly recommend this excellent review. It beautifully sums up the current state of play in the management of distal radial fractures and is superbly referenced for further reading.
2. Forward DP, Davis TR, Sithole JS. Do young patients with malunited fractures of the distal radius inevitably develop symptomatic post-traumatic osteoarthritis? J Bone Joint Surg [Br] 2008;90-B:629-37.
The controversy in management of distal radial fractures continues to rage – to fix or not to fix? This study adds weight to the ‘don’t fix’ camp.
A 38 year follow-up was undertaken of patients who had sustained a distal radial fracture before the age of 40 and been treated non-operatively. Although there was a 43% increase in the prevalence of radiological arthritis in the injured wrists, the differences in symptoms and objective outcome measures were small.
This finding is certainly thought-provoking, but should be taken in the context of other long-term follow-up studies of distal radial fractures which find otherwise.i i. Földhazy Z, Törnkvist H, Elmstedt E, et al. Long-term outcome of nonsurgically treated distal radius fractures. J Hand Surg[Am] 2007;32-A:1374-84. 3. Three prospective randomised trials comparing different treatment methods for distal radial fractures.
Leung F, Tu YK, Chew WK, Chow SP. Comparison of external and percutaneous pin fixation with plate fixation for intra-articular distal radial fractures: a randomized study. J Bone Joint Surg [Am] 2008;90-A:16-22. Kreder HJ, Hanel DP, Agel J, et al. Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: a randomised, controlled trial. J Bone Joint Surg [Br] 2005;87-B:829-36.
Egol K, Walsh M, Tejwani N, et al. Bridging external fixation and supplementary Kirschner-wire fixation versus volar locked plating for unstable fractures of the distal radius: a randomised, prospective trial. J Bone Joint Surg [Br] 2008;90-B:1214-21.
For many reasons, it is difficult to acquire definitive evidence on the optimal treatment for distal radial fractures. The fracture patterns are heterogenous and there are no reliable means of classifying them, the surgical learning curve is long, and associated soft tissue injuries are often untreated. A robust trial is difficult to design and anything less than a very large, multi-centre trial is unlikely to suffice.
These three studies, each highly commendable in their own right, illustrate the problem. Leung finds firmly in favour of plate fixation. Egol reports better early movement with plate fixation, but similar outcome at one year, with more re-operations in the plate group. Kreder shows that percutaneous fixation is superior to plate fixation, as long as the fracture can be reduced closed.
4. Varitimdis SE, Basdekis GK, Dailiana ZH, et al. Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction? J Bone Joint Surg [Br] 2008;90-B:778-85.
This neat study challenges us to refine our techniques for dealing with wrist fractures and supports the findings of previous publications.ii In a prospective randomised trial of 40 patients, the authors illustrate how adding arthroscopy to the surgical fixation allows better fracture reduction, clearance of fracture debris from the joint and concomitant treatment of associated injuries. They demonstrate an improved outcome, maintained at two years in patients whose fractures were fixed with arthroscopic assistance. ii. Ruch DS, Vallee J, Poehling GG, et al. Arthroscopic reduction versus fluoroscopic reduction in the management of intra-articular distal radial fractures. Arthroscopy 2004;20:225-30.
5. Bajammal SS, Zlowodzki M, Lelwica A, et al. The use of calcium phosphate bone cement in fracture treatment. A meta-analysis of randomized trials. J Bone Joint Surg [Am] 2008;90-A:1186-96.
Some surgeons favour the use of bone substitute to treat the metaphyseal defect in distal radial fractures. The evidence for and against this practice has long been controversial.
Bajammal’s meta-analysis of 14 studies, 6 of which involved the distal radius, shows several benefits of calcium phosphate bone cement in fracture management, including reduced pain and better maintenance of fracture reduction. There was no change in the rate of fracture healing when calcium phosphate bone cement was used and the infection rate for wrist fractures was reduced. No adverse consequences or complications were noted.
This meta-analysis provides support for the use of calcium phosphate bone cement in the management of distal radial fractures.
Sue Fullilove, Consultant Hand and Wrist Surgeon |
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