OTA 2004 Posters
Does Repair of Distal Radius Fractures Require Orthopaedic Expertise?
Purpose: We evaluated initial management of distal radius fractures by health care workers with respect to adequacy of reduction, need for re-manipulation and malunion rates. We reviewed the radiographic results from two large teaching institutions. One hospital had no formal orthopaedic presence and has relied on a limited number of emergency physicians with "expertise" in orthopaedic injuries to perform initial emergency care or definitive treatment of fractures. The other hospital had full-time emergency orthopaedic-resident coverage. Initial management of distal radius fractures was often delegated to non-orthopaedic surgeons.
Method: A 2-year retrospective chart review (N = 175) documented initial management of distal radius fractures performed by orthopaedic residents (circular cast), a single orthopaedic staff member (Jones' type slab), or an emergentologist (circular cast). Serial radiographs were assessed for adequacy of initial reduction and incidence of malunion.
Results: Breakdown for the groups respectively: 1, total; 2, orthopaedic resident (cast); 3, orthopaedic staff (Jones' type slab); or 4, emergency staff (ER). Initial treatment chosen as closed reduction/cast: 95.0%, 96.1%, 86.7%, 100%; incidence of intraarticular fracture: 39.6%, 43.8%, 33.3%, 30.4%. The results were generally better in all categories for the orthopaedic resident reduction by circular cast. The ER care of this fracture was worse for all outcomes, but the use of a splint reduction by a single orthopaedic staff member was almost as poor. The malunion rate was 36.4% versus 14.7% for ER versus resident, despite the fact that the residents reduced significantly more intraarticular fractures. The revision after malreduction was more difficult in the cases reduced by ER, with twice as many revised wrists having an unsatisfactory outcome. Revision manipulation had a poorer outcome than revision manipulation plus closed pinning, but secondary percutaneous pinning still had a malunion rate of 33%. Although 93% of the injuries occurred because of a fall on an outstretched hand, 11.2 % of the patients had a significant concomitant injury.
Conclusions: Casting after reduction by an orthopaedic resident is associated with a reduced re-manipulation and malunion rate. Future directions should employ strategies to optimize and make uniform initial management of these mistreated fractures.
Significance: This study definitely points out the dangers in the treatment policies of these institutions. The practice of allowing a non-orthopaedic surgeon to initially reduce distal radius fractures needs to be re-examined. Even more dangerous was the managed health care scenario where a gatekeeper had determined that more complicated fractures, such as scaphoid fractures, would be initially cared for by non-orthopaedic staff.