Transcript The Evolution of Management of Fractures of the Distal Radius

“The Evolution of Management
of Fractures of the Distal
Radius”
David S Ruch, MD
Chief of Hand and Microsurgery
Vice Chairman of Orthopaedic Surgery
The Fracture
 Most common fracture
in the upper limb
 1/6 of all fractures
treated in the
emergency room
 Estimated 700,000
fractures per year
Incidence: 2 Peaks
Male 20-45
High energy injury
Comminuted fracture
Malunion results in loss of
function and pain
Females over 65
Low energy/Osteopenic
“insufficiency fractures”
Malunion may be well
tolerated
Previous Research
 Data base mining
 Largely cohort based level 4 evidence
comparing outcomes of operative treatment
 Focus has been on the disability seen in
younger patients
Previous Work
 Single surgeon database
 Twenty seven publications 4 book chapters
 Primarily compared treatment modalities
based on level four case controlled cohort
 Allowed demonstration of the significance of
restoration of the “critical corner” of distal
radius in patient reported outcomes
Level 3 Evidence“Arthroscopic
v. Flouroscopic”
Ruch et al Arthroscopy 2004;20(3)
 1995-1999 prospectively acquired
 38 pts Arthroscopically Assisted
reduction and fixation of fractures of
the distal radius- (DSR)
 Entry Criteria
 Isolated Fracture
 Multi-fragmentary articular (Lunate
Impaction)
Arthroscopic Distal Radius:
Lunate Impaction Fx
-Reduce articular Surface-
No statistically significant difference in
outcomes with average $5.8K additional
cost
C.Y. 48y/o s/pMVA
Articular reduction anatomic but collapse as fracture
heals
C.Y. 2 y f/u
Palmar Versus Dorsal Plate Fixation for
Distal Radius Fractures
Ruch DS Papadonikolakis A JHS 2006
Study Population
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157 patients (88m/69f)
Mean age 45.5yM 53.6F
MOA- FOOSH 87 /MVA 59 other 11
Dom 85/ Non Dom 72
Operative Treatment
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External fixation +wires n=53
Dorsal plate n=32
Palmar plate n=46
Combined dorsal and volar n=26
Group 1 (n=41) >2mm depression
 External Fixation (n=17)
 Dorsal plate (n=17)
 Palmar plate (n=7)
Group 2 (n=116) less than 2 mm
of displacement
 External fixation (n=34)
 Dorsal plate (n=36)
 Palmar plater (n=46)
Demographics in both
groups similar in age sex
and hand dominance
Results ROM
 Patients without residual depression had a
significantly higher
 median wrist extension (65 degrees) than
those with lunate displacement (45 degrees)
(p=.002)
 Median Supination (78 degrees) than those
with lunate displacement (67degrees)
(p=.004)
Multi Center Trials
“Indirect reduction and percutaneous
fixation versus ORIF for displaced intraarticular fractures of the distal radius”
Kreder,HJ et al JBJS 87-B 2005
Ex Fix
ORIF
“Indirect reduction and percutaneous
fixation versus ORIF for displaced intraarticular fractures of the distal radius”
Kreder,HJ et al JBJS 87-B 2005
 179 Patients
 Prospective randomized
 Outcomes
 Subjective-MFA
 Objective -Radiographic/Physical Exam
 Functional
“External Fixation Versus Open Reduction
Internal Fixation for Intra-articular
Fractures of the Distal Radius”
Kreder,HJ et al JBJS 87-B 2005
 External Fixation superior
 Grip/pinch/range of motion
 Functional outcome scores
 No difference in xrays
 Gap
 Step
Dilemma
72y/o active
retiree
Single lives
alone
Concerns about
ability to remain
independent
1 week post closed reduction
Dilemma
Ex Fix +Allograft bone through
3-4 interval
2 weeks post ex fix and bone graft
Failure of the osteopenic bone
to hold the hardware
4 weeks post op
Final result
Maybe Colles Was Right?
Trends in the United States in the treatment of distal radial
fractures in the elderly.
Chung KC, Shauver MJ, Birkmeyer JD JBJS (Am) 2009
 5% sample of Medicare data from 1996 to 1997
 20% sample from 1998 to 2005.
 four treatment methods (closed treatment, percutaneous
pin fixation, internal fixation, and external fixation)
 frequencies and rates to compare the utilization of different
treatments over time.
 RESULTS: Over the ten-year time period examined, the
rate of internal fixation of distal radial fractures in the
elderly increased fivefold, from 3% in 1996 to 16% in 2005.
 Since 2000, although the majority of distal radial fractures
are still treated nonoperatively, there has been an increase
in the use of internal fixation and a concurrent decrease in
the rate of closed treatment of distal radial fractures in the
elderly in the United States.
“ A Prospective Randomized Comparison of
Operative v Non Operative Management of
Distal Radius Fractures in the Elderly”
 Inclusion criteria:
 All patients under sixty five
 Closed intra articular/extra articular fracture of the
distal radius
 Exclusion
 Co morbidities precluding operative management
 Open fractures
 Ipsilateral injuries
Power analysis
 608 patients
 Randomized /
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Cast treatment
Percutaneous pinning
External fixation
Open reduction plate fixation
 Outcome 1` /2` variables
 Physical parameters ROM Grip Digital motion
 Patient reported outcome variables
 PRWE /DASH/SF36
NIH Funding
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18 centers
35K per center
Estimated 34 patients enrolled per center
Attrition rate at one year ~10%
Goals
 Identify any measures between treatment
groups
 Extrapolation of cost data both regionally
and nationally
 “ Is the cost of operative management
justified based upon outcomes at one year?”
Conclusions
 Orthopedic Clinical Research has
traditionally been cohort based and largely
level four
 Expert opinion considered
 Prospective randomized trials have largely
gone unfunded
 Previous trials generally have grouped all
patients with a given radiographic diagnosis
despite obvious dissimilarities based upon
age and fracture severity
Future Directions
 Data base management between centers to
allow for actuarial type data analysis similar
to the Northeastern Cardiac Consortium
(Dartmouth Hitchcock Center) to allow for
analysis of variation between centers
Special Thanks
 Duke Orthopaedic Faculty / Residents
 Drs James Nunley and Farshid Guilak
 Special Thanks to Dean Andrews