Emergency Department

There is only one randomised controlled trial that fulfils the exact criteria set out in the question i.e. immobilisation in a full cast is compared to a back slab.  

Evidence Statement

Level 3:

The number of patients in the only RCT available for review is not sufficient to draw meaningful conclusions.

Recommendation

Best Practice Point:

Immobilisation can be adequately achieved either by the use of a full cast or by use of a back slab depending on the expertise of the personnel carrying out the application of the splint and the preference of the patient.  The GDG recommends that the patient is provided with a written care sheet with emergency contact numbers as per BOAST guidelines for DRFs.

Vitamin C for prevention fo complex regional pain syndrome (CRPS)

Introduction

CRPS is a complication which may be seen after a distal radius fracture characterised by severe pain, swelling and skin changes. Vitamin C has been advocated as a cheap, safe and effective treatment to prevent CRPS following injury or surgery.  The aim is to review whether treatment with Vitamin C compared with placebo prevents CRPS in patients with a fracture of the distal radius.

Review Question

How does Vitamin C compared to placebo affect rates of CRPS?

Evidence

A total of 38 papers were reviewed for this question, including three meta analyses and three RCTs.  Six papers met the inclusion criteria. View here. 

Evidence Statement

Level 1++:

For adult patients with a distal radius fracture, there is no evidence that treatment with Vitamin C prevents CRPS when compared to placebo.

Recommendation

Grade of Recommendation: Grade A

Vitamin C is not recommended for the prevention of CRPS in patients with DRFs. 

Radiological Parameters and Outcome

Introduction

Several parameters are commonly measured on radiographs of DRFs.  The aim is to review whether any of these parameters seen on radiographs influence the patient reported or functional outcome of the patient.

Review Question

Which radiological parameters affect the patient reported outcome/functional outcome of the patient?

Evidence

No randomised controlled trials or cohort studies were found for this review question. 42 papers met the inclusion criteria. All were case series and many were retrospective. The study findings are varied with no strong evidence that any radiological parameter affects outcome. View here.

Evidence Statement

Level 3:

There is insufficient evidence in the literature to determine a meaningful association between any of the radiological parameters and patient rated outcome.

Recommendation

Grade of Recommendation: Grade D

Currently there is insufficient evidence to demonstrate a clear association between any measured radiological parameters and patient rated outcome. Further high quality research is required to answer this question.

The review has identified that the most commonly measured parameters were radial height, radial inclination, volar tilt, ulnar variance and intra articular step and gap. To investigate the influence of these radiological parameters on treatment decision making further, a Delphi study was organised. The Delphi method solicits the opinions of experts through a series of carefully designed questionnaires interspersed with information and opinion feedback in order to establish a convergence of opinion.

Delphi Study aims

• To identify which radiographic parameters are clinically important
• To quantify the threshold of displacement at which surgical intervention should take place for the commonly measured parameters
• To determine which patient factors influence the decision to intervene

Method

A Delphi study was completed with a panel of national and international experts who are experienced in the treatment of acute DRFs and their longer-term sequelae and/or have published clinical research investigating outcome after DRF.

Full ethical approval was obtained from the University of Leicester (Ethics Reference: 9559-nj94- healthsciences).  The study protocol was registered with ClinicalTrials.gov (Identifier NCT03126474).

Delphi panel recruitment

The panel was composed of three groups of expert surgeons. Blue Book committee members were excluded. Many panel members fitted the criteria to belong in more than one of the following groups:

• Hand and wrist specialists – these surgeons would have considerable experience dealing with acute injuries and longer term problems after DRF. Participants were identified by sampling from UK BSSH members geographically.
• Trauma surgeons - those who deal acutely with patients with DRF and operate on them regularly. An email invitation was sent via the Orthopaedic Trauma Society (OTS) asking for volunteers to take part who fulfilled the above criteria.
• International researchers - surgeons who are also researchers and have published studies investigating outcome in patients with DRFs in the last 2 years so have a comprehensive understanding of the nature of the injury and likely outcome. A literature review of major orthopaedic and hand journals was carried out to identify potential participants.

Questions

Questions were based around six short case vignettes regarding a displaced extra-articular fracture in a 38, 58 and 75 year old patient, followed by a displaced intra-articular fracture in the same age groups. Those age groups were selected as it was considered that they would stimulate greater thought about decision making than if more extremes of age had been used.

Intervention was defined as any type of reduction and stabilisation, including manipulation and cast application.

Participants were asked to consider the functional outcome for each patient at three months after injury.

Question 1: Importance of parameters

Participants were asked to rank the parameters in order of importance on a visual analogue scale of 0 to 10 (0 = extremely unimportant, 10 = extremely important). Parameters were then ranked by median score and the results presented to the panel. Participants were asked if they agreed with the ranking. Consensus was defined as at least 70% agreement between participants.

Question 2: Thresholds for intervention

For each case vignette, panellists were asked at what measurement of displacement for each parameter they would intervene surgically. Agreement was then sought on the value at which intervention is required for each parameter by presenting the median value (from those scores independently offered in round one) alongside a scale of greater or lesser values. Where 70% agreed we accepted this as the point at which intervention should take place.

Question 3: Patient factors influencing decision making

Ten factors were presented to participants and they were asked to rate how important the factor is when deciding to intervene on a visual analogue scale of 0 to 10 (0 = extremely unimportant, 10 = extremely important). Factors were then ranked in order of importance by median score. A factor with a median score of three or less was accepted to be not important. A median score with an inter-quartile range of two or less was accepted as consensus for that score according to RAND criteria. Participants were asked if they agreed with the ranking. Consensus of the ranking was defined as at least 70% agreement between participants.  Qualitative analysis was performed on the free text answers and comments. Stability of participants’ answers was analysed individually and between the three groups of panel members.

Results

Participant responses

56 surgeons were invited to take part. One declined and there was no response from nine after repeat reminders. 46 agreed to take part. 43 of those completed round one. All 43 who took part in round one then completed all rounds of the Delphi study.

Question 1: Importance of parameters

Ulnar variance was consistently rated as the most important extra-articular parameter with dorsal tilt rated as the second most important for all age groups.

Intra-articular step (joint surfaces not aligned properly) was rated as the most important intra-articular parameter for all age groups. The panel agreed with these ranking orders for all parameters.

The following traffic light system is used to illustrate agreement and importance:

Question 2: Thresholds for intervention

Agreement denotes the percentage of the expert panel who would intervene at this radiographic threshold.

Consensus was obtained for all thresholds for intervention except ulnar variation in a 75 year old patient. For this case half of the panel would intervene at 4mm of positive ulnar variance whereas 42% would accept over 5mm of displacement.

Agreed thresholds were the same for all parameters for patients aged 38 and 58. There was no difference seen in thresholds between the three groups of participants

Question 3: Patient factors influencing decision making

Seven parameters were identified as important by the panel. Consensus was gained on the following rank order:

1. Mental capacity
2. Function
3. Medical co-morbidities
4. Age
5. Compliance with rehabilitation
6. Occupation
7. Fragility

Consistency was seen between rounds indicating that panel members did not significantly change their choices throughout the rounds. There was no difference seen in preferences between the three groups of participants.

Qualitative review

Analysis of free text and comments revealed the following themes:

• Restoring function is the main aim of treatment.
• Establishing pre-injury function is consequently a significant factor in decision making.
• Assessment of function is multidimensional and will involve discussion with patient and carers, subjective judgement by clinician, and may include some standard assessment tools.
• Occupation is sometimes a factor.
• Comorbidities and mental capacity may illustrate functional level but are not influential in their own right.
• Independence is an important threshold in this assessment.
• Age may suggest broad treatment modalities but is less significant than function in individual cases.
• Assessment of compliance is sometimes a factor and mental capacity is a factor in this.
• Fragility may influence type of treatment but not the need for treatment.

Recommendation

Through this Delphi process our panel of experts agreed that ulnar variance and dorsal tilt are the most important extra-articular parameters and step is the most important intra-articular parameter. Consensus was gained on thresholds for intervention for all parameters for the three age groups except ulnar variance in a 75 year old patient. Seven patient factors were thought to be important regarding whether to intervene surgically and rank order of importance was agreed reflecting the preinjury functional state.

References:

ANAESTHESIA TECHNIQUES for MANIPULATION

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