Adult DRFs are common injuries at any age but particularly in the older person where they may be associated with osteoporosis or osteopaenia and so are considered fragility fractures. The treatment of patients with DRFs remains controversial. There are many published studies analysing specific parameters of their treatment however there is a need for a guide to summarise the treatment options for both specialist and non-specialist clinicians. This document collates the current evidence from English language journals that considers the management of patients with DRFs from presentation to rehabilitation with reference to Patient Reported Outcome Measures (PROMs). These guidelines have been produced in collaboration between the BOA and BSSH and complement the BOAST on DRFs.
The management of patients with distal radial fractures remains controversial. There are many studies that have analysed specific sections of the management of DRFs but there is a need for a guide to summarise the treatment options for both specialist and non-specialist clinicians. . The BSSH and the British Orthopaedic Society have collaborated to produce guidelines on the management of these fractures and the full document can be viewed here.
The GDG Members
Summary of Audit Standards
The GDG consists of consultant and trainee orthopaedic and trauma surgeons, a physician/orthogeriatrician, a general practitioner, extended scope practitioners, a nurse with plaster room experience and a patient representative.
The production of Guidelines promoting optimum standards of care is key to the achievement of both the BOA’s and the BSSH’s charitable objectives. No external funding has been sought for the production of these guidelines.
Definition of a Guideline
Clinical practice guidelines are systematically developed statements to assist surgeon and patient decisions about appropriate health care for specific clinical circumstances.
These guidelines have been developed by researching the pathway of the patient with a DRF through the Emergency Department (ED) to the Fracture Clinic, to Surgery (if required) and then Rehabilitation. A separate study into Outcome Measures was performed.Fragility fractures are discussed but not include in the search questions.
Fractures of the distal radius are amongst the commonest fractures with which adult patients present to ED. Many DRFs will be seen and treated in the ED and then discharged to specialist follow up. Patients may attend with displaced fractures or neurovascular problems which require urgent treatment and so appropriate initial assessment and management is essential.The mechanism of injury and clinical findings, including skin integrity, assessment of circulation and sensation, should be documented at presentation. Radiographic assessment should be postero—anterior and lateral views centred at the wrist.
Open fractures should undergo surgical debridement and stabilisation in accordance with the Open Fracture BOAST.
Displaced DRFs have traditionally been treated with initial manipulation on presentation to the ED. Manipulation is not only a first aid measure to minimise the risk of developing neurological symptoms, but for many patients can be the definitive treatment. The following aspects of management in ED were studied:
- Anaesthetic techniques for manipulation
- Methods of fracture reduction
- Types of cast immobilisation outcome following reduction
- Whether manipulation affects functional outcome
- Full cast versus back slab immobilisation
- The effect of Vitamin C preventing complex regional pain syndrome
- The effect of radiological parameters on functional outcome
The Fracture Clinic Services BOAST guidelines outline general standards of care in fracture clinic. It is assumed that those guidelines are being followed. The review questions in this section further assumed the following factors:
- The fracture configuration on that particular day in clinic was deemed likely to provide that patient with an acceptable functional outcome, if the fracture healed as it was.
- Associated injuries that would further impair the functional outcome in that patient had also been evaluated.
- Any further imaging required to assist in the decision-making process had been acquired.
- The patient’s opinion regarding the various treatment options available and their desired functional outcome had been sought.
- The GDG considered several further factors that were deemed to have possible relevance to ongoing management of such patients.
- Re-displacement and initial displacement
- Re-displacement and age of patient
- Re-displacement and comminution
- Does this fracture need a plaster cast?
- What position should a fractured distal radius be immobilised in?
- Should further radiographs be taken at 2-3 weeks following injury?
- When should immobilisation be discontinued?
- Will the anxious patient recover less well?
- Radiographs at the time of removing immobilisation
The baseline functional demands of the patient, the consequences of mal-union and the potential risks of surgery need to be considered and discussed with the patient when assessing the role of surgical intervention. The following factors should be considered:
- Timing of surgery
- Non-operative versus operative management
- Manipulation under anaesthesia with K-wires versus open reduction and internal fixation
- External fixation versus open reduction and internal fixation
- Concomitant distal ulnar styloid fracture management
Many patients are referred to a rehabilitation provider following a DRF to optimise return to function. The questions consider how functional outcome after DRF is affected by:
- The impact of providing rehabilitation during the immobilisation period
- The impact of providing rehabilitation after definitive treatment implementation (surgically and non-surgically managed patients)
- The type of rehabilitation intervention
- The mode of rehabilitation delivery
- The discipline of the rehabilitation provider
The aim was to appraise critically the evidence concerning the measurement properties of questionnaires used to capture self-reported outcome in the setting of adult patients with DRFs.