Is There a Best Form of Treatment for Distal Radius Fracture?



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Running Header: BEST TREATMENT FOR DISTAL RADIUS FRACTURE



Is There a Best Form of Treatment for Distal Radius Fracture?

Jessica Stanford

Northeastern University

Abstract

Orthopedic trauma is one of the primary reasons for emergency room visits. The average person will experience at least two fractures in their lifetime. However, there is no standard of practice for treating orthopedic injuries. Naturally, no two cases are the same but there is no set criterion for determining how a fracture is treated. There are ways to classify an injury and different ways to classify the patient. But for the most part, decision of treatment is subject to the physician’s discretion. Which form of treatment is typically the best form of treatment? And how can this treatment be improved?



Introduction

Worldwide, trauma is one of leading causes of death. With trauma there is what is known as the “Golden Hour”. The first hour post trauma is the most crucial, it is important to rapidly transport an injured person to a facility where they can receive the care needed. Being able to get a victim of trauma to treatment within this hour greatly increases the likelihood of survival and decreases the chance of limb loss with orthopedic injuries.

Once brought to a trauma center, a trauma team will assess the patient using an ATLS approach. ATLS or Advanced Trauma Life Support was developed by the American College of Surgeons as a training program for medical providers in management of acute trauma cases. The purpose of ATLS is to teach medical providers a simple and standardized approach to treating trauma patients. With ATLS the goal is to treat the greatest threat to life first. This ATLS approach is universally accepted and practiced in trauma centers across the globe. If it is possible to implement a protocol such as this, why is it difficult to determine the best treatment plan for a distal radius fracture and implement that course of treatment worldwide?

Advanced Trauma Life Support

The primary survey follows an ABCDE mnemonic to identify life-threatening injuries. The A stands for airway maintenance with cervical spine protection. During this step physicians will assess the airway to ensure that the airway is not occluded in anyway. Primarily, a neck collar will be placed to open up the airway as well as stabilizes the cervical spine. Physicians will then examine the airway for any blood, emesis, or other item that could be blocking the airway. An endotracheal tube may be placed if needed. Next, the B stands for breathing and ventilation. To assess for breathing and ventilation physicians will use inspection, palpation, percussion and auscultation to examine the chest. The C in the mnemonic stands for circulation with hemorrhage control. In the trauma center, large bore IVs will be placed in order to be able to transfuse blood and fluids and to draw blood for testing. Any external bleeding is controlled by direct pressure. Ultrasounds may be used to look for internal bleeding in the thoracic cavity. There is then D, which stands for disability/neurological assessment. During this assessment the patient’s level of consciousness, pupil size and reaction, lateralizing signs, and spinal cord injury level are determined. Finally, there is E which stands for exposure and environmental control; this is when the patient’s clothes are removed so that physicians can fully examine the patient.

Following this primary survey, the secondary survey will delve deeper into examining a patient’s skeleton. During the orthopedic assessment, X-rays and CT scans will be performed, distal pulses will be evaluated to determine circulation to injury site, peripheral nerves will be assessed, and reductions and splinting may occur.

Orthopedic Trauma

Depending on the injury, injuries due to orthopedic trauma can affect any other body system and may cause abnormal findings in the primary assessment. Blunt force trauma, motor vehicle accidents and falls primarily cause orthopedic trauma. Orthopedic trauma is a severe injury to part of the musculoskeletal system such as bones, ligaments, or joints. The injuries include fractures, dislocations, etc. Orthopedic injuries are usually classified by a number of different factors including: severity or location of the injury, type of fracture (open, closed, comminuted, etc.) demographics such as age or gender, and type of force applied to the body (blunt, penetrating, etc.). This classification helps determine the plan of care for a particular injury. However, there are many different classification systems and classification is generally subjective to each physician, therefore it is not universal. This makes it difficult to determine guidelines for treatment plans.



Case Study

Injury

The distal radius is one of the most common sites for fractures in patients of all ages. Many things such as direct blunt force trauma cause these fractures from a motor vehicle accident or indirect trauma from something like trying to break a fall. These fractures can sometimes be complicated and may require external fixation. Without suitable treatment, fractures may not heal completely or properly and can result in decreased range of motion and function. However, determining which course of treatment is not always easy.



Treatment Options

There are many different ways to treat fractures of the distal radius. The first step in treating a distal radius fracture is determining whether it needs to be reduced openly or closed. “Treatment method must be determined by the fracture pattern, amount of displacement, stability of segments and articular surfaces, age and physical requirements of patients” (Bahari-Kashani, pg 3). A closed reduction is the resetting of a bone without needing surgery while open reduction is used for fractures that require surgery to reset the bone. Fractures that are reset by closed reduction will usually heal with either a splint or cast alone. Typically, a splint will be placed for the first few days post reduction to allow for swelling to decrease, a cast may then be placed. Casts may be changed every 2-3 weeks as the bone heals and swelling decreases. Physicians may also order x-rays every few weeks or so to ensure that the bone is healing correctly. An x-ray will be taken immediately prior to having the cast removed; this is roughly 6 weeks post injury. All open reductions require casts and most fractures that require open reduction also require some type of fixation device, either internal (pins, screws or plates) or external. There are many different types of fixation devices and it is up to the physician’s discretion to determine which one will be used.

The most basic method for internal fixation is called the “pin and plaster” method. With x-ray guidance the fractured bone will be manipulated back into place, the physician will then place metal pins through bone fragments to fixate them together. Once the pins are in place, a plaster cast will be placed to stabilize the fracture. These pins are left in place for roughly 4-6 weeks as the fracture heals and are removed post cast removal. Generally, pins are used to treat fractures in smaller bones or used in comminuted fractures where there are many small bone fragments. Screws are very similar to pins; screws serve the same purpose as pins but are typically used for fractures in larger bones. Although they may be used in conjuncture with other forms of internal fixation, pins are generally used alone. However, screws are most commonly used with either rods or plates.

Rods are generally not used for the treatment of a distal radial fracture because they are placed in long bones, and are typically used for treatment of the lower extremities. However, plates are very often used in upper extremity fractures, such as a distal radius fracture. A plate is like an internal splint that holds the broken bone fragments together. Placing screws into the bone holds plates in place to ensure proper healing of the fracture. Plates may either be removed or stay in place once the fracture has healed.

There are also methods of external fixation used to treat fractures. Generally, external fixation devices are only temporary and are used until the patient is stable enough to undergo the final surgery to place some type of internal fixation device. However, it is possible that an external fixation device is used to stabilize the bone until the fracture is entirely healed. External fixation devices are different from casts because they use the internal use of pins or screws. The pins or screws are placed externally through small incisions in the skin and muscle into the bone. Once placed in the bone, the pins or screws will be attached to a metal bar on the outside of the skin that acts as a stabilizing frame.

Pros and Cons of Different Treatment Plans

Each different treatment plan has both pros and cons to it. Simple reduction and casting reduces the risk of infection because there is no break in the skin. However, without any fixation device there is a chance of nonunion (incomplete healing), malunion (healing in improper position) and shortened forearm. The pin and plaster method is simple and common but there are complications such as pin loosening, reduction failure, bone fracture at the site of the pin, and infection. With internal fixation there are usually excellent functional results. However, there is often surgical trauma such as soft tissue dissection, devascularization of segments, wrist stiffness, tendon irritation or rupture, along with a high risk of infection. As for the external fixator method, there are good functional and anatomical results but there is a longer recovery period, high risk of pin and screw infection, nerve injury and cosmetic deformity.



Determining Preferred Treatment Plan

Trauma centers around the globe generally follow the Orthopedic Trauma Association (OTA) classification system for orthopedic injuries. However, based on injury location there are many more different sub-classification systems. For example, the OTA classifies distal radius fractures into three different categories based on whether the articular surface is involved completely, partially or not at all. There is also the Fernandez classification system that categorizes distal radius fractures into five groups based on pathologic mechanism and the number of fractured pieces (Bahari-Kashani, pg 1). There is no rule for classification, so physicians may use whatever classification system they prefer.

Once the fracture is classified, a treatment plan is then developed. Through research it has been determined that most distal radius fractures are complicated and require more intensive treatment with a fixation device rather than simple casting. This then brings up the debate over internal or external fixation. Research suggests that internal fixation with a volvar locking plate is superior to external fixation in terms of anatomical outcomes and complication rates, but that the two are similar in functional outcomes.

Room for Improvement

With every treatment plan there is a risk of complications. As previously mentioned, internal fixation with plates carries the risk of soft tissue dissection, devascularization of segments, wrist stiffness, tendon irritation or rupture, and the risk of infection. However, there are new methods that decrease the risk of some of these complications. For example, there is the minimally invasive plate osteosynthesis technique.

The minimally invasive plate osteosynthesis technique minimizes soft tissue damage, tendon injury, nerve injury and vascular damage to the bone. This method uses two small incisions (2 mm) to implant a palmar locking plate. Normally, plate implantation involves both palmar and dorsal incisions but it has been proven that palmar incisions are superior because they avoid the “complications caused by the attrition of the extensor tendon in the dorsal approach” (Sun, pg 3). Palmar incisions are also superior because there is less visibility of the scar and more importantly, the cortex on the palmar side is wide and flat, allowing the exposure of fracture fragments and easier placement of the plate. Finally, the palmar locking plate has superior biomechanics to the dorsal locking plate. As well as providing these benefits and decreasing some of the risks of internal fixation devices, this technique has proven to have good functional results.

Another possibility for improvement is using antibiotic-coated internal fixation devices. With internal fixation devices, one of the major risks is the risk of infection. Typically, an orthopedic infection is difficult to manage and usually patients must be treated prophylactically. However, there are complications to prophylactic treatment itself. There can often be unwanted side effects from antibiotics, systemic administration may not reach adequate concentration at the fracture site, and there is the risk of patient non-compliance. Patient non-compliance can then increase the risk of multi-drug resistant microbes. With antibiotic-coated devices, the chances of patient non-compliance are eliminated, the unwanted side effects of systematic antibiotics are decreased, and local delivery to increase local concentrations and length of action is ensured. This technique is ideal because it combines antimicrobial prophylaxis/treatment and stabilization.



Conclusion

In order to determine the “gold standard” of treatment for distal radius fractures, one must begin with an ideal classification system. Considering that the OTA classification system is generally accepted universally, this seems to be the best option. Although it could use some updating and may even be able to incorporate some of the other classification systems, this is the one that is most commonly used and should therefore be the standard classification system. Due to physician subjectivity, there will still be some differences, but overall this is the best practice.

There is then the issue of determining which treatment is the best treatment plan. Based on research, it seems that internal fixation with palmar locking plates produces the best outcomes. Although there is the possibility of complications, new treatment methods such as minimally invasive techniques and the implantation of antibiotic-coated devices reduce these complication rates.

Sources

Song, X., Sun, Z., & Wei, X. (2014). Minimally invasive plate osteosynthesis for distal radius fractures. Indian Journal of Orthopaedics. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3931148/


Bahari-Kashani, M., Taraz-Jamshidy, M. H., & Rezazade, J. (2013). Outcomes of Pin and Plaster Versus Locking Plate in Distal Radius Intraarticular Fractures. Trauma Monthly. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860657/
Belloti, J. C., Faloppa, F., Neto, J. R., & Ynoe de Moraes, V. (2014). Treatment of reducible unstable fractures of the distal radius: randomized clinical study comparing the locked volar plate and external fixator methods: study protocol. BioMed Central Musculoskeletal Disorders. Retrieved from http://www.biomedcentral.com/content/pdf/1471-2474-15-65.pdf

Cecilia-Lopez, D., Jorge-Mora, A. A., & Resines-Erasun, C. (Dec 2012). Comparison Between External Fixators and Fixed-Angle Volar-Locking Plates in the Treatment of Distal Radius Fractures. Journal of Hand and Microsurgery. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509289/

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(March 2014). Internal Fixation for Fractures. American Academy of Orthopaedic Surgeons OrthoInfo. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=A00196



(March 2013). Distal Radius Fractures. American Academy of Orthopaedic Surgeons OrthoInfo. Retrieved from chttp://orthoinfo.aaos.org/topic.cfm?topic=A00412

Note

I believe that this piece of writing would fit well in a professional portfolio because it addresses a scholarly audience. I also think it is a topic that needs to be addressed by professionals in the field in order to determine a standard protocol for orthopedic injuries such as the one discussed here.

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