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ERCAST


Welcome to ERCast, a focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

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Jul 8, 2011

How important is it to get a perfect reduction of a distal radius fracture in the ED? Is it even worthwhile?

Pro

-Pain is improved when a severely displaced fracture is reduced and immobilized.

-The ED has sedation capabilities that the orthopedist's office does not. If we can get good anatomic alignment in the ED and save a trip to the OR, we've benefitted the patient

-You are treating the patient for their presenting complaint

Con

-A significant portion of reduced fractures will fall out of reduction

-They are a huge time and resource sink. Time to reach NPO status keeps a bed occupied. The sedation and splinting involve multiple staff members. A nurse is taken away from other ED patients for as long as the patient needs close monitoring

-Many of these patients may not actually benefit from reduction.

Do you like to reduce Colles fractures? If so, have at it. They're one of my favorite procedures and I rarely pass up the chance. But there is no fault in splinting and referring to the orthopedist as long as the skin and neurovascular exam are intact. You just need to explain to the patient/family why you're not fixing a deformed wrist.

Written Summary:  Justin Arambasick MD  Akron General  Medical Center

Consult with Hans Moller, MD

Does a mild to moderate (< 35˚) nonarticular fracture of the distal radius have to be reduced?
Not necessarily. Many countries in Europe do no perform surgery or reduction on
these, and a variety of low powered studies have not shown functional benefit
in doing so.

Is there a benefit to doing an ED reduction?
Yes, patients whom have had a reduction in the ED and show up in the orthopedic
follow up clinic have in general better pain control and less skin changes.

When should a patient follow up with orthopedics after an ED reduction?
7-10days

Does intraarticular involvement necessitate a trip to the OR?
Not necessarily.  These fractures are at higher risk for subsequent arthritis, which can be mitigated by surgery (but not completely prevented). The problem with these is that the pieces of the fracture tend to drift apart, increasing the chance of an unfavorable outcome.

What is radial shortening?This refers to the length of the radius comparing the carpal articular surface of the ulna and the lunate fossa of the radius. A line drawn across the end of the ulna should be at the same level as the radial lunate fossa. If the lunate fossa is behind (proximal to) this line, the radius is shortened.

 Radial length

Radial Shortening (yellow arrow)

What is the purpose of finger traps?
To elongate the shortened radius. Hans prefers placing the thumb and
index finger in the trap and separating them by a 3 inch roll of Webril, thus
elongating the radius and providing ulnar deviation.  Place splint on while
still in trap.

What are the hallmarks of an adequate fracture reduction?
<2mm articular step off
<20 degrees of volar angulation
<3mm of radial shortening
With these parameters, the functional outcome should be the same as someone who has had surgery.  Surgery has quicker return to full function than casting.

Papers Discussed
Injury. 2010 Jun;41(6):592-8. Epub 2009 Dec 2.
The efficacy of closed reduction in displaced distal radius fractures.
Neidenbach P, Audigé L, Wilhelmi-Mock M, Hanson B, De Boer P.

J Bone Joint Surg Am. 2010 Aug 4;92(9):1851-7.
Distal radial fractures in the elderly: operative compared with nonoperative treatment.
Egol KA, Walsh M, Romo-Cardoso S, Dorsky S, Paksima N.