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.