Distal Radius Fracture
– Treatment, Complications, and Risk Factors for Re-operation.
Version 3Author: Alexandra Pickett, MB,
School of Medical Sciences Örebro University Örebro Sweden
Supervisor: Per Fischer, MD PhD,
Department of Orthopedics Hand surgeon CSK Karlstad Sweden Degree Project, 30 ECTS June 3, 2020
Word count Abstract: [247] Manuscript: [2235]
Abstract
Introduction: Distal radius fractures (DRF’s) are one of the most common types of fractures,
especially in elderly women. In the last decade, there has been a shift in the treatment method employed for DRF’s from the traditional non-operative to an operative method using plates and screws even though there is no evidence to suggest that this method has superior outcomes.
Aim: The primary objective of this study was to identify risk factors for complications and
re-operations in the treatment of DRF’s.
Method: The study was designed as a retrospective cohort study. Patients treated for DRF’s
between 2016-2017 were included through the Swedish Fracture Register and complemented with the patients’ charts and classification of X-Ray Images from The Orthopedic Clinic at The Central Hospital in Karlstad. The risk for re-operation was valued through treatment methods and fracture classification and presented as Odds Ratio.
Result: Positive ulnar variance was correlated to having an increased risk for re-operation, OR
4.8 (95% CI 1.7-13.8). Those who had volar comminution in their fracture had a greater risk for re-operation, OR 12.4 (95% CI 4.6-34.1, p<0.001), but also a greater risk for corrective
osteotomy, OR 12.6 (95% CI 1.4-113.9, p=0.024).
Conclusion: Volar comminution and positive ulnar variance are associated with an increased
risk for re-operation. However, the degree of the risk is difficult to measure due to the low incidence of re-operations.
Abbreviations
AO classification - Arbeitsgemeinschaft für Osteosynthesefragen
AP view – Anteroposterior view
CRPS – Complex Regional Pain Syndrome CSK – Central Hospital in Karlstad Sweden CTS – Carpal Tunnel Syndrome
DRF – Distal Radius fracture EF – External Fixation
Introduction
Distal radius fractures (DRF’s) are one of the most common types of fractures, slightly more common in the left wrist [1,2]. The incidence varies with age and gender. It is more common in young males due to sports-related injuries and high-energy trauma usually resulting in intra-articular fractures. It is also common in elderly women due to osteoporosis after low-energy trauma usually resulting in extra-articular fractures [2–6]. The most common cause of injury in adults is falling with an outstretched arm, due to the primitive motor reflex that activates when falling to ultimately protect the skull [2,7,8].
The Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification is the most widely used system today when classifying DRF’s [9]. It divides DRF’s into type A1-A3 (extra-articular), type B1-B3 (simple articular), or type C1-C3 (complex articular), with each fracture type consisting of 3 subtypes (i.e. A2.1, A2.2, A2.3) [10]. Radiographic measurements that can be examined include dorsal/volar angulation, fracture comminution (when the bone is broken into more than two pieces), ulnar variance (ulna’s height in comparison to radius), and fracture type when viewing lateral and anteroposterior (AP) X-ray images when assessing treatment method [11].
Treatment methods can either be non-operative or operative. There is no gold standard treatment or strong evidence suggesting when and if to recommend one method of treatment over the other [12]. If non-operative treatment, re-evaluation of the fracture is usually performed with a weekly X-ray to assess fracture stability [13]. Indications for surgery include several variables apart from the fracture itself such as age, hobbies, co-morbidities, mental state, and dominant hand. E.g. elderly patients who receive non-operative treatment without reduction have a poorer
radiographic outcome, but this seems to not effect functional outcome [14]. Most importantly, the patient’s wishes must be emphasized, further complicating the decision of operative or non-operative treatment. However, some factors have been correlated with bad outcome, including positive ulnar variance >2mm in adolescents or >5mm in elderly patients, presence of fracture comminution (especially volar), dorsal angulation over 15 degrees or volar angulation of 20-30 degrees, making them more susceptible for secondary displacement, suggesting surgical
Several operative treatment methods are available. External fixation (EF) is mostly used in elderly patients since screw fixation can be challenging due to osteoporotic bone [12]. Pinning is another operative treatment method that can be used in unstable AO type A and C1-2 fractures [22]. In the last decade, there has been a shift from external fixation (EF) and/or pinning to plate and screw fixation, although this treatment method has not shown to be superior to the other [3]. Furthermore, plating is the most common surgical treatment method that requires re-operations due to complications [14].
It is of great importance to conduct studies like this to benefit future patients treated for DRF’s by investigating differences in fracture types, treatment methods employed, and associated complications and re-operations in patients receiving various treatment methodologies.
Objective Aim
The primary objective of this study was to identify risk factors for complications and re-operations in the treatment of DRF’s.
Hypothesis
Fracture type and treatment methods have an impact on the risk for complications and re-operation.
Materials and method Study Design and Ethics
This study has a retrospective cohort design. The study was performed as an internal quality control at the Orthopedic Clinic CSK. Therefore, an ethical application and patient consent was not needed.
Subjects
The study included patients who had sustained DRF’s between January 1, 2016 and December 31, 2017, both men and women. Patients younger than 18 years were excluded. Patients were
divided into two subgroups, since the mechanism of injury and bone quality may differ, one consisting of those under the age of 65 and the second group represented those 65 years or older. If one subject had obtained bilateral fractures, they were considered as two separate fractures. The patients were discovered using The Swedish Fracture Register and data was complemented by studying the patients’ digital charts using Cambio COSMIC®. Study data included mechanism of injury, fracture classification, treatment method, complications and re-operations. Pain as a complication was defined as persistent pain more the 3 months post treatment. The definition of high- and low-energy trauma was obtained from The Swedish Fracture Register [23].
Classification
Radiographic analysis of both lateral and AP projections using Sectra (Sectra Workstation IDS7, version 19.3, Linköping, Sweden) was performed to classify the fractures into groups using the AO classification system (Figure 1) [24]. The only fractures that were classified as a subtype were the A2 fractures. Radiographic measurements that were obtained included ulnar variance, dorsal/volar angulation, and dorsal/volar comminution (Figure 2) and were considered before treatment using the Medoff method [25]. All fractures were classified by one observer (the author of this study).
Statistics
In an effort to accurately measure and report findings of the sample population and draw meaningful conclusions of the data collected, we used a logistic regression modeling with re-operation as outcome. Results are presented as odds ratios (OR) with 95% confidence intervals (CI), adjusted for age and sex. A p-value under 0.05 was considered significant. Statistical analysis was done using SPSS (IBM SPSS Statistics, version 26, Armonk, NY, USA). All other results are presented as total and percentages. Excel (Microsoft®, version 2019, Redmond, WA, USA) was used to design the tables and figures.
Results
Subjects
A total of 637 DRF’s were included in the study, with the majority being women (79.9%). Mean age the time for injury was 62.1 years (range 18-97). The most common cause of injury was due to low-energy trauma, with the most common location being at home or outdoors, and more
common in the left wrist (Table 1). Among the fracture types, A2.2 was the most common fracture. A2.1 (no displacement) was the leading fracture in patients <65, vs A2.2 (Dorsal displacement) in patients >65 (Figure 3). Seventeen patients were lost to follow-up due to unrelated death.
Table 1. Patient demographics (n=637). Variables Total (%) Sex Male Female 128 (20.1%) 509 (79.9%) Side Left Right 372 (58.4%) 265 (41.6%) Dementia Yes No 47 (7.4%) 590 (92.6%) Trauma High-energy Low-energy 14 (2.2%) 623 (97.8%) Mechanism of injury Home/outdoors Sports Traffic Nursing home Hospital 511 (80.2%) 49 (7.7%) 41 (6.4%) 33 (5.2%) 3 (0.5%)
Figure 3. AO fracture types A (extra-articular), B (simple articular), and C (complex articular) in different age groups.
Treatment method
Non-operative treatment with cast immobilization was the leading treatment choice (40%). The decision to treat operatively occurred more frequently on the date of injury compared to the weekly X-ray control (5%). Plating and pinning were more common in patients <65 years. All EF surgeries were performed on patients >65 years (Table 2).
Table 2. Non-operative (n=460) and operative (n=177) primary treatments in different age groups.
Primary Treatment Age <65 (%) Age >65 (%) Total (%) Non-operative
None Cast
Cast with reduction
2 (0.6%) 140 (43.5%) 69 (21.4%) 3 (1.0%) 115 (36.5%) 131 (41.6%) 5 (0.8%) 255 (40.0%) 200 (31.4%) Operative Plating External Fixation Pinning 93 (28.9%) 0 (0.0%) 18 (5.6%) 52 (16.5%) 7 (2.2%) 7 (2.2%) 145 (22.8%) 7 (1.1%) 25 (3.9%)
Complications and Re-operations
A total of 60 complications (9.4%) were reported by the patients, with the leading complication being pain, (Table 3). A total of 23 patients (3.6%) underwent a re-operation (Table 4). Fracture types C2 (p = 0.023) and C3 (p = 0.009) were the most common fractures that lead to
re-operations, p = 0.023 and 009 respectively. The most common re-operation was extraction of osteosynthesis (47.8%). Positive ulnar variance was correlated to having an increased risk for re-operation, OR 4.8 (95% CI 1.7-13.8), adjusted for age and sex. Presence of volar comminution was also correlated with a greater risk for re-operation, OR 12.4 (95% CI 4.6-34.1, p<0.001), but also a greater risk for corrective osteotomy, OR 12.6 (95% CI 1.4-113.9, p=0.024). Out of all re-operations, 5 were corrective osteotomies of the radius, where of 3 had received non-operative primary treatment. Four of the corrective osteotomies were performed on patients with fracture type A3 or C3, both defined with comminution of the Radius metaphysis. There was also a greater risk for re-operation if the patients’ primary treatment was plating, OR 17.8 (95% CI 4.1-77.9), with the most common re-operation being extraction of the plate and screws (61%). Some patients who received non-operative treatment with reduction and cast immobilization as their primary treatment, suffered complications followed by re-operation although statistically non-significant, OR 1.9 (95% CI 0.32-11.7). Only 1 participant underwent a second re-operation (arthrodesis) due to pain and persistent volar subluxation of the radiocarpal joint.
Table 3. Complications (n=60) that were reported by the patients.
Complication n (%)
Extensor tendon rupture 3 (5.0%) Pain resulting in osteosynthesis
extraction 11 (18.3%) Osteosynthesis failure 1 (1.7%) Pain 38 (63.3%) CRPSa 1 (1.7%) CTSb 4 (6.7%)
Flexor tendon rupture 1 (1.7%) Wrong placement of osteosynthesis 1 (1.7%)
aComplex Regional Pain Syndrome bCarpal Tunnel Syndrome
Table 4. Re-operations in relation to the treatment method that the patient received. Re-operation Cast without
reduction
Cast with reduction
Plating Total (%)
Radius Osteotomy 0 3 2 5 (0.8%)
Carpal Tunnel release 2 0 0 2 (0.3%)
Extraction osteosynthesis 0 0 11 11 (1.7%)
Flexor tendon transfer 0 0 1 1 (1.6%)
Extensor tendon transfer 0 0 2 2 (0.3%)
Re-osteosynthesis 0 0 2 2 (0.3%)
*Total(%) are those patients who underwent a re-operation out of the entire study group. Plating was the only surgical method that lead to re-operations, therefore the other methods are not included.
Discussion
Overall, the frequency of re-operation following treatment of DRF’s was low in this study (3.6%). Fracture types C2 and C3 (complex articular) were the most common fractures resulting in re-operation. Radiographic findings of positive ulnar variance and volar fracture comminution were correlated to having an increased risk for re-operation in this study. These results are consistent with previous studies showing that positive ulnar variance and fracture comminution are correlated with a bad outcome [15,26].
Fracture types C2 and C3 were the most common fractures resulting in re-operation, however this was probably due to the fact that they were the most common fracture types treated
operatively with plates and screws. Extraction of osteosynthesis material was the most common cause of re-operation. Four out of five radius osteotomies were performed following C3 and A3 fractures, with three treated non-operatively. These results are consistent with the fact that presence of fracture comminution is correlated with a bad outcome and therefore an indication to treat operatively [26].
A total of 60 complications were reported, with the leading complication being persistent pain, but only one case of complex regional pain syndrome (CRPS). The results may be misleading
however due to the risk that not all complications are reported by the patient, or the possibility that the treating physician may not have documented the complications properly.
DRF’s occurred more often in women (79.9%) than men, with the mean age being 62.1 years (including both men and women). The most common mechanism of injury was due to low-energy trauma after falling at home or outdoors and more common in the left wrist. These results found in patient demographics are consistent with previous results; that DRF’s are more common in elderly women due to osteoporosis, with the most common mechanism of injury being low-energy trauma after falling with an outstretched arm, and slightly more common in the left wrist [1–8]. The most common fracture subgroup were type A fractures. This also correlates with previous studies; that most low-energy trauma results in type A (extra-articular) fractures [2–6]. Patient demographics such as age, dementia, date of death, and the mechanism of injury (nursing home and hospital) were included in this study since these factors play a role in the treatment plan. E.g. patients might have sustained a fracture where one can predict a poorer radiographic outcome if treated non-operatively, but still have a good functional outcome and therefore received conservative treatment due to variables such as co-morbidities, mental state, and low life expectancy and therefore not an indication to treat operatively, as discussed earlier [14]. The same fracture in a younger patient would most likely receive an operative treatment.
DRF’s are one of the most common fractures. However, there is no gold standard treatment and currently no strong evidence suggesting when and if to recommend non-operative or operative treatment. In this study, the most common treatment choice was non-operative treatment with a cast and immobilization and the most common fracture type was extra-articular type A. EF was only performed on patients over the age of 65, which is consistent with previous studies that EF is mostly used in elderly patients due to osteoporosis and difficulties in achieving fragment specific fixation [12]. The most common surgical method used was plating and the most common complication was extraction of plates and screws. These results are consistent with previous studies that show that plating is the most common surgical method that requires re-operations due to complications [14].
Non- operatively treated DRF’s are typically followed up with a weekly radiograph to monitor any displacement [13]. Out of those that were followed up with a weekly X-ray in this study, only 5% were converted from non-operative treatment to operative treatment due to secondary displacement. These results are an interesting finding since one can question the importance of having to follow up patients with a weekly X-ray since only a small percentage of them changed treatment plans. Roth et al [27] found that non-displaced DRF’s appeared to be inherently stable, questioning the need for weekly radiographic follow-up in these cases.
The AO classification system was used in this study since it is the most widely used system today and since the Swedish Fracture register also uses this system [9]. When classifying DRF’s, doctors look at X-ray images, both AP and lateral projections, using the measurements that were discussed earlier [11]. Every doctor classifies DRF’s depending on their experience, playing a role in the accuracy of the classification system due to interobserver reliability. Due to this concern, only one observer classified all DRF’s and made all of the radiographic measurements in this study after much practice with a hand specialist.
One of the strengths of this study is the fact that there was only one observer, therefore strengthening the accuracy of the results. One of the limitations of this study was the small sampling size of patients, which resulted in a low incidence of re-operations and therefore not being able to draw meaningful conclusions. Additional limitations include the accuracy of the radiographic measurements due to lack of experience of the observer and the retrospective design of the study.
In summary, the number of re-operations was low in this study, supporting the current treatment regime for DRF’s. However, since data regarding other outcome measurements such as patient-reported outcome measures, hand grip-strength, and range of motion were not available, we could not assess the functional outcome. According to the results in this study, there was a greater risk for re-operation when comparing different fracture types and treatment methods, therefore supporting the hypothesis that fracture type and treatment methods have an impact on the risk for complications and re-operation. Even though some of the results were statistically
significant, they may not be relied upon scientifically due to the fact that there were only a total of 23 patients that underwent a re-operation, therefore a larger sample size is needed.
Conclusion
Volar comminution and positive ulnar variance are associated with an increased risk for re-operation and the presence of volar comminution is also associated with an increased risk for corrective osteotomy. The low incidence of re-operations suggest that the current treatment protocol for DRF’s is effective and therefore study results do not support changing the current treatment plan. However, the degree of the risk is difficult to measure due to the low incidence of re-operations and therefore needs to be investigated in a larger study.
Acknowledgements
I would like to give a special thanks to my supervisor Per Fischer for all of your help and support.
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Populärvetenskaplig Sammanfattning
Distal Radiusfraktur –
behandling, komplikationer, och riskfaktorer för reoperation.
Distala radiusfrakturer (handledsfrakturer) kan behandlas på flera olika sätt och det finns ingen gold standard eller starka bevis i dagsläget som tyder på när och om man ska rekommendera en behandlingsmetod framför den andra. Trots detta har det skett en övergång till att använda kirurgi med platta och skruv trots att studier visar att det är den vanligaste kirurgiska
behandlingsmetoden som leder till reoperationer på grund av komplikationer som till exempel smärta. Därför är det viktigt att bedriva fler studier som denna för att försöka kartlägga vilka frakturtyper och komplikationer som leder till reoperationer för att kunna hjälpa framtida patienter som drabbas av en handledsfraktur.
Denna studie inkluderade patienter som ådrog sig en distal radiusfraktur och som behandlades på Ortopedkliniken i Karlstad mellan år 2016-2017, totalt 637 frakturer. Av dessa var det endast 23 patienter som genomgick en reoperation på grund av någon komplikation. Studien motiveras utifrån den potentiella nyttan för framtida patienter som behandlas för en distal radiusfraktur.
Denna studie visar att volar kommunition (benet är brutet i fler än två delar) och positiv ulna varians (att ena underarmsbenet är högre än det andra) är förknippade med en ökad risk för reoperation. En större studiepopulation behövs för att kunna dra bättre slutsatser. Den låga incidensen av reoperationer talar för att de riktlinjer som finns idag gällande behandlingen av handledsfrakturer är välfungerande!
Alexandra Pickett M.B. Examensarbete 30hp
Läkarprogrammet Örebro Universitet Juni 2020
Dear Editor,
It would be greatly appreciated if you could find the time to read through the enclosed
manuscript below titled “Distal Radius Fracture – Treatment, complications, and risk factors for re-operation.” and consider it for publication in your journal.
We investigated a total of 637 patients treated for distal radius fractures (DRF’s) between 2016-2017 at The Orthopedic Clinic at the Central Hospital in Karlstad. One observer classified all fracture types using The Arbeitsgemeinschaft für Osteosynthesefragen (AO) Classification system after reviewing X-ray images. We found that Volar comminution and positive Ulna variance are associated with an increased risk for re-operation.
These findings are of importance due to the fact that there is currently no gold standard treatment for DRF’s or strong evidence suggesting when and if to recommend one treatment method over the other. And despite this, there has been a shift from external fixation and pinning to plate and screw fixation in the last decade even though studies show that plating is the most common surgical treatment method that requires re-operations due to complications. Therefore, it is of great importance to conduct studies like this to benefit future patients treated for DRF’s by investigating differences in fracture types, treatment methods employed, and associated complications and re-operations in patients receiving various treatment methodologies.
Thank you for your time.
Sincerely, Alexandra Pickett Bachelor of Medicine Örebro University Örebro Sweden May 7, 2020 The Journal of Hand Surgery
American Society for Surgery of the Hand 822 West Washington Boulevard
Chicago, IL 60607 USA
ETISK REFLEKTION
Studien är designad som en retrospektiv kohortstudie. Studien är en intern kvalitetskontroll på Ortopedkliniken på Centralsjukhuset i Karlstad, därför behövdes ingen etisk ansökan. Samtycke av patienterna behövde inte erhållas eftersom studien var utformad som en intern
kvalitetskontroll. Patienter som ådrog sig en distal radiusfraktur och behandlades på
Ortopedkliniken i Karlstad mellan 2016-01-01 t.o.m 2017-12-31 inkluderades med hjälp av Svenska Frakturregistret. Totalt 637 patienter inkluderades i studien som var över 18 års åldern, både män och kvinnor. Data kompletterades genom journalgranskning på alla patienter via Cambio Cosmic, enbart ortopedanteckningar granskades. Data som inhämtades inkluderade kön, ålder, trauma, skadelokalisation, behandlingsval, komplikationer, reoperationer, ev dödsdatum, och även namnet på ortopedkirurgen om patienten genomgick en operation. Sedan
klassificerades alla frakturtyper genom att granska röntgenbilder på samtliga patienter. Några etiska överväganden som kan medföra risker för deltagande inkluderar integritetsintrång. Till exempel att de ådrog sig en fraktur på grund av alkoholöverkonsumtion. Detta är personlig livsstilsinformation som respondenterna kan vara motvilliga att dela med sig av om de ges möjlighet. Åtgärder som vidtogs för att förebygga dessa risker var att begränsa information om patienterna genom att endast ge författaren tillgång till de ortopediska anteckningarna i
journalen, för att säkerställa att endast viktig information relevant för studien fanns tillgänglig. All data som samlades in sparades på ett externt USB-minne och förvarades på ortopedkliniken. Studien motiveras utifrån den potentiella nyttan för framtida patienter som behandlas för en distal radiusfraktur på Ortopedkliniken i Karlstad.
