Fragmentation can be a predictor for displacement in distal radius fractures

Study finds correlation, however one physician says the evidence doesn’t support the conclusion.

Issue: September 2009

Fragmentation was found to correlate with a higher degree of radiographic displacement in distal radius fractures in a study by Charles S. Day, MD, and colleagues.

However, reviewers of the study claimed that while it highlights an important research question, its findings could not be fully justified based on the data presented.

Working under the hypothesis that the presence of multiple fragments would lead to both a higher rate of displacement and a likelihood for operative management, the study was retrospective, covering 138 patients with distal radius fractures who presented at the Beth Israel Deaconess Medical Center Emergency Department between April 2002 and September 2004.

Radiographic data was collected on presentation, after initial treatment and finally at healing. Radiographic displacement was defined according to commonly used criteria, and Fisher’s exact and chi-square tests were used when comparing outcomes data.

Results and implications

“More fracture parts correlated with a higher percentage of displaced fractures at presentation,” Day said. “If initially displaced, operative fixation yields the highest radiographic success rate. After closed reduction treatment, the rate of secondary displacement correlates with an increasing number of fracture parts. Lastly, operative fixation was effective regardless of the number of parts at presentation.”

Fifty-three percent of two-part, 72% of three-part and 96% of more-than three-part fractures at presentation, were radiographically displaced. Eighty-one percent of closed reductions secondarily displaced after initial treatment, as compared to only 18% of operative fixations. Fractures with an intra-articular component displayed an even greater difference, with 83% displaced after closed reduction, compared to 8% after operative treatment.

Operative fixation was initially prescribed 8% and 14% of the time for two-part and more-than two-part fractures. Patients with secondary displacement after casting or closed reduction underwent successful follow-up operative treatment 63% and 80% of the time, respectively. Seventy-one percent of the two-part fractures that were initially displaced ended up secondarily displaced after closed reduction, as compared to only 33% that did so after operation. When more than two fragments were present, there was an 88% rate of displacement after closed reduction, as compared to only 13% after operation.

“If the goal is radiographic alignment, then displaced distal fractures with more than two parts should be considered for surgical management,” Day said.

An “unfounded” conclusion

Scott W. Wolfe, MD, praised the study for asking questions in an area where few answers previously existed, but added he felt its findings were not fully supported by the data presented.

“While it is certainly an interesting hypothesis and one that merits further study, unfortunately in the author’s submitted manuscripts, the conclusion that operative fixation leads to the highest degree of success and that loss of reduction correlated directly with fracture fragmentation could not be justified,” he said.

Wolfe added that it was difficult for the authors to demonstrate a correlation because “fully 80% of their closed reductions subsequently displaced.”

The most important question to be asked, Wolfe said, was that of which closed reductions were unstable and required operative treatment.

For more information:

Charles S. Day, MD, is an assistant professor of orthopedic surgery at Harvard Medical School. He can be reached at the Beth Israel Deaconess Medical Center, 330 Brookline Ave., Stoneman 10, Boston, MA 02215; 617-667-9750; e-mail: cday1@bidmc.harvard.edu.

Scott W. Wolfe, MD, is a professor of orthopedic surgery at the Weill Medical College of Cornell University, and can be reached at the Hospital for Special Surgery, 523 E. 72nd St., East River Professional Building, 4th floor, Vilar Hand Center, New York, NY 10021; 212-606-1529; e-mail: wolfes@hss.edu.

Reference:

Makhni MC, Kamath AF, Ewald T, Day CS. Fragmentation predicts displacement in treatment of distal radius fractures. Presented at the 63rd Annual Meeting of the American Society for Surgery of the Hand in Chicago, Illinois. Sept. 18-20, 2008.