Distal Radius Fractures

Evidence-Based Management

Geert Buijze, Jesse Jupiter, Michel Chammas

• Éditeur: Elsevier
• Année: 2021
• ISBN:
  9780323757652
• Sujet: Médecine
• Sous-sujet: Orthopédie

Edited and authored by leading international experts, Distal Radius Fractures: Evidence-Based Managementprovides a state-of-the-art overview of diagnosis and management based ontoday'sbest practices. Each chapter focuses on one key issue, offering a challenging case and thenquestioning the reader in an engaging fashionto provide the best available evidence on each topic.Practical and easy toread, this innovative text is a useful resource for all residents, physicians and surgeons who manage fractures.

• Combines current best practices with the knowledge and experience of a global team of expert contributing authors, with a focus onpractical use in applying the evidence.
  
  

• Coversneed-to-know topicssuch as anatomy and biomechanics, diagnostic management, acute fracture management, management of pediatric and elderly fractures, and more.
  
  

• Includes valuablecase scenarios, technicaltips and tricks, andpearls and pitfalls.
  
  

• Featureshigh-quality illustrationsincluding CT scans, x-rays, and clinical photographs.
  
  

• Consolidates the latest evidence on distal radius fractures intoone convenient resource.
  
  

Section IV

Acute Fracture Management

Chapter 7: Closed Reduction and Immobilization of Displaced Distal Radius Fractures

Hyoung-Seok Jung; Jae-Sung Lee Department of Orthopedic Surgery, Hospital of Chung-Ang University of Medicine, Seoul, Republic of Korea

Abstract

Despite the popularity of surgical treatment, most displaced distal radius fractures (DRFs) are initially managed with closed reduction and immobilization. What is the most effective technique for closed reduction and immobilization in the treatment of DRFs? Here, we tried to describe the optimal methods based on the evidence. In terms of the reduction technique, hematoma block is able to be recommendable, while reduction using finger-trap traction does not seem to be effective comparing manual reduction. Immobilization with a sugar tong or above-the-elbow splint is equivalent to a short-arm splint for maintaining the reduction. The evidence of the benefit of repeating reduction in DRFs is insufficient.

Keywords

Close reduction; Immobilization; Displaced distal radius fracture

Key Points

• • Despite the popularity of surgical treatment, most displaced distal radius fractures (DRFs) are initially managed with closed reduction and immobilization.
• • Radiological outcomes were not significantly different between mechanical reduction using finger-trap traction and manual reduction.
• • Compared to procedural sedation, local anesthesia (hematoma block) is a safe and effective alternative anesthesia for reduction of DRFs, which provides excellent pain relief in adult and pediatric patients.
• • Immobilization using a sugar-tong or above-the-elbow splint is equivalent to a short-arm splint for maintaining the reduction and quality of molding has more influence on maintaining reduction than the length of the cast.
• • The evidence of the benefit of routinely repeating reduction or routine preoperative reduction in DRFs is insufficient
• • Repeated reduction should be reserved for experienced teams in selected patients, such as those with minimal comminution, those who fail to get appropriate reduction due to inadequate anesthesia or those who have relative contraindications to surgery.

Panel 1: Case Scenario

A 46-year-postmenopausal woman visited the emergency department with a swollen and deformed right wrist after falling on an outstretched hand. Radiographs showed a displaced distal radius fracture with a 40 degrees dorsal angulation and metaphyseal comminution (Fig. 1). How is her fracture most effectively reduced and maintained?

Fig. 1 Radiographs showing an extraarticular displaced distal radius fracture: (A) anteroposterior view. (B) Lateral view.

Importance of the Problem

Distal radius fractures (DRFs) are a common orthopedic condition among adults and high incidence is reported worldwide.^1–3 Multiple treatment options are available for patients with DRFs, including cast immobilization, percutaneous pinning, external fixation, and open reduction with internal fixation (ORIF) using a plate. The optimal choice depends on several factors such as patient age, fracture pattern, displacement, fracture instability, and surgeon preference. Over the recent decades, surgical approaches such as ORIF have been increasingly used.^{2, 4, 5} Despite the popularity of ORIF, most displaced DRFs are initially managed with closed reduction and subsequent orthosis. Closed reduction of DRFs is commonly performed in the emergency department to obtain acceptable fracture alignment and maintain stability. In some cases, two or more reduction attempts are performed to achieve these goals.⁶

Main Question

What is the most effective technique for closed reduction and immobilization in the treatment of DRFs?

Current Opinion

The initial management of DRFs typically consists of closed reduction and immobilization in the emergency department. The quality of reduction can influence definitive management; thus, some authors have suggested that significant efforts should be made to obtain anatomical reduction when possible. Therefore, a combination of closed reduction and cast immobilization remains a preferred treatment option in most cases. However, the optimal method for closed reduction remains to be determined.

Closed reduction of a fracture is considered acceptable when the following radiologic conditions are obtained: radial inclination ≥ 15 degrees, loss of radial height ≤ 5 mm, dorsal angulation ≤ 15 degrees and palmar angulation ≤ 20 degrees.⁷ The classic method of closed reduction for DRFs requires two people pulling in opposite directions to produce and maintain longitudinal traction. This is termed manual reduction. The mechanical methods of reduction usually include the use of “finger traps.” In fi...