Fracture Clinic

The aim is to review whether the degree of initial radiographic displacement affected the likelihood of a DRF to displace over time. Radiographic outcomes were used in this review rather than functional outcome scores.

Review Question

Are patients with displacement on their initial radiographs and whose fractures are reduced more likely to displace than those whose fractures are not displaced on presentation?

Evidence

A total of 22 papers were reviewed for this question all of which were case series.

11 papers met the inclusion criteria.  View here.

Evidence Statement

Level 3:

All 11 studies included found that initial displacement increased the chance of later displacement of a DRF.

Recommendation

Grade of recommendation: Grade D

Patients with a DRF that is displaced on their initial films may merit more vigilant follow up in clinic after reduction as they are at increased risk of subsequent re-displacement.

Re-displacement and age of patient

Introduction

The aim is to review whether patient age affected the likelihood of a DRF to displace over time. Radiographic outcomes were used in this review rather than functional outcome scores.

Review Question

Are DRFs in patients over 50 years of age more likely to displace again than those under 50 years of age?

E

vidence

A total of 15 papers were reviewed for this question all of which were case series.

Ten met the inclusion criteria. View here.

Evidence Statement

Level 3:

All ten studies included found that increasing age increased the chance of later displacement of a DRF.

Recommendation

Grade of recommendation: Grade D

Elderly patients with a DRF may merit more vigilant follow up in clinic as they are at increased risk of displacement if treated non-operatively.  

Re-displacement and comminution

Introduction

The aim is to review whether radiographic comminution predicted the likelihood of DRF displacement over time. Radiographic outcomes were used in this review rather than functional outcome scores.

Review Question

Are those with radiographic signs of comminution more likely to displace than those without?

Evidence

A total of 19 papers were reviewed for this question all of which were case series.

Seven papers met the inclusion criteria.  View here.

Evidence Statement

Level 3 evidence.

Five of the seven studies included found that comminution correlated with final radiographic outcome.  

Recommendation

Grade of recommendation: Grade D

Patients with a comminuted DRF may merit more vigilant follow up in clinic as they are likely to be at increased risk of subsequent displacement if treated non-operatively.

Does this fracture need a plaster cast?

Introduction

The aim is to review whether fractures which were deemed by the treating surgeon to be stable would be better treated in a plaster or a removable splint.

Review Question

Is the functional outcome better with the use of a removable splint compared to standard plaster immobilisation?

Evidence

A total of 11 papers were reviewed for this question.

Four papers met the inclusion criteria.  View here.

Evidence Statement

Level 1:

Early functional scores better with removable splint but no difference in later scores.

Recommendation

Grade of recommendation: Grade B

Patients with a stable fracture of the distal radius should be considered for early mobilisation with a removable support once pain allows.

In what position should a fractured distal radius be immobilised?

Introduction

The aim is to review the evidence for immobilising the fractured distal radius in any particular wrist position.

Review Question

Is the functional outcome better with a POP cast holding the wrist in neutral flexion compared to a POP cast holding the wrist in palmar flexion?

Evidence

A total of two papers were reviewed for this question.

Both failed to meet the inclusion criteria.

Evidence Statement

No evidence.

Recommendation

Best Practice Point:

When using a moulded POP cast or back slab to treat a DRF the wrist should be in neutral flexion with three-point moulding used to hold the fracture, rather than forced palmar flexion. This is supported by evidence that a palmar flexed position increases pressure in the carpal tunnel. In addition, a wrist that becomes stiff in palmar flexion is functionally less useful than one that is stiff in neutral or dorsiflexion. Reference: view here.

Should further radiographs be taken at 2-3 weeks following injury?

Introduction

The aim is to review whether radiographs of the wrist at two to three weeks following injury influenced the functional outcome of the patient.

Review Question

Do radiographs at two to three weeks following injury compared with no radiographs at that time, affect the patient reported outcome/functional outcome of the patient?

Evidence

No evidence.

Evidence Statement

No evidence.

Recommendation

Best Practice Point:

No evidence can be found to support a benefit of radiographs at 2-3 weeks, but, as a best practice point, the GDG recommend repeat radiographs of the wrist between 1-2 weeks after injury (or manipulation) where it is thought that the fracture pattern is unstable AND when subsequent displacement will lead to surgical intervention.

When should Immobilisation be discontinued?

Introduction

The aim of this question was to review the evidence regarding the best time to discontinue immobilisation of the wrist following a DRF.

Review Question

In patients with an unstable DRF is the functional outcome better if wrist mobilisation starts four weeks after the injury or six weeks after the injury?

Evidence

A total of five papers were reviewed for this question.

None of the studies met the inclusion criteria.

Evidence Statement

No evidence.

Recommendation

Best Practice Point:

When using a plaster cast to treat a DRF, consideration should be given to removing the plaster and starting wrist mobilisation four weeks after the injury rather than six.

The GDG felt this represented a balanced approach between the risk of further radiographic deterioration and earlier return to function.

Will the anxious patient recover less well?

Introduction

The aim is to review whether anxiety or catastrophising scores affected the functional recovery after a DRF.

Review Question

Does a high catastrophising/anxiety score affect the functional outcome?

Evidence

A total of ten papers were reviewed for this question.

One paper met the inclusion criteria. View here.

Evidence Statement

Level 3 evidence.

No correlation between anxiety and catastrophising scores and poor functional outcomes after DRFs was found in the one study included.

Recommendation

Best Practice Point:

No recommendation can be made regarding this issue on the currently available evidence. Best practice would suggest that patients who seem more anxious or concerned following a DRF are given adequate support whilst recovering from their injury.

Radiographs at the time of removing immobilisation

Introduction

The aim of this question was to determine whether radiographs of the wrist at the time of removing immobilisation for a non-operatively managed DRF influence the patient reported or functional outcome of the patient.

Review Question

How do radiographs at the time of removing immobilisation, compared with no radiographs at this time, affect the patient reported outcome?

Evidence