Summary of Audit Standards

 

Emergency Department

Anaesthesia techniques for manipulation

The GDG supports the NICE guidelines to consider intravenous regional anaesthesia (IVRA) when reducing dorsally displaced DRFs in adults (16 or over) in the emergency department. This should be performed by healthcare professionals trained in the technique, not necessarily anaesthetists.  However, as there are known complications of IVRA, if suitably qualified and trained personnel are not available to perform IVRA, then haematoma block is a safe and viable option to reduce the fracture. The use of gas and air (nitrous oxide and oxygen) on its own is not recommended.  Given that IVRA, through superior pain relief when compared to haematoma block, allows the manipulator to achieve a better quality of fracture reduction, when clinically appropriate patients should be offered the opportunity to wait up to 72 hours for availability of suitably qualified personnel.

 

Does manipulation affect functional outcome?

Manipulation may not improve outcome in patients aged 65 years or older with moderately displaced fractures.

 

Full cast versus back slab immobilisation?

Immobilisation can be adequately achieved by either the use of a full plaster of Paris (POP) cast or a back slab depending on the expertise of the personnel carrying out the application of the splint and the preference of the patient.  The GDG recommends that the patient is provided with a written care sheet with emergency contact numbers as per Fracture Clinic Services BOAST guidelines.

 

The effect of Vitamin C in preventing complex regional pain syndrome?

Vitamin C is not recommended for the prevention of CRPS in patients with distal radius fractures. 

 

Which radiological parameters affect functional outcome?

There is insufficient evidence to demonstrate an association between any measured radiological parameters and patient rated outcome. As most practitioners currently use radiological parameters in their decision-making a Delphi study of experts in the treatment of distal radius fractures was carried out. The panel of experts agreed that in patients under the age of 65 years, ulnar variance and dorsal tilt are the most important extra-articular parameters whilst the presence of the step is the most important intra-articular parameter. Seven patient factors were considered important in the decision making regarding surgery and rank order of importance was agreed.

 

Fracture Clinic

Risk factors for re-displacement?

Elderly patients with a DRF that is displaced on their initial films and/or have comminution are likely to be at increased risk of re-displacement. If this re-displacement could affect management more vigilant follow-up in clinic may be required.

 

Does this fracture need a plaster cast?

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?

When using a moulded plaster cast or back slab to treat a distal radius fracture, the wrist should be positioned in neutral flexion with three-point moulding used to hold the fracture, rather than forced palmar flexion.

 

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

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

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

The GDG agreed that this represented a balanced approach between the risk of further radiographic displacement and earlier return to function.

 

Will the anxious patient recover less well

No recommendation can be made regarding this issue on the currently available evidence. Best practice recommendation is that patients who seem more anxious or concerned following a distal radius fracture are followed more closely to provide adequate support whilst recovering from their injury.

 

Radiographs at the time of removing immobilisation?

A radiograph of the patient’s wrist at the time of removing immobilisation is not required unless there is clinical concern.

 

Surgery

Timing of surgery

When surgery is indicated, the patient is best served by prompt intervention by an appropriately trained surgeon, as delay confers no benefit to the patient’s recovery. Surgical intervention should be performed within 72 hours of injury for intra-articular fractures and within one week for extra-articular fractures. When operative management is required for re-displacement following manipulation, surgery should be undertaken within 72 hours of the decision to operate. The patient must be fully involved in the decision to operate and informed of all common options, recommended guidelines and potential risks.

 

Non-operative versus operative management

In patients 65 years of age or older, non-operative treatment can be considered as a primary treatment for a displaced distal radius fracture.  However, other factors such as activity level, medical comorbidities and fractures characteristics should be considered and discussed with the patient.

 

Manipulation under anaesthesia with K-wires versus open reduction and internal fixation

When surgery is needed for dorsally displaced distal radius fractures that can be reduced closed, offer K-wire fixation and cast. For DRFs that require open reduction, or for those with an intra-articular step or gap which cannot be reduced closed, open fixation can be considered.

 

External fixation versus open reduction and internal fixation

External fixation should not be used as the definitive treatment of closed DRFs where open reduction and internal fixation of the fracture fragments is possible.

 

Concomitant distal ulnar styloid fracture management

Stability of the distal radio-ulnar joint (DRUJ) should be assessed and recorded after surgical treatment of distal radius fractures. In the presence of a DRF with a clinically stable DRUJ it is not necessary to surgically fix an ulnar styloid fracture. 

 

Rehabilitation

The impact of providing rehabilitation during the immobilisation period

The impact of providing rehabilitation after definitive treatment implementation (surgically and non-surgically managed patients)

Information regarding the signs and symptoms of common complications should be given along with a simple self-directed management plan. Patients should be provided with advice and education to manage pain and oedema and to prevent loss of limb motion. Immobilisation should allow for a full fist with the fingers. The patient should be encouraged to use the injured limb for light functional activities. Patients with disproportionate levels of pain, oedema, loss of movement or delayed functional recovery should be referred to the hand therapy for further treatment.

 

The type of rehabilitation intervention

The mode of rehabilitation delivery

The discipline of the rehabilitation provider

Patients who have ongoing pain, loss of movement and/or delayed functional recovery should be referred for rehabilitation.  This should be delivered by a health care specialist with the appropriate level of knowledge and skills to address complications including complex regional pain syndrome. Choice of intervention should consider the patient’s roles and responsibilities and physical impairments. Education and rehabilitation programmes should be delivered in a timely manner and in a variety of forms to suit the patient’s specific needs.

 

Outcome Measures

There is insufficient evidence to recommend the optimal Patient Reported Outcome Measure (PROM) for capturing outcome in studies of adult patients with DRFs. However, pending future research, an interim recommendation can be made for the use of either the PRWE or the DASH, based on available evidence for responsiveness in this setting.

 

Conclusions

The view of the GDG is that the management of DRFs is based on patient factors. The personality of the fracture, the patient’s views and the experience of the clinician are all factors that should be considered in the decision to treat either non-operatively or by surgery.  In each case the patient needs to have an informed discussion on the treatment options but it may be acceptable to avoid operative treatment of moderately displaced fractures in selected older patients. All patients should receive information regarding expected functional recovery and rehabilitation, including advice about return to normal activities such as work, education and driving. Patients should be able to self-refer to the Fracture Service if progress is not as anticipated and Hospitals should provide this mechanism.