Keywords
distal radius fracture - fracture immobilization - volar plate - hand surgery - early
mobilization
Distal radius fractures are the most common fractures of the upper extremity[1]
[2] and can be a cause of significant morbidity and functional impairment when not properly
treated.[3] Operative fixation remains the principal method of treatment for unstable distal
radius fractures to achieve anatomic reduction of articular surfaces, stable fixation,
and subsequent early mobilization.[4] Open reduction and internal fixation (ORIF) of unstable distal radius fractures
has gained popularity over the last several years. Single volar fixed-angle constructs[5] as well as fragment-specific fixation[6] have demonstrated favorable outcomes with respect to earlier functional recovery
compared with external fixation and pinning techniques.[7]
[8] However, long-term results remain similar between different methods of fixation,[7]
[9]
[10] and larger meta-analyses, that have combined data from multiple studies to create
weighted, well-powered analyses of effects, have suggested little clinically significant
differences in outcomes.[11]
[12]
Distal radius fractures are particularly common in the elderly female population secondary
to the sequelae of osteoporosis.[13] Recently, more conservative management has been advocated in older patients with
lower functional demands. Studies have demonstrated that closed reduction and casting
have similar subjective and functional outcomes as ORIF in this population,[14]
[15] though these fracture patterns traditionally would warrant operative fixation.
Many aspects of the postoperative care of unstable distal radius fractures are also
evolving. Early mobilization has long been a mainstay of fracture treatment after
acceptable fixation.[16] Reported lengths of rigid immobilization after operative fixation vary significantly
in the literature, ranging from no immobilization,[17]
[18] to other arbitrary lengths such as two[19] and four weeks.[20] Accelerated active motion protocols have also been suggested to improve return to
function[21]; however, studies are conflicting on the functional benefits of earlier therapy.
Despite well-established principles for the treatment of unstable distal radius fractures,
several aspects in the continuum of management of these injuries remain unclear, particularly
with regard to postoperative mobilization of fixated fractures and treatment within
specific patient populations. The purpose of this study is to investigate the state
of treatment of unstable distal radius fractures in the United States with regard
to operative fixation techniques, postoperative immobilization, and conservative management
in patients with lower functional demands by means of surveying fellowship-trained
hand surgeons. Additionally, this study serves to compare these practices to current
evidence-based protocols, or clinical recommendations supported by high-level research
studies. Obtaining a better understanding of the current management in the practicing
population will serve two purposes: (1) to assess the impact of recent studies advocating
changes in traditional treatment algorithms and (2) guide research that identifies
optimal postoperative management and helps standardize care.
Methods
Survey Instrument
An anonymous, 13-item, multiple-choice online research survey was developed by the
senior authors to query current practices of American Society for Surgery of the Hand
(ASSH) members with regard to operative fixation of unstable distal radius fractures,
postoperative immobilization and range of motion (ROM) therapy, and treatment of unstable
fractures in the elderly population. Study approval was obtained from the Institutional
Review Board (16–01394).
The survey consisted of three sections pertaining to (1) participant demographics,
(2) preferred methods of fixation, and (3) postoperative immobilization protocols
([Supplementary Figs. 1], [2], [3], available in the online version). Participant demographics included questions on
surgeon training, years in practice, and type of practice. Preferences for operative
fixation focused on preferred type of rigid fixation for operative distal radius fractures
defined as unstable fracture patterns and/or those with significant intra-articular
step-off. Questions on postoperative immobilization addressed type of immobilization
after operative fixation, length of rigid immobilization, and initiation of ROM therapy.
Questions also longitudinally addressed variance in protocols with volar fixed-angle
plate fixation and differing practices in the elderly population (>65 years old).
Contact information was obtained for all physician ASSH members. Individuals from
all training backgrounds and practice settings were included in the study. Respondents
were excluded if they were currently in residency or fellowship training and/or had
zero years of post-fellowship experience. An email was sent to all prospective study
participants twice over the period of 1 month with an invitation to complete the survey
on Google Forms (Google Inc., Mountain View, CA) via a directly embedded link.
Statistical Analysis
Descriptive statistics were examined for all respondents as well as for subgroups
of survey participants based on the number of years in practice (greater or less than
20 years of post-training experience), residency training background, and practice
setting (academic, private, etc.). Differences in response patterns among these subgroups
were analyzed using Pearson's chi-squared test with significance for the omnibus test
statistic set at an α = 0.05. When a significant p-value was obtained, raw, standardized, and adjusted standardized residuals were calculated
to determine cells making the greatest contribution to the observed difference.
Results
Respondent Demographics
Four-hundred eight-five complete surveys were received and analyzed (19.9% response
rate). The majority of surgeons were trained in Orthopaedic Surgery (82.3%) and respondents
had an average of 17.4 years in practice ([Table 1]). The respondents were most likely to work in exclusively private practice (35.9%),
followed by private practice with academic affiliation or privademics (29.0%), and
exclusively academic (18.9%).
Table 1
Respondent demographics
|
Years in practice (n = 485)
|
|
Mean ± SD
|
17.4 ± 11.6
|
|
Median
|
17
|
|
Range
|
0.5–62
|
|
Interquartile range (Q3-Q1)
|
18
|
|
Area of primary residency training (n = 485)
|
|
Orthopaedic surgery
|
399 (82.3%)
|
|
Plastic surgery
|
66 (13.6%)
|
|
General surgery
|
18 (3.7%)
|
|
Other
|
2 (0.4%)
|
|
Practice setting (n = 482)
|
|
Academic only
|
91 (18.9%)
|
|
Private with academic affiliation—“Privademics”
|
140 (29.0%)
|
|
Private practice only
|
173 (35.9%)
|
|
Hospital-employed
|
66 (13.7%)
|
|
Retired
|
5 (1.0%)
|
|
Other
|
7 (1.5%)
|
Abbreviation: SD, standard deviation.
Operative Methods
Volar fixed-angle plating was the most common method of preferred operative fixation
of unstable distal radius fractures (85.1%) among respondents followed by fragment-specific
fixation (7.2%) ([Fig. 1]). Preferences for operative fixation in elderly patients were similar, with olar
fixed-angle plating preferred by nearly three-quarters of respondents (74.4%). Only
5.8% (n = 28) of surgeons indicated they prefer nonoperative immobilization of unstable distal
radius fractures in this population. When opting to utilize nonoperative immobilization
in this population, 43.3% of surgeons opted for a period of immobilization between
4 and 6 weeks and 41.8%, between 6 and 8 weeks.
Fig. 1 Distribution of responses for preferred method of fixation of unstable distal radius
fractures. The majority of respondents reported volar fixed-angle plates as the preferred
fixation construct.
Immobilization
Ninety percent of respondents endorsed using a short arm cast or splint after volar
fixed-angle plating of an unstable distal radius fracture, with 46.1% opting for a
removable splint and 42.3% electing to use a nonremovable short arm cast or splint.
“No immobilization” after operative fixation was only selected by 3.9% surgeons. Surgeons
were most likely to immobilize patients for “1-2 weeks” following operative fixation
(40.1%), followed by “4-6 weeks” (24.2%), and then “greater than 2 but less than 4
weeks” (22.1%). Only 7.4% of respondents immobilized patients for a period shorter
than 1 week, while 4.3% indicated that they do not immobilize patients ([Fig. 2A]). Almost 60% of respondents indicated that they did not change length of postoperative
immobilization for other methods of fixation other than volar fixed-angle constructs,
while 30.7% noted a shorter immobilization period after use of a volar fixed-angle
plate ([Fig. 2B]).
Fig. 2 (A) Distribution of responses for duration of immobilization after operative fixation
of unstable distal radius fracture with volar-fixed angle plating and (B) differences in length of immobilization compared with other fixation methods. Immobilization
for 1 to 2 weeks postoperatively after operative fixation was the most common response
followed by 4 to 6 weeks. The majority of respondents indicated using the same length
of immobilization regardless of fixation type.
With regard to timing of initiation of wrist ROM therapy, respondents most commonly
began therapy between 1 and 4 weeks postoperatively (47.7%), while only 8.1% began
ROM therapy “immediately postoperatively” (8.1%) ([Fig. 3A]). The majority of surgeons did change timing of initiation of ROM therapy for other
methods of fixation (52.8%), while 37.0% begin wrist ROM therapy sooner following
volar fixed-angle plating ([Fig. 3B]).
Fig. 3 (A) Distribution of responses for initiation of range of motion therapy after operative
fixation of unstable distal radius fracture with volar-fixed angle plating and (B) differences in timing of therapy compared with other fixation methods. The majority
of respondents initiated range of motion therapy between 1 and 4 weeks after surgery
with no difference in timing with methods of operative fixation other than volar fixed-angle
plates.
Differences in practice trends were also explored regarding postoperative immobilization
and wrist ROM protocols in elderly patients versus those younger than 65 years of
age. The majority of surgeons indicated that they do not treat elderly patients any
differently with respect to the length of postoperative immobilization (72.8%) ([Fig. 4A]). Similarly, most surgeons do not treat elderly patients any differently when determining
how long after operative fixation to begin wrist ROM therapy (72.4%) ([Fig. 4B]).
Fig. 4 (A) Distribution of responses for length of immobilization and (B) initiation of range of motion therapy in elderly patients (age greater than 65 years
old) after operative fixation compared with patients less than 65 years old. The majority
of respondents did not endorse any difference in length of immobilization or initiation
of range of motion therapy after operative fixation of unstable distal radius fracture
in patients greater than 65 years old compared with those less than 65 years old.
Practice Preferences and Surgeon Characteristics
The population of survey respondents was separated on the basis of number of years
in practice into high (≥20 years) (n = 209–212) and low (<20 years) (n = 271–272) experience groups. These groups differed significantly in their postoperative
management of patients with unstable distal radius fractures treated by operative
fixation with a volar fixed-angle plate (χ2 = 10.55; p = 0.032). A greater percentage of the low experience group (63.2%) stated that they
would keep individuals in rigid immobilization for the same period of time regardless
of which method of nonspanning operative fixation was used, compared with 53.3% in
the high experience group. A significant difference in responses was also observed
with respect to the initiation of wrist ROM therapy following operative fixation with
a volar fixed-angle plate (χ2 = 10.67; p = 0.031). Those in the high experience group were more likely to allow patients to
begin wrist ROM therapy sooner than when other methods of nonspanning methods of fixation
are utilized (40.8% [high] vs 34.2% [low]).
Survey respondents were also grouped according to practice setting with significant
difference in the length of rigid immobilization following volar fixed-angle plating
of an unstable distal radius fracture between the groups comprised of those working
in an “academic only” setting (n = 91) and those working in “privademics” (n = 140) (χ2 = 16.60; p = 0.011). More than half (52.8%) of those in the “academic only” group stated that
they would only place patients in rigid immobilization for 1 to 2 weeks. This contrasted
with the “privademics” group, where 31.4% endorsed a preference for 1 to 2 weeks of
immobilization while 51.4% indicated that they would opt for periods between 2 and
6 weeks.
Discussion
Despite long-standing principles on the management of unstable distal radius fractures,
protocols for postoperative care after fracture fixation remain a point of contention.
Review of evidence-based protocols from prospective comparative studies in the current
literature suggests that shorter periods of rigid immobilization and earlier initiation
of wrist ROM may improve functional outcomes without compromising fixation ([Table 2]).[18]
[21] However, these findings are not consistent across the literature as studies have
conversely shown little benefit to early mobilization.[22] Current evidence has also demonstrated that conservative management of unstable
distal radius fractures in elderly patients may yield equivalent long-term functional
outcomes as operative fixation,[23] though fixation may allow for earlier improved function ([Table 3]).[23]
[24] While review of the literature yields information on the outcomes of particular
institutions and providers, it is still unknown whether practices of physicians nationally
reflect these findings.
Table 2
Studies from 2007 to 2017 comparing outcomes between different postoperative lengths
of immobilization after volar plate fixation of unstable distal radius fractures
|
Authors
|
Year
|
Study type
|
LOE
|
Size
|
Fixation
|
Immobilization method
|
Immobilization length
|
Conclusions
|
|
Quadlbauer et al[18]
|
2017
|
Prospective randomized trial
|
I
|
30
|
Volar locking plate
|
Thermoplast splint versus short-arm cast
|
1 week (splint) versus 5 weeks (cast)
|
Splint—better:
–Sagittal ROM & grip strength (6 months)
–Forearm rotation (6 weeks)
–DASH scores and PRWE
(6 weeks)
No differences:
–Fracture reduction, pain
|
|
Brehmer and Husband[21]
|
2014
|
Prospective randomized trial
|
I
|
81
|
Volar locking plate
|
Custom wrist extension splint
|
4 weeks + AR versus 6 weeks + SR
|
AR group—better:
–Better mobility, strength, DASH scores (0–8 weeks)
–Earlier return to function
|
|
Lozano-Calderón et al[22]
|
2008
|
Prospective randomized trial
|
I
|
60
|
Volar locking plate
|
Thermoplastic volar splint
|
2 weeks versus 6 weeks
|
No difference:
–Motion, grip strength
–Radiographic parameters
–Gartland and Werley, Mayo, pain or DASH scores
|
Abbreviations: AR, accelerated rehabilitation; DASH, disabilities of the arm, shoulder,
and hand; LOE, level of evidence; PRWE, patient-rated wrist evaluation; ROM, range
of motion; SR, standard rehabilitation.
Table 3
Studies from 2007 to 2017 comparing outcomes between conservative management and operative
fixation of unstable distal radius fractures in the elderly population
|
First author
|
Year
|
Study type
|
LOE
|
Study size
|
Mean age (years)
|
Immobilization method
|
Immobilization length
|
Conclusions
|
|
Chan et al[24]
|
2014
|
Retrospective case–control
|
III
|
75
|
64.5
|
Short arm cast versus volar locking plate
|
6 weeks
|
In active elderly patients, fixation:
–earlier improved grip strength and motion
No difference:
–Long-term function and DASH scores (12 months)
|
|
Arora et al[14]
|
2011
|
Prospective randomized trial
|
I
|
73
|
76.7
|
Short arm cast versus volar locking plate
|
5 weeks
|
No difference:
–ROM, pain
–DASH scores and PRWE (6 and 12 months)
Fixation:
–Improved DASH score and PRWE (6 and 12 weeks)
–Improved grip strength all time points
–Better radiographic results (12 months)
–Higher complications
|
|
Egol et al[33]
|
2010
|
Retrospective case–control
|
III
|
90
|
74.5
|
Sugar tong splint versus volar locking plate/external fixation (if splint failed)
|
Until healing
|
No difference:
–Complications
–Wrist extension (1 year)
–DASH scores, pain
Fixation—better:
–Wrist extension (24 weeks)
–Grip strength (1 year)
–Radiographic outcome
|
|
Arora et al[23]
|
2009
|
Retrospective case–control
|
III
|
114
|
79
|
Cast versus volar fixed-angle plate
|
6 weeks (1–2 weeks plaster slab + 4–5 weeks short arm cast)
|
Fixation:
–Better radiographic results
No difference:
–Active ROM
–PRWE, DASH, and Green and O'Brien scores (4 years)
Casting:
–Less pain
|
Abbreviations: DASH, disabilities of the arm, shoulder, and hand; LOE, level of evidence;
PRWE, patient-rated wrist evaluation; ROM, range of motion.
The purpose of this study was to analyze national practice trends among hand surgeons
to determine the impact of changing operative and postoperative protocols in the academic
literature on current-day management of unstable distal radius fractures. Members
of the ASSH were chosen to be surveyed as an organization consisting of a diverse
group of hand surgeons from different training backgrounds and practice models across
the country, making it an ideal cohort of providers to assess practice trends. The
majority of ASSH hand surgeons surveyed in this study were Orthopaedic Surgery trained.
Given that around 81% of Hand Fellowship programs are Orthopaedic Surgery programs,[25] this distribution is not unexpected. Mean years in practice after fellowship training
were 17.4 years, similar to years of experience among ASSH members in prior studies[26] and the private office setting was the most common type of practice as with prior
surveys of ASSH members.[27] However, almost 50% of respondents had some affiliation with academic centers allowing
for a broad sampling of different practice types.
The wide variety of fracture patterns of the distal radius precludes the utility of
a single, universally superior method of fixation. However, volar plate fixation has
demonstrated good functional outcomes with a variety of different fracture patterns[7]
[8]
[9]
[12] while avoiding soft tissue complications associated with dorsal plating. This method
has gained significant popularity since its introduction in 2002 which is reflected
in this survey as volar fixed-angle plates were the preferable method of fixation
for unstable distal radius fractures in 84.7% of respondents.
Results of this survey showed significant variability in length of postoperative rigid
immobilization among ASSH members between 1 and 6 weeks. A period of immobilization
from 1 to 2 weeks was the most common preference (40.0%); however, the majority of
responses were outside this range. Biomechanical studies have demonstrated the ability
of volar plate constructs to withstand early mobilization at 1 week,[4] and several studies have demonstrated the benefits of early mobilization on return
to functionality.[18]
[28]
[29] Despite this, there was a significant discrepancy between the evidence in the literature
and national practice trends. Only 11.7% of survey respondents stated they would remove
rigid immobilization prior to1 week and over 40% would keep patients in rigid immobilization
for greater than 2 weeks. In addition, volar fixed-angle plating has been shown to
be more stable than other fixation constructs allowing for immediate active ROM[30]; however, the majority of surgeons in our survey stated they would not change the
length of immobilization with other methods of fixation. Adherence to similar postoperative
mobilization practices regardless of fixation type suggests that practitioners may
follow certain familiar postoperative protocols despite changing evidence.
Survey trends with progression of postoperative ROM therapy were similar, in that
surgeons were most likely to begin wrist ROM therapy between 1 and 4 weeks (47.2%
of respondents) regardless of the type of fixation (52.4%). While certain studies
have demonstrated the benefits of early and accelerated rehabilitation protocols after
operative fixation,[21] these findings again have not translated to current practices as reflected in this
survey.
The rate of ORIF of distal radius fractures in the elderly has increased significantly
since the year 2000.[31]
[32] Several recent studies, however, have suggested that conservative management of
unstable distal radius fractures with cast immobilization in this population yields
similar long-term functional outcomes compared with surgical fixation.[14]
[15]
[23]
[24] Despite the evidence in favor of less-invasive management of lower-functional populations,
the overwhelming majority of survey respondents endorsed ORIF as their preferred treatment
of unstable distal radius fractures in patients greater than 65 years of age (87.8%).
Only 5.8% reported nonoperative immobilization as a preferred treatment suggesting
that evidence from recent studies has not influenced larger-scale practice changes.
Evidence, however, has not been completely consistent across studies. Egol et al reported
decreased grip strength at 1 year in patients that were treated with casting compared
with fixation if they failed conservative management.[33] Furthermore, studies have suggested that functional outcomes improve earlier with
operative fixation in elderly patients despite similar long-term outcomes.[14]
[24] It is also important to note, however, that Medicare beneficiaries treated by ASSH
members have been shown to have higher rates of internal fixation compared with patients
of other physicians,[34] potentially biasing the observed trends.
The results of this survey demonstrated no discernible consensus among ASSH members
on length of postoperative immobilization and initiation of ROM therapy after operative
fixation of the presented unstable distal radius fracture. Additionally, the majority
of surgeons also endorsed treating unstable fractures in the elderly population, as
presented in the survey, no different than those in a younger, more functionally demanding
cohort. Why then do current practices among fellowship-trained hand surgeons diverge
from the evidence presented in the literature? Several possible explanations warrant
exploration.
First, surgeons may find the evidence presented in the literature inadequate or of
low quality. The majority of the studies addressing postoperative immobilization of
distal radius fractures and conservative management in the elderly population are
not large, prospective comparative studies.[14]
[28]
[29]
[35] While randomized prospective studies do exist, for example, with regard to early
postoperative mobilization, certain studies present conflicting results,[18]
[22] which significantly diminish acceptance of a new paradigm. Surgeons may also not
follow evidence reported in the literature, regardless of quality, or may feel their
patient population does not reflect that of the literature. Isolated practice patterns
may be more likely when sampling a smaller, uniform group of physicians. This survey,
however, consisted of large cohort of ASSH members in a variety of different practice
settings, making this relatively unlikely. Finally, the implementation of practice
change from scientific research takes time. Much of the evidence for changes in management
of immobilization and elderly patients has only been recently published, whereas volar
plate fixation, on the other hand, has been described for well over 15 years.[5] The availability of fewer studies on particular interventions may therefore hinder
the adoption among the practicing community currently.
Analysis of demographic subgroups showed that physicians with greater than 20 years
of post-fellowship experience were significantly more likely to begin wrist ROM sooner
with volar plating versus other fixation techniques compared with physicians with
less than 20 years of experience. Timing of mobilization after operative fixation
is multifactorial, and can be influenced by the particular injury, stability of fixation,
and patient tolerance, among other factors. Surgeons utilizing volar plate fixation
for longer periods of time may also be more comfortable initiating ROM exercises sooner
than those with less experience. Physicians in academic-only practices were also more
likely to immobilize patients for a shorter time after volar plating compared with
those in privademics. Respondents working within an academic environment may be more
exposed to different management protocols that could influence clinical decisions.
Prior studies have shown a correlation of surgeon age with fixation type, in which
younger surgeons were more likely to perform ORIF of distal radius fractures compared
with older surgeons.[36]
[37] Fixation type, however, was not found to be influenced by length of years in practice
in our study. This may be secondary to inclusion of only distal radius fractures,
as well as polling of only ASSH members, who have been shown to favor ORIF of distal
radius fractures in prior studies.[34]
[36]
Certain limitations of this study must be considered upon interpretation of results.
Foremost, a survey study inherently offers only descriptive data on trends. Additionally,
querying opinions on preferred methods of fixation or immobilization techniques can
be difficult to generalize as these interventions often rely on individual variances
in fracture patterns or stability of the fixation construct, respectively. Furthermore,
survey results cannot delineate among the multitude of different postoperative rehabilitation
protocols. Instead, the survey focused on numerous common options for postoperative
splints, that still showed significant variability, which is likely exaggerated with
more detailed regimes. Similarly, use of age criteria to signify elderly or lower-functional
demand patients is simpler but not ideal. This age cut-off was determined according
to prior studies as well as the Medicare age; however, differences in preferred treatments
should more accurately be determined by functionality rather than absolute age. While
the response rate for the survey was only 20%, the absolute number of responses was
high, and reflective of the demographics of ASSH hand surgeons.
Conclusion
Overall, survey of fellowship-trained hand surgeons that are members of the ASSH showed
a general preference for volar fixed-angle plating of unstable distal radius fractures.
Recent evidence for improved functional outcomes with early mobilization after operative
fixation of distal radius fractures and conservative management of these fractures
in elderly patients is not reflected in management preferences reported by hand surgeons.
While causative factors are likely multifactorial, there is a need for further high
level-of-evidence studies supporting these interventions before changes in management
are likely adopted by hand surgeons.
