Distal Radius Fracture: Still No Definitive Treatment Preference

Distal radius fracture-also called a wrist fracture by patients-is common. Its incidence is expected to increase in the next 20 years, since our population is aging and the risk of this specific fracture increases in patients with metabolic disorders, including osteoporosis. However, the health care community has yet to reach a consensus regarding indications for surgery, and there is insufficient data to identify a preferred operative technique.

Distal radius fracture—also called a wrist fracture by patients—is common. Its incidence is expected to increase in the next 20 years, since our population is aging and the risk of this specific fracture increases in patients with metabolic disorders, including osteoporosis. In developed or economically stable countries, surgeons tend to treat distal radius fractures with open reduction and internal fixation. However, the health care community has yet to reach a consensus regarding indications for surgery, and there is insufficient data to identify a preferred operative technique.

Currently available information does not clearly show if radiographic alignment correlates with symptoms and disability. In its ahead-of-print articles, The Journal of Hand Surgery confirms that this lack of evidence continues today.

This global study evaluated surgeon, patient, and radiographic factors influencing the recommendation for operative treatment in distal radius fractures. The researchers collated 30 consecutive sets of radiographs taken of distal radius fracture patients who presented to the Massachusetts General Hospital emergency department in Boston, MA. They asked 252 orthopedic surgeons to review and evaluate either the radiographs alone or the radiographs and supplemental clinical information.

Surgeons in both arms of the study recommended surgery 52% of the time. Overall, the researchers found that patient factors exerted surprisingly little influence.

Hand and wrist surgeons, female surgeons, and surgeons with fewer than 21 years of experience were more likely to recommend surgery. The researchers indicate that these results were tempered by the fact that only 6% of the orthopedic surgeons surveyed were women. In addition, these factors explained only 1% of the overall variation. Radiographic criteria explained and additional 49% of the variance.

The remaining 49% of variation was attributed to availability of clinical information. Surgeons who had access to clinical information in addition to radiographs were equally likely to recommend surgery. They were also less likely to agree with their colleagues who received radiographs alone. The researchers hypothesize that these surgeons used patient age and activity levels to inform their decisions.

Radiographic criteria (intra-articular fractures, ulnar styloid fractures, dorsal comminution, dorsal tilt, and ulnar variance) explained 49% of the variation.

The researchers conclude that clinical information is the foundation of sound clinical decisions. If clinical information was unavailable, surgeons in this study retreated to their comfort zones and usual habits. If it was available, they made better decisions.