Inconsistent evidence suggests no difference in outcomes between use of arthroscopic assistance and no arthroscopic assistance when treating patients for distal radius fractures.
There was 1 high (Yamazaki, H 2015), and 2 moderate strength (Varitimidis, SE 2008 and Selles, CA ) studies evaluating the use of wrist arthroscopy as an adjunctive treatment for distal radius fracture fixation. Although many comparative studies have been done, the variability of study design, surgical indications, fracture classification systems and implants used makes interpretation of the literature challenging. Evaluation of these studies, however, does not show apparent treatment benefit for the use of wrist arthroscopy at the time of distal radius fracture fixation.
One high strength study (Yamazaki, H 2015 ) that specifically evaluated arthroscopic-aided reduction and fluoroscopy with fluoroscopy alone at the time of distal radius fracture fixation with volar locking plate technology did not show a significant difference in patient functional outcomes at 48 months. This finding is corroborated by a moderate quality study (Selles, CA 2019) that also compared the intraoperative use of wrist arthroscopy to remove fracture hematoma and debris with a similar cohort treated by open reduction and internal fixation. Here also, a significant difference in outcome could not be determined at 12 months. One moderate strength study (Varitimidis, SE 2008) did conclude that some parameters of radiographic outcome could be improved using a combination of distal radius fracture fixation, arthroscopic evaluation, and fragment-specific pinning and that these patients had improved clinical outcomes.
Risks and Harms of Implementing this Recommendation
There are no known harms associated with implementing this recommendation as it supports not using wrist arthroscopy during fixation of distal radius fracture.
Continued high quality comparative studies that assess contemporary fracture care for specific fracture patterns and the adjunctive use of arthroscopy to improve fracture reduction, treatment of associated soft tissue injury, and implant position may further clarify the role (if any) of wrist arthroscopy in the treatment of specific patterns of distal radius fracture that requires operative treatment.
- Selles CA, Reerds STH, Roukema G, van der Vlies KH, Cleffken BI, Schep NWL. Relationship between plate removal and Soong grading following surgery for fractured distal radius. J Hand Surg Eur Vol. 2018;43(2):137-141. doi:10.1177/1753193417726636
Home Exercise Program
Inconsistent evidence suggests no difference in outcomes between a home exercise program and supervised therapy following treatment for distal radius fractures.
Current evidence is insufficient to answer the question of whether supervised hand therapy leads to different outcomes as compared to an independent home exercise program following surgical or non-surgical treatment of a distal radius fracture (DRF). There were only a few studies that met the inclusion criteria and even those had some important shortcomings. After expanding the number of studies, issues with the experiments included risk of bias, lack of homogeneity regarding injury severity, variable ages, and low prevalence of post-fracture complications. One high (Gutierrez Espinoza et al, 2017) and six moderate quality studies (Valdes et al, 2015; Souer et al, 2011; Oken et al. 2011; Krischak et al, 2009; Maciel et al. 2005; Wakefield et al, 2000) were included and appraised. One found a benefit to supervised therapy 3 weeks after injury or surgery (Oken et al. 2011), and one (Gutierrez Espinoza et al, 2017) at 6 weeks and at 6 months. In contrast, one study (Krischak et al, 2009) favored independent exercises at 6 weeks, and 4 found no difference between supervised and independent exercises (Valdes et al, 2015; Souer et al, 2011; Maciel et al. 2005; Wakefield et al, 2000).
Risks and Benefits of Implementation
It is possible that a subset of people recovering from distal radius fractures might benefit from supervised hand therapy, and experience more rapid return to function with decreased total societal costs. For those that independent exercises are sufficient, we can preserve health care resources and minimize cost and time burden for patients recovering from distal radius fractures through independent exercises.
A rule prohibiting supervised therapy after distal radius fractures might limit access for a subset of people who stand to benefit. We might conclude that—to date--routine supervised hand therapy does not seem to provide a benefit on average.
Cost Effectiveness/Resource Utilization
We currently lack sufficient evidence to determine if there are circumstances in which supervised therapy limits patient and societal costs.
There is a risk that surgeons might feel this statement restricts their ability to ask for help from expert colleagues when a patient’s recovery from distal radius fractures is delayed or difficult. There is a risk
that hand therapists will feel the summary of the evidence undervalues their contributions to the recovery of some people recovering from distal radius fractures.
Implementation of this summary is feasible to the extent that it does not become an all or none policy and that we continue to investigate factors that facilitate recovery and utilize supervised hand therapy for those subset(s) of patients where clinical benefit can be demonstrated.
More and better evidence is needed to determine when supervised hand therapy benefits people recovering from DRF. Most importantly, further research is needed to determine prognostic criteria that would allow for proper patient selection. Thus, research should be invested in establishing a classification system for DRF patients sub-categorization based on their rehabilitation needs, while considering all contextual factors that may limit their recovery potential.
Indications for Fixation (Non-Geriatric Patients)
Moderate evidence supports that for non-geriatric patients (most commonly defined in studies as under 65 years of age), operative treatment for fractures with post reduction radial shortening >3mm, dorsal tilt >10 degrees, or intraarticular displacement or step off >2 mm leads to improved radiographic and patient reported outcomes.
This guideline is based on 1 high quality study, and 26 moderate quality studies using radiographic parameters of radial shortening >3mm, dorsal tilt >10, or intra-articular displacement or step-off >2mm in adult patients less than 65 years of age diagnosed with a distal radius fracture. The term non-geriatric was used as the spirit of this guideline is to address distal radius fractures in those patients with high functional demand. Age is commonly used as a proxy for functional demand, often using less than 65 years of age to describe those with high functional demand. Although outcomes vary, overall, these studies consistently demonstrated that operative treatment led to improved radiographic outcomes and/or patient reported outcomes in those less than 65 years of age.
Risks and Benefits of Implementation
The results from this CPG align with those of the AAOS Clinical Practice Guideline from 2009, suggesting current practice based on the aforementioned radiographic parameters leads to improved patient outcomes. As such, we anticipate no risks with implementing this guideline.
The effects of using more rigid radiographic criteria (e.g. any fracture displacement not just >2mm) as indications for surgical fixation, and their effect on patient outcomes have not been well studied. The durability of these treatment indications on patient outcomes in the longer term (e.g. 10-20 years) should also be studied.
Indications for Fixation (Geriatric Patients)
Strong evidence suggests that operative treatment for geriatric patients (most commonly defined in studies as 65 years of age and older) does not lead to improved long-term patient reported outcomes compared to non-operative treatment.
This guideline is based on 2 high quality studies, and 11 moderate quality studies comparing operative and nonoperative treatment in those >65 years of age. Some studies demonstrated improvements in patient reported outcomes in the short term (usually less than 3 mo.). Studies consistently showed no difference in patient reported outcomes in the long-term (1 year or greater) despite improvements in radiographic parameters as this is currently the most common metric (parameter or variable) cited in the relevant literature. The term geriatric was used as the spirit of this guideline is to address distal radius fractures in those patients with low functional demand. Age is commonly used as a proxy for functional demand when studying this population, often described as 65 and greater in age.
Risks and Benefits of Implementation
The workgroup acknowledges that age, as used in the cited evidence as well as this clinical practice guideline, is used as a proxy for functional demand. As such, a high functioning patient with high functional demands, despite having an age greater than 65, may benefit from operative fixation based on the literature supporting fixation in young, active patients. At the same time, there may be low functioning younger patients with low functional demands, that despite having an age less than 65, that may benefit from non-operative treatment. A patient-centered discussion understanding an individual patient’s values and preferences can inform appropriate decision making to ensure his/her age and functional demands align to appropriately apply this clinical practice guideline. The recommendations regarding operative treatment are principally based upon literature studying distal radius fracture as an isolated injury. Mitigating circumstances may also be factors in the shared decision-making process.
Research using other tools that better describe a patient’s functional demand instead of age are needed. These tools could better inform point of care decisions for the treatment of distal radius fractures in the elderly that avoid the aforementioned risks of treatment based on age alone. While the workgroup acknowledges that functional demand would be a better explanatory variable for understanding the benefits of operative treatment, this clinical practice guideline uses age greater than 65 as this is what is used in the literature.
Limited evidence suggests no difference in outcomes based on frequency of radiographic evaluation for patients treated for distal radius fractures.
No high-quality studies were identified to address this question. One moderate quality study (van Gerven, P., 2019) was identified. This multicenter, prospective, randomized, controlled trial was specifically designed to evaluate the impact of eliminating routine radiographs after the two-week follow up for distal radius fracture. Control group patients received x-rays of the wrist at 1,2,6, and 12 weeks post injury. The experimental group received x-rays of the wrist at 1 and 2 weeks. Thereafter they received wrist x-rays only if they experienced a new trauma, a spike in their pain, or a worsening of their neuro-vascular condition. Patients were followed for 52 weeks. At no time during the 52-week study were there statistically significant differences between the two groups in patient reported measures, (DASH, PRWHE), quality of life, (EQ5), or pain, (VAS). At 52 weeks there were minimally statistically significant differences in range of motion favoring the more frequent x-ray group. Total flexion/extension arc was 10 degrees better, (123 vs 113), and pronation/supination was also better, (175 degrees vs 155 degrees). These differences appear not to impact patient reported outcomes. There was no difference in the complication rate. Patients in the control group received four sets of wrist radiographs. Patients in the experimental group received an average of three.
Risks and Benefits of Implementation
This recommendation is based on a PICO question which was specifically focused on acute management. The benefits of implementing this strategy of eliminating routine radiographs of distal radius fractures after the two-week follow up include reduced radiation to the patient and reduced cost to patient, payer, and society. In this study there was no increase in the complication rate. There may be some possible value in obtaining a final radiograph outside of the time frame addressed within this PICO to establish a healed baseline for comparison against future wrist pain.
Longer term follow-up, (5 and 10 year) will be useful to determine if non-inferiority of the reduced radiograph group is maintained.
Strong evidence suggests no significant difference in radiographic or patient reported outcomes between fixation techniques for complete articular or unstable distal radius fractures, although volar locking plates lead to earlier recovery of function in the short term (3 months).
This guideline is based upon 6 high quality studies, with 3 comparing different fixation techniques for complete intra-articular distal radius fractures (Jakubietz, Yazdanshenas, Hammer) and 3 comparing different fixation techniques for unstable distal radius fractures (Marcheix, Rozental, Goehre). Yazdanshenas compared external fixation to a “pins and plaster” technique, Jakubietz compared volar and dorsal locking plate fixation and Hammer compared volar locking plates to augmented external fixation. Early in the recovery period the 2 studies that compared volar locked plating demonstrated more rapid recovery of function but at longer term follow up, no significant differences were seen in radiographic outcomes or patient reported outcomes. Marchiex, Rozental, and Goehre each compared volar locked plating to closed reduction and percutaneous fixation and included intra- articular and extra-articular fractures. All 3 demonstrated earlier return of function for the volar locked plating group in the recovery period but the 2 studies with results at 12 months or longer, showed no difference in patient reported outcomes at final follow-up.
Risks and Harms of Implementation
There are no known harms associated with implementing this recommendation beyond those attributed to an open surgery and placing a volar plate (e.g. symptomatic hardware or tendon rupture).
The current literature suggests that function recovers earlier in patients treated with volar locked plating than with other methods, but outcomes equalize before a year from injury. Further randomized controlled trials should help address multiple questions including long term complication profiles (tendon ruptures, secondary surgery etc.) and the impact of the differences in cost between various treatment approaches. Further, studies that use fracture type (e.g. extraarticular, partial articular, etc.) to group patients may lead to more actionable results that can be applied to real life care.
In the absence of sufficient evidence specific to distal radius fractures, it is the opinion of the workgroup that opioid sparing and multimodal pain management strategies should be considered for patients undergoing treatment for distal radius fractures.
There have been very few studies directly comparing pain management regimens including opioids and opioid alternatives for the management of postoperative pain following treatment for distal radius fractures. In 2018, Luo et al examined the effectiveness of celecoxib vs. buprenorphine transdermal patch vs. codeine with ibuprofen. In this study, the authors examined pain at rest, daily activities, rehabilitation, and functional outcomes among 315 patients undergoing volar plate fixation for a distal radius fracture. The authors compared patients in the 2 weeks following surgery to 200 mg celecoxib twice per day (n=149), buprenorphine transdermal patch at 5 μg/h (n=89), and 13 mg codeine plus 200 mg ibuprofen twice per day (n=77), and followed outcomes for the 6 weeks following surgery. for pain management. The authors identified that functional outcomes as measured by the PRWE and DASH scores as well as range of motion among patients receiving celecoxib group were significantly lower at one month and three months compared with other groups. Pain at rest was similar across all groups and was mild. However, the authors noted patients receiving celecoxib had poorer pain management compared with the other groups during rehabilitation. The authors conclude that transdermal buprenorphine or codeine/ibuprofen should be considered for pain management during rehabilitation among patients with distal radius fractures undergoing volar plate fixation. However, this study was deemed low quality by the working group given methodologic gaps.
Despite the lack of evidence for the use of opioids or opioid alternatives among patients with a distal radius fracture, there is a growing body of evidence supporting opioid sparing and/or opioid free pain management options for other musculoskeletal conditions. Based on these studies and the risks of opioid analgesics (adverse events, misuse, opioid use disorder, diversion for nonmedical use), it is the recommendation of the committee that opioid alternatives (pharmacologic (local anesthetics, nonsteroidal anti-inflammatory agents, acetaminophen) and nonpharmacologic (ice, elevation, compression, cognitive therapies) should be considered alongside opioid sparing protocols when possible.
Risks of Implementation
Given the lack of evidence regarding effective pain management, failure to control post-injury and postoperative pain is a potential harm if pain is inadequately treated. Conversely, excess opioid prescribing is associated with greater opioid use, prolonged use, and the potential for misuse, opioid use disorders, and diversion to unintended users and nonmedical use.
Continued comparative studies are needed to compare the effectiveness of opioid analgesics and non-opioid pharmacologic and nonpharmacologic alternatives to determine the need for opioids, the dose and duration of therapy, and effective alternatives for pain management following distal radius fractures.