|SYMPOSIUM - DISTAL RADIAL FRACTURES
|Year : 2020 | Volume
| Issue : 2 | Page : 41-44
Distal radial fractures: Conservative treatment
Sameer Mittal, Alok Chandra Agrawal, Harshal Sakale, Bikram K Kar
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh, India
|Date of Submission||13-Jul-2020|
|Date of Decision||23-Jul-2020|
|Date of Acceptance||24-Aug-2020|
|Date of Web Publication||10-Sep-2020|
Alok Chandra Agrawal
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Undisplaced distal end radius fracture is traditionally managed with conservative treatment, that is, closed reduction and immobilization. This approach has excellent result in undisplaced distal radial fractures and in displaced fractures where stable reduction can be achieved after closed reduction. Subjective results of conservative treatment are as good as the results of operative treatment in patients aged > 65 years at 1-year follow-up. Closed reduction is done mainly with two methods – direct reduction by manipulation and by ligamentotaxis. Immobilization is done mainly by a cylindrical plaster cast. Immobilization of the wrist in neutral radial-ulnar deviation and neutral or slight extension is recommended. Rehabilitation is a very important part of conservative treatment and is started from the day of the first visit in the form of mobilization of adjacent joints and limb elevation. The goal of rehabilitation is to achieve maximum range of motion and strength in the extremity with good fracture healing.
Keywords: Closed reduction, conservative treatment, distal radius fracture, rehabilitation
|How to cite this article:|
Mittal S, Agrawal AC, Sakale H, Kar BK. Distal radial fractures: Conservative treatment. J Orthop Dis Traumatol 2020;3:41-4
|How to cite this URL:|
Mittal S, Agrawal AC, Sakale H, Kar BK. Distal radial fractures: Conservative treatment. J Orthop Dis Traumatol [serial online] 2020 [cited 2020 Sep 22];3:41-4. Available from: http://www.jodt.org/text.asp?2020/3/2/41/294738
| Introduction|| |
Conventionally, most distal radius fractures are managed nonoperatively, but in the last decade, a shift toward stable internal fixation is seen along with the development of new fixation devices. However, no strong evidence has been published to support this increase in operative treatment. With time, the number of publications regarding treatment of distal radius fractures is increasing rapidly, and there is hope in the near future to have better evidence to support our decision-making.,
| Indication of Conservative Management|| |
The choice of treatment of distal radius fracture is influenced by multiple variables such as age, gender, occupation, dominant hand, hobbies/sports, bone quality, and comorbidity, etc., The indications for operative treatment are different for young active male and old-aged patients.
The primary goal of treatment is to gain bone union without symptomatic malunion. Some degree of displacement is usually tolerated, but only to a certain extent. For the physiologically young and active patients, these measurements should indicate an acceptable range of values.
- Radial shortening <2 mm
- Intra-articular gap or displacement < 2 mm
- Dorsal tilt ≤10° and carpus aligned.
Unless the fracture is undisplaced, closed reduction and immobilization in a forearm cast is almost always indicated in an attempt to gain the best possible anatomical restoration. If the reduction is acceptable, and there are no other operative demanding injuries, nonoperative treatment is chosen. If the reduction is acceptable, but the fracture is unstable, operation should be considered, for example, volar angulated fractures (Smith's fractures) and shear fractures (volar or dorsal Barton's fractures). If nonoperative treatment is chosen, the patient must be followed closely with radiographs until union is complete. The patient should be involved in the clinical decision-making, the so-called shared decision-making.,
The conservative treatment for distal end of radius should be considered for:
- Fractures of the low-demand elderly and infirm patients
- Undisplaced extra-articular fractures, and
- Extra-articular fractures with an initial position of <10° of dorsal angulation, minimal comminution, and <2 mm of shortening.
| Closed Reduction|| |
Closed reduction is normally done in the accident and emergency department under hematoma or Bier or regional nerve block. It is performed through direct manipulation of the fracture or indirectly via ligamentotaxis.
- Direct manipulation typically involves a bidigital grip across the distal fragment by which it can be maneuvered into a reduced position. Often, this exaggeration of the initial displacement is done to disengage the distal fragment from the shaft, where after the volar cortices can be brought into contact and distal fragment be pivoted into reduction. Once reduced, further traction is not necessary to maintain reduction (which of course is a prerequisite for successful plaster treatment) – moderate dorsal pressure on the distal fragment is sufficient
- Ligamentotaxis is the process of applying traction forces to the distal radius fragment through the surrounding soft tissues. Longitudinal traction alone will not completely reduce the fracture. When the fingers are pulled distally (e.g., by using “Chinese” finger traps), traction of the distal fragment is exerted mainly via the volar ligaments because the dorsal ligaments are weak and the technique of “multiplanar” ligamentotaxis has to be employed.
In an operatively treated fracture, anatomic reduction is the standard. In a closed reduction, a less-than anatomic reduction can still be acceptable. However, there is a significant debate about what and how much malreduction can be tolerated., With regard to the extra-articular aspect of the reduction, loss of radial length causes two problems. First, it can lead to incongruency of the distal radio-ulnar joint and result in pain and interference with pronation and supination. Second, it can lead to ulnocarpal impaction. Loss of radial inclination leads to radial deviation of the hand and subsequently causes scaphoid flexion and an increase in the scapholunate angle. Volar or dorsal translation of the distal radius can create an adaptive midcarpal instability because the carpus compensates for the altered radial position.
| Immobilization Technique|| |
The comfortable and safe position to immobilize the wrist is in neutral radial-ulnar deviation and neutral or slight extension. Moderate ulnar deviation is accepted to preserve radial length with the support from the intact ulna. This is the natural position for undisplaced, or minimally displaced fractures. In displaced fractures, reduction with manipulation is done before immobilization is done. Immobilization in extreme flexion and ulnar deviation was historically the only option as internal fixation was not available., Flexion of the wrist will move the loading forces dorsally in the radio-carpal joint and thereby cause dorsal re-displacement of the fracture. This has been shown in a prospective randomized study, which compared circular plaster immobilization in moderate extension with immobilization in flexion. The goal with plaster treatment is to maintain the reduced position of the fracture without compromising the finger function. The cast should be well molded, without obstructing the full motion of the metacarpophalangeal (MCP) joints or the elbow. For minimally displaced fractures, an adjustable brace gives better patient satisfaction than a plaster cast with equal hand function. Above-elbow plaster, for instance, “sugar-tong plaster,” may occasionally be used when there is a concomitant distal ulnar fracture and still conservative management is the treatment of choice.
Treatment period should be long enough to allow consolidation of the fracture before mobilization. With a functional cast or brace, this period would normally be 4–6 weeks depending on the fracture type. With immobilization in an extreme position, as outlined above, a treatment period of 6 weeks is not recommended, but rather a change after 3–4 weeks into a cast or a splint for the remaining 2–3 weeks to optimize finger mobility. Some further settling of the fracture may take place after 6 weeks; this can be expected to be more pronounced in fractures with poor contact between fragments.
| Plaster for Immobilization|| |
Plaster is traditionally been used for the treatment of fracture distal radius as definitive fixation method in the form of complete cylindrical cast as well as a method of temporary fixation in fractures awaiting surgery and to supplement a semi-stable internal fixation or simply for comfort for patients with operated fractures. The fracture is reduced mainly by distraction, and the idea of plaster immobilization is to maintain the reduced position, that is, to counteract the compressive and displacing forces. Because plaster immobilization itself cannot maintain distraction, preservation of length relies solely on bone contact between the fracture fragments and therefore proper reduction of the main fragments. A prerequisite for a good outcome is restoration of radial length. Fractures to be treated with a cast therefore need an intact volar cortex, that is, no volar comminution. After perfect reduction, the distal fragment will be supported by volar cortical contact, the cortical hinge, and the purpose of the plaster is to prevent dorsal angulation or dorsal displacement of the distal fragment. It, therefore, needs to exert a volarly directed pressure on the distal fragment, which requires a counterforce generated more proximally on the volar surface of the forearm. This requires a well-molded full cast or well-designed prefabricated brace that can be adjusted to the patient.
| Comparison of Results of Conservative Versus Operative Management|| |
Arora et al. compared nonoperative treatment with volar locking plate fixation for patients aged 65 years or older and found no difference in range of motion (ROM), level of pain, or functional scores at follow-up, 12 months later. Patients in the operative treatment group had better grip strength throughout the entire period. Achieving anatomical reconstruction in the operative group did not improve the ROM or the ability to perform daily living activities. Similar results were found in a study by Egol et al. These studies suggest that patients aged 65 years and older might not benefit from operative treatment, when looking at the subjective outcome after 1 year.
| Rehabilitation After Conservative Management of Distal Radius Fracture|| |
Activities during healing can be divided into the following phases: early protective phase (or during immobilization or protected motion), motion or mobilization, and function and strengthening. Educating the patient regarding the healing process should be done in a way that will be meaningful to that person's status and daily life requirements. Patient compliance and its importance in the rehabilitation partnership need to be emphasized.
- Early protective phase – It starts immediately after fracture fixation and lasts 1–6 weeks depending on the fracture fragment stability. Active motion of the digits, elbow, and shoulder (and wrist and forearm, if permitted) and “overhead fisting” should be encouraged to be performed several times daily. A stringent effort of elevating the hand and wrist above the heart level may be successful in controlling pain and edema. Strategies to decrease the pain, such as elevation, massage, heat or cold modalities, and active exercises, should be encouraged. In most patients, pain will fade as stable fracture fixation is achieved. However, treatment of pain is given priority if it seems to be a greater problem than the stiffness. Early predictors of difficulty in recovery can include the following: MCP or proximal interphalangeal joint pain and swelling, tingling in digits, and rapid change in swelling with position change. Some of these patients may develop complex regional pain syndrome
- Mobilization or motion phase – This phase starts immediately after immobilization. The goal during this phase is to restore as much motion as possible, but at least functional wrist ROM, defined as 40° of flexion and 40° of extension of the wrist and a total of 40° of radial and ulnar deviation. Most motion gains will be made during the first 3 months after fracture. There can be motion gains up to 1 year, but the rate and magnitude of these changes lessen with time. Active motion of the wrist, forearm, and digits should be emphasized early in the motion phase. Wrist extension without concurrent finger extension may be difficult to achieve early on. A priority in therapy is to overcome this substitution pattern because finger flexion, grip strength, and hand function cannot improve until the wrist extensors relearn to “work alone” without help from the digital extensors. If active exercise and verbal cues are not sufficient to activate wrist extensors, then neuromuscular electrical stimulation isolated to the wrist extensors may be helpful for muscle reeducation and to enhance tissue extensibility. Several orthosis can be used for sustained low force passive stretch to increase ROM. This low-load prolonged stress is more effective than high-load brief stress (manual passive stretching)
- Function and strengthening phase – When fracture healing has progressed, exercises that apply stress or load to the wrist can be initiated. In general, at approximately 8 weeks, the wrist can typically handle progressive loading from light grip to wrist isometrics to progressive resisted exercises to closed chain activities. Closed kinetic chain activities include exercises performed in weight bearing such as wall push-ups, plyoball exercises, and pushing or pulling activities. These exercise tools and exercise devices can be used in a supervised therapy session and then used on a home program basis.
| Conclusion|| |
Nonoperative treatment is the most common method of treatment of distal radius fractures, delivering reasonable short- and long-term outcomes. Good cast treatment of a distal radius fracture requires as much knowledge and skill as operative treatment. Patients need to be advised of this option. All clinicians must be competent in nonoperative treatment of distal radius fractures and be able to advise patients on the pros and cons of this method of treatment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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