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ORIF or Cast Following Acceptable Distal Radius Fracture Reduction?

December 14, 2021

Essentials of Emergency Medicine Education Fellowship

The article summary for today is below, but first, we have a very exciting announcement!

The EEM 2022 conference organizers are offering an amazing opportunity for EM residents anywhere in the U.S./Canada to serve as an EEM Fellow for the next EEM conference May 10-12, 2022.

JournalFeed and EEM have partnered to offer one mini-fellowship position to eligible residents anywhere in the U.S./Canada. Those selected to participate will receive:

  • FREE conference registration

  • FREE 4-night hotel stay at the Hilton Union Square, San Francisco, CA

  • A travel stipend of US $500

JournalFeed’s contest involves writing a blog post about controversies in Emergency Medicine: present both sides of a clinical scenario, the best evidence and arguments for both, and summarize your take and recommendations in practice.

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Written by Seth Walsh-Blackmore

Spoon Feed
Following an acceptable closed reduction of a displaced intra-articular distal radius fracture, adults treated with volar plate fixation had better patient-reported functional outcomes through 6 months, but not at 1-year follow-up, compared to those treated nonoperatively. 28% of those initially treated non-operatively ultimately received surgery.

Why does this matter?
Distal radius fractures are among the most common traumatic orthopedic injuries encountered by emergency physicians. Operative management is the subject of ongoing debate in orthopedics, but it is generally indicated when intraarticular fractures are not acceptably reduced, meaning anatomic findings on radiographs meet or exceed certain criteria. Outcomes based on reduction would inform the decision to refer or consult for early operative management in borderline cases.

Fix the FOOSH?
This was an RCT of 90 patients age 18-75 years from 13 centers in the Netherlands with a displaced complete intraarticular radius fracture that was acceptably reduced. Acceptable reduction was as defined by the most ubiquitous ortho reference. Open fractures, poly-trauma, or those with prior wrist dysfunction were excluded. Patients were randomized to receive ORIF with a volar plate (n =46, median age 59) or continued cast immobilization (n=44, median age 62).

The primary outcome was a Patient-Rated Wrist Evaluation (PRWE) score, a 0-100 scale with 0 indicating no functional impairment. The study was powered to detect the reported minimal clinically important difference (MCID) of 14 points. A MCID favoring operative intervention was reported at follow-up through 6 months. The median score of 12 for non-operative vs 5 for operative at 12 months was statistically (p = 0.01) but not clinically significant. Secondary outcomes included a clinical evaluation of range of motion and grip strength, superior in the operative group at 6 weeks but not at subsequent follow-ups. Pain measured by the visual analog scale (VAS) did not differ between groups at any time point. In total, 13 non-operative patients (28%) had subsequent surgery due to displacement or malunion observed during the follow-up period.

This study indicates ORIF improves early functional status without meaningful differences after a year. This is logical, as ORIF allows for earlier mobilization and more rapid return to function. Given that 28% of nonoperative patients required surgery, prolonging their recovery, operative management may also provide a more reliable timeline to regain function. If uncertain about in-house ortho consultation after an acceptable reduction, consider the patient’s dependence on wrist function for their occupation or social responsibilities and arm dominance. Even in less dependent patients, early ortho follow-up following initial reduction and immobilization is indicated to identify those at higher risk of malunion and reevaluate the reduction status.

Volar Plate Fixation Versus Cast Immobilization in Acceptably Reduced Intra-Articular Distal Radial Fractures: A Randomized Controlled Trial. J Bone Joint Surg Am. 2021 Nov 3;103(21):1963-1969. doi: 10.2106/JBJS.20.01344.

What are your thoughts?