Sam Anand looks at the guidelines introduced in December 2017 and the problems faced when adhering to the guidelines in practice
The British Orthopaedic Association Standards for Trauma (BOAST) sets out guidelines for best practice of specific injuries. The latest guidelines for distal radial fracture were published in December 2017. We will have a look at the guidelines in detail and the specific problems which most of us will face in sticking to these guidelines in our practice. I have decided to look at distal radius fracture as it is a common injury which most of us encounter in our daily practice.
- The mechanism of injury and clinical findings, including skin integrity, assessment of circulation and sensation, should be documented at presentation. Radiographic assessment should be posteroanterior and lateral views centred at the wrist.
This is hopefully standard practice at most A&E departments. If this is an isolated injury no other imaging modalities are required at presentation in the A&E setting.
2. If manipulation is indicated, it should be undertaken using regional anaesthesia, performed by a suitably qualified and trained practitioner (as opposed to local haematoma block).
Most A&E departments reduce these fractures under a haematoma block and this is a significant change in practice. This will need more training in the administration of regional anaesthesia and is also going to be more time consuming, especially in a busy A&E setting.
3. Open fractures should undergo surgical debridement and stabilisation in accordance with the BOAST Open Fractures.
Open fractures of the distal radius will be treated in the majority with urgent or immediate surgery, as would be the practice for any open fracture.
4. Patients should be referred to the Fracture Clinic service and assessed within 72 hours (BOAST for Fracture Clinic Services).
Most hospitals now offer next day fracture clinic appointments and this should be offered to all distal radius fractures.
5. Patients with a stable fracture of the distal radius should be considered for early mobilisation from a removable support once pain allows.
Stable distal radius fractures can be treated in a removable splint, most commonly a rigid wrist support, to facilitate early mobilisation.
6. When using a plaster cast to treat a distal radius fracture, the wrist should be in neutral flexion with three–point moulding used to hold the fracture and not forced palmar flexion. Consider removing the cast and starting mobilisation four weeks after injury.
Extremes of palmar flexion is best avoided and if it is required to maintain reduction then consideration should be given for surgical intervention to fix these fractures. Early mobilisation should be encouraged as stiffness and CRPS (Chronic regional pain syndrome) are a significant problem with distal radius fractures.
7. In patients 65 years of age or older, non-operative treatment can be considered as a primary treatment for dorsally displaced distal radius fractures, unless there is significant deformity or neurological compromise.
65 is a relatively arbitrary age cut off, but when this is used importance should be given for co-morbidities and physiological age as opposed to chronological age.
8. In patients under 65, consider ulnar variance, intra-articular step, dorsal tilt and reflect on the patient’s needs when assessing whether the patient may benefit from surgical reconstruction.
Even for patients under 65 the potential risks against the perceived benefits of surgical fixation of distal radius should be carefully considered.
9. Volar displaced fractures are unstable and should be considered for open reduction and plate fixation.
This is an absolute indication for surgical fixation, unless there are specific contra indications, such as the patient is not fit for any form of anaesthesia.
10. When surgical fixation is indicated for dorsally displaced distal radius fractures, offer K-wire fixation if displacement of the radial carpal joint can be reduced by closed manipulation. If this is not possible consider open reduction and internal fixation.
Dorsally displaced two-part distal radius fractures can be treated by closed reduction and Kirschner wire fixation if they are treated early post injury. If the fracture is likely to require an open reduction then plate fixation should always be considered.
11. If surgical intervention is undertaken, this should be performed within 72 hours of injury for intraarticular fractures and within one week for extra-articular fractures. When operative management is indicated for re-displacement following manipulation, surgery should be undertaken within 72 hours of the decision to operate.
As with most injuries early fixation of distal radial fractures provides a better outcome for most patients. This is not always achievable because of local resources, but every effort should be undertaken for early surgical intervention once a decision to operate is made.
12. Repeat radiographs of the wrist between 1–2 weeks after injury (or manipulation) where it is thought that the fracture pattern is unstable AND when subsequent displacement will lead to surgical intervention.
Unstable distal radius fractures treated in plaster should ideally be seen in weekly intervals for the first two weeks with radiographs when there is highest risk of re-displacement and the need for surgical fixation.
13. A radiograph of the patient’s wrist at the time of removing immobilisation is not required unless there is clinical cause for concern.
Most distal radius fractures treated non-surgically do not require radiographs unless clinically symptomatic at the time of coming out of immobilisation.
14. Patients should be assessed for falls risks and bone health, and referred to the fracture liaison services and or falls service where appropriate.
Prevention is always better than cure and all patients at risk of further falls should be referred to local falls services and fracture liaison services to start treatment for osteoporosis if necessary, especially in the at-risk population.
15. All patients should receive information regarding expected functional recovery and rehabilitation, including advice about return to normal activities such as work, education and driving. Patients should be able to self-refer to the fracture service if progress is not as anticipated and hospitals should provide this mechanism.
Printed patient information leaflets should be provided in all fracture clinics giving detailed information about expected return to normal activities and a safety net mechanism for re-referral if recovery is not going according to plan.
Distal radius fractures are common injuries which is encountered every day in A&E departments and fracture clinics. The above guidelines give us a good framework for the management of this common injury. This will be a good audit tool for A&E and trauma departments to implement quality improvement projects..
NICE Non-Complex Trauma Guidelines: www.nice.org.uk/guidance/ng38
BSSH BOA Blue Book: www.bssh.ac.uk/professionals/management_of_distal_radial_fractures.aspx