From evidence to best practice in the management of fractures of the distal radius in adults: working towards a research agenda

BACKGROUND: Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis. We report our work towards evidence-based and patient-centred care for adults with these injuries. METHODS: We developed a systematic programme of research that built on our systematic review of the evidence of effectiveness of treatment interventions for these fractures. We devised schemata showing 'typical' care pathways and identified over 100 patient management questions. These depicted the more important decisions taken when progressing along each care pathway. We compiled a comprehensive document summarising the evidence available for each decision point from our reviews of randomised trials of treatment interventions. Using these documents, we undertook a formal and structured consultation process involving key players, including a patient representative, to obtain their views on the available evidence and to establish a research agenda. The resulting feedback was then processed and interpreted, using systematic methods. RESULTS: Some evidence from 114 randomised trials was available for 31 of the 117 patient management questions. However, there was sufficient evidence to base some conclusions of effectiveness for particular interventions in only five of these. Though only 60% of those approached responded, the responses received from the consultation group were often comprehensive and provided important insights into treatment practice and policy. There was a clear acceptance of the aims of the project and, aside from some suggestions for the more explicit inclusion of secondary prevention and management of complications, of the care pathways scheme. Though some respondents stressed that randomised trials were not always appropriate, there was no direct overall criticism of the evidence document and underlying processes. We were able to identify important core themes that underpin management decisions and research from the feedback of the consultation exercise. CONCLUSIONS: Overall, this project is an important advance towards evidence-based and patient-centred management of adults with distal radial fractures. It exposes the serious deficiency in the available evidence but also provides a template for further action. As well as being a valuable basis for viewing and informing current practice, the insights gained from this project should inform a future research agenda

Treatment of post-traumatic degenerative changes of the radio-carpal and distal radio-ulnar joints by combining radius, scaphoid, and lunate (RSL) fusion with ulnar head replacement

Distal radial fractures are a common type of fracture. In the case of intra-articular fractures, they often result in post-traumatic arthrosis. The objective of this study is to describe a novel alternative to the established salvage techniques for the treatment of post-traumatic arthrosis of the radio-carpal and distal radio-ulnar joints (DRUJ). Six patients with radio-carpal and DRUJ arthrosis were treated with a combined radius, scaphoid, and lunate (RSL) arthrodesis and as a Herbert ulnar head prosthesis. Follow-up consisted of both radiographic and functional assessments. Functional measurements were noted both pre- and postoperatively. No non-union or pseudoarthrosis was seen; neither did any of the ulnar head prostheses show loosening. Clinical examination showed an improvement in strength, pain, and range of movement, as well as a decrease in disability. Combining RSL arthrodesis with a Herbert ulnar head prosthesis, which deals with pain while retaining partial wrist movement, can be an alternative to established salvage procedures

Can radiological results be surrogate markers of functional outcome in distal radial extra-articular fractures?

The purpose of this study was to evaluate the relationship between radiological and functional results in patients with extra-articular fractures of the distal radius. We conducted a prospective study of radiological and functional assessment in 95 consecutively selected extra-articular distal radius fractures. There were two patient groups: more than 60 and less than 60 years of age. The final fracture union radiographs were analysed for their functional outcome using the Michigan Hand Outcomes Questionnaire (MHQ) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. In patients with acceptable radiological results, 62% (MHQ group) and 72% (DASH group) of patients had satisfactory functional outcome. Analysing patients with satisfactory functional results, 56% (MHQ group) and 59% (DASH group) had satisfactory radiological results. There was a higher proportion of patients with better functional results, despite poor radiological results, in both of the age groups. There was a statistically significant correlation between satisfactory radial tilt and functional outcome in the younger patients. In the older age group, patients with satisfactory radiological results had satisfactory functional outcome (p < 0.05). However, in the older age group, satisfactory functional results were achieved, despite unsatisfactory radiological results