Management of Unstable Distal Radius Fractures: A Survey of Hand Surgeons

Abstract

Background Length of immobilization after operative fixation of unstable distal radius fractures and management in elderly patients is an area of debate. Purpose The purpose of this study is to delineate common practices of fellowship-trained hand surgeons and how they compare with current evidence-based protocols. Methods Surveys were distributed to American Society for Surgery of the Hand members on preferred methods of fixation, postoperative immobilization, and variations in treatment of elderly patients with unstable distal radius fractures. Responses were analyzed in comparison to a literature review. Subgroups were compared with regard to training, practice type, and years in practice. Results Four-hundred eighty-five surveys were analyzed. Volar fixed-angle plating was the most common choice of fixation (84.7%). Patients are most often immobilized for 1 to 2 weeks (40.0%) with range of motion (ROM) therapy begun most commonly between 1 and 4 weeks (47.2%). The majority of surgeons do not treat fractures differently in patients more than 65 years old. Physicians with more than 20 years of experience were significantly more likely to begin wrist ROM sooner with volar plating versus other fixation techniques compared with physicians with less than 20 years of experience (40.7% vs. 34.2%, respectively). Also, physicians in academic-only practices were more likely to immobilize patients for a shorter time after volar plating compared with those in privademics. Conclusion Volar fixed-angle plating is the dominant fixation method for unstable distal radius fractures among fellowship-trained hand surgeons. Elderly patients are not treated more conservatively and rigid immobilization after operative fixation remains the treatment of choice despite current evidence-based protocols.

A systematic review of how daily activities and exercises are recommended following volar plating of distal radius fractures and the efficacy and safety of early versus late mobilisation

“…Recommendations on activity use are lacking in the literature and the safety of early fracture loading has been debated. 9,33,34 In general, the review confirms the safety of early activity. The parameters of early activity were not well-defined in the studies but commonly described as needing to be light, non-forceful, and within pain limits.…”

Comparative clinical and radiographic outcomes between early and delayed wrist mobilization after volar fixed-angle plate fixation of distal radius fracture

“…Despite the clear benefits of early rehabilitation demonstrated in various studies, these findings have not altered the practice of hand surgeons, as reflected by a survey of fellowship-trained hand surgeons. Only 3.9% of surgeons did not perform wrist immobilization after the operative fixation of DRF, and only 8.1% of the surgeons immediately initiated postoperative range-of-motion exercises 19 . Most surgeons preferred postoperative immobilization and postponed the time to initiate range-of-motion exercises due to doubtfulness regarding fixation stability, which might lead to fracture displacement over time.…”

In adults, early mobilization may be beneficial for distal radius fractures treated with open reduction and internal fixation: a systematic review and meta-analysis

“…Postoperative EM improved the patient's quality of life and physical comfort [ 10 , 29 ], and therefore assures the individuals early return to activities of daily living and work. Despite the lack of supporting studies demonstrating its effectiveness, immobilization has been empirically used to provide analgesia after surgery [ 30 , 31 ]. The latest Cochrane Database Review published in 2015 by Handoll et al [ 8 ] on rehabilitation for DRFs pointed out that as in 2006 [ 32 ], there is a lack of sufficient evidence about the effectiveness of the various rehabilitation programs after ORIF for DRF.…”