Abstract
Distal radius fractures are very common yet controversy exists regarding which require treatment and is reflected by significant variation in surgical intervention rate. Evidence regarding which fractures would benefit from intervention is varied and largely poor quality. This study had three aims; identify which radiographic parameters are clinically important; quantify the threshold of displacement at which intervention should occur and investigate which patient factors influence the decision to intervene. A modified three round Delphi study was carried out and responses were qualitatively analysed. The Delphi panel was composed of three groups of national and international expert surgeons: hand and wrist surgeons, trauma surgeons, and international researchers. 46 participants initially agreed to take part. 43 completed the first round and all then completed three rounds. Participants were asked questions based around case vignettes in patients of three ages (38, 58, 75 years). For all age groups ulnar variance was ranked as the most important extra-articular parameter, step was ranked as the most important intra-articular parameter. Agreed thresholds were the same for all parameters for patients aged 38 and 58. Surgeons would intervene with +2 mm ulnar variance, 10 degrees dorsal tilt, 2mm step and 3mm gap. In patients aged 75 the agreed thresholds were 20 degrees dorsal tilt, 3mm step and 4mm gap, consensus was not achieved for ulnar variance.Mental capacity, pre-injury functional level and medical co-morbidities were ranked as the most important factors influencing the decision to intervene. Qualitative analysis suggested that pre-injury function was the main theme within these factors. Our findings provide useful advice about which parameters should be measured and radiographic thresholds for intervention. These thresholds may then be modified depending on important patient factors. This information can help guide clinicians with management decisions and reduce variation.
Highlights
Distal radius fractures (DRF) are the most frequently treated fracture worldwide and a huge burden on healthcare resources
The protocol and first round questions were presented to the British Society for Surgery of the Hand (BSSH) blue book for distal radius fracture management committee and feedback obtained
100% (43) of participants who took part in round 1 completed all rounds of the Delphi study
Summary
Distal radius fractures (DRF) are the most frequently treated fracture worldwide and a huge burden on healthcare resources. Around 70,000 individuals are affected each year in the United Kingdom (UK).[1] Incidence continues to rise with an ageing population.[2] Despite the frequency in which these injuries are encountered optimum treatment remains controversial. Many fractures may require only simple, safe, low cost interventions such as cast immobilisation. Displaced or intra-articular injuries are often treated surgically with manipulation and Kirschner wire (K-wire) fixation, or with open reduction and internal fixation using locking plates. Plate fixation is significantly more expensive [3]and has become an increasingly common management strategy[4]. Randomised trials have not shown a benefit of locking plates compared to K-wire fixation for fractures that can be reduced closed. Randomised trials have not shown a benefit of locking plates compared to K-wire fixation for fractures that can be reduced closed. [5, 6] Several meta-analyses combining these results have generated conflicting findings. [7,8,9]
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