Does the Location of Initial Management After Distal Radius Fracture Impact the Ultimate Need for Operative Intervention?

Abstract

BACKGROUND: Fractures of the radius and/or ulna comprise the largest proportion (44%) of the estimated 1.5 million cases of hand and forearm fractures seen in Unites States emergency departments each year.1 Displaced distal radius fractures (DRFs) are often managed with closed reduction and splinting. After initial management of these injuries, patients are referred to tertiary care facilities or specialty groups for continuing care. Failure to obtain a stable, near-anatomic reduction may lead a specialist to recommend and/or perform surgery to re-establish appropriate radiographic relationships. Complication rates associated with nonoperative management have been studied though data on conversion to surgical management are not widely reported.2 Surgery incurs a significant financial and physical cost to the patient and healthcare system. The primary aim of this study was to assess how location and type of facility at which a DRF is initially managed impacts rates of surgical intervention. Specifically, we compared a tertiary care facility, staffed with hand specialists, to referring community institutions where no hand specialists were readily available. METHODS: We performed a retrospective chart review of all patients treated at University of Wisconsin—Hospital and Clinics (UW) for DRFs from January 1, 2018 to December 31, 2018. Patients were placed into one of 2 groups: (1) initial treatment performed at any location within the UW system and (2) initial treatment performed at any location outside of the UW system. We calculated the operative rate for each group. We also analyzed the effect of sex and type of injury on the conversion to surgical management. RESULTS: We identified 1,337 patient encounters associated with a DRF current procedural terminology (CPT) code. Eight hundred twenty-four patients were initially managed at UW Health, whereas 513 patients were initially managed at non-UW facilities. Patients initially managed at UW went on to surgical intervention at a significantly lower rate of 15.0% (n = 124) compared to those patients initially treated outside of UW Health who underwent surgery 26.3% of the time (n = 135) (P < 0.0001). Type of injury was not a predictor of conversion to surgery nor initial presentation to UW. Sex was not a predictor of surgical conversion. CONCLUSIONS: These data suggest that initial management of DRFs at UW Hospital and Clinics significantly decreases the rate of operative reduction and fixation. A decrease in operative intervention reduces both the physical and financial impact of DRFs. This indicates that there may be a need to educate community providers to either perform an acceptable bony reduction or refer patients to treating facilities capable of performing these techniques in the early postinjury period. REFERENCES: 1. Chung C, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001;26:908–915. 2. Chung KC, Malay S, Shauver MJ, et al, for the WRIST Group. Assessment of distal radius fracture complications among adults 60 years or older: a secondary analysis of the WRIST Randomized Clinical Trial. JAMA Netw Open. 2019;2:e187053.