AAOS issues new clinical practice guidelines for treating distal radius fractures

The American Academy of Orthopaedic Surgeons (AAOS) recently approved and released an evidence-based clinical practice guideline on the Treatment of Distal Radius Fractures. A distal radius fracture -one of the most common fractures in the body- usually occurs as a result of a fall. For example, a fall may cause someone to land on his or her outstretched hands, breaking the larger of the two bones in the forearm, near the wrist.

• In 2007, more than 261,000 people visited the emergency room due to a distal radius fracture.

"The Academy created this clinical practice guideline to improve patient care for those sustaining a distal radius fracture," stated David Lichtman, MD, chair of this guideline workgroup. "This serves as a point of reference and an educational tool for both primary care physicians and orthopaedic surgeons, streamlining possible treatment processes for this ever-so common problem," he added. "While a wide range of treatment options are available, they should always be tailored to individual patients after discussions with their orthopaedic surgeons."

The final patient-oriented guidelines for treating distal radius fractures contain 29 evidence-based recommendations overall, some of which are included below:

• The research suggests that a rigid cast is better than a splint if the fracture was displaced.
• If a fracture was not displaced - as in a hairline crack - a removable splint can be worn.
• If a fracture has a tendency to fall back the way it was before the physician fixed it, research suggests that these fractures heal better if the surgeon operates on them, rather than treating them with a cast.

According to the work group, one key question that needs to be answered in future research is whether surgeons should perform the same operations and use the same fixation methods with older patients as they do with younger patients. Lichtman points out that some elderly patients are physiologically younger than others. By lifting weights, getting regular exercise, and staying in shape, some seniors have the same bone structure of an individual 20 or 30 years younger. Lichtman and his colleagues had been looking for answers to this particular question in the current review of the literature and were surprised, once again, to find that no answers existed at this time.

Due to the current studies lacking evidence based support, the following recommendations were a consensus among the Academy work group:

• Distal radius fractures treated without surgery should have repeated x-rays for three weeks and when the use of a splint or cast is discontinued.
• Patients should perform active finger motion exercises following diagnosis of distal radius fracture.
• Patients with distal radius fractures and unremitting pain need to be re-evaluated promptly by their physician.

"Probably the most valuable part of this exercise was the realization that better studies are needed to precisely determine which current treatments work the best under different clinical circumstances. We also came up with some helpful ideas on how to design future studies," said Dr. Lichtman.

More than 4,000 journal articles from around the world were analyzed over the course of a year and every article was graded on a five-point scale depending on the strength and quality of the evidence. Only prospective, randomly controlled clinical trials with enough patients to establish clinical and statistical significance could earn the highest grade, ranking as strong evidence.