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Closed Reduction of Distal Radius Fractures

- Discussion: (distal radius fracture menu)

     - closed reduction & immobilization in plaster cast remains accepted method of treatment for majority of stable distal radius frx;
            - unstable fractures will often lose reduction in the cast and will slip back to the pre-reduction position;
     - patients should be examined for carpal tunnel symptoms before and after reduction;
            - carpal tunnel symptoms that do not resolve following reduction will require carpal tunnel release;
     - cautions:
            - The efficacy of closed reduction in displaced distal radius fractures.

- Technique:
    - anesthesia: (see: anesthesia menu)
         - hematoma block w/ lidocaine;
               - w/ hematoma block surgeon should look for "flash back" of blood from hematoma, prior to injection;
         - references:
               - Regional anesthesia preferable for Colles' fracture. Controlled comparison with local anesthesia.
               - Neurological complications of dynamic reduction of Colles' fractures without anesthesia compared with traditional manipulation after local infiltration anesthesia.
    - methods of reduction:
         - Jones method: involves increasing deformity, applying traction, and immobilizing hand & wrist in reduced position;
               - placing hand & wrist in too much flexion (Cotton-Loder position) leads to median nerve compression & stiff fingers;
         - Bohler advocated longitudinal traction followed by extension and realignment;
         - consider hyper-extending the distal fragment, and then translating it distally (while in extended position) until it can be "hooked over" proximal fragment;
               - subsequently, the distal fragment can be flexed (or hinged) over the proximal shaft fragment;
         - closed reduction of distal radius fractures is facilitated by having an assistant provide counter traction (above the elbow) while the surgeon controls the distal fragment w/ both hands (both thumbs over the dorsal surface of the distal fragment);
    - flouroscopy:
               - it allows a quick, gentle, and complete reduction;
               - prepare are by prewrapping the arm w/ sheet cotton and have the plaster or fibroglass ready;
         - if flouroscopy is not available, then do not pre-wrap the extremity w/ cotton;
               - it will be necessary to palpate the landmarks (outer shaped of radius, radial styloid, and Lister's tubercle, in order to judge success of reduction;
    - casting:
         - generally, the surgeon will use a pre-measured double sugar sugar tong splint, which is 6-8 layers in thickness;
               - more than 8 layers of plaster can cause full thickness burns:
         - reference: Setting temperatures of synthetic casts.
    - position of immobilization
    - follow up:
         - radiographs:
         - repeat radiographs are required weekly for 2-3 weeks to ensure that there is maintenance of the reduction;
         - a fracture reduction that slips should be considered to be unstable and probably require fixation with (pins, or ex fix ect.)
         - there is some evidence that remanipulation following fracture displacement in cast is not effective for these fractures;
         - ultimately, whether or not a patient is satisfied with the results of non operative treatment depends heavily on their personal expectations, non dominant side, and functional status;
               - hence, younger patients w/ involvement of dominant side, moderately high functional demands, and high expections for outcome may not be satisfied with non operative care;
         - references:
               - The value of remanipulating Colles fractures.  
               - Closed reduction of axial compression in Colles fracture is hardly possible.  
               - Redisplaced unstable fractures of the distal radius: a prospective randomized comparison of four methods of treatment.
               - Fractures of the distal radius in low-demand elderly patients: closed reduction of no value in 53 of 60 wrists.

- Comparative Studies:
    - in the report by Earnshaw SA, et al, the authors compared closed treatment of Colles fractures using a finger trap reduction
           technique as compared to manual reduction techniques;
           - no significant differences were found between the alignment of the fractures in the two treatment groups at any time;
           - with dorsal tilt of <10° and radial shortening of <5 mm considered acceptable, the two techniques both produced an 87% rate of satisfactory reductions;
           - percentages of fractures in an acceptable alignment were only 57% and 50% at one week after finger-trap traction and manual manipulation, respectively, and only 27% and 32% at five weeks;
           - although closed reduction was successful for the majority of fractures, most redisplaced substantially during the period of cast immobilization;
    - Closed Reduction of Colles Fractures: Comparison of Manual Manipulation and Finger-Trap Traction. A Prospective, Randomized Study
    - Plaster cast versus external fixation for unstable intraarticular Colles' fractures.
    - External fixation or plaster for severely displaced comminuted Colles' fractures  A prospective study of anatomical and functional results.
    - Displaced distal radius fractures. A comparative study of early results following external fixation, functional bracing in supination, or dorsal plaster immobilization.
    - External fixation or plaster cast for severely displaced Colles' fractures? Prospective 1-year study of 46 patients.
    - Cast or external fixation for fracture of the distal radius. A prospective study of 126 cases.
    - A prospective randomized trial of external fixation and plaster cast immobilization in the treatment of distal radial fractures.

Colles' fracture. How should its displacement be measured and how should it be immobilized.

Forearm fractures in children. Cast treatment with the elbow extended.

Outcome following non operative treatment of displaced distal radius fractures in low demand patients older than 60 years.  

Predictors of early and late instability following conservative treatment of extra-articular distal radius fractures.

Predicting Alignment After Closed Reduction and Casting of Distal Radius Fractures

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Clifford R. Wheeless, III, MD on Friday, April 24, 2015 9:57 am

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