1. “The Evolution of Management of Fractures of the Distal Radius” David S Ruch, MD Chief of Hand and Microsurgery Vice Chairman of Orthopaedic Surgery

2. The Fracture  Most common fracture in the upper limb  1/6 of all fractures treated in the emergency room  Estimated 700,000 fractures per year

3. Incidence: 2 Peaks Male 20-45 High energy injury Comminuted fracture Malunion results in loss of function and pain Females over 65 Low energy/Osteopenic “insufficiency fractures” Malunion may be well tolerated

4. Previous Research  Data base mining  Largely cohort based level 4 evidence comparing outcomes of operative treatment  Focus has been on the disability seen in younger patients

5. Previous Work  Single surgeon database  Twenty seven publications 4 book chapters  Primarily compared treatment modalities based on level four case controlled cohort  Allowed demonstration of the significance of restoration of the “critical corner” of distal radius in patient reported outcomes

6. Level 3 Evidence“Arthroscopic v. Flouroscopic” Ruch et al Arthroscopy 2004;20(3)  1995-1999 prospectively acquired  38 pts Arthroscopically Assisted reduction and fixation of fractures of the distal radius- (DSR)  Entry Criteria  Isolated Fracture  Multi-fragmentary articular (Lunate Impaction)

7. Arthroscopic Distal Radius: Lunate Impaction Fx -Reduce articular Surface-

8. No statistically significant difference in outcomes with average $5.8K additional cost C.Y. 48y/o s/pMVA C.Y. 2 y f/u Articular reduction anatomic but collapse as fracture heals

9. Comparison Studies Dorsal plate fixation of a distal radius fracture

10. Dorsal Plate-pitfall Distal 2.0mm screws poor pull out strength in metaphyseal bone BUTBUT

11. Pitfall Dorsal Plate Palmar collapse results in DRUJ incongruity/prominent dorsal hardware

12. DRUJ incongruity from planar flexion of radius ECRL Rupture from prominent plate Extensor tendon ruptures

13. Palmar Versus Dorsal Plate Fixation for Distal Radius Fractures Ruch DS Papadonikolakis A JHS 2006

14. “Combined Palmar Plate and Dorsal External Fixation to Treat Intra- articular Farctures of the Distal Radius” Ruch DS et al JOT 1998

15. “The Significance of the Palmar Lunate Facet in Outcomes following Operative Management of Intra articular Fractures of the Distal Radius” Ruch et al JBJS (Am) 2012

16. Study Population  157 patients (88m/69f)  Mean age 45.5yM 53.6F  MOA- FOOSH 87 /MVA 59 other 11  Dom 85/ Non Dom 72  Operative Treatment  External fixation +wires n=53  Dorsal plate n=32  Palmar plate n=46  Combined dorsal and volar n=26

17. Group 1 (n=41) >2mm depression  External Fixation (n=17)  Dorsal plate (n=17)  Palmar plate (n=7)

18. Group 2 (n=116) less than 2 mm of displacement  External fixation (n=34)  Dorsal plate (n=36)  Palmar plater (n=46) Demographics in both groups similar in age sex and hand dominance

19. Results ROM  Patients without residual depression had a significantly higher  median wrist extension (65 degrees) than those with lunate displacement (45 degrees) (p=.002)  Median Supination (78 degrees) than those with lunate displacement (67degrees) (p=.004)

20. Results Outcome scores  Gartland and Werely scores were significantly lower for patients without displacement (mean =1.85 median =0) compared with those with residual displacement (mean =3.31 median = 2) (p=.036)  significant difference noted in VAS at at 3mo and six mos  No significant differences were noted in the VAS DASH outcome scores at one year

21. Multi Center Trials

22. Ex Fix ORIF “Indirect reduction and percutaneous fixation versus ORIF for displaced intra- articular fractures of the distal radius” Kreder,HJ et al JBJS 87-B 2005

23.  179 Patients  Prospective randomized  Outcomes  Subjective-MFA  Objective -Radiographic/Physical Exam  Functional

24. “External Fixation Versus Open Reduction Internal Fixation for Intra-articular Fractures of the Distal Radius” Kreder,HJ et al JBJS 87-B 2005  External Fixation superior  Grip/pinch/range of motion  Functional outcome scores  No difference in xrays  Gap  Step

25. Dilemma 72y/o active retiree Single lives alone Concerns about ability to remain independent 1 week post closed reduction

26. Dilemma Ex Fix +Allograft bone through 3-4 interval 2 weeks post ex fix and bone graft

27. Failure of the osteopenic bone to hold the hardware 4 weeks post op

28. Final result

29. Maybe Colles Was Right?

30. Trends in the United States in the treatment of distal radial fractures in the elderly. Chung KC, Shauver MJ, Birkmeyer JD JBJS (Am) 2009 Chung KCShauver MJBirkmeyer JD Chung KCShauver MJBirkmeyer JD  5% sample of Medicare data from 1996 to 1997  20% sample from 1998 to 2005.  four treatment methods (closed treatment, percutaneous pin fixation, internal fixation, and external fixation)  frequencies and rates to compare the utilization of different treatments over time.  RESULTS: Over the ten-year time period examined, the rate of internal fixation of distal radial fractures in the elderly increased fivefold, from 3% in 1996 to 16% in 2005.  Since 2000, although the majority of distal radial fractures are still treated nonoperatively, there has been an increase in the use of internal fixation and a concurrent decrease in the rate of closed treatment of distal radial fractures in the elderly in the United States.

31. financial implications?

32. Medicare Data 2008  Operative Management of a distal radius fracture  Standard office practice  1 PA or Nurse  Use of over 1 hour of operative time  Regardless of implant  Actual loss of revenue

33. “ A Prospective Randomized Comparison of Operative v Non Operative Management of Distal Radius Fractures in the Elderly”  Inclusion criteria:  All patients under sixty five  Closed intra articular/extra articular fracture of the distal radius  Exclusion  Co morbidities precluding operative management  Open fractures  Ipsilateral injuries

34. Power analysis  608 patients  Randomized /  Cast treatment  Percutaneous pinning  External fixation  Open reduction plate fixation  Outcome 1` /2` variables  Physical parameters ROM Grip Digital motion  Patient reported outcome variables  PRWE /DASH/SF36

35. NIH Funding  18 centers  35K per center  Estimated 34 patients enrolled per center  Attrition rate at one year ~10%

36. Goals  Identify any measures between treatment groups  Extrapolation of cost data both regionally and nationally  “ Is the cost of operative management justified based upon outcomes at one year?”

37. Conclusions  Orthopedic Clinical Research has traditionally been cohort based and largely level four  Expert opinion considered  Prospective randomized trials have largely gone unfunded  Previous trials generally have grouped all patients with a given radiographic diagnosis despite obvious dissimilarities based upon age and fracture severity

38. Future Directions  Data base management between centers to allow for actuarial type data analysis similar to the Northeastern Cardiac Consortium (Dartmouth Hitchcock Center) to allow for analysis of variation between centers

39. Special Thanks  Duke Orthopaedic Faculty / Residents  Drs James Nunley and Farshid Guilak  Special Thanks to Dean Andrews