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Conceptual Paradigm Shift In Delayed Distal Radius Fracture Management: A Five-Year Single-Surgeon Experience
Clifford T. Pereira, MD, James Rough, MD, Mark Sugi, MD, Prosper Benhaim, MD.
UCLA Medical Center, Los Angeles, CA, USA.
Current guidelines recommend that open reduction and internal fixation (ORIF) for distal radius fractures (DRFs) be performed within 4 weeks of injury. Unfortunately, due to innate difficulties with the county hospital system, not all of our patients receive their operation within the requisite time frame. Delayed DRF management (4 weeks and over) is traditionally subject to corrective osteotomy, with assumed technical difficulties in recreating the fracture secondary to callus formation. We report a five-year single-surgeon series of delayed DRFs that were treated by ORIF rather than osteotomy.
A retrospective chart review was performed on all patients admitted to Olive View Medical Center, Los Angeles with DRF requiring ORIF from March 2007 to August 2011. IRB approval was obtained prior to commencement of study. Patients were divided into an early group (EG) (surgery performed <4 weeks post-injury) and delayed group (DG) (surgery performed ≥4 weeks). Emergency department consultation notes, clinic notes, operative reports and preoperative/postoperative x-rays were reviewed. Information gathered was divided into the following categories: patient demographics, injury pattern, operative technique, timing and pre and postoperative x-ray findings. Data was analyzed using Microsoft Office Excel 2007.
Of 154 patients with DRFs that were taken to the operating room, from 2007-2011, 137 patients (EG=41, DG=96) had ORIFs performed by the senior author. Of the 96 patients in DG, only one patient required an osteotomy and was excluded from subsequent data analysis. The remaining 95 patients underwent ORIFs at 37.3 ± 8.3 days (range: 28-76 days) post-injury as outpatients. Both groups had similar age, gender and racial demographics. Preoperative fracture patterns were radiographically also similar with similar intra-articular fractures (EG = 58.4%, DG = 65.2%) and fracture dislocations (EG = 4.8%, DG = 5.2%). Intra-operatively the dorsal approach was required more frequently in the EG (7.3%) compared to DG (1%). The Orbay maneuver was performed more frequently in DG (54.7%) compared to EG (39%). Both groups had minimal (<10ml) blood loss and no intra-operative complications. Tourniquet times were also not significantly different (EG = 91.6 ± 24.5 minutes, DG = 98.8 ± 23.8 minutes). Postoperative articular incongruency rates were similar in both groups (ED 2.4%, DG 3.15%). Preoperative and postoperative x-ray findings were not statistically significant in both groups (See Table).
There was no significant difference found in intraoperative technique, operative time, and postoperative radiological results in patients treated within 4 weeks or after 4 weeks post-injury. Despite current belief that ORIFs in delayed DRFs are technically not possible and warrant an osteotomy, our series indicates that ORIFs are indeed a viable option in DRFs as late as 8 weeks.
Table: Preoperative and Postoperative finding in Early versus Delayed groups
|Preop Dorsal Angulation|
|Postop Volar Tilt|
|Preop Ulnar Variance |
|Postop Ulnar Variance |
|Preop Radial Tilt |
|Postop Radial Tilt |
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