Distal radial fractures: the significance of the number of instability markers in management and outcome.

Introduction: Distal radial fractures are one of the most common orthopaedic injuries. An effective treatment strategy is needed to ensure good outcome and better resource usage.

Aim: To identify the significance of the number of instability markers in distal radial fractures in predicting outcome and proposing a standardized management strategy.

Methods: Data was collected retrospectively over three months at the Northern General Hospital, Sheffield. All patients who had a distal radius fracture in the defined time period and matched our criteria were included. Relevant instability markers identified through a literature review were: age >60 years, dorsal angulation >20°, intra-articular fracture, ulna fracture, dorsal comminution, radial shortening and osteoporosis. The number of instability markers, management and outcome were recorded for each patient. The strategy of management was subdivided into: plaster cast immobilisation with subsequent rehabilitation, manipulation with subsequent cast immobilization and surgery (locked volar plating). Outcomes were graded as "good" or "poor" based on the complications and the function achieved at discharge from follow-up.

Results: Two hundred and seven patients were included in our study. One hundred and nineteen patients had <3 instability markers (Group A) and 88 had >4 (Group B). One hundred and sixty-two were female and 45 were male. The average age was 60 years and the age range was 19 to 96 years. In Group A, 91% achieved "good" outcome regardless of management strategy, versus 66% in Group B (p<0.001). In Group B, amongst patients who had surgery (29), 79% achieved "good" outcome, however those with manipulation alone (38), only 58% achieved "good" outcome (p > 0.03 (one tailed), p > 0.06 (double tailed)).

Conclusions: We have found that four or more instability markers are globally associated with a poorer outcome. Patients with four or more markers who underwent surgery did uniformly better than those with manipulation alone. However, in patients with three or fewer markers, non-operative management yielded equally good outcomes. We plan to use this as a pilot study for future primary research.