Radiographs late in the follow up of uncomplicated distal radius fractures – Are they worth it? Clinical outcome and financial implications

Abstract

Fractures of the distal radius are common. Displacement can quickly lead to secondary osteoarthritis. Early follow up radiographs are subsequently paramount to facilitate for early attempts at reduction. Developing callus eventually makes this impractical. In the absence of complications we propose that radiographs may become obsolete at the later stages of follow up. We investigate whether clinical deformity, range of wrist movement and grip strength are independent of radiographs taken later than 2 weeks into the follow up of uncomplicated cases. Local cases between May 2009 and December 2011 were reviewed. Devised criteria regulated case selection. Data was collected from radiological software and occupational therapy clinical notes. Fractures were placed in short or term follow up groups dependant on whether they were imaged later than 2 weeks into follow up. T-tests compared our outcomes measures between these groups. 138 cases were included; 77 short term; 61 long term. No cases reported visible clinical deformity. There were no significant differences between grip strength or range of wrist movement for the short and long term groups. No cases required intervention for late displacement. Although complications may justify delayed imaging, our results suggest radiographs late in the follow up of uncomplicated distal radius fractures have no impact on our outcome measures. Further studies are required to confirm this. Financial regulation means any potential benefits from the removal of these unnecessary radiographs should be recognised. Established radiological follow up regimes need to be devised.

Full text

[page 88] [Orthopedic Reviews 2012; 4:e20]
Radiographs late in the follow
up of uncomplicated distal
radius fractures: are they
worth it? Clinical outcome
and financial implications
Nicholas Eastley, Randeep Aujla,
Zeeshan Khan
Kettering General Hospital, Northants, UK
Abstract
Fractures of the distal radius are common.
Displacement can quickly lead to secondary
osteoarthritis. Early follow up radiographs are
subsequently paramount to facilitate for early
attempts at reduction. Developing callus eventu-
ally makes this impractical. In the absence of
complications we propose that radiographs may
become obsolete at the later stages of follow up.
We investigate whether clinical deformity, range
of wrist movement and grip strength are inde-
pendent of radiographs taken later than 2 weeks
into the follow up of uncomplicated cases. Local
cases between May 2009 and December 2011
were reviewed. Devised criteria regulated case
selection. Data was collected from radiological
software and occupational therapy clinical notes.
Fractures were placed in short or term follow up
groups dependant on whether they were imaged
later than 2 weeks into follow up. T-tests com-
pared our outcomes measures between these
groups. 138 cases were included; 77 short term;
61 long term. No cases reported visible clinical
deformity. There were no significant differences
between grip strength or range of wrist move-
ment for the short and long term groups. No
cases required intervention for late displace-
ment. Although complications may justify
delayed imaging, our results suggest radi-
ographs late in the follow up of uncomplicated
distal radius fractures have no impact on our
outcome measures. Further studies are required
to confirm this. Financial regulation means any
potential benefits from the removal of these
unnecessary radiographs should be recognised.
Established radiological follow up regimes need
to be devised.
Introduction
Distal radius fractures are one of the com-
monest encountered by orthopaedic surgeons.
The injury constitutes 18% of all human frac-
tures, and over one sixth of those seen in the
emergency department.1,2 Depending on frac-
ture configuration, operative or non-operative
treatment may be appropriate. Kirschner wires,
external fixators, and palmar or dorsal plates all
provide potential surgical options.3,4 Non-opera-
tively managed fractures are usually manipulat-
ed (if warranted by displacement) and immo-
bilised in plaster. Resolution of soft tissue
swelling and poor cast application leaves these
cases at risk of displacement.5This is particular-
ly true if there is dorsal radial tilt, dorsal com-
minution or an intra-articular radiocarpal com-
ponent to a fracture.6The radiocarpal joint is
formed by the distal radius and the proximal
carpal row. Loss of congruity between these
structures can quickly lead to uneven joint load-
ing, osteoarthritis and a poor functional out-
come.7This makes the early accurate reduction
of displacement paramount. Within the first two
weeks of follow up this be achieved with relative
ease and a good outcome.2,8 Later, the formation
of osteoid callus makes the process increasingly
difficult and eventually impractical. At this stage
we propose imaging asymptomatic cases subse-
quently become obsolete. Currently very little
formal guidance exists for surgeons choosing
when to perform follow up radiographs for distal
radius fractures. We found only two published
regimes. The first involved plain radiographs
taken at initial presentation and then again ten
days later.9The second included radiographs on
a weekly basis for the first three weeks post
injury and finally at 6 weeks post injury.10
Our research question is whether radi-
ographs taken more than 2 weeks into the follow
up of uncomplicated distal radius fractures have
a significant effect on clinical outcome. We are
unaware of any previous studies investigating
this. Our primary outcome measure was visible
clinical deformity. Our secondary outcome
measures were range of wrist movements and
grip strength. If outcomes are shown to be inde-
pendent, results would form the basis of an argu-
ment to remove late radiographs from the radi-
ographic follow up regime of these cases. We
also highlight the financial and staffing benefits
which would result from the removal of any
unnecessary radiographs.
Materials and Methods
We performed a retrospective review of cases.
Consecutive distal radius fractures treated at
our unit between May 2009 and December 2011
were reviewed. The inclusion and exclusion cri-
teria below were devised to regulate case selec-
tion and define uncomplicated cases.
Inclusion criteria
– Extra-articular fractures within the distal 3
cm of the radius (AO 23-A2.1, 23-A2.2 and 23-
A3.1/2/3).
– Patients discharged by local occupational
therapy following a complete course of hand
therapy.
– Documented values of grip strength, wrist
flexion, extension, radial deviation and ulna
deviation up to occupational therapy dis-
charge.
Exclusion criteria
– Patients aged less than 16.
– Cases initially treated operatively.
– Intra-articular fractures (AO 23-B1/2/3 / AO
23-C1/2/3).
– Goyrand-Smith fractures (AO 23-A2.3).
– Open fractures.
– Fractures associated with distal neurovascu-
lar symptoms or signs.
– Fractures not initially managed at our emer-
gency department.
– Cases without initial and all follow up radi-
ographs available.
– Cases with palpable instability, loading pain
or tenderness at the fracture site during fol-
low up.
When discharged policy dictates that patients
are routinely referred to local outpatient occupa-
tional therapy (OT) departments for hand thera-
py. Here serial measurements of wrist flexion,
extension, and radial and ulna deviation are
recorded with the use of a goniometer. Grip
strength is also recorded with a dynamometer.
One of three therapists routinely record these
values using consistent technique. A spread-
sheet was formulated to aid data extraction.
Data collected included patients’ age, sex, later-
ality of the fracture and date of injury. To assess
our primary outcome measure a note of any vis-
ible clinical deformity was recorded. To address
Orthopedic Reviews 2012; volume 4:e20
Correspondence: Nicholas Eastley, 8 Main Street,
Marston Trussell, Market Harborough, Leicester,
LE16 9TY, UK. Tel. +44.07890619380.
E-mail: neastley@doctors.org.uk
Key words: distal, radius, fracture, radiographs.
Contributions: NE, design, acquisition of data,
analysis and interpretation of data, drafting the
article; RA, acquisition of data, analysis and
interpretation of data; ZK, conception, revision of
article, final approval of the version to be pub-
lished.
Conflict of interests: the authors report no poten-
tial conflict of interests.
Received for publication: 27 March 2012.
Accepted for publication: 30 April 2012.
This work is licensed under a Creative Commons
Attribution NonCommercial 3.0 License (CC BY-
NC 3.0).
©Copyright N. Eastley et al., 2012
Licensee PAGEPress, Italy
Orthopedic Reviews 2012; 4:e20
doi:10.4081/or.2012.e20

[Orthopedic Reviews 2012; 4:e20] [page 89]
our secondary outcome measures the values of
grip strength and range of wrist movements at
time of OT discharge were recorded. Two
authors systematically collected this data from
clinical notes. Next patients’ radiographs were
systematically reviewed using local software.
In general 2 radiographic follow up regimes
are currently used by local surgeons. The first
consists of radiographs at initial presentation,
and again at 1 and 2 weeks post injury. The sec-
ond regime is initially the same, but an addition-
al radiograph is performed at 6 weeks post injury
prior to clinic discharge. For the purpose of our
study cases only imaged within the first 2 weeks
of follow up were placed in a short term follow up
group. Cases imaged later than 2 weeks into fol-
low up were placed into a long term follow up
group. At presentation displaced fractures were
reduced by our local emergency department
using a haematoma block. Adequacy of reduc-
tion was accepted on an individual patient basis.
Two tailed unpaired t-tests looked for significant
differences between groups.
Results
A total of 201 patients were referred for outpa-
tient OT during our capture period. Following
analysis of clinical notes and radiographs 63
cases were excluded. Reasons for exclusion are
shown in Table 1. Of the eligible 138 cases 77
were placed in the short term group and 61 in
the long term group. 84 fractures involved the
left wrist and 54 the right wrist. 17 of the eligible
138 patients were male. The demographics of
each subgroup are shown in Table 2. No cases
were identified with clinically detectable defor-
mity. There were no statistically significant dif-
ference between the grip strengths or range of
movements of the short term and long term fol-
low up groups at discharge (Table 2). P-values
varied from 0.21 to 0.91. Further analysis
showed no significant differences between short
and long term follow up groups when those aged
more than 50, or less than 50 were analysed in
isolation. The same was true when patients
were segregated according to sex and compared.
No asymptomatic cases from the long term
group underwent surgery based on findings of
late radiographs. No cases required surgical
intervention after discharge from clinical care.
Discussion
Nonunion of distal radius fractures is
uncommon.11 In contrast, malunion rates have
been reported as high as 17%.12 Malunion
often occurs when a secondary loss of fracture
reduction is missed during follow up.12,13 Loss
of reduction may result from a combination of
poor cast application, resolution of soft tissue
swelling, fracture comminution or mechanical
forces spanning the radiocarpal joint.
Unsurprisingly non-operatively managed cases
are at highest risk of this.12
Several well recognised radiological indices
have been devised to help surgeons define
acceptable reduction for distal radius frac-
tures.14 These are radial inclination, radial
length, ulnar variance, radial tilt and radial
shift. Although the clinical significance of
these parameters is debated,7,15-17 groups have
shown that correcting these variables in cases
of established symptomatic malunion increas-
es patient satisfaction. More specifically wrist
and hand function appear to improve, and
wrist pain is reduced.18,19
When recognised early enough fracture dis-
placement is most commonly corrected by
repeated attempts at closed reduction, or open
reduction followed by surgical stabilisation. If
malunion becomes established osteoid callus
makes this impossible. In these cases a formal
osteotomy may be required. These highlights
the importance of recognising and correcting
malunion as early as possible during follow up,
and early follow up radiographs to facilitate
this.20
Fractures of the distal radius are extremely
common. It has been estimated that 71,000
adult men and women sustain the injury in
Britain each year.21 At present there is mount-
ing financial regulation within the Health
Service. Our results suggests that radiographs
performed more than 2 weeks into the follow
up of uncomplicated distal radius fractures
have no effect on final grip strength or range of
wrist movement. They also suggest that no
cases of late displacement would be missed if
these radiographs were removed from the rou-
tine follow up regime. Prospective studies have
calculated the average cost of managing a dis-
tal radius fracture is £ 320.50, with 90% of this
costs being defined as service costs and not
consumables.22The current cost of a radi-
ograph in our department is £ 25.90. This high-
lights the clear financial benefits that would
result from the removal of late radiographs
from the routine follow up of uncomplicated
cases. The time taken to carry out radiographs
and the exposure of staff and patients to radi-
ation should also be recognised.
Our report has limitations. The small sam-
ple size makes it difficult to draw definitive
conclusions. Local practice dictates that
patients are followed up in fracture clinic for a
minimum of 6 weeks. Throughout this period
before they are discharged to the care of hand
therapists patients are examined by senior
members of the orthopaedic team. The retro-
spective design of this study, small number of
participants and quick rotation of orthopaedic
registrars meant we were unable to categorise
our results according to individual observers.
Results are consequently reliant on the exam-
ination skills and findings of many surgeons.
Retrospective data collection also meant
ranges of wrist movement and grip strengths
were not available for patients’ contralateral
uninjured wrists for comparison.
Future trials are required to confirm our
results and an agreed radiographic follow up
regime for these cases. These should ideally
take the form of multi centred prospective ran-
domised trials. Given the bimodal incidence of
distal radius fractures we recommend that
cases are segregated according to age and
analysed independently. Work showing the eld-
erly as particularly susceptible to malunion
further supports this.23
Article
Table 2. Demographics and outcome for included cases.
Mean values
Group Mean Grip Flexion Extension Radial Ulnar
age strength deviation deviation
(range) (kg)
Short term (77) 63 (17-91) 15.3 64.3° 58.7° 22.7° 30.3°
Long term (61) 62 (17-93) 15.0 64.5° 56.9° 23.7° 32.0°
P 0.82 0.91° 0.37° 0.31° 0.21°
Table 1. Cases excluded from our study and reasons.
Reasons for exclusion Number of cases
Intra articular fractures 14
Inadequate documentation 9
Goyrand-Smith fractures fractures 8
Fractures managed operatively 32

[page 90] [Orthopedic Reviews 2012; 4:e20]
Conclusions
In summary we propose that the removal of
late radiographs from the follow up of non-
operatively managed extra-articular distal
radius fractures may have no adverse effects
on clinical outcome, whilst providing financial,
staffing and timing benefits. Larger trials
should be devised to confirm this. We suggest
follow up radiographs are organised only at
weeks 1 and 2 post index injury. We recognise
however that complications may justify
delayed imaging, and that the need for further
radiographs should be guided by clinical exam-
ination and the presence of concerning symp-
toms.
References
1. Kulej M, Dragan S, Krawczyk A, et al.
Epidemiology of distal radius fractures in
own material - own experience. Ortop
Traumatol Rehabil 2008;10:463-77.
2. Jupiter JB. Fractures of the distal end of
the radius. J Bone Joint Surg Am 1991;
73:461-9.
3. Asche G. External fixators for distal radius
fractures therapy and results based on 25-
years experience with external fixators.
Osteo Trauma Care 2002;10:141.
4. Hollevoet N, Vanhoutie T, Vanhove W, et al.
Percutaneous K-wire fixation versus pal-
mar plating with locking screws for Colles'
fractures. Acta Orthop Belg 2001;77:180-7.
5. Cooney WP 3rd, Dobyns JH, Linscheid RL.
Complications of Colles' fractures. J Bone
Joint Surg Am 1980;62:613-9.
6. Lafontaine M, Delince P, Hardy D, et al.
Instability of fractures of the lower end of
the radius: apropos of a series of 167
cases. Acta Orthop Belg 1989;55:2033-216.
7. Ng CY, McQueen MM. What are the radio-
logical predictors of functional outcome
following fractures of the distal radius? J
Bone Joint Surg Br 2011;93:145-50.
8. McQueen MM, MacLaren A, Chalmers J.
The value of remanipulating Colles' frac-
tures. J Bone Joint Surg Br 1986;68:232-3.
9. Rustam Z, Hasan Khan Niazi P, Ahmad M,
et al. Frequency of carpal tunnel syndrome
(CTS) after conservatively managed colles’
fracture. Pakistan Armed Forces Medical
Journal 2004. Available from: http://www.
pafmj.org/showdetails.php?id=7&t=o
10. Schatzker J, Tile M. The rationale of oper-
ative fracture care. 3rd edn. Springer;
1987.
11. Prommersberger KJ, Fernandez DL.
Nonunion of distal radius fractures. Clin
Orthop Relat Res 2004:51-6.
12. Bushnell BD, Bynum DK. Malunion of the
distal radius. J Am Acad Orthop Surg 2007;
15:27-40.
13. Hove LM, Solheim E, Skjeie R, Sörensen
FK. Prediction of secondary displacement
in Colles' fracture. J Hand Surg Br 1994;
19:731-6.
14. Graham TJ. Surgical Correction of malu-
nited fractures of the distal radius. J Am
Acad Orthop Surg 1997;5:270-81.
15. Arora R, Lutz M, Deml C, et al. A prospec-
tive randomized trial comparing nonoper-
ative treatment with volar locking plate
fixation for displaced and unstable distal
radial fractures in patients sixty-five years
of age and older. J Bone Joint Surg Am
2011;93:2146-53.
16. Batra S, Gupta A.The effect of fracture-
related factors on the functional outcome
at 1 year in distal radius fractures. Injury
2002;33:499-502.
17. Tsukazaki T, Takagi K, Iwasaki K. Poor cor-
relation between functional results and
radiographic findings in Colles' fracture. J
Hand Surg Br 1993;18:588-91.
18. Ring D. Treatment of the neglected distal
radius fracture. Clin Orthop Relat Res
2005:85-92.
19. Ladd AL, Huene DS. Reconstructive
osteotomy for malunion of the distal
radius. Clin Orthop Relat Res 1996:158-71.
20. Haase SC, Chung KC. Management of
malunions of the distal radius. Hand Clin
2012;28:207-16.
21. O'Neill TW, Cooper C, Finn JD, et al.
Incidence of distal forearm fracture in
British men and women. Osteoporos Int
2001;12:555-8.
22. Kakarlapudi TK, Santini A, Shahane SA,
Douglas D. The cost of treatment of distal
radial fractures. Injury 2000;31:229-32.
23. Makhni EC, Ewald TJ, Kelly S, Day CS.
Effect of patient age on the radiographic
outcomes of distal radius fractures subject
to nonoperative treatment. J Hand Surg
Am 2008;33:1301-8.
Article