Can Surgeons Accurately Predict Future Loss of Threshold Fracture Alignment of a Distal Radius Fracture After Index Treatment With Closed Reduction and Cast Immobilization?

Purpose: Common initial management for a displaced distal radius fracture (DRF) is closed reduction and cast immobilization with the aim that the fracture heals with an acceptable fracture alignment. However, it is known that displaced DRFs often lose their threshold alignment during the first treatment weeks. Loss of threshold fracture alignment is based on measuring standardized radiographic parameters within defined thresholds for alignment. Losing alignment is variably associated with limited grip strength, motion of the wrist and forearm and pain intensity. There is notable international variation in treatment of DRFs. This variation is due to surgeon bias, and correctly predicting whether a fracture will lose alignment is an important role in choosing correct treatment. This study will objectify the accuracy of surgeons in predicting future loss of threshold fracture alignment of reduced DRFs, based on trauma and reduction radiographs.

Methods: Radiographs of 20 adults with a DRF initially treated with closed reduction and cast immobilization were retrospectively selected. The alignment of all follow-up radiographs of the patients were measured, and based on the Dutch guideline for DRFs it was determined whether there was loss of threshold fracture alignment or not: classifying it as a stable or unstable fracture. Based on these guidelines 11 were deemed stable, and 9 unstable. Trauma and post-reduction radiographs (posteroanterior and lateral) were collected of each DRF. These radiographs were sent out to an international group of surgeons through a web-based questionnaire. These surgeons were randomized in 2 groups: (1) both trauma and post-reduction radiographs, and (2) post-reduction radiographs only. Participating surgeons were asked to predict whether the presented DRF would lose fracture alignment or not.

Results: 116 surgeons responded to the questionnaire. Group 1 consisted of 56 surgeons and group 2 of 60 surgeons. 43% (n = 50) of the surgeons were from the US, and 36% (n = 42) were from Europe. Group 1 evaluated the DRFs with an accuracy of 54%, sensitivity of 56%, specificity of 31%, positive predictive value (PPV) of 49,0%, and negative predictive value (NPV) of 37%. Group 2 had an accuracy of 55%, sensitivity 44%, specificity 45%, PPV 50%, and NPV 40%.

Conclusion: Surgeons struggle in predicting whether loss of threshold fracture alignment will happen in distal radial fractures after treatment with closed reduction and cast immobilization.

Graphic