How would you treat this fracture?

[iliacus]

Q: An elderly women with osteoporosis falls on her outstreched hand. She comes in with a deformed and painful wrist that looks like a dinner fork. X-ray films show a dorsally displaced, dorsally angulated fracture of the distal radius. There is also an associated fracture of the ulnar styloid. Neurological and vascular exam is normal. Which of the following is the most appropriate management?

A.) Closed reduction short arm cast?

B.) Closed reduction long arm cast?

C.) Skeletal traction?

D.) IM rod?

E.) ORIF?

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[asdf123]

this is such a stupid question it gave me a headache. Are you so naive to think anyone can answer this question correctly without looking at a freaking Xray?

 

[iliacus]

this is such a stupid question it gave me a headache. Are you so naive to think anyone can answer this question correctly without looking at a freaking Xray?

I don't know about being naive, but this was a usmle qbank question I thought was impossible to answer. I was curious as to how other people would answer it.

 

[ortho060802]

ORIF (likely)

 

[Tired]

this is such a stupid question it gave me a headache. Are you so naive to think anyone can answer this question correctly without looking at a freaking Xray?

Way to be a a$$hole, and apparently one who doesn't read much either.

For the OP, let's get into it a little:

1) Distal radius fractures - standard is closed reduction, except in the elderly and low-demand patients. Take a look at the abstract below, straight out of Wheeless off the Duke website (which apparently asdf123 doesn't read).

Acta Orthop Scand. 2003 Feb;74(1):98-100. "Fractures of the distal radius in low-demand elderly patients: closed reduction of no value in 53 of 60 wrists." Beumer A, McQueen MM.

To determine the value of reduction of fractures of the distal radius in the very elderly and low-demand or demented patient, we assessed 60 fractures in 59 patients for the reduction achieved and maintained. The mean patient age was 82 (65-93) years. All fractures were initially reduced under regional or general anaesthesia. In 44 dorsally displaced fractures, reduction failed in 7 cases initially, and 37 lost reduction during the following weeks of immobilisation in plaster. In 9 wrists with volarly displaced fractures, reduction was achieved in 6; all malunited. A total of 53/60 fractures healed in a malunited position. We found no correlation between fracture classification, initial displacement, and final radiographical outcome. On the basis of these observations we conclude that reduction of fractures of the distal radius is of minimal value in the very old and frail, dependent or demented patient.


2) Associated fractures of the ulnar styloid - depends on the location of the fracture. Distal ulnar styloid avulsion fractures are considered stable and do not require operative intervention or manipulation. However, fractures at the base of the ulnar styloid run the risk of destabilizing the DRUJ, and require operative fixation.

All in all, I think the answer is ORIF. Closed reduction has a high likelihood of failure given the patient's age. I'm not too far along, so don't know the criteria for IM nailing of radius fractures off the top of my head, but have never seen a simple Colles treated so dramatically, especially given the availability of very nice plate sets. Skeletal traction is a bad answer. That leaves ORIF.

 

[PediBoneDoc]

Q: An elderly women with osteoporosis falls on her outstreched hand. She comes in with a deformed and painful wrist that looks like a dinner fork. X-ray films show a dorsally displaced, dorsally angulated fracture of the distal radius. There is also an associated fracture of the ulnar styloid. Neurological and vascular exam is normal. Which of the following is the most appropriate management?

A.) Closed reduction short arm cast?

B.) Closed reduction long arm cast?

C.) Skeletal traction?

D.) IM rod?

E.) ORIF?

i would say you need more information and xray. in general, the current treatment for intra articular fractures in the non pediatic practice tends to be ORIF. that being said depending on on other factores such as other medical problems (heart dz, DM, et) which would make going under anesthesia risky.

for mutiple choice test, the questions answers give you the the proper answer and you don't need to actually know the answer. you can scratch out casting because you have 2 different types of casting (nonsurgical). skeletal traction has not been used in the united stated for treatment of distal radius freactures. IM rod can not fix the dital radius without going into the wrist joint. the last answer is ORIF. if they wanted to through some confusion, they would have put in external fixation. that is just test taking 101.

the ulna styloid only has significants if is is below the insertion of the TFCC.

ORIF better for adults because it allows the early motion and can correct any intraarticular problems.

 

[Tired]

i would say you need more information and xray. in general, the current treatment for intra articular fractures in the non pediatic practice tends to be ORIF. that being said depending on on other factores such as other medical problems (heart dz, DM, et) which would make going under anesthesia risky.

Aside from torus fractures in kids (and I know even this is controversial) do you ever treat any distal radius fractures with an initial short-arm cast? Just curious.

 

[PediBoneDoc]

Aside from torus fractures in kids (and I know even this is controversial) do you ever treat any distal radius fractures with an initial short-arm cast? Just curious.

i treat a lot in a cast. both long and short arms depending on the stability. so it can be either. we treat a lot by initial casting (when swelling is not an issue). as you know many peds distal radius fractures are treated non op.

 

[Tired]

i treat a lot in a cast. both long and short arms depending on the stability. so it can be either. we treat a lot by initial casting (when swelling is not an issue). as you know many peds distal radius fractures are treated non op.

Interesting. Of the two Peds groups I have worked with, one refused to use short arm casts period out of worries about supination/pronation. They would do a long-arm for three weeks, then convert to short arm for the remainder. The other limited short arm casts to fractures they were reasonably sure were stable. I have yet to see an adult treated with an initial short arm.

 

[iliacus]

Way to be a a$$hole, and apparently one who doesn't read much either.

For the OP, let's get into it a little:

1) Distal radius fractures - standard is closed reduction, except in the elderly and low-demand patients. Take a look at the abstract below, straight out of Wheeless off the Duke website (which apparently asdf123 doesn't read).

Acta Orthop Scand. 2003 Feb;74(1):98-100. "Fractures of the distal radius in low-demand elderly patients: closed reduction of no value in 53 of 60 wrists." Beumer A, McQueen MM.

To determine the value of reduction of fractures of the distal radius in the very elderly and low-demand or demented patient, we assessed 60 fractures in 59 patients for the reduction achieved and maintained. The mean patient age was 82 (65-93) years. All fractures were initially reduced under regional or general anaesthesia. In 44 dorsally displaced fractures, reduction failed in 7 cases initially, and 37 lost reduction during the following weeks of immobilisation in plaster. In 9 wrists with volarly displaced fractures, reduction was achieved in 6; all malunited. A total of 53/60 fractures healed in a malunited position. We found no correlation between fracture classification, initial displacement, and final radiographical outcome. On the basis of these observations we conclude that reduction of fractures of the distal radius is of minimal value in the very old and frail, dependent or demented patient.


2) Associated fractures of the ulnar styloid - depends on the location of the fracture. Distal ulnar styloid avulsion fractures are considered stable and do not require operative intervention or manipulation. However, fractures at the base of the ulnar styloid run the risk of destabilizing the DRUJ, and require operative fixation.

All in all, I think the answer is ORIF. Closed reduction has a high likelihood of failure given the patient's age. I'm not too far along, so don't know the criteria for IM nailing of radius fractures off the top of my head, but have never seen a simple Colles treated so dramatically, especially given the availability of very nice plate sets. Skeletal traction is a bad answer. That leaves ORIF.

This is excellent..thank you very much

 

[PediBoneDoc]

Interesting. Of the two Peds groups I have worked with, one refused to use short arm casts period out of worries about supination/pronation. They would do a long-arm for three weeks, then convert to short arm for the remainder. The other limited short arm casts to fractures they were reasonably sure were stable. I have yet to see an adult treated with an initial short arm.

tired ... remember nondisplaced or minimally displaced distal radius only fx are stable inherently and displaced distal radius and ulna fx are unstable inherently. one gets a short and the other a long. children differ by age, the younger are more stable than the older. young kids (say 7y/o and younger) can be treated for only 4 weeks in a cast with removable splint after; where as older patients may need up to 6-8 weeks, long then short. fracture patterns are different and to say there is one way to treat things is probably not correct. there are a million different ways of treating things.

as far as adult fractures are concerned, most end up with surgical treatment because of intraarticular involvement and/or instability. if you are concern with a fracture being unstable rotation wise then you have to lock the elbow with a long arm or place a munster cast (which allows flex/ext of the elbow but no rotation kind of like a PTB).

 

[SOUNDMAN]

Many times with a low demand elderly patient and a simple dorsally angulated distal radius fracture on say their non dominant hand we would treat this very conservatively, with even splinting and begin gentle ROM after a few weeks. Realistically I think the question needed more information as I've seen us treat this fracture with ex fix, ORIF, cast, or splint and early mobilization. Really I think it depends on the patient many times more than anything as we get into this age group.