Data analysis was performed using SPSS version 24.0 (IBM Corp, Armonk, NY). Analysis included one-way ANOVA tests, and a P-value of<0.05 was interpreted to be statistically significant. Cohen’s kappa scores were calculated for interrater reliability for all radiographic parameters. Data was organized, and tables were constructed using Microsoft Excel 2010 (Microsoft Corporation; Redmond, WA).
Consideration of Candidacy
The most studied radiographic parameters used to predict functional outcomes in DRF managed with CRC include RH, VT, RI, and UV. Most of the data support RH as being the strongest predictor of functional outcomes, especially among elderly patients,10,21 but VT10,14,21,22 also has been found to predict outcomes to a lesser degree. In general, at final bone union, a RH greater than 9.3 mm or VT greater than 3 degrees has correlated with better functional outcomes in conservatively managed patients, and despite little evidence correlating RI with functional outcomes, a RI greater than 15 degrees has been postulated as a management goal.21,23 Similarly, conservatively treated patients with a UV less than 3 mm has been reported by Kodama et al.14 to have superior Mayo wrist scores (MWS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Thus, using these values as a cutoff to determine whether CRC management was successful or not, the prereduction means of successfully managed fractures were compared against the prereduction means of unsuccessfully managed fractures using a Student t-test, and a P-value of<0.05 denoted statistical significance.
The present study identified 42 patients, 31 of whom were women, with a mean age of 58.98 yr (range, 23 to 100 yr) (Table 1).
Radial Height, Radial Inclination, and Ulnar Variance
The mean RH was significantly restored after CRC (7.5 to 10.4 mm; P<0.01), regressing only slightly by 1.3 mm after final union. Mean RH was not significantly different between postreduction and final union measurements or prereduction and final union measurements. A similar pattern of significant change was observed with RI, which increased from 14.4 to 19.4 degrees (P<0.01) following CRC and returned to 17.3 degrees after final bone union (Table 2). Prereduction UV decreased at postreduction CRC (1.2 to −0.2 mm, P<0.02), and UV was restored by final bone union (1.2 mm, P<0.01). There was no difference in UV between pre-CRC and final union.
Volar Tilt and Teardrop Angle
The mean VT angle significantly changed at each radiographic period, from −9.9 degrees at initial presentation to 7.9 degrees after CRC (P<0.01) to 1.1 degrees after union (P<0.05). The mean TDA also significantly increased following CRC (34.1 to 49.9 degrees, P<0.01) and did not deviate significantly from this measurement through final bone union (Table 2).
The mean prereduction RH in patients who achieved a favorable final bone RH was significantly higher than the mean prereduction RH in those who failed to achieve a satisfactory RH (9.58 vs. 5.26 mm, P=0.0002). A similar pattern was appreciated with respect to RI (16.92 vs. 8.08 degrees, P=0.0006) and UV (0.41 vs. 3.88 mm, P<0.01); however, no significant difference was found between mean prereduction VT values (Table 3).
Between the two surgeons who performed radiographic measurements, the Cohen’s kappa scores for interrater reliability for all radiographic parameters were >0.892, indicating a strong level of agreement.24
Radiographic measurements have been described in various ways in the literature, which results in significant interobserver variability. However, the literature appears to agree that the majority of DRF managed with CRC undergo secondary displacement at some time prior to final bone union.18 Furthermore, the literature trends show that a distal radial malunion in younger patients is associated with poorer functional outcomes.25 For the elderly, secondary displacement occurs at higher rates.18 However, the correlation between malunion and poorer functional outcomes has not been made in this population.13,26,27 Between 1996 and 2004, the rates of internal fixation across all age groups nearly doubled, reflecting the recent introduction of volar locking plates and some literature showing improved functional outcomes for operatively treated DRF.28,29
Many studies have sought to analyze radiographic measurements in conservatively managed DRF, but most of these studies were conducted before or during the time that trends were shifting toward increased management with internal fixation. The present study, which evaluated DRF treated with CRC between 2012 and 2015, determined that all radiographic measurements significantly improved after CRC, and acceptable RH, RI, and VT values were maintained through union. On the other hand, TDA, despite improving significantly after CRC, never attained normal values. However, this measurement is relatively new to the literature, and normal postreduction values have not been reported elsewhere. Additionally, the present study found that patients with a RH less than 9.5 mm and UV of greater than 3.8 mm at time of presentation may be at significant risk for having suboptimal functional outcomes if treated conservatively. This is based on the present study’s radiographic findings in the context of previous studies that have evaluated correlations between radiographic parameters and functional outcomes.
Radial height is normally 9 to 12 mm in length.23 Shortening of this measurement below 9 mm results from comminution and impaction of fracture fragments, and shortening of 5 mm or more compared to the contralateral distal radius is a marker of fracture instability.23 Similar to the present study, Azzopardi et al.30 between 1997 and 2000 and Wong et al.31 between 2006 and 2007 demonstrated RH improvement after CRC, achieving postreduction values of 10 mm and 10.7 mm, respectively. However, after final bone union, both studies reported that CRC-managed patients had a mean RH that regressed below prereduction values (4.2–5.0 mm), possibly suggesting that these patients were poor candidates for conservative management.30,31 Similarly, Bagul et al.32 found statistically significant improvement in the mean RH of 15 DRF following CRC (6.1 to 7.9 mm, P<0.001). However, this postreduction RH was outside what is considered “normal,” suggesting that either the patients of this study were poor candidates for CRC, or that there was poor technique used to reduce fractures in this study. Many other studies dating from 1990 to 2015 failed to achieve acceptable final union RH values.8,27,33 A 2015 study by Cai et al.21 demonstrated that RH was the most important radiographic determinant of final function and that loss of RH was associated with poor functional outcomes, evidenced by a strong correlation between a final union RH>9.3 mm and a Mayo Wrist Score (MWS) of 80 or higher. Using this 9.3-mm cutoff for RH at final union, the present study found that patients who achieved this measurement goal had a mean RH of 9.5 mm at the time of injury. Similarly, Kodama et al.14 demonstrated that among patients treated conservatively, those with UV of less than 3 mm at final examination had superior MWS and DASH scores. Using this 3-mm cutoff at final union, the present study found that patients who achieved this measurement goal had a mean UV of 0.4 mm. Therefore, the authors of this study believe that patients initially presenting with a RH less than 9.5 mm or UV greater than 3.8 mm at time of injury may benefit from consideration of nonconservative treatment, given the potential for poor functional outcomes based on RH and UV values at union.
The normal range of RI is 19 to 29 degrees, but in the event of a DRF, improvement of inclination to greater than 15 degrees is considered acceptable.23 Loss of radial inclination in DRF shifts the load distribution more to the lunate fossa and less to the scaphoid fossa, resulting in abnormal wrist joint mechanics.34 Altering wrist joint mechanics can predispose the wrist to posttraumatic arthritis. Wong et al.31 examined pre and post-CRC, and final union radiographs in 30 patients with DRF, and reported comparable mean RI measurements to the present study (13 degees at initial presentation, 23 degrees after CRC, and 16 degrees after bone union). Other studies have shown similar findings, although in these studies, the RI was within a normal range at initial presentation as well.13,30 Multiple other studies agree that an acceptable RI can be achieved with CRC by time of bone union.27,33,35,36 However, it should be noted that reduction technique influences postreduction radiographic parameters. Wichlas et al.37 reported substantially higher RI values when reduction was preceded by 15 min of hanging traction. Overall, the literature suggests that RI can be restored and maintained to normal values with CRC management, contrary to varying results pertaining to radial height. The present study found a significant difference between mean RI at time of presentation based on the achievement or lack of achievement of a final union RI of 15 degrees. However, most studies have demonstrated appropriate restoration of RI, and there is little evidence to support RI as a predictor of functional outcomes in RI, making little significance of this finding.
A negative VT indicates dorsal angulation of the distal radial articular surface. Although normal values range from 0 to 22 degrees, an acceptable value after reduction of a DRF is any value within 20 degrees of the contralateral distal radius.23 Loss of VT greater than 10 degrees has been shown to markedly decrease the radioscaphoid and radiolunate articular contact areas, leading to significant increases in pressure load to the dorsal aspect of the radiocarpal joint and predisposing the wrist to dorsal radiocarpal instability.38 Studies have shown significant reductions in dorsal angulation after CRC in DRF patients.18,30 Although multiple studies have reported acceptable VT values at time of bone union after CRC comparable to this study, these studies did not report prereduction or postreduction measurements, making it hard to draw definitive conclusions.8,27,35 Other studies have refuted CRC success by reporting that dorsal angulation persisted in the long-term.39 For example, Egol et al.33 reported that, the mean VT decreased from -1.1 to -5.8 degrees between 3 and 12 mo after reduction, but the study failed to report any normalized VT values, making it uncertain whether acceptable values were attained immediately after reduction. Largely, there is a lack of convincing evidence in the current literature to determine if restoration of VT is more achievable with CRC now than in the past. To the best of the authors’ knowledge, no previous study has reported prereduction or postreduction VT measurements in CRC-managed patients. Additionally, some studies have supported the fact that restoration of VT has a positive influence on functional outcomes.14 Cai et al.21 suggested a goal value for final union VT to be greater than 3 degrees, at which point the MWS was likely to be 80 or higher. The present study found that patients on either side of this cutoff did not significantly differ in terms of mean VT at presentation; thus, despite correlation between VT and functional outcomes, we were unable to predict which patient might achieve an acceptable reduction with restoration of VT with CRC therapy based on prereduction VT.
The normal TDA of 68 to 70 degrees was first described by Medoff in 2005.10 After reduction, a depression of this angle may be an indicator that articular incongruity remains despite restoration of radial inclination and volar tilt.10,40 There is a significant paucity of data regarding TDA in the literature, especially as it relates to CRC. In 2011, Forward et al.41 published the only other study to date that analyzed prereduction, postreduction, and final union TDA values, finding that the TDA significantly improved after CRC (47 to 58 degrees, P<0.0001) and was maintained through final union (56 degrees). No study to date, including those that have evaluated TDA outcomes after surgical management, has achieved successful restoration of the TDA in the normal reported range.
The retrospective nature of the present study poses certain limitations. The size of the cohort included is one major limitation; these patients were included, as they met all inclusion criteria and had full radiograph sets. Nevertheless, there is a downward trend in conservative management of distal radial fractures and a paucity of literature on acceptable parameters at presentation for conservative management.28 Moreover, this cohort size is similar to several related studies.8,42,43 Additionally, the mean age of the study population was 58.98 yr; while this may indicate a relatively younger cohort, the study population actually had a bimodal age distribution (46 and 67 yr). Although age has been determined to effect reduction outcomes, our study population, though small, represented both relatively younger and elderly patients.18 In addition, the study cohort varied in patient demographic data, and fracture classification and severity were not recorded.
In conclusion, most of the current literature on the topic of radiographic outcomes of CRC-managed DRF is underpowered, and few studies have reported analyzing radiographs at initial presentation, postreduction, or after final union. With the literature that does exist, follow-up timelines vary, and marked inconsistencies in results have been reported. Also, little attempt has been made to assess the predictive value of various radiographic measurements on functional outcomes. This supports the fact that management decisions for DRF with CRC remain subjective. Results from the present study underscore the importance of developing standardized guidelines to properly assess radiographs in DRF patients. Additionally, using predetermined final union goals, this study found that patients with a RH greater than 9.5 mm and UV less than 3.8 mm at time of injury would be likely to achieve successful reduction without functional deficit. Establishment of guidelines would offer surgeons the ability to make better management decisions that are both evidence-based and will correlate better with radiographic and functional outcomes.
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Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved
distal radius; fracture; closed reduction; casting; radiographic parameters; patient selection