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International Survey

Factors Associated With Operative Treatment of Distal Radius Fractures and Implications for the American Academy of Orthopaedic Surgeons' Appropriate Use Criteria

Kyriakedes, James C. MD*; Crijns, Tom J. BSc; Teunis, Teun MD, PhD; Ring, David MD, PhD; Bafus, Blaine T. MD* Science of Variation Group

doi: 10.1097/BOT.0000000000001517
Opinions and Surveys

Objectives: Through an international survey, we assessed whether deciding to operatively treat an intra-articular distal radius fracture (DRF) is guided by identifiable patient and surgeon factors. In addition, we compared surgeons' treatment decisions with the American Academy of Orthopaedic Surgeons' Appropriate Use Criteria (AUC) treatment recommendations.

Methods: This cross-sectional survey asked 224 surgeons to operatively or nonoperatively treat 28 hypothetical patients with radiographs of an intra-articular DRF. We randomized patient age (50/70 years), gender, mechanism of injury, activity level, and OTA/AO fracture type. We classified 6 fractures as “nonclinically significant displacement” and 22 as “potentially clinically significant displacement.” Multilevel logistic regression analysis was performed. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported. Statistical significance was P < 0.05.

Results: Patient factors independently associated with surgery included younger age (OR 6.7, P = 0.003), clinically significant fracture displacement (type B: OR 122, CI, 20–739, P < 0.001; type C: OR 59, CI, 12–300, P < 0.001), normal activity level (OR 5.0, P < 0.001), and high-energy mechanisms (OR 1.3, P = 0.002). Surgeon factors associated with recommending surgery included practicing outside the United States (Europe: OR 2.6, P < 0.001; “other”: OR 4.8, P < 0.001). Hand surgeons most often selected surgery, as compared to orthopaedic trauma surgeons (OR 2.3, P = 0.001) and “other orthopaedists” (OR 2.2, P = 0.022). Thirty-seven percent of treatment decisions for patients with normal activity levels were rated by AUC recommendations as “rarely appropriate,” which included 91% disagreement for 70-year-olds with nonclinically significant displacement.

Conclusions: Surgeons use patient age and fracture displacement to make treatment recommendations for intra-articular DRF. We recommend that the AUC be updated to include these clinical factors as essential components in its algorithm.

Level of Evidence: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

*Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH;

Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX; and

Department of Plastic, Reconstructive and Hand Surgery; University Medical Center Utrecht, Utrecht, the Netherlands.

Reprints: James C. Kyriakedes, MD, Department of Orthopaedic Surgery, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109 (e-mail:

One of the authors (D.R.) received royalties from Tornier (Memphis, TN) (formerly Wright Medical) for elbow plates in the amount of less than USD 10,000 per year and from Skeletal Dynamics for an internal joint stabilizer elbow in the amount of less than USD 10,000 per year. One of the authors certifies that he (D.R.) is a Deputy Editor for Hand and Wrist, Journal of Orthopaedic Trauma, and Clinical Orthopaedics and Related Research and has received or may receive payments or benefits in the amount of USD 5000 per year. One of the authors certifies that he (D.R.) received honoraria from meetings of the AO North America (Wayne, PA), AO International (Davos, Switzerland), and various hospitals and universities. One of the authors certifies that he (T.T.) received payments in the amount of less than 10,000 USD per year from AO Trauma (Dubendorf, Switzerland), DePuy Synthes (West Chester, PA), and PATIENT+ (The Hague, the Netherlands). The remaining authors report no conflict of interest.

A complete list of author names of the Science of Variation Group is listed in Appendix 1.

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Accepted May 01, 2019

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