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Fractures of the Distal Radius-Have We Raised the Bar Too High?

Jupiter, Jesse B. MD

Techniques in Hand & Upper Extremity Surgery: March 2006 - Volume 10 - Issue 1 - p 1

Since assuming the co-editorship of the Journal, nearly every issue has contained at least one article presenting the techniques of application of new technology in the management of fractures of the distal end of the radius. Needless to say, all offer unique and potential improvements in achieving successful outcomes of these commonplace but troubling injuries. We usually see the results of these technologies, both in the articles as well as in presentations in meetings and workshops, accompanied by clinical pictures of smiling patients demonstrating full restoration of wrist and forearm motion. Perhaps in part a result of our profession's tendency to such enthusiasm, patients' expectations for a full functional result devoid of complications has followed. As recently related to me by an attorney who defends physicians in malpractice litigation, the distal radius is becoming a more common source of patient dissatisfaction and he suggested the perhaps the Orthopaedic specialty may have "raised the bar too high" for outcome expectations.

Yet, having been a "student" of the distal radius fracture since I was an Orthopaedic resident some 30 years ago, I can bear witness to the extraordinary changes in understanding the structural anatomy of the end of the radius, radiocarpal, and distal radioulnar joint; the pathophysiology of the wide variation of injury patterns; and the reasons why complaints and complications were so commonplace. Furthermore, through patient rated outcome tools, we have been taught that perhaps our anecdotal impressions may not have been so accurate especially as people not only live longer but are more healthy and active in their senior years. Perhaps we have traditionally placed "the bar" too low!!

I can readily recall discussions at our fracture conferences during my residency hearing our senior attending surgeons suggest such generalizations regarding distal radius fractures as "they all do well"; "you can always do a Darrach resection"; "avoid external fixation as it will cause wrist stiffness"; "you cannot operatively repair these small articular fragments". Even a sage such as my former chairman Henry Mankin in writing a forward to Dr Diego Fernandez and my text on the distal radius fracture wondered why an entire text would be devoted to a subject which he thought was a solved problem!!

Over the past 30 years I have had the opportunity to read, review, and even contribute to the vast body of literature on the subject of the distal radius fracture. Unfortunately for the most part (including most of my own contributions), the literature is lacking from a scientific perspective. Most studies have been to small, most have methodologic shortcomings, and most are weakened by a lack of standardization and nonvalidated outcomes. Yet, in our interests in providing the best care to our patients, we tend to look favorably on reports of new technologies and, at times, are influenced by industrial promotions.

The Journal of Techniques in Hand and Upper Extremity Surgery continues to provide our readers with well illustrated articles regarding the technical aspects of new technologies or creative techniques in the management of distal radius fractures. We believe our readers understand that these are expositions of techniques but not necessarily always the optimal approach for either specific fractures or individual surgeons. It remains for our specialty to also provide level 1 scientific studies using methodology consistent with that required of evidence-based medicine as well as validated outcome tools assessing both physician and patient rated outcomes to best understand the role of these new technologies.

Jesse B. Jupiter, MD

© 2006 Lippincott Williams & Wilkins, Inc.