The Effectiveness of Mini–C-Arm Fluoroscopy for the Closed Reduction of Distal Radius Fractures in Adults: A Randomized Controlled Trial

Published:March 22, 2018DOI:https://doi.org/10.1016/j.jhsa.2018.02.015

      Purpose

      Most distal radius (DR) fractures are initially managed with closed reduction and orthosis application. Mini–C-arm fluoroscopy provides assessment of reduction quality in real time. Our null hypothesis was that there would be no difference in the reduction quality of DR fractures in the emergency department when using mini–C-arm fluoroscopy during reduction compared with standard reduction techniques (evaluating reduction quality with orthogonal radiographs taken in an orthosis).

      Methods

      Sixty-three consecutive patients with closed DR fractures requiring reduction between April 2015 and April 2017 were prospectively randomized to standard versus fluoroscopically aided reductions. Reductions were performed by orthopedic surgery residents. The primary outcome measurement was reduction quality (radial height, radial inclination, ulnar variance, and volar tilt) as measured on postreduction radiographs.

      Results

      Standard reductions were performed in 34 patients and fluoroscopically aided reductions in 29 patients. The 2 groups were similar in regards to all potential confounders that were analyzed. No differences in postreduction radial height, radial inclination, ulnar variance, or volar tilt were noted. Overall reduction attempts and subjective difficulty of fracture reduction were increased when using fluoroscopy. The rate of initial operative management did not differ between groups.

      Conclusions

      The use of mini–C-arm fluoroscopy during the initial closed reduction of adult DR fractures results in equivalent postreduction radiographic parameters when compared with conventional reduction techniques. Additional research regarding time spent in the emergency department and overall cost could elucidate potential benefits of fluoroscopically aided DR fracture reduction.

      Type of study/level of evidence

      Therapeutic I.

      Key words

      Distal radius (DR) fractures are the most common long bone fracture in the United States, with an annual incidence of approximately 16 fractures per 10,000 persons.
      • Karl J.W.
      • Olson P.R.
      • Rosenwasser M.P.
      The epidemiology of upper extremity fractures in the United States, 2009.
      • MacIntyre N.J.
      • Dewan N.
      Epidemiology of distal radius fractures and factors predicting risk and prognosis.
      The majority of displaced DR fractures are initially managed with closed reduction and subsequent orthosis application.
      • Padegimas E.M.
      • Ilyas A.M.
      Distal radius fractures.
      • Handoll H.H.
      • Madhok R.
      Closed reduction methods for treating distal radial fractures in adults.
      The quality of reduction can influence definitive management; thus, efforts should be made to obtain an anatomical reduction when possible.
      • Lichtman D.M.
      • Bindra R.R.
      • Boyer M.I.
      • et al.
      Treatment of distal radius fractures.
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      Disclosures for this Article

      Editors

      Jennifer Moriatis Wolf, MD, has no relevant conflicts of interest to disclose.

      Authors

      All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page.

      Planners

      Jennifer Moriatis Wolf, MD, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose.

      Learning Objectives

      Upon completion of this CME activity, the learner should achieve an understanding of:
      • The utility of mini–C-arm fluoroscopy in closed reduction of distal radius fractures
      • The differences noted in ultimate alignment between fractures reduced with and without mini–C-arm fluoroscopy
      • Recommendations for emergency department management of displaced distal radius fractures
      Deadline: Each examination purchased in 2018 must be completed by January 31, 2019, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each JHS CME activity is up to one hour.
      Copyright © 2018 by the American Society for Surgery of the Hand. All rights reserved.
      Mini–C-arm fluoroscopy provides assessment of the quality of fracture reduction in real time. Mini–C-arm fluoroscopy for the closed reduction of pediatric wrist and forearm fractures has been shown to produce more accurate reductions with fewer reduction attempts compared with conventional methods.
      • Lee M.C.
      • Stone N.E.
      • Ritting A.W.
      • et al.
      Mini-C-arm fluoroscopy for emergency-department reduction of pediatric forearm fractures.
      To our knowledge, no study to date has prospectively investigated mini–C-arm fluoroscopy for the reduction of DR fractures in adults. Our null hypothesis was that there would be no difference in the reduction quality of DR fractures in the emergency department using mini–C-arm fluoroscopy during fracture reduction compared with standard reduction techniques (assessing reduction quality with postreduction orthogonal radiographs taken in an orthosis). Reduction quality (radial height, radial inclination, ulnar variance, and volar tilt) was the primary outcome variable.

      Methods

      This was an institutional review board–approved, prospective, randomized controlled trial evaluating the effectiveness of mini–C-arm fluoroscopy for the closed reduction of DR fractures in the emergency department of a single academic, level-1 trauma center. Seventy skeletally mature patients with closed DR fractures requiring reduction between April 2015 and April 2017 were randomized using a closed-envelope method to standard versus fluoroscopically aided reductions. Exclusion criteria included ipsilateral upper extremity fractures outside of the distal radius, open fractures, pregnancy, incomplete radiographic records, and skeletal immaturity. Seven patients were excluded following randomization (3 mini–C-arm and 4 standard reductions): 3 ipsilateral upper extremity fractures, 2 open fractures, 1 remote DR fracture, and 1 DR fracture that did not require reduction. Thus, 63 patients met inclusion criteria and underwent analysis.
      Standard reductions were defined as fractures that were reduced and subsequently evaluated with postreduction orthogonal radiographs in an orthosis. Mini–C-arm reductions were defined as fractures in which the reduction was aided by the use of fluoroscopy throughout the reduction process. These DR fractures were assessed with fluoroscopy during fracture reduction and also to assess the adequacy of reduction following manipulation. If the fracture reduction was deemed appropriate, a molded orthosis was applied. The maintenance of reduction following orthosis application was then confirmed fluoroscopically. The mini–C-arm reductions then underwent postreduction orthogonal plain radiographs in an orthosis. All reductions were performed by orthopedic surgery residents using a standard protocol. A hematoma block using 1% lidocaine and narcotic analgesia was administered. The affected extremity was hung in finger traps with 10 lb countertraction for 10 minutes. Manual manipulation of the fracture was then performed and stabilized with a well-padded plaster sugar-tong orthosis.
      The primary outcome measurement was reduction quality (radial height, radial inclination, ulnar variance, and volar tilt) as measured on immediate postreduction standard posteroanterior and lateral radiographs of the wrist.
      • Stirling E.
      • Jeffery J.
      • Johnson N.
      • Dias J.
      Are radiographic measurements of the displacement of a distal radial fracture reliable and reproducible?.
      Measurements were performed by 2 residents (S.K.D. and A.R.M.) blinded to the reduction method. Secondary outcome measurements included number of reduction attempts, number of orthoses applied, subjective difficulty of the reduction, and initial fracture management (surgical vs nonsurgical). Reduction attempts in each group (standard and mini–C-arm) were defined as the number of fracture manipulations performed prior to orthosis application. Residents recorded the subjective difficulty of fracture reduction on a 10-point visual analog scale immediately after performing the reduction, which ranged from easiest (0) to most difficult (10).

      Statistical methods

      An a priori sample size estimate was performed to determine the number of patients needed to identify a 3° difference in acceptable reduction at 80% power. Significance was determined at an alpha of 0.05 assuming an SD of 4°. It was determined that a sample size of 28 patients was necessary per group. Numeric data was compared using a 2-tailed Student t test assuming unequal variances. Analysis of variance was used to compare means when 3 or more groups were evaluated. Ordinal data with 5 or more outcomes was compared using chi-square analysis. For all variables, a P value of.05 or less was considered statistically significant.

      External funding

      No external funding was provided for this study. This study adheres to the Consolidated Standards of Reporting Trials (CONSORT) guidelines.

      Results

      Sixty-three patients were enrolled in the study with a mean age of 53 years (range, 17–88 years). There were 34 males and 29 females, with a mean body mass index of 29 (range, 14–48). The most common mechanism of injury was a low fall. The most common AO/OTA fracture classification pattern was 23-C2 (Table 1).
      Table 1Patient Demographics and Injury Characteristics
      AllStandardMini–C-Arm
      Age (y)53 (17–88)5254
      Sex34 M, 29 F16 M, 18 F18 M, 11 F
      BMI29 (14–48)2830
      Laterality36 L, 27 R21 L, 13 R15 L, 14 R
      Ulnar styloid39 Y, 24 N22 Y, 12 N17 Y, 12 N
      Mechanism of injury
       Low fall
      Low fall < 5 ft; High fall > 5 ft; Ped vs auto, pedestrian versus automobile.
      321814
       High fall
      Low fall < 5 ft; High fall > 5 ft; Ped vs auto, pedestrian versus automobile.
      1569
       MVA1055
       MCC220
       Ped vs auto
      Low fall < 5 ft; High fall > 5 ft; Ped vs auto, pedestrian versus automobile.
      220
       Bicycle110
       Crush101
      AO/OTA Classification
       23-A2752
       23-A314113
       23-B1110
       23-B2000
       23-B3220
       23-C1954
       23-C221714
       23-C3936
      BMI, body mass index; MVA, motor vehicle accident; MCC, motorcycle crash.
      Low fall < 5 ft; High fall > 5 ft; Ped vs auto, pedestrian versus automobile.
      Standard reductions were performed in 34 patients, and fluoroscopically aided reductions were performed in 29 patients. No significant differences were noted between groups on postreduction radiographs in regards to radial height, radial inclination, ulnar variance, or volar tilt (Table 2). Overall reduction attempts were increased when using fluoroscopy (mean, 2.4 vs 1.9). Four patients in the standard group and 2 patients in the mini–C-arm group underwent repeat orthosis application. Subjective difficulty of fracture reduction was increased when utilizing fluoroscopy compared with standard technique (5.7 vs 4.3) (Table 3).
      Table 2Mean Reduction Radiographic Measurements
      StandardMini–C-ArmP Value
      Prereduction
       Radial height (mm)6 (–11 to 17)3 (–12 to 15).08
       Radial inclination (°)14 (–21 to 31)8 (–27 to 36).08
       Ulnar variance (mm)2 (–7 to 15)3 (–12 to 13).32
       Volar tilt (°)–25 (–50 to 24)–19 (–48 to 22).23
      Postreduction
       Radial height (mm)10 (1 to 22)10 (2 to 17).68
       Radial inclination (°)19 (1 to 32)18 (3 to 30).7
       Ulnar variance (mm)1 (–4 to 6)1 (–3 to 6).98
       Volar tilt (°)–1 (–26 to 20)2 (–27 to 26).5
      Table 3Reduction and Treatment Characteristics
      StandardMini–C-ArmP Value
      Manipulations (n)1.92.4≤ .05
      Splints applied (n)1.11.1.32
      Subjective difficulty
      Measured on 10-point visual analog scale (0 = easiest, 10 = most difficult).
      4.35.7≤ .05
      Open reduction internal fixation (%)4745.86
      Measured on 10-point visual analog scale (0 = easiest, 10 = most difficult).
      Subset analysis by year of resident training showed that 29 reductions were performed by postgraduate year (PGY) 1s, 17 by PGY 2s, and 17 by PGY 3s. No differences between year of training and initial fracture displacement, reduction quality (radial length, inclination, ulnar variance, and volar tilt), overall reduction attempts, number of orthoses applied, or subjective ease of reduction were identified.
      When analyzing these variables within each year of training (PGY 1–3) while controlling for reduction technique (standard vs mini–C-arm), no differences between groups in regards to initial fracture displacement, reduction quality, reduction attempts, or orthoses applied were observed. In the PGY 3 subset, reductions were felt to be more difficult with fluoroscopy (4.6 vs 6.8).
      Time spent in the emergency department was greater for the standard group (453 minutes) than the mini–C-arm group (374 minutes), although this difference did not reach statistical significance. The rate of initial nonsurgical management did not differ between groups: 47% of fractures in the standard group were managed nonsurgically versus 45% in the mini–C-arm group (Table 3).

      Discussion

      The initial management of displaced DR fractures usually entails closed reduction and orthosis fabrication in the emergency department.
      • Padegimas E.M.
      • Ilyas A.M.
      Distal radius fractures.
      • Handoll H.H.
      • Madhok R.
      Closed reduction methods for treating distal radial fractures in adults.
      The quality of reduction obtained can influence the decision to manage these injuries surgically or nonoperatively. The American Academy of Orthopaedic Surgeons has published guidelines for the management of DR fractures: a moderate recommendation is made for the operative fixation of DR fractures with postreduction radial shortening greater than 3 mm, dorsal tilt greater than 10°, or intra-articular displacement greater than 2 mm.
      • Lichtman D.M.
      • Bindra R.R.
      • Boyer M.I.
      • et al.
      Treatment of distal radius fractures.
      Thus, obtaining a near-anatomical reduction of DR fractures can potentially spare patients a surgical procedure.
      In a retrospective review of 279 displaced pediatric forearm and wrist fractures, Lee et al
      • Lee M.C.
      • Stone N.E.
      • Ritting A.W.
      • et al.
      Mini-C-arm fluoroscopy for emergency-department reduction of pediatric forearm fractures.
      found that the use of mini–C-arm fluoroscopy for closed fracture reduction resulted in an improved average fracture angulation (6° vs 8°) compared with standard reduction techniques. Furthermore, they found that the use of fluoroscopy resulted in fewer remanipulations (2% vs 8%), decreased radiation exposure (14 mrem vs 50 mrem), and average orthopedic consultation time (28 minutes vs 47 minutes).
      • Lee M.C.
      • Stone N.E.
      • Ritting A.W.
      • et al.
      Mini-C-arm fluoroscopy for emergency-department reduction of pediatric forearm fractures.
      In a separate retrospective review comparing the use of fluoroscopy for the closed reduction of DR fractures in adults versus standard imaging, Lee et al
      • Lee S.M.K.
      • Orlinsky M.
      • Chan L.S.
      Safety and effectiveness of portable fluoroscopy in the emergency department for the management of distal extremity fractures.
      found the use of mini–C-arm fluoroscopy resulted in an increased rate of “successful” reduction attempts. Successful reductions were those that did not require remanipulation, although radiographic parameters were not cited or included in the results. They found that 100% (46 of 46) of cases managed with fluoroscopy were reduced successfully compared with 86% (47 of 55) in the standard group.
      • Lee S.M.K.
      • Orlinsky M.
      • Chan L.S.
      Safety and effectiveness of portable fluoroscopy in the emergency department for the management of distal extremity fractures.
      Kodama et al
      • Kodama N.
      • Takemura Y.
      • Ueba H.
      • Imai S.
      • Matsusue Y.
      Ultrasound-assisted closed reduction of distal radius fractures.
      compared 43 patients who prospectively underwent ultrasound-guided DR fracture reduction with a retrospective cohort of 35 fluoroscopically guided and 22 image-unassisted reductions. Whereas all radiographic parameters measured (volar tilt, radial inclination, radial shortening) were improved following fluoroscopically guided reduction, they were not significantly different from the ultrasound-guided or standard groups.
      • Kodama N.
      • Takemura Y.
      • Ueba H.
      • Imai S.
      • Matsusue Y.
      Ultrasound-assisted closed reduction of distal radius fractures.
      Our results were similar to those of Kodama et al.
      • Kodama N.
      • Takemura Y.
      • Ueba H.
      • Imai S.
      • Matsusue Y.
      Ultrasound-assisted closed reduction of distal radius fractures.
      No significant radiographic differences between fluoroscopic-guided and standard reductions of adult DR fractures were observed in the present study. Our findings, compared with the pediatric population, could be related to a relative absence of thick periosteum, which may act as an internal orthosis and aid in the maintenance of fracture reduction. In addition, it is possible that reduction technique may play a role in the difference. Pediatric patients often undergo conscious sedation prior to closed reduction, whereas the adult patients in our cohort underwent closed reduction following a hematoma block.
      We found that DR fractures randomized to mini–C-arm fluoroscopy underwent more manipulation attempts (2.4 vs 1.9) with equivalent radiographic reduction quality and rate of operative intervention. These findings are possibly secondary to the physician initially thinking they could improve the reduction when observing a slight displacement in real time. Furthermore, residents felt fracture reduction using the mini–C-arm was subjectively more difficult than when using standard technique when measured on a 10-point visual analog scale. Several factors may have played a role in this finding. The residents involved in this study do not typically utilize fluoroscopy for fracture reduction in the emergency department and may not have been accustomed to operating a mini–C-arm efficiently. In addition, residents needed to contact a radiology technician to obtain the mini–C-arm, which may have influenced their work flow and, thus, their perception of reduction difficulty. Despite these observations, a shorter emergency department was observed for the mini–C-arm group.
      There are several limitations to our study. Residents performing the reduction recorded the number of manipulations, number of orthosis applied, and subjective difficulty of reduction. The veracity of the number of manipulations performed and orthoses applied is subject to the physician recording the data. In addition, the subjective difficulty of reduction could be influenced by institutional bias because our facility does not routinely implement fluoroscopy for fracture reduction in the emergency department. Although the residents performing the reduction had varying levels of experience, no differences in reduction quality were noted between year of training or reduction technique. In the PGY-3 subset, reductions were felt to be more difficult with fluoroscopy. This is interesting because one would think that, with more experience using the mini–C-arm, reductions would be easier. This finding suggests that the increase of difficulty of reduction seen in this study may relate to work flow issues when using the mini–C-arm rather than fracture complexity or experience. It is possible that our findings of increased difficulty of reduction with fluoroscopy would be nullified if the mini–C-arm was utilized more frequently in our emergency department, or if more experienced providers were performing the reductions.
      Whereas fluoroscopy has been shown to be advantageous for the closed reduction of pediatric DR fractures, it does not appear to enhance the reduction quality of DR fractures in the adult population. Further research investigating overall cost and time spent in the emergency department (both for the patient and the orthopedic surgeon) could elucidate potential differences between the 2 methods.

      References

        • Karl J.W.
        • Olson P.R.
        • Rosenwasser M.P.
        The epidemiology of upper extremity fractures in the United States, 2009.
        J Orthop Trauma. 2015; 29: e242-e244
        • MacIntyre N.J.
        • Dewan N.
        Epidemiology of distal radius fractures and factors predicting risk and prognosis.
        J Hand Ther. 2016; 29: 136-145
        • Padegimas E.M.
        • Ilyas A.M.
        Distal radius fractures.
        Orthop Clin North Am. 2015; 46: 259-270
        • Handoll H.H.
        • Madhok R.
        Closed reduction methods for treating distal radial fractures in adults.
        Cochrane Database Syst Rev. 2003; 1CD003763
        • Lichtman D.M.
        • Bindra R.R.
        • Boyer M.I.
        • et al.
        Treatment of distal radius fractures.
        J Am Acad Orthop Surg. 2010; 18: 180-189
        • Lee M.C.
        • Stone N.E.
        • Ritting A.W.
        • et al.
        Mini-C-arm fluoroscopy for emergency-department reduction of pediatric forearm fractures.
        J Bone Joint Surg Am. 2011; 93: 1442-1447
        • Stirling E.
        • Jeffery J.
        • Johnson N.
        • Dias J.
        Are radiographic measurements of the displacement of a distal radial fracture reliable and reproducible?.
        Bone Joint J. 2016; 98-B: 1069-1073
        • Lee S.M.K.
        • Orlinsky M.
        • Chan L.S.
        Safety and effectiveness of portable fluoroscopy in the emergency department for the management of distal extremity fractures.
        Ann Emerg Med. 1994; 24: 725-730
        • Kodama N.
        • Takemura Y.
        • Ueba H.
        • Imai S.
        • Matsusue Y.
        Ultrasound-assisted closed reduction of distal radius fractures.
        J Hand Surg Am. 2014; 39: 1287-1294