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Repeated Closed Reduction Attempts of Distal Radius Fractures in the Emergency Department Are we Helping our Patients to Avoid Surgery?
Haggai Sherman, MD; Assaf Kadar, MD; Tamir Pritsch, MD
Tel Aviv Sourasky Medical Center Orthopaedic Division, Tel Aviv, Israel

Background: Repeated attempts of closed reduction of distal radius fractures are often performed in the emergency department (ED) setting in order to optimize reduction, provide definitive treatment and thus potentially avoid surgical treatment. However, the additional manipulation of the fracture, especially in osteoporotic bones, may increase dorsal comminution and consequently compromise fracture stability. This may eventually lead to loss of reduction, and complicate the surgical treatment if needed. We hypothesized that repeated reductions of displaced distal radius fractures would not significantly change the need for surgical treatment, and may add complexity to the operation because of increased dorsal comminution and decreased fracture stability.

Methods: We reviewed the radiographs of 94 patients with distal radius fractures, who were treated in our ED between 2007-2010 and underwent two closed reduction attempts. Indications for surgical treatment were based on acceptable published criteria. Follow -up radiographs of patients, whose fracture alignment was deemed acceptable following the second reduction, were evaluated according to the above criteria. In addition, the amount of dorsal comminution was compared between radiographs taken after the first and second reduction attempts.

Results: A second reduction attempt improved mean radial height by 1.12 mm (p=0.01) and mean volar tilt by 4.16 (p=0.01) at the expense of increase in mean dorsal comminution length by 1.62 mm (p<0.01). Seventy-eight (82%) patients were classified as surgical candidates after the first reduction, and following the second reduction attempt 64 (82%) still had at least one parameter advocating surgery. Of the 14 patients with acceptable alignments following the two reduction attempts, follow up radiographs were identify for 10, showing loss of reduction in all but three (3.9%) cases.

Conclusions: A second close reduction attempt improved overall fracture alignment, but also worsen the dorsal comminution. Only 3.9% of patients who underwent two reduction attempts, healed in an acceptable alignment, and did not require surgery. Worst dorsal comminution compromise fracture stability and may increase the complexity of open reduction and internal fixation. Based on our results, we recommend avoiding repeated closed reduction attempts of distal radius fractures in the ED setting.

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