Orthopedics

Assessment of complications associated with casting of acute distal radius fractures in adults

a b s t r a c t

Purpose: Controversy exists regarding the closed treatment of Distal radius fractures. Circumferential casting of acute distal radius fractures has been shown to be safe in children, however, little research has demonstrated its safety in adults. The purpose of this study was to assess the risk of complications associated with casting acute distal radius fractures in adult patients.

Methods: Patients with a distal radius fracture treated by a single hand surgeon at a level 1 trauma center were retrospectively reviewed over a 3-year period. Patients were evaluated in the emergency room and were provi- sionally immobilized either with short-arm fiberglass casts or with splints. Patients were followed for a minimum of 4 weeks. Complication rates associated with casting were recorded, including rates of compartment syndrome and acute carpal tunnel syndrome.

Results: Eighty-one patients were included in this study. A total of 30 patients met inclusion criteria for placement of a short arm cast in the Emergency Department. Mean patient age was 63.2 years. The majority of patients sus- tained their injuries from a ground level fall. A minority of patients had radiographic evidence of intra-articular extension or underwent a reduction prior to casting. There were no patients who developed compartment syn- drome or acute carpal tunnel syndrome as a result from the casting. The majority of patients did not require a cast change for at least 4 weeks. None of our patients went on to surgery.

Conclusion: There were no major complications associated with casting of acute, low energy distal radius frac- tures in this series of 30 adult patients. While further studies with larger numbers of patients are necessary to es- tablish safety of casting, this study suggests that casting may be a safe and effective treatment for low-energy distal radius fractures in adult patients presenting with a normal neurovascular exam.

Type of study/Level of evidence: Retrospective comparative study, Level III.

(C) 2022

  1. Introduction

Distal radius fractures (DRF) are the most common orthopedic in- jury [1-3]. In order to appropriately manage these fractures, clinicians must be able to use clinical and radiographic parameters to choose a treatment course, and to perform a closed or open reduction when ap- propriate. In 2009, the American Academy of Orthopedic surgeons es- tablished distal radius practice guidelines. Of the 29 published recommendations, not one received a grade of strong [4]. Overall, there is a lack of evidence regarding many aspects of the management of DRF [5-9].

Closed management of distal radius fractures may be accomplished using a number of techniques and materials. Splinting may be done

? Investigation performed at Yale New Haven Hospital, New Haven, CT.

* Corresponding author at: Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, United States of America.

E-mail address: [email protected] (A. Halim).

using plaster or orthoglass, while casts are most commonly performed using fiberglass. However, it is not well-established that any method is superior. A meta-analysis of 37 trials concluded that insufficient evi- dence exists to guide the best method and duration of immobilization during nonsurgical treatment of distal radius fractures [7].

Severe but complications that have been associated with closed management of acute distal radius fractures are acute carpal tunnel syn- drome and compartment syndrome. Acute carpal tunnel syndrome, with a reported incidence ranging from 1.1% to 8.6% after DRF, is more likely to occur with high energy fractures, ipsilateral upper extremity trauma, multiple closed reduction attempts, associated radiocarpal dis- location, and immobilization in excessive wrist flexion [13-18]. While less common, young males who suffer high energy trauma, or those with an ipsilateral upper extremity injury are the most at risk of com- partment syndrome [19-21].

There is a paucity of evidence regarding the use of a circumferential cast compared to plaster splinting in adults. Circumferential casting

https://doi.org/10.1016/j.ajem.2022.03.017

0735-6757/(C) 2022

theoretically carries with it a risk of causing compartment syndrome or acute carpal tunnel syndrome. Chaudhury et al. found that circumferen- tial fiberglass casting generated the highest intracast pressure com- pared to plaster casts or splints in a lower extremity biomechanical model [22]. Of note, in a Swedish study of 430 patients with uncompli- cated forearm and lower extremity fractures there were no cases of compartment syndrome due to fiberglass casting [23].

Circumferential casts carry their own advantages when applied

properly. These include improved durability compared to plaster splints, and greater patient comfort due to their relatively lighter weight. Further, when applied skillfully, a patient can avoid having a cast change for several weeks, which may potentially decrease the risk of displacement.

Circumferential casting of acute distal radius fractures has been shown to be safe in children. However, to our knowledge, no studies have demonstrated its safety in adults [24]. The purpose of this study is to understand complication rates of casting for acute distal radius fractures treated in the Adult Emergency Department.

  1. Methods

After obtaining institutional review board approval, charts were ret- rospectively reviewed for all distal radius fractures referred to a single surgeon at single Level 1 trauma center from the emergency room from October 2016 to September 2019. All emergency room consults at our institution are recorded securely to ensure follow-up, and this da- tabase was mined to collect all distal radius fractures during this time period. Data extraction was done by the treating surgeon, and a second- ary check was done by the contributing authors.

When selected, casts were performed with fiberglass material (3 M, St. Paul, Minnesota) and were not bivalved or univalved. Decision criteria for acutely casting in the Emergency Department included closed isolated injury, age >18 years, and a normal neurovascular exam prior to casting. Reasons for placement of plaster splints included unambiguous recommendation of outpatient surgical intervention, patients who sustained other non-orthopedic injuries and were admit- ted to the hospital,or trainee inexperience with casting. The patients who were recommended to undergo surgical treatment were based on injury radiographs with intra-articular displacement, shear-type fractures, significant dorsal angulation, or shortening with dorsal com- minution. When surgical treatment was recommended, splints were selected as a simpler method of immobilization both to apply in the emergency room and to remove in the operating room.

Demographics were recorded, in addition to mechanism of injury, acuity of injury, and need for reduction. Patients were followed for a minimum of 4 weeks after their injury. Complication rates associated with casting were recorded. Specific outcomes of interest included rates of compartment syndrome and acute carpal tunnel syndrome. Cast replacement prior to 4 weeks of treatment was also recorded.

The standard protocol for treatment of distal radius fractures with short arm casting, typically included maintenance of the cast for a total of 4 weeks. At that time, if there was maintenance of acceptable re- duction and swelling and tenderness had improved, then patients were transitioned to a removable wrist brace, and referred to occupational therapy.

  1. Results

A total of 81 patients were identified for inclusion. Of those, 37% (n = 30) were treated with short arm casting in the Emergency Depart- ment, with or without closed reduction.A total of 30 patients presenting with a distal radius fracture met inclusion criteria for placement of a short arm cast in the Emergency Department. The remaining 63% (n = 51) of patients were placed in plaster splints. Patient demograph- ics as well as injury characteristics are shown in Table 1.

In total, 27% (n = 8) of casted patients had radiographic evidence of intra-articular extension, compared to 78% (n = 40) of splinted patients. No patients had concurrent hand injuries or decreased neurovascular exam at the time of injury. 40% (n = 12) of patients treated with a cast required closed reduction in the Emergency Department.

Associations with casting are shown in Table 2. There were no pa- tients who developed compartment syndrome or acute carpal tunnel syndrome as a result from the casting. 33% (n = 10) required a cast change prior to 4 weeks of their definitive treatment, most of which oc- curred two or three weeks after their injury. Reasons for early cast change included loosening of cast, cast discomfort, or a cast getting wet.

  1. Discussion

There were no major complications associated with casting of acute, low energy, isolated, non-operative distal radius fractures in this series of 30 adult patients. Additionally, none of these patients went on to re- quire surgical fixation. While larger studies are needed to appropriately determine safety, this small study suggests that short arm casting may be considered as an acute means of immobilization in the appropriate clinical setting.

Treatment of acute distal radius fractures in emergency and urgent care settings varies widely. It can range from placement in a removable brace with instructions to follow up, to fluoroscopic-guided closed re- duction and rigid immobilization. Short arm casting presents a poten- tially safe and effective option for immobilization of these fractures, which may reduce patient need for frequent splint or cast changes and provide a more comfortable method of immobilization than long-arm splints or casts. Historically, the sugartong plaster splint that includes elbow immobilization is the most commonly used option for initial treatment of acute distal radius fractures [25]. However, even well- molded sugartong splints often extend past the metacarpal phalangeal joints, causing the patient additional dysfunction and disuse of the extremity. A short arm cast allows for free elbow range of motion and improved early mobilization of the fingers.

Our cohort of patients had an average age of 63 years, with the ma- jority between 54 and 84 years of age. None of the patients who were casted acutely went on to surgery. There is an abundance of literature

Table 1

Demographics and injury characteristics.

Casted patients

Splinted patients

Number

30

51

Mean Age (SD)

63.2 (21.5)

54.8 (19.2)

Gender

Male

33% (n = 10)

24% (n = 13)

Female

67% (n = 20)

75% (n = 38)

Side

Left

70% (n = 21)

57% (n = 29)

Right

30% (n = 9)

43% (n = 22)

Mechanism

Ground Level Fall

83% (n = 25)

74% (n = 38)

Fall From Height

7% (n = 2)

10% (n = 5)

Motor Vehicle Accident

10% (n = 3)

16% (n = 8)

Time from injury

Day of injury

80% (n = 24)

98% (n = 50)

1 day after injury

10% (n = 3)

2% (n = 1)

>2 days after injury

10% (n = 3)

0%

Injury Characteristics

Intra-articular extension

27% (n = 8)

78% (n = 40)

Decreased Sensation at Initial Exam

0%

0%

Concurrent Hand Injuries

0%

8% (n = 4)

Reduction Performed

40% (n = 12)

96% (n = 49)

Table 1 demonstrates patient demographics and presenting characteristics of patients with distal radius fractures treated with casting in the Emergency Department.

Table 2

Casting complications and casting changes.

Casting complications

Compartment syndrome

0% (n = 0)

Acute Carpal Tunnel Syndrome

0% (n = 0)

Cast changed prior to 4 weeks

33% (n = 10)

Cast change at 1 week

7% (n = 2)

Cast change at 2 weeks

13% (n = 4)

Cast change at 3 weeks

13% (n = 4)

Table 2 demonstrates casting complications and timing of cast changes of patients with distal radius fractures treated with casting in the Emergency Department.

about the treatment of distal radius fractures in the elderly, however many controversies remain about the optimal non operative and oper- ative treatment choices [32]. Larger, above elbow splints can particu- larly cumbersome in elderly patients who are already fall risks. Regardless of immobilization technique, it has been shown that low- demand elderly patients are often able to tolerate distal radius malunion without complaint or noticeable dysfunction [26,33]. Many elderly pa- tients also stand the most to benefit from a lighter-weight and easier to manage fiberglass casts, as opposed to heavy plaster splinting.

The importance of patient selection for casting of acute DRF in the ED cannot be understated. All casted patients had a normal neurovascular exam at the time of presentation and the majority of injuries were from low energy mechanisms. Additionally, while clinical indications for surgical treatment of distal radius fractures vary, none of these pa- tients went on to surgery. While acutely casting distal radius fractures advantageously allows for the patient to be appropriately immobilized in a smaller and lighter-weight construct, clinic cast technologist or surgeon time is also made available as fewer initial clinic visits require transition from splint to cast. This may increase cost-efficiency to the system, and avoid office delays or wait-times.

Limitations of this study include a relatively small sample size. Addi- tionally, while these patients were selected based on non-operative treat- ment parameters, this may contribute to the lack of casting complications as these injuries were low-energy, and some did not require any reduction. Our study is also reliant on resident physician or other competent provider to be available for consultation and application of a well molded short arm cast, which may not be practical at every institution or setting.

In conclusion, short arm casting with or without reduction in appro- priate adult distal radius fractures may present no higher risk of com- partment syndrome or acute carpal tunnel syndrome than sugar tong splinting, while avoiding cumbersome plaster splints and frequent splint changes. Initial casting can be a safe treatment for both displaced and non-displaced distal radius fractures in adult patients with a normal neurovascular exam. Further study is needed to evaluate this treatment in a larger series of patients, to determine the efficacy of casting in main- taining reduction beyond four weeks, and cost effectiveness of immedi- ate short arm casting.

Credit authorship contribution statement

Anna Jorgensen: Writing – review & editing, Writing – original draft, Visualization, Validation, Resources, Project administration, Meth- odology, Investigation, Formal analysis, Conceptualization. Joseph Kahan: Writing – review & editing, Writing – original draft, Visualiza- tion, Validation, Supervision, Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Jay Moran: Writing – review & editing, Writing – original draft, Validation, Resources, Meth- odology, Investigation, Data curation, Conceptualization. Andrea Halim: Writing – review & editing, Writing – original draft, Visualiza- tion, Validation, Supervision, Resources, Project administration, Meth- odology, Investigation, Formal analysis, Conceptualization.

Acknowledgements

This study is exempt from IRB review under exemption 45 CFR 46.101(b)(4).

Name of IRB: Yale University Human Investigation Committee. HIC protocol number: 1312013185.

There was no financial remuneration to authors or family members related to the subject of this article, and the authors received no funds of any kind for equipment or other materials necessary for the production of this manuscript.

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