The Emergency Management of Distal Radius Fractures in a UK Trauma Unit. Are we Following the BOAST Guidelines?
Background: Distal radius fractures are common injuries secondary to high or low energy trauma. They account for 18% of all fractures in the elderly population. There is great variability in practice in the initial management of these injuries with the overall goal achieving anatomical reduction and satisfactory post injury function. Objectives: We aimed to compare our practice of the management of distal radius fractures in a large trauma unit in the UK with the new 2017 BOAST (British Orthopaedic Association Audit Standards for Trauma) guidelines to assess if significant improvements within our management protocol could be achieved to optimise patient care. Methods: We performed a retrospective review of all patients admitted with a distal radius fracture to the Royal Derby Hospital UK, between the 1st January 2017 and the 31st December 2017. All radiographs, electronic records and discharge summaries were reviewed to identify times and dates of admission, type of initial reduction and plaster type, subsequent time to review by orthopaedic specialists as well whether a further manipulation was required and whether this was performed in the clinic or in theatre. One of the main objectives of the 2018 BOAST guidelines includes time from the decision for surgical intervention to the actual time and date of surgery. This critical time was reviewed in all surgical cases. Results: 814 patients were identified with distal radius fractures between the 1st January 2017 and the 31st December 2017. After applying our exclusion criteria (coding error, initial fracture occurring abroad or in another region of the country thus delaying treatment, isolated radius styloid fractures, carpal bones involvement), 550 patients remained. The mean age was 62 years (range 17-100 years). There were 108 males (19.7%) and 442 females (80.3%). 379 of the distal radial fractures were displaced, of which 297 were dorsal, 59 volar and 22 impacted. 358 were extra-articular and 192 were intra-articular. Initial treatment of our patients was performed with a cast and no manipulation in the majority of cases (n = 277), a cast after manipulation (n = 239), a splint (n = 29) or direct surgical intervention (n = 4). Post manipulation radiographs were performed in 77.9% (n = 276) of cases and 13% of fractures required re-manipulation, either immediately or at a later date. Definitive treatment consisted of surgical fixation in 122 patients (22.1%) and conservative management in 428 (77.8%). When surgical fixation was required, intra-articular fractures were operated after an average of 74.45 hours, median of 56.5 hours ([2;240] hours), and extra-articular fractures after an average of 65.35 hours, median of 43 hours ([5;188] hours). Surgical intervention for fracture displacing after re-manipulation was performed within the recommended 72 hours post displacement in 37 patients (56%). Finally, our patients had an average of 3.2 follow-up appointments. Conclusions: Our 1 year study has identified that 99% of patients who sustained a distal radius fracture were initially treated conservatively however, definitive non-surgical management was seen in 77.8% of cases. Post manipulation radiographs were performed in only 77.9% which has highlighted an area for future improvement. BOAST recommends surgery within 72 hours for intra-articular and within 7 days for extra-articular fractures. Our study confirms that in our Trauma Unit we were able to meet this standard for extra-articular fractures but currently there is a delay in the time for surgery for intraarticular fractures and this may be explained by the fact that often these cases are more challenging requiring an upper limb specialist to undertake which may delay the time to theatre. BOAST also recommends operating within 72 hours of fractures re-displacing following failed manipulation, and this was achieved in only 56% of cases. We recommend for departments to set a system highlighting those patients at trauma meetings and ensuring there is a clear timer in place to avoid delays ultimately detrimental to the patient. We strongly recommend all units to be aware and use the BOAST guidelines for distal radial fractures to improve the management of these often complex upper limb injuries.
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