For Distal Radius Fracture, Don't Overlook Closed Reduction and Percutaneous Pinning

Closed reduction and percutaneous pinning (CRPP) of distal radius fractures has become relatively unpopular, according to Hand and Upper Extremity Orthopaedic Surgeon Chaitanya S. Mudgal, MD, and colleagues. There are no well-established guidelines or algo­rithms for the choice of procedure, but in carefully selected cases, CRPP may have advantages over open reduction and internal reduction (ORIF), which is more invasive.

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In a retrospective study published in the Journal of Hand and Microsurgery, the researchers confirmed that all Massachusetts General Hospital patients who were treated with CRPP by Dr. Mudgal ended with good or excellent range of forearm rotation, and almost 80% had good or excellent flexion or extension of their wrist.

Dr. Mudgal's team identified 34 adults with a distal radius fracture who were treated with CRPP using Kirschner wire, followed by 5-6 weeks of casting between 2012 and 2016. The average age was 47 (range: 22–85) and the cohort was 82% female. Nearly all fractures were AO Müller type A (n=8) or C (n=25).

Radiographic Results and Range of Motion

Evaluation of final follow-up radiographs showed 32% improvement in average radial height and improvement of 19° in average palmar tilt. At final follow-up, 79% of patients demonstrated good or excellent flexion/extension of the wrist, and all patients ended with good or excellent forearm rotation (defined as arc of ≥120° for both outcomes).

Complications

One patient in the current study developed a superficial pin tract infection five weeks after surgery, which was treat­ed by pin removal. Another patient required a more minor procedure to remove a radial styloid pin due to subcutaneous migration.

In previous studies, rates of superficial pin tract in­fection rates after CRPP of distal radius fractures have varied from 1.7% to 9.5%. The infections nearly always resolved after pin removal.

Discussion of Randomized Trials

In a pro­spective, randomized trial that compared CRPP with ORIF, early post­operative functional outcomes seem to favor ORIF. However, neither technique was superior to the other in terms of long-term radiographic or functional outcomes.

Another prospective, randomized trial showed no difference in six-month clinical outcomes when early rehabilitation after ORIF was compared with delaying rehabilitation for six weeks. It therefore seems intuitive that CRPP followed by six weeks of casting would have similar outcomes for carefully selected fractures that are suitable for either ORIF or CRPP.

Health Care Costs

Only a few studies have assessed the cost of treating distal radius fractures, but data consistently show that the financial burden of distal radius fractures is in­creasing, mainly due to the prevailing use of volar-locked plating.

Medicare reimburses surgeons nearly twice as much for ORIF as for CRPP. When making treatment choices, surgeons should carefully consider whether that inequity is influencing their decision.

ORIF is a good option for patients with distal radius fractures who have poor bone quality or multiple fragments. For relatively young patients who have few and large fracture fragments, surgeons should consider CRPP more often.

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