Management of distal radius fractures in emergency departments in England and Wales
- 1Department of Trauma and Orthopaedics, Royal Gwent Hospital, Newport, UK
- 2Department of Trauma and Orthopaedics, Avon Orthopaedic Centre, Bristol, UK
- 3Department of Trauma and Orthopaedics, Leicester Royal Infirmary, Leicester, UK
- 4Department of Trauma and Orthopaedics, University Hospital of Wales, Cardiff, UK
- Correspondence to Harry Sprot, Royal Gwent Hospital, Cardiff Road, Newport, Gwent NP10 8UD, South Wales, UK;
Contributors HS was responsible for data collection, analysis of results and primary authorship of the paper. AM and AO contributed to the design, data collection and editing of the paper. JP contributed to the design and editing of the paper. SW contributed to the design and data analysis and was overall project lead and senior author. All authors were involved in the preparation of the manuscript and approved it in its final form.
- Accepted 19 February 2012
- Published Online First 20 March 2012
Aims To examine variations and consistencies in the emergency management of distal radial fractures across England and Wales.
Methods A survey was conducted of emergency departments (ED) in England and Wales regarding the acute management of patients with distal radius fractures. The study investigated the use of anaesthesia, the person performing both the anaesthetic and the manipulation, the use of resuscitation facilities and monitoring, the cast applied, the follow-up and the management of complex injuries or those in younger patients.
Results Surveys were conducted in 105 units, giving a response rate of 91% of ED in England and Wales. The most frequent anaesthetic types were haematoma block (50%), intravenous benzodiazepines (20%), Bier's block (17%) and a small minority using other techniques such as brachial plexus blocks (2%). Basic cardiorespiratory monitoring was variable, and 10% of trusts did not routinely monitor patients undergoing Bier's blocks or manipulation with sedatives. Only 50% of ED would manipulate comminuted fractures or fractures in young adult patients.
Conclusion There are significant regional variations. The use of monitoring is highly variable and there are no consistent standards when administering potentially potent anaesthetic medications. The low percentage of units attempting reduction of complex fractures or fractures in young patients will disadvantage training in ED as well as patients. Guidelines are required to improve care, which is highly inconsistent at present.
- Bone (C26.404)
- Colles' fracture (C26.404.562.356)
- emergency care systems
- emergency department management
- emergency departments
- fractures and dislocations
- radius fractures (C26.404.562)
Fractures of the distal radius have an in incidence of 1.8/1000 rising to 12/1000 in people over the age of 85 years, making them one of the most common fractures.1 This represents a significant cost to the health service, which has been estimated at £320.50 per patient.2 There is also an associated morbidity reflecting on the patient, especially if they have to undergo more than one manipulation or surgical intervention.
There have been numerous studies investigating the best anaesthetic techniques for the emergency manipulation of distal radius fractures, with a large amount of literature suggesting that Bier's block or intravenous regional anaesthetic (IVRA) is the most effective type of anaesthesia.3–5 Serious adverse events have, however, been reported with IVRA.6 The type of cast used to hold the reduction has also been a significant source of debate, with early papers advocating the use of sugar tong casts.7 A recent study has shown very little difference in the maintenance of reduction between circumferential and non-circumferential casts.8 Our impression was that there is substantial variation in clinical practice around the country and although there are trends in the evidence, we wanted to know if this has been reflected in clinical practice.
In this survey of emergency departments (ED) in the UK we looked at the initial treatment patients received when first presenting with a distal radius fracture. The purpose of this study was to assess current UK clinical practice in the emergency management of distal radius fractures and to compare this with the current evidence base.
Materials and methods
We compiled a list of 115 ED across England and Wales with a consultant-led service. All departments were contacted by telephone. The surveys were conducted according to a standard proforma (see supplementary appendix 1, available online only) in discussion with the most senior member of staff available at that particular time. The standardised surveys included details of the blocks or analgesia the patient received during manipulation and who was administering it (ie, the lowest level of seniority allowed to perform the procedure). We also wanted to know the grade of the individual who would be responsible for fracture manipulation, what type of cast was used and whether any monitoring equipment was used during the procedure. The survey also included questions on the typical management of young adults and patients with highly comminuted fractures in terms of whether they were manipulated or directly referred to orthopaedics. The data were collated and analysed using a Microsoft Excel database.
One hundred and five departments responded to the survey, giving an overall response of 91%. Despite repeated attempts we were not able to get a response from 11. The most common respondents were ED middle grades (51%), consultants (20%), senior house officers (20%) and finally emergency nurse practitioners (9%).
We found a great deal of variation in terms of the type of anaesthetic that was used. We specifically asked about the techniques that were most commonly utilised, but occasionally some trusts indicated that they routinely used more than one anaesthetic technique (figure 1).
In terms of anaesthesia, haematoma blocks were the most commonly used (50%), followed by midazolam (20%) and then Bier's block (17%), see figure 2. We can also see from the figures that the use of monitoring is very inconsistent.
Overall, monitoring is used in 48% of ED. However, monitoring of vital signs did not appear to be mandatory, with 10% of ED not routinely monitoring patients undergoing reduction under midazolam, opiates or IVRA, see table 1.
Although middle grades performed the majority (60%) of the anaesthetics used for manipulation, they only performed 47% of the actual manipulations, with 45% being performed by senior house officers (table 2).
After reduction the cast applied was a backslab in 89% of departments, with 7% of trusts applying full plaster of Paris casts and 4% applying split full casts (table 3). Fracture clinic appointments were made within a week in 99% of cases.
In terms of monitoring of patient vital signs during the manipulation (table 1), 70% of trusts used full monitoring of blood pressure, pulse, ECG and oxygen saturations. Of the remaining 30% of trusts that did not routinely use monitoring, 87% used haematoma blocks as the anaesthetic for reduction. Ten per cent of trusts who utilised Bier's blocks (n=4) or sedatives (n=6) did not routinely use monitoring.
In terms of patients receiving manipulation, 55% of departments would perform a manipulation on young adults (patients aged 18–50 years), while the remaining 45% would make a direct referral to orthopaedics (table 4). In patients in whom there was a high level of comminution such that surgical intervention was thought to be likely, 50% of trusts attempted some sort of reduction.
There seems to be significant variation in practice when reducing distal radius fractures, and this seem to have been the case for some time. Previous data have shown a shift away from general anaesthesia and more recently Bier's block (table 5). General anaesthesia has lost favour due to high staff demand, safety and efficiency, with a significant number of patients being admitted post general anaesthesia.9
The most common form of anaesthesia now it seems is haematoma blocks, despite evidence to show that Bier's block provides superior analgesia and a better radiological reduction,4 ,5 ,10 although one study does report equivocal results.10 However, Bier's blocks require monitoring, are not necessarily suitable for every patient, and have had significant complications reported in the literature. While transit times are reported as equal,4 the procedure requires two doctors to be present for the manipulation. Haematoma blocks do not require the presence of a second doctor and in practical terms require far less equipment and monitoring and therefore have become more widely used. While there is a risk of infection, this appears to be very small, with only one reported case in the literature.11 It is likely that this technique is favoured because of the ease of administration and relative safety.
Manipulations were performed in the vast majority by ED registrars and senior house officers in almost equal amounts. One paper identified a higher re-manipulation when senior house officers (F2–CT2) were unsupervised compared with middle grades.2
Monitoring of patients undergoing manipulation should be mandatory for those being administered IVRA, midazolam and general anaesthesia. Interestingly, 14% of departments chose to monitor patients undergoing haematoma block. Complications from local anaesthetic toxicity have been reported from haematoma block, but this is thought to be secondary to intravascular administration.12
Referring younger patients to orthopaedics in 45% of cases before manipulation would be contrary to the literature, which suggests that younger patients (18–44 years) have a significantly lower risk of secondary displacement.13
With respect to plaster techniques, various types have been studied, and overall there does not seem to be any advantage of circumferential casting over other techniques8 in terms of secondary displacement. With 95% of ED using non-circumferential casting, practice appears to be in line with the evidence.
It is also noteworthy that 50% of ED would attempt reduction of a comminuted fracture despite the propensity of these fractures to instability and malunion; up to 73% malunion rate without further intervention.14 However, functional outcome and patient satisfaction in older patients was not found to be related to radiological reduction in a study of 74 patients managed conservatively in the over 50-year age group.15 Even in comminuted fractures, with the associated high rate of secondary displacement, early reduction reduces tension on the skin and neurovascular structures and therefore should be considered an emergency treatment, even if the patient will subsequently need a planned procedure on the next available trauma list.
The data presented here highlight the variation in practice in anaesthetic technique within and between EDs for the initial manipulation of distal radius fractures. There have been comparison studies between Bier's and haematoma block suggesting an improved outcome in the former. However, this has obviously not translated into a change in clinical practice. The use of monitoring is highly variable, and there are no consistent standards. With significant, potentially life-threatening complications reported, it is unacceptable not to use monitoring when administering an IVRA (Bier's block).
The low percentage of units willing to attempt reduction of complex fractures or fractures in young patients presents a disadvantage to training in ED, promotes delays to treatment for patients, and is contrary to the evidence base.
An additional appendix is published online only. To view this files please visit the journal online (http://dx.doi.org/10.1136/emermed-2011-200782).
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.