Distal radius fractures are among the most common fractures seen in the emergency department. Closed reduction can provide definitive management when acceptable radiographic parameters are met. Repeated attempts of closed reduction are often performed to improve the alignment and avoid operative management. However, multiple reduction attempts may worsen dorsal comminution and lead to eventual loss of reduction, resulting in no demonstrable benefit. We hypothesize that compared to one closed reduction attempt, repeated closed reduction of extra-articular, dorsally angulated, displaced distal radius fractures has a low success rate in the prevention of operative fixation and improvement of radiographic parameters.

Initial and post reduction radiographs for all distal radius fractures managed at Vancouver General Hospital between 2015 and 2018 were reviewed. Inclusion criteria were based on the AO fracture classification and included types 23-A2.1, 23-A2.2 and 23-A3. Exclusion criteria included age less than 18, intra-articular involvement with more than two millimeters of displacement, volar or dorsal Barton fractures, fracture-dislocations, open fractures and volar angulation of the distal segment. Distal radius fractures that met study criteria and underwent two or more attempts of closed reduction were matched by age and gender with fractures that underwent one closed reduction. Radiographic parameters including radial height and inclination, ulnar variance and volar tilt were compared between groups.

Sixty-eight distal radius fractures that met study criteria and underwent multiple closed reduction attempts were identified. A repeated closed reduction initially improved the radial height (p = 0.03) and volar tilt (p < 0.001). However, by six to eight weeks the improvement in radial height had been lost (p = 0.001). Comparison of radiographic parameters between the single reduction and multiple reduction groups revealed no difference in any of the radiographic parameters at one week of follow up. By six to eight weeks, the single reduction group had greater radial height (p = 0.01) ulnar variance (p = 0.05) and volar tilt (p = 0.02) compared to the multiple reduction group. With respect to definitive management, 38% of patients who underwent a repeated closed reduction subsequently received surgery, compared to 13% in the single reduction group (p = 0.001).

Repeated closed reduction of extra-articular, dorsally angulated, displaced distal radius fractures did not improve alignment compared to a single closed reduction and was associated with increased frequency of surgical fixation. The benefit of repeating a closed reduction should be carefully considered when managing distal radius fractures of this nature.

Distal radius fractures are among the most common fractures seen in the emergency department. Closed reduction can provide definitive management when acceptable radiographic parameters are met. Repeated attempts of closed reduction are often performed to improve the alignment and avoid operative management. However, multiple reduction attempts may worsen dorsal comminution and lead to eventual loss of reduction, resulting in no demonstrable benefit. We hypothesize that compared to one closed reduction attempt, repeated closed reduction of extra-articular, dorsally angulated, displaced distal radius fractures has a low success rate in the prevention of operative fixation and improvement of radiographic parameters.

Initial and post reduction radiographs for all distal radius fractures managed at Vancouver General Hospital between 2015 and 2018 were reviewed. Inclusion criteria were based on the AO fracture classification and included types 23-A2.1, 23-A2.2 and 23-A3. Exclusion criteria included age less than 18, intra-articular involvement with more than two millimeters of displacement, volar or dorsal Barton fractures, fracture-dislocations, open fractures and volar angulation of the distal segment. Distal radius fractures that met study criteria and underwent two or more attempts of closed reduction were matched by age and gender with fractures that underwent one closed reduction. Radiographic parameters including radial height and inclination, ulnar variance and volar tilt were compared between groups.

Sixty-eight distal radius fractures that met study criteria and underwent multiple closed reduction attempts were identified. A repeated closed reduction initially improved the radial height (p = 0.03) and volar tilt (p < 0.001). However, by six to eight weeks the improvement in radial height had been lost (p = 0.001). Comparison of radiographic parameters between the single reduction and multiple reduction groups revealed no difference in any of the radiographic parameters at one week of follow up. By six to eight weeks, the single reduction group had greater radial height (p = 0.01) ulnar variance (p = 0.05) and volar tilt (p = 0.02) compared to the multiple reduction group. With respect to definitive management, 38% of patients who underwent a repeated closed reduction subsequently received surgery, compared to 13% in the single reduction group (p = 0.001).

Repeated closed reduction of extra-articular, dorsally angulated, displaced distal radius fractures did not improve alignment compared to a single closed reduction and was associated with increased frequency of surgical fixation. The benefit of repeating a closed reduction should be carefully considered when managing distal radius fractures of this nature.

Malunion following displaced fractures of clavicle most commonly occurs with shortening and anterior rotation of the distal fragment. This results in scapular malalignment, which has been documented clinically as scapular winging. However, to our knowledge, this scapular malalignment has never been quantified radiographically. The purpose of our study was to quantify the radiographic parameters in patients with symptomatic midshaft clavicle malunions demonstrating scapular winging.

Fourteen patients with symptomatic midshaft clavicle malunions demonstrating scapular winging of the affected shoulder were identified. Each patient underwent CT scanning of both clavicles and scapulae. A standardised CT protocol was used for each patient. Multiple measurements were used to document the clavicle malunion and scapular malalignment including clavicular length, the distance from the tip of the scapula to the chest wall and to the nearest adjacent spinous process, and the relative height of each scapula on the chest wall. Statistical analysis using the Student t-test was performed.

The mean time from fracture was twenty-nine months. There were eleven males and three females with a mean age of 33.1 years. The mean clavicular shortening was 17mm (P> 0.001). The mean anterior-rotation through the malunion was nine degrees, and showed a trend toward significance (P=0.1). The distal fragment was anteriorly translated 13.5mm (P> 0.001) relative to the opposite normal shoulder. The scapula was displaced laterally 10.3mm (P> 0.001) from the nearest spinous process, superiorly 16.3mm and 12.2mm (P> 0.001) off the chest wall on average compared to the opposite normal shoulder.

Patients with symptomatic clavicle malunions often complain of periscapular pain, and winging of the scapula has been noted in such individuals. Ours is the first study to document and quantify scapular malalignment in this clinical setting. Since most shoulder musculature is scapular based, identification and quantification of scapular malalignment may have important ramifications in decision-making regarding treatment of clavicle fractures and malunions.

When deciding on treatment for displaced mid-shaft clavicle fractures, patients often inquire if repair of (potential) nonunion results in outcome similar to acute fixation. We used objective muscle strength testing and patient-oriented outcome measures to examine this question. Late reconstruction of nonunion following displaced mid-shaft fractures of the clavicle results in restoration of objective muscle strength similar to that seen with immediate fixation. However, there was a significant loss in muscle endurance as well as a trend towards a decrease in outcome scores (DASH, Constant) following late reconstruction. This information is useful in surgical decision making and in counseling patients.

Using objectively measured strength and patient-oriented health-status instruments, we sought to determine if delay in repair of displaced, mid-shaft clavicle fractures negatively affected shoulder strength or outcome.

Late reconstruction of clavicle nonunion results in restoration of objective muscle strength similar to that seen with immediate fracture fixation, but there was a significant loss in muscle endurance as well as a trend towards a decrease in outcome scores (DASH, Constant).

All patients had sustained completely displaced, closed, isolated mid-shaft clavicle fractures. Fifteen patients had immediate plate fixation (mean 0.6 months post-fracture) and fifteen had plate fixation for non-union (mean fifty-eight months post-fracture). Objective muscle strength testing on the BTE was done a mean of twenty-nine months post-fixation (normal contralateral limb as control). There were no significant differences between acute fixation and delayed reconstruction groups with regards to strength of shoulder flexion (acute = 92.4%, delayed = 89.4%, p=0.56), shoulder abduction (acute = 98.8%, delayed = 96.7, p=0.75), external rotation (acute = 98.4%, delayed = 91.9%, p=0.29), or internal rotation (acute = 96.3%, delayed = 97.4%, p=0.87). However, there was a trend for improved Constant scores (acute = 94.5, delayed = 90, p=0.09) and the DASH scores (acute = 3.4, delayed = 9.0, p=0.09) in the acute fixation group. We found a significant decrease in muscle endurance with regards to shoulder flexion (acute = 107.0%, delayed = 71.1%, p=0.007) and a trend towards weaker shoulder abduction (acute = 103.1%, delayed = 88.7 %).

Funding: Mr. Potter was supported by a St. Michael’s Hospital Summer Student Scholarship