Design and Setting
In our single-center, retrospective clinical observational study, the data of the patients in the hospital system were examined after the ethics committee approval dated 09.12.2019 and numbered 77/09 was obtained from the ethics committee of Dışkapı Yıldırım Beyazıt Training and Research Hospital. Written informed consent was obtained from all patients and this study was conducted in accordance with the Declaration of Helsinki.
Selection of Patients
Between March 1, 2019 and September 1, 2019, a total of 208 patients over the age of 18 were admitted to the emergency department of our hospital (level 1 trauma center) with the diagnosis of distal radius fracture. Patients in whom surgery was decided at the time of initial presentation, open fractures, patients with impaired general condition, patients in whom plaster could not be applied due to soft tissue compromise, patients who refused suggested treatment, previous fractures, pathologic fractures, patients with swelling in the distal extremity, circulatory disturbance or suspicion of median nerve compression after cast application, bilateral fractures, upper extremity injuries (i.e. ulna diaphysis fractures), patients who did not want to participate in the study, patients without adequate follow-up and 2-way radiographs were excluded. After exclusion, total of 96 patients were included in the study.
Interventions and follow-up
The first closed reduction and cast application was performed by a single senior resident under supervision of an orthopedic surgeon under conscious sedation and analgesia. One of the two assistants applied traction to the forearm while the other assistant applied counter traction by pulling the patient's fingers. The aim was to distract the fracture ends, with the help of ligament taxis. Force was applied to the fracture line from the volar or dorsal side in the direction of deformity and then towards the opposite side of the orientation of the fracture line in the initial state. After the reduction maneuvers, cast cotton was wrapped around the forearm, plaster of Paris was molded on the cast cotton at the distal metacarpophalangeal level and a short arm circular cast was applied. The cast was molded to achieve flexion at the level of the fracture line with the wrist in slight flexion and ulnar deviation. Control antero-posterior and lateral radiographs of the patients were evaluated after cast application14.
All patients were called for follow-up visits at 24 hours and 3 days after cast application for neurovascular examination, especially for median nerve compression. All patients were re-evaluated at weekly outpatient clinic visits. In patients in whom the quality of reduction and fracture alignment were accepted to be appropriate (shortness <3 mm, radial inclination <10 degrees, intra-articular stepping <2 mm)15 in the first three weeks of follow-up radiographs, the short arm casts were removed in the sixth week if radiologic union was observed in the follow-up radiographs. In the follow-up radiographs, the patients who were followed up by the same surgeon were found from the hospital information system and noted if there was a loss of reduction and re-reduction or surgery in the first three weeks was decided.
AO/OTA classification was performed according to AP and lateral radiographs of all patients. The 2-way radiographs taken after reduction and cast application and the cast index defined by Chess as the ratio of the width of the cast on the fracture line on the lateral radiograph to the width of the cast on the fracture line on the antero-posterior radiograph were recorded in patients6. CI measurements of these patients after initial reduction were performed by two different surgeons on PACS viewer (Innbiotec DICOM Viewer, Innbiotec Software, Dubai, UAE).
Cast index and outcomes
The method described by Chess et al.6 in pediatric distal radius fractures was used to determine CI. For this purpose, the anteroposterior distance between the casts (excluding casts) at the level of the fracture line was calculated on the lateral radiograph, and then the medial-lateral distance between the casts (excluding casts) at the level of the fracture line on the AP radiograph was calculated and the ratio was calculated. While Chess et al. initially said that a ratio of 0.7 was ideal, recent studies have found that a ratio between 0.80 and 0.84 is more important and ratios above this value increase the risk of reduction loss8,16.
CI after initial reduction of all patients were measured twice at two weeks intervals by two investigators using the method described by Chess et al.6 (Figure 1) and intra- and inter-observer correlations were evaluated.
Patients were divided into two groups according to the presence or absence of reduction loss. The differences between the two groups according to fracture subtypes in the AO/OTA classification17, cast index and demographic data (age, sex, body mass index) were analyzed.
Statistical analysis
Statistical evaluation of the data was performed using Statistical Package for the Social Sciences (SPSS) for Windows version 20.0 software. Descriptive statistics for categorical variables were presented as numbers and percentages, and for numerical variables as mean ± standard deviation and minimum-maximum values. Chi-square test was used to analyze relationship between categorical data (i.e. sex, AO/OTA types, CI being less than 0.8 and loss of reduction). In the analysis of numerical data, conformity to normal distribution was examined with one sample Kolmogorov-Smirnov test. Since normal distribution of continuous data was confirmed, independent samples t test was used to assess statistical significance of difference between two groups in terms of age, BMI and CI. Also, logistic regression analysis was done to assess parameters that may have an impact on loss of reduction. p values less than 0.05 is considered statistically significant. Inter- and intra-observer reliabilities of CI were measured with inter and intraclass correlation coefficients (ICC) and 95% confidence intervals. A cut-off value of 0.8 was set for CI8,16 and sensitivity and specificity for CI was assessed accordingly.
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