Distal radius fractures: Value based diagnosis, treatment and outcome

A 57-year old male falls on the outstretched wrist during sports. He visits an Emergency Department, were the AWR are implemented. The AWR smart phone application recommends to make a wrist radiograph, which shows a displaced extra-articular distal radius fracture with a concomitant ulnar styloid process fracture. The fracture is reduced by closed means with an acceptable reduction. Although the VIPER study shows that operatively-treated patients with an acceptably reduced extra-articular distal radius fracture have better functional outcomes after one year than non-operatively treated patients, the current guideline advocates non-operative treatment. The fracture of the ulnar styloid process is left untreated since we know that this concomitant fracture does not result in worse functional outcomes. After one week the patient undergoes another wrist radiograph, in order to confirm if the fracture is still adequately reduced. The chance of redisplacement of the displaced distal radius fractures during conservative treatment is up to 60%, and up to 40% of patients undergo subsequent surgery. Moreover, a specially designed calculator is unable to accurately predict which fractures have a high probability of secondary displacement. The radiograph at the outpatient clinic shows redisplacement of the fracture and the patient and surgeon decide to go for open reduction and volar plate fixation. During this procedure the pronator quadratus is detached to accurately reduce and internally fixate the plate on the distal radius. Reinsertion of the pronator quadratus is not performed since it has been shown that there are no advantages of pronator quadratus repair.