Pain Level in the Preoperative Care of Unstable Dorsally Displaced Distal Radius Fractures
Authors: Löw Steffen , Papay Marion , Eingartner Christoph , Strobl Ute , Spies Christian 
Published: September 2016

Objective/Hypothesis: Closed reduction and plaster immobilization are commonly accepted as initial treatment for unstable dorsally displaced distal radius fractures, which are scheduled for internal fixation. However, no study reports on the pain level, that accompanies this initial treatment. We expected that the pain level in the preoperative period can be significantly reduced by closed reduction prior to plaster immobilization. Materials and Methods: This prospective study included 30 consecutive patients with isolated and unilateral unstable dorsally displaced distal radius fractures, who presented primarily to our trauma care unit. After finger-trap traction for a minimum of 5 minutes, closed reduction was performed under fluoroscopy. Still under axial traction, a circulated plaster was applied and split after complete setting. During the process of closed reduction, the patient received intravenous analgesics according to the surgeons’ preferences. Thereafter, the patients were asked to rate their pain level on the visual analogue scale prior to presentation to the trauma care unit, during the process of reduction, during the process of plaster application, as well as for every day until readmittance for surgery. From the same period, a control group of 11 patients with only slightly displaced fractures were included. In them, only axial traction but no reduction was performed prior to plaster application. Radiological assessment included palmar and ulnar inclination of the radius as measured by the index radiographs, the radiographs after removal of axial traction following plastering, as well as by the intraoperative fluoroscopic images, respectively. Results: Reduction improved palmar tilt significantly from −26.3° (±10.8°) to −10.8° (±7.3°; P < .001). Surgery resulted in almost anatomical restoration, with a mean palmar tilt of 6.1° (±3.8°; P < .001). In the control group of patients without reduction, palmar tilt was improved from −14.1° to −10.0° and to +5.6° after surgery. The ulnar tilt of the radius was improved from 15.5° to 19.1° and to 21.6°, respectively, in the reduction group. In the control group, there was no difference prior and after treatment. The pain level at presentation was a mean of 5.7 (±2.4). Reduction caused a mean pain level of 7.5 (±2.0; P < .001) despite the application of intravenous analgesics, whereas the application of the plaster was associated with a pain level of 3.7 (±2.1; P < .001). At the evening and the following days after initial treatment, the mean pain level was still as high as 4.1 ( P < .001), 4.2, 4.1, 3.6, 3.9, 2.8, 3.0, and 3.0, respectively. In the control group, the initial pain level of 6.0 (±2.0) was reduced to 3.4 (±1.9; P = .013) at evening following plastering and to 3.4, 3.8, 2.2, 1.6, 1.7, respectively, during the following days. Conclusions: The existing literature does not prove an advantage of closed reduction prior to cast immobilization. The current study, instead, demonstrates significantly increased pain during the process of reduction with only little benefit of reduced pain in the period of plaster immobilization. The indication of closed reduction prior to plaster application is therefore more than questionable. It should be performed only when dislocation-related median nerve neuropathy is suspected.