Pain Perception following Initial Closed Reduction in the Preoperative Care of Unstable, Dorsally Displaced Distal Radius Fractures

Abstract

Introduction Closed reduction and cast immobilization is a common practice as initial treatment for distal radius fractures. This study examines the pain perception that accompanies this approach.

Materials and Methods Thirty dorsally displaced distal radius fractures were reduced and casted under finger-trap traction with intravenous analgesics. Patients rated their pain perception on visual analog scale prior to presentation, during reduction, during casting, and for every day until surgery. Closed reduction improved palmar tilt from −26.3 to −10.8 degrees. Surgery improved palmar tilt from −10.8 to +6.1 degrees. Closed reduction improved radial inclination from 15.5 to 19.1 degrees. Surgery improved radial inclination from 19.1 to 21.6 degrees. Mean pain perception was 5.8 at presentation. Reduction increased pain to 7.5 ( p < 0.001), whereas casting was less painful (3.7; p < 0.001). At the evening following casting and the following days until surgery, mean pain was still as high as 4.1, 4.2, 4.1, 3.6, 3.9, 2.8, 3.0, and 3.0, with some patients experiencing more pain than initially.

Conclusion Reduction generates significant pain with only minor relief during cast immobilization. The indication for closed reduction prior to cast application is therefore questionable.

Introduction

Distal radius fractures are the most common fractures and are expected to increase in number in aging populations and with increasing life expectancy. 1 The management of unstable dorsally displaced distal radius fractures has essentially changed by the implementation of locking plates. 2 3 A vast number of studies report on operative outcome measures, and complication rates of what has become a standard procedure. 3 4 5 However, few studies describe the preoperative care of such unstable distal radius fractures, for which palmar locking plate osteosynthesis is already scheduled. It is widely accepted to perform closed reduction prior to plaster immobilization, before definitive stabilization is conducted by internal fixation. 6 The rationale is to diminish bony impaction and relieve tension in the soft tissue as well as in the median nerve. 6 However, closed reduction is accompanied by significant pain, which necessitates the application of intravenous analgesics or even hematoma blocks. 7 8 9 10 This is thereby accepted in the light of an expected relief of pain and discomfort during plaster immobilization. While pain perception during initial reduction has been extensively reported in the literature, the time period from initial treatment to surgery is not addressed yet.

The purpose of this study was to assess the preoperative pain level in patients with unstable dorsally displaced distal radius fractures, who were already scheduled for palmar plate osteosynthesis. We hypothesized that the pain perception in the preoperative period can be significantly reduced, when closed reduction is performed prior to plaster immobilization.

Materials and Methods

This study protocol was approved by the ethical committee of the appropriate university Würzburg, Germany. For this prospective study, we included 30 consecutive patients with isolated and unilateral unstable, dorsally displaced distal radius fractures, who presented primarily to our trauma care unit. Detailed inclusion and exclusion criteria are listed in Table 1 . Initial treatment was conducted according to the house treatment regimen for this injury. Clinical examination included the assessment for median nerve neuropathy by asking for loss of sensation. Radiologic examination included standard wrist X-rays in anteroposterior and lateral views. Indications for the operation were the instability criteria described by Lafontaine et al, 11 including dorsal comminution, dorsal angulation of more than 20 degrees, or radial shortening by more than 5 mm. After obtaining informed consent to participate in the study, the surgeons initiated finger-trap traction for a minimum of 5 minutes. Then, the surgeons performed closed reduction under fluoroscopy. Still under axial traction, a circular plaster was applied, which was split after complete setting. During the process of closed reduction, according to the house standard, all patients received intravenous analgesics according to the surgeons’ preferences. Thereafter, the surgeons asked the patients to rate their pain perception per visual analog scale (VAS; 0 = no pain; 10 = severe, intolerable pain). The pain perception was to be rated prior to presentation to the trauma care unit, during the process of reduction, and during the process of plaster application. The patients’ pain ratings were noted on assessment sheets, which were handed out to the patients, when they were discharged to home. At home, the patients ought to complete the assessment sheets by rating the pain perception, the amount of analgesics they have taken, an eventual loss of sensation for the evening after initial treatment, as well as for every following day, including the day of re-admittance for surgery.

Table 1. Inclusion and exclusion criteria.

	Inclusion criteria	Exclusion criteria
Patients-based criteria
	Adult patients	Patients who were not able to cooperate
		Multiple sites’ injuries
Fracture-based criteria
Instability expected due to…	Dorsal comminution	Flexion fractures
	> 20 degrees dorsal angulation
	> 5 mm radial shortening
	Intra-articular radiocarpal involvement
	Concomitant fractures of the ulnar styloid

Radiologic assessment included palmar tilt and radial inclination as measured by the index radiographs, by the radiographs after removal of axial traction following plaster application, and by the intraoperative fluoroscopic images, respectively. Ulna variance was measured according to Gelberman et al 12 by the standard postoperative X-rays in posteroanterior (PA) view.

Statistical Analysis

All assessed data were examined for normal distribution by Kolmogorov-Smirnov test. Parametric or nonparametric (Wilcoxon-test) tests were accordingly applied for further testing. In case of multiple comparisons, Bonferroni-corrected t -test was used. Comparison between initial pain perception and that of the days following initial treatment was reduced to the first 3 days, as the number of patients diminished each day. For the fourth to seventh day after initial treatment, results were presented in a descriptive manner.

Results

Radiographic Measurements

Figs. 1 2 illustrate the palmar tilt and radial inclination according to the index X-rays, as well as after casting and following surgery. Reduction improved palmar tilt and radial inclination significantly ( p < 0.001, each). However, a neutral or even palmar tilt was seldom achieved. Surgery resulted in restoration of almost physiologic angles ( p < 0.001, each) and a mean ulna variance of 0.2 mm, ranging from −1 to +2 mm.

Fig. 1.

Palmar tilt and radial inclination of radius.

Fig. 2.

This 75-year-old patient with a distal radius fracture presented with an initial pain perception of 6.5 on visual analog scale. Her radius was dorsally displaced by 36 degrees, whereas radial inclination was 20 degrees (A) . Closed reduction increased pain to 8 out of 10 despite the IV application of 7.5 mg piritramide and 500 mg novaminsulfon. Reduction thereby improved dorsal tilt to −4 degrees and radial inclination to 22 degrees (B) . During cast application, as well as the evening following initial treatment, she perceived a pain of seven. The following 4 days until surgery, she stated to have had pain of 8. Surgery finally improved her radial inclination to an almost physiologic palmar tilt of 4 degrees and a radial inclination of 24 degrees (C, D) .

Pain Perception during Preoperative Care

Table 2 illustrates pain perception prior to treatment. Reduction caused significant increase in pain perception (mean increase of 1.72), whereas casting under axial traction was felt to be significantly less painful compared with initial pain level (mean reduction by 2.07). The evening following initial treatment, pain perception decreased by a mean of 1.63, compared with initial pain level, with four patients having perceived more pain than before treatment. The next day following initial treatment, mean decrease in pain perception was 1.52. Thereby, six patients perceived even more pain than before. The second, third, and fourth days following initial treatment, respectively, three, two, and two patients perceived more pain than at first. Fig. 2 is an example of one of these patients, who perceived more pain during immobilization than initially at presentation.

Table 2. Pain perception per visual analog scale in 30 patients with reduced and casted wrists.

					Number of patients with change in pain perception compared with initial level
		Standard deviation			Decreased pain		No change	Increased pain
	Mean		Range	p -Value on Wilcoxon text	by ≥ 2	by < 2		by < 2	by ≥ 2
Initially at presentation	5.75	± 2.36	1.5–10	–	–	–	–	–	–
During reduction	7.47	± 1.98	3–10	< 0.001	3	0	3	5	19
During casting	3.68	± 2.14	1–8	< 0.001	16	7	4	2	1
Evening following primary care ( n = 30)	4.12	± 2.36	1–9	< 0.001	15	8	3	2	2
1st day ( n = 30)	4.23	± 2.11	1–9	0.001	15	6	3	4	2
2nd day ( n = 21)	4.10	± 2.26	1–8	0.004	10	4	4	2	1
3rd day ( n = 15)	3.60	± 2.23	1–8	0.011	8	3	2	1	1
4th day ( n = 14)	3.86	± 2.21	1–8	–	6	3	3	1	1
5th day ( n = 5)	2.80	± 1.48	1–5	–	3	2	0	0	0
6th day ( n = 3)	3.00	± 2.00	1–5	–	1	2	0	0	0
7th day ( n = 1)	3.00	–	3	–	0	1	0	0	0

Discussion

One of the main goals in the treatment of acutely injured patients is to relieve pain. With respect to distal radius fractures, initial treatment has to be effective to prevent complex regional pain syndrome (CRPS). In nonsurgically treated patients, CRPS is expected during the third and fourth weeks after cast removal, especially in women who report severe pain and impairment of physical quality of life. 13 Moseley et al 14 found pain perception in the first week following trauma a strong predictor for the development of CRPS. In their prospectively followed cohort of 1,549 patients, 1 in 26 patients developed CRPS within 4 months following trauma. They considered a pain score greater than or equal to 5 in the first week, a “red flag” for CRPS. In this study, mean initial pain perception at presentation to the emergency department was above this threshold. Despite the intravenous application of analgesics, pain significantly increased even more during reduction. This fact implies the need for a change in pain control during this painful maneuver. In this context, different approaches are examined in the literature. Chong et al compared forearm and conventional Bier's blocks in a randomized controlled trial and found no significant difference with mean pain scores rating 18.4 and 33.7, respectively. 7 Johansson et al 8 compared a new method of manual reduction without anesthesia with what they called the usual method including intravenous anesthesia. They reported the new method as significantly more painful than the conventional technique with anesthesia (5.2 vs. 3.4), with no patient having interrupted the reduction process because of intolerable pain. Liu et al 9 compared isoflurane and propofol for general anesthesia during reduction with respect to the occurrence of emergence agitation as well as the peak pain score at arrival at postanesthetic care unit. They reported no statistical difference between the two groups for pain scores (4.1 vs. 4.7) or for the occurrence of emergence agitation. Funk 10 finally examined pain perception before, during, and after manipulation, while using general anesthesia with propofol, hematoma block, or hematoma block plus sedation with midazolam. General anesthesia was found to be most effective in pain control during manipulation compared with hematoma block plus midazolam and hematoma block alone, respectively (0 vs. 0.9 and 3.7). On the other hand, pain control lasted longer with hematoma blocks. The patients rated their pain after manipulation as high as 5.8 in the general anesthesia group compared with 1.6 and 1.5 in the groups with hematoma blocks. It is noteworthy that a lasting pain-reducing effect cannot be expected by reduction. Funk reported significantly decreased pain after manipulation compared with before (5.8 vs. 6.9; p < 0.01). However, it is questionable if a mean difference of 1.1 is really perceived as relevant change by the patients. According to Schomacher, 15 with baseline pain ratings above 4, a minimal change of 2 or 30% is indicated for rating a change as clinically relevant. Accordingly, Johansson et al 8 reported no significant difference between the mean pain scores before and after reduction under anesthesia (3.8 vs. 3.1), with 11 patients in one group reporting unchanged or even worsened pain following reduction. The same applies to our own data. The mean decrease in pain perception was 1.63. In addition, like in the study by Johansson et al, 8 some patients perceived even more pain following initial treatment. One could therefore suppose that axial traction and even more reduction may destabilize the fracture, leading to more pain after casting.

Whereas the moment of reduction and the accompanied pain levels were subject of many studies, the time interval until surgery, to our knowledge, has not yet been examined. This study provides data for the following days until day of surgery. Table 2 indicates that until day 4 following reduction and casting, some patients experienced even more pain compared with the initial pain perception at arrival at the emergency department. According to Schomacher, 15 Table 2 thereby differentiates between changes less than 2 and 2 or more as per VAS. It is obvious that the patients’ pain cannot be completely relieved with the measures described in this study. According to the literature, beside general anesthesia, hematoma blocks seem to be most effective in pain control during manipulation of distal radius fractures. 10 However, it can be expected that the patients experience some pain and discomfort the following days until surgery. Assuming that axial traction and even more reduction destabilize the dislocated but impacted and therefore relatively “stable” situation, one could question the necessity of the reduction itself.

Nowadays, unstable distal radius fractures are treated surgically, in the most cases, as loss of reduction is likely to occur. 2 11 16 Even if such fractures are treated nonsurgically, a benefit in clinical or radiographic outcome cannot be expected by reduction. 17 Neidenbach et al 18 reported even worse clinical results 1 year after nonsurgical treatment, when reduction is performed. In addition, Brogren et al 16 reported more deterioration in radiographic parameters after 1 year when the fractures have been reduced compared with when they have not been reduced prior to cast application. With respect to surgically treated distal radius fractures, Teunis et al 6 did not find a difference in adverse events if fractures were left unreduced until surgery; as long as the fractures were not open, the skin tented or the fractures have been otherwise complicated like by neuropathy or compartment syndrome.

One limitation of this study is the small number of patients included as well as the lack of middle- to long-term results. Therefore, beside pain perception, frequency of CRPS cannot be assessed by this cohort. The major limitation of this study is the lack of a control group. This study is therefore not suitable to examine the question whether presurgical manipulation reduces pain in the preoperative care of distal radius fractures.

Conclusion

Reduction maneuver in unstable distal radius fractures is accompanied by significant increase in pain, which is not sufficiently treated by intravenous analgesics. Because reduction is not able to reduce pain perception by a clinically relevant degree, we doubt the necessity of closed reduction, as long as compelling indications, like a median nerve neuropathy, are missing. Whether indeed the omitting of reduction leads to less pain during cast immobilization is yet to be examined.