Outcome Of Conservative Management Of Distal Radial Fractures In Adults As Seen At Kenyatta National Hospital

Abstract

Background: Fractures of the distal radius are quite common accounting for around one sixth of all fractures seen in the emergency department in the USA. Locally, data on the prevalence of these fractures is scarce. Due to the shortage of qualified personnel and inadequate theatre facilities in Kenya, the majority of these fractures are managed conservatively. With closed reduction and casting proper joint alignment may not be achieved in some of intra-articular fractures, or in the case of extra-articular fractures, secondary collapse of the fragments may not restore the distal radial anatomy. Concerns over the morbidity thereof have resulted in a paradigm shift towards restoration of the articular congruency and bony anatomy of the distal radius operatively. The outcome of conservative management in resource limited settings has not been assessed locally. Objective: To determine the outcome of conservative management of distal radial fractures in adults as seen at Kenyatta National Hospital (KNH). Study design and setting: A prospective descriptive study on conservative management of adult patients with distal radial fractures presenting at KNH’s fracture clinics and the Accident and Emergency (A&E) department, from June 2013 to October 2013. Patients and methods: Seventy five skeletally mature patients, with unilateral closed distal radial fractures treated by closed reduction and casting, who consented to the study, were recruited. Outcome assessment was done at six weeks after cast removal. Outcome measures were assessed both objectively and subjectively. Objective assessment included wrist deformity based on a radiographic score determined by measuring the dorsal angle, ulnar variance and radial inclination on wrist radiographs; and the wrist function by measuring the range of motion and hand-grip strength. Subjective assessment was done using wrist pain and disability based on the patient rated wrist evaluation (PRWE) score. Data were analyzed using SPSS version 17.0. Chi-square test (χ²) was used to determine whether the distribution of categorical variables differed from each other. The t-test was used to compare the means and correlation/association between variables. Results: The ages of patients ranged from 20 to 80 years with a mean of 42(±14) years, with a male to female ratio of 1:1. Fernandez type I fracture was the most common (48%) regardless of age and gender. Fernandez type III fractures were more common in females and older age-groups. A fall, in 45 patients (60%) was the most likely cause of the fractures more so in older age-groups while assaults and RTA contributed more common in young males. Majority of patients had a good radiographic score (59%), twenty nine percent had fair score, and 12% had an excellent one. Sixty one patients (81.3%) had a good functional objective score, in 13.4% it was fair and 5.3% had an excellent score. 2 In the subjective assessment of pain and disability the PRWE score was highest in the 20-39 years age group at 45/100 and least in those at 60 and above years (35/100; p= 0.004). There was a positive correlation (p =0.023) between radiographic assessment and the objective functional assessment; however, there was no correlation between the radiographic score and the subjective assessment (p =0.952). Conclusion: At KNH, distal radial fractures occur uniformly across all adults’ age-groups and affect males and females equally. The most common fracture is Fernandez type I caused mainly by falls, although there is significant contribution by RTA in younger males. The majority of the patients had a good radiographic score which correlated positively with the objective functional score, especially in the younger patients and simple extra-articular Fernandez type I and IV fractures; however, a good radiographic score does not seem to positively affect the subjective functional outcome. The patient’s age is an important factor in the overall patient satisfaction regardless of the radiographic and the objective functional scores, hence to be considered during planning of treatment options.