Factors associated with variation in treatment of the distal radioulnar joint after plate fixation of distal radial fractures.

Abstract

Evidence suggests that the distal radioulnar joint injury associated with an operatively treated displaced fracture of the distal radius does not benefit from specific treatment after the radius is realigned. To better understand variation in treatment of the distal radioulnar joint we performed a scenario-based experiment presenting radiographs of displaced distal radial fractures accompanied by clinical scenarios with randomized aspects. In a survey-based experiment, participants of the Science of Variation Group viewed a random subset of five of 10 sets of radiographs showing displaced fractures of the distal radius before and after anterior plate fixation. Each was accompanied by a clinical scenario with trauma energy level, age and gender randomized. Participants indicated their preferred distal radioulnar joint treatment: none, cast immobilization, operative reattachment of ligaments or ulnar styloid fixation, or distal radioulnar joint pinning. Factors associated with any treatment and with reattachment were sought in multivariable regression. Surgeons recommended distal radioulnar joint treatment in 67% (404 of 607) of the scenarios, most commonly cast immobilization in 41% (247 of 607). Recommendation for any distal radioulnar joint treatment was associated with younger patient age, and for reattachment specifically, was associated with younger patient age, high-energy trauma and fracture of the base of the ulnar styloid. The observation of frequent recommendation for distal radioulnar joint treatment, relatively more so for younger patients with higher energy injuries, and some tendency to repair an aligned ulnar styloid base fracture may diverge from existing evidence.