1
DRF project. Appendix 2
Usual treatment pathways for ‘typical’ fractures of the distal radius in adults
Care pathway: core – preliminaries / Key questions/ Q1.1 What are the components of a satisfactory examination?
Q1.2 What information should be requested / noted in patient’s notes?
Q1.3 What other assessment / measures would be desirable or useful on a routine basis?
/ Q2.1 What are the essential components of a preliminary treatment?
Q2.2 Who is suitable to provide preliminary treatment?
/ Q3.1 When should definitive treatment begin?
Q3.2 Who is suitable to decide appropriate definitive treatment?
YES
NO / Q4 When is reduction (non surgical or surgical) required?
NOTES: Care pathways 6 (internal fixation) & 7 (bone scaffolding) are not developed fully in this document. Surgical treatment is presented in terms of the main methods in common use: variations in surgical technique (e.g. approach for internal fixation) and operations involving a combination of methods are not considered here.
Care pathway: core – non reduce / Key questionsYES / Q5 Is immobilisation of the injured wrist for any duration necessary?
NO
Care pathway: 1 – non reduce, non immobilise / Key questions
/ Q6.1 What type of wrist support should be used?
Q6.2 Who is suitable to apply the wrist support?
Q6.3 When should wrist support be applied and for how long?
Q6.4 What advice / instructions should be given?
Q6.5 Who is suitable to supply advice / instructions?
/ Q6.6 Should a patient be called back for examination?
Q6.7 What is the best timing for examination visits(s)?
Q6.8 Who is suitable to examine the patient?
YES
NO / Q21.1 Who is suitable to decide appropriate secondary treatment?
Q23.1 For what reason(s) is extra hand therapy (physiotherapy) indicated?
/ Q23.4 What intervention(s) should be routinely provided aimed at secondary prevention? For example, should patients be screened for osteoporosis?
Q23.5 Are additional services needed? If so, what and when?
Care pathway: 2 – non reduce, immobilise / Key questions
/ Q7.1 When shouldimmobilisation be applied?
Q7.2 What type of immobilisation is required?
Q7.3 How should the arm be positioned?
Q7.4 Who is suitable to apply the wrist immobilisation?
Q7.5 What rehabilitation interventions should be given at this stage?
Q7.6 Who is suitable to supply rehabilitation?
/ Q7.7 How long should the wrist be immobilised?
Q7.8 What is the best timing for examination visits(s)?
Q7.9 Who is suitable to examine the patient?
YES / Q21.1 Who is suitable to decide appropriate secondary treatment?
Q23.1 For what reason(s) is extra hand therapy (physiotherapy) indicated?
NO / Q7.10 Who is suitable to remove the cast / brace (and where)?
Q7.11 What rehabilitation interventions should be given at this stage?
Q7.12 Who is suitable to provide rehabilitation?
YES / Q23.1 For what reason(s) is extra hand therapy (physiotherapy) indicated?
/ Q23.4 What intervention(s) should be routinely provided aimed at secondary prevention?
Q23.5 Are additional services needed? If so, what and when?
Care pathway: core – surgery? / Key questions
YES YES / Q8 When is surgery indicated for definitive treatment (at start)?
NO
Care pathway: core – closed reduction / Key questions
/ Q9.1 Who is suitable to reduce fracture?
Q9.2 What method of closed reduction should be used?
Q9.3 What method(s) of anaesthesia is preferable?
Q9.4 Who is suitable to provide anaesthesia?
YES
NO / Q9.5 What are the criteria for a successful reduction. Who should decide this?
Q9.6 What is the preferred immediate treatment option if reduction is immediately unsuccessful?
YES / Q10 When is surgery indicated for failed primary closed reduction?
Care pathway: 3 – reduce fracture, conservative treatment / Key questions
/ Q11 What type of analgesia is needed?
YES YES NO / Q12 When should a patient be admitted to hospital?
/ Q13.1 When shouldimmobilisation be applied?
Q13.2 What type of immobilisation is required?
Q13.3 How should the arm be positioned?
Q13.4 Who is suitable to apply the wrist immobilisation?
Q13.5 What rehabilitation interventions should be given at this stage?
Q13.6 Who is suitable to supply rehabilitation?
/ Q13.7 How long should the wrist be immobilised?
Q13.8 What is the best timing for examination visits(s)?
Q13.9 Who is suitable to examine the patient?
YES
NO / Q21.1 Who is suitable to decide appropriate secondary treatment?
Q23.1 For what reason(s) is extra hand therapy (physiotherapy) indicated?
Care pathway: 3 – reduce fracture, conservative treatment / Key questions
/ Q13.10 Who is suitable to remove the cast / brace (and where)?
Q13.11 What rehabilitation interventions should be given at this stage?
Q13.12 Who is suitable to provide rehabilitation?
YES / Q23.1 For what reason(s) is extra hand therapy (physiotherapy) indicated?
/ Q23.4 What intervention(s) should be routinely provided aimed at secondary prevention?
Q23.5 Are additional services needed? If so, what and when?
Care pathway: core – reduce fracture, surgical treatment / Key questions
/ Q14 What method(s) of surgery (could be a combination) are preferable for typical circumstances (fracture types)?
/ Q15.1 How often are supplementary methods of reduction needed?
Q15.2 Who is suitable to operate?
Q15.3 What are the criteria for a successful reduction. Who should decide this?
Q15.4 What method(s) of anaesthesia is preferable?
Q15.5 Who is suitable to provide anaesthesia?
Q15.6 What are the criteria for a successful procedure on completion? Who should decide this?
Care pathway: core – surgical treatment / Key questions
/ Q11 What type of analgesia is needed?
YES YES N NO / Q12 When should a patient be admitted to hospital?
/ Q16.1 What method(s) of wound care should be used?
Q16.2 When should antibiotics be given?
Q16.3 Who is suitable to provide wound care?
Q16.4 How frequently does the wound need to be checked?
Care pathway: 4 – percutaneous pinning / Key questions
/ Q17.1 What method(s) of percutaneous pinning is / are preferable?
Q17.2 What type of pins should be used?
Q17.3 What method of pin insertion is preferable?
Q17.4 How experienced should the operator be?
Q17.5 How should the K-wires / pins be finished off?
YES NO / Q17.6 Is immobilisation for any duration necessary?
Care pathway: 4 – percutaneous pinning / Key questions
/ Q17.7 What type of immobilisation is required?
Q17.8 When should immobilisation be applied?
Q17.9 How should the arm be positioned?
Q17.10 Who is suitable to apply the wrist immobilisation?
/ Q17.11 What rehabilitation interventions should be given at this stage?
Q17.12 Who is suitable to provide rehabilitation?
/ Q17.13 What duration of immobilisation is required?
Q17.14 What is the best timing for examination visits?
Q17.15 Who is suitable to examine the patient?
YES / Q21.1 Who is suitable to decide appropriate secondary treatment?
Q23.1 For what reason(s) is extra hand therapy (physiotherapy) indicated?
NO
YES
/ Q17.16 Should and when should K-wires / pins be extracted?Q17.17 Who is suitable to remove the cast / brace (and where)?
Q17.18 Who is suitable to examine the patient?
Q17.19 What rehabilitation should be given at this stage?
Q17.20 Who is suitable to provide rehabilitation?
/ Q23.1 For what reason(s) is extra hand therapy (physiotherapy) indicated?
/ Q23.4 What intervention(s) should be routinely provided aimed at secondary prevention?
Q23.5 Are additional services needed? If so, what and when?
Care pathway: 5 – external fixation
/ Q18.1 What method(s) of external fixation is / are preferable?
Q18.2 What method of pin insertion is preferable?
Q18.3 What type (shape / coating) of pins is preferable?
Q18.4 How experienced should the operator be?
Q18.5 What supplementary methods are used and why?
Q18.6 If used, what type of plaster cast immobilisation is needed?
/ Q18.7 What rehabilitation should be given at this stage?
Q18.8 Who is suitable to provide rehabilitation?
/ Q18.9 Should and when some limited wrist mobilisation be allowed?
Q18.10 What is the best timing for examination visits?
Q18.11 Who is suitable to examine the patient?
YES / Q21.1 Who is suitable to decide appropriate secondary treatment?
Q23.1 For what reason(s) is extra hand therapy (physiotherapy) indicated?
NO / Q18.12 When should external fixation be removed?
Q18.13 Who is suitable to remove the fixator / cast (and where)?
Q18.14 Who is suitable to examine the patient?
Q18.15 What rehabilitation should be given at this stage?
Q18.16 Who is suitable to provide this?
Care pathway: 5 – external fixation / Key questions
YES
NO / Q23.1 For what reason(s) is extra hand therapy (physiotherapy) indicated?
/ Q23.4 What intervention(s) should be routinely provided aimed at secondary prevention?
Q23.5 Are additional services needed? If so, what and when?
Care pathway: 6 (incomplete) – internal fixation / Key questions
YES / Q19.1 What method(s) of internal fixation is / are preferable?
Q19.2 Is triangular ligament repair necessary?
Q19.3 What supplementary method(s) of immobilisation are needed?
/ Q23.1 For what reason(s) is extra hand therapy (physiotherapy) indicated?
/ Q23.4 What intervention(s) should be routinely provided aimed at secondary prevention?
Q23.5 Are additional services needed? If so, what and when?
Care pathway: 7 (incomplete) – bone scaffolding / Key questions
/ Q20.1 What materials for filling bony defects are acceptable?
Q20.2 What method of immobilisation is needed and for how long?
Care pathway: 7 (incomplete) – bone scaffolding / Key questions
YES / Q23.1 For what reason(s) is extra hand therapy (physiotherapy) indicated?
/ Q23.4 What intervention(s) should be routinely provided aimed at secondary prevention?
Q23.5 Are additional services needed? If so, what and when?
Care pathway: core – significant loss of position / Key questions
YES NO / Q21.2 Should reduction (non surgical or surgical) be attempted?
Q21.3 When should reduction be done?
YES NO / Q21.4 When is surgery indicated for loss of position?
Q21.5 Does the choice of surgical method fundamentally differ whether the fracture is for primary or secondary displacement?
/ Q22.1 Should there be any change in the type and duration of immobilisation for these circumstances?
/ Q22.2 Should there be any change in the type and duration of immobilisation for these circumstances?
/ Q22.3 Should there be any change in the type and duration of immobilisation for these circumstances?
Care pathway: core – other rehabilitation / Key questions
/ Q23.2 What are good (practical and effective) ways of (routinely) deliveringrehabilitative interventions?
Q23.3 Where is/are the best local place(s) for (routine) rehabilitation?
Q23.4 What intervention(s) should be routinely provided aimed at secondary prevention? For example, should patients be screened for osteoporosis?
Q23.5 Are additional services needed? If so, what and when?
Review references
Handoll HHG, Madhok R. Conservative interventions for treating distal radial fractures in adults (Cochrane Review). In: The Cochrane Library, Issue 1, 2002. Oxford: Update Software.