The demographics of our two groups were quite evenly matched. They were of similar ages and gender distribution. The median ages of 67.5 and 69 years are in keeping with fragility fractures (epidemiological studies report the highest incidences of DRFs being in the over 65s). The gender discrepancy seen in our participants matches that seen in previous studies of a nearly 5 times increased risk seen in women: one that is largely attributed to higher rates of female osteoporosis [4, 5]. The types of DRFs sustained were equally well matched, with the same proportions of left sided injuries between the two groups, and a similar proportion of intra-articular fractures. The preference of this injury for the left wrist is a previously reported phenomenon, as is the predominance of DRFs to remain extra-articular .
10% of our study participants were eventually treated with operative fixation. Although operative intervention for DRFs seems to be on the increase, rates appear to vary vastly between areas . After BOA guidelines recommended non-operative management of upper limb fractures during the pandemic, we would have expected to see a decrease in DRF fixation. Instead, we saw a two times increase in operative intervention after 27th March 2020 in our two groups (although as we only looked at DRFs that had undergone manipulation this may simply represent an increase in failed attempts at conservative management) . One paper theorised we will see poorer outcomes for DRFs from March 2020 onwards as well as an increase in the number of future corrective surgeries required. This was based on more than 50% of DRFs managed non-operatively at their trust during the pandemic having at least one radiological parameter that would have previously indicated surgical fixation . This does not take into account, however, that patient factors are widely considered to be the most important markers for whether to intervene surgically, as appose to a unanimous radiological threshold for intervention . In addition, previous research has shown surgical management to improve radiological outcomes only, and not functional outcomes, when compared to conservative management of DRFs [8, 9]. Some studies, in fact, report that improvements in dorsal tilt with operative, over conservative, management do not extend past the 2-week follow-up. Fracture slippage after this point is greater in those operated on, resulting in no statistical difference in final radiological outcomes between the two management options .
The radiological parameters seen on initial presentation were similar for both groups in our study. Manipulation was seen to improve, on average, all radiological parameters, with the greatest improvement being seen in the angulation. Anatomical reduction is a key factor to preventing DRF redisplacement after reduction and cast immobilisation .
The soft-combi casts appeared to be more effective at maintaining the reduction than the rigid casts. The average DRF managed with a soft-combi cast allowed the fracture to slip 1.5 degrees dorsally after 2 weeks, and a total of 2 degrees at the completion of treatment. This is compared to a mean of 4.9 degrees at 2 weeks, and 5.6 degrees at final follow-up, seen with the rigid casts. The loss of radial height and inclination, however, was minimal, and fairly consistent, for both cast types. This is despite a mean cast index of 0.83 and 0.86 for the two groups, which are above the CI previous studies have deemed acceptable for distal forearm fractures (although it is acknowledged that this may not increase the likelihood of redisplacement) [11, 12]. These results suggest that the soft-combi cast may be better at maintaining fracture position, although the differences seen were not statistically significant within our study sample. We can, however, at least conclude, that the new soft-combi casts are no worse at preventing fracture displacement than their previous rigid counterparts.
In addition to the radiological outcomes for the soft-combi casts, anecdotally our plaster technicians are reporting reduced rates of patient reattendance for complications. With non-severe skin and cast problems normally affecting around a quarter of fibreglass and hybrid casts, new materials or techniques are needed to prevent re-attendances to hospital . So, with patients experiencing fewer cast complications, and having the ability to safely remove them at home, the soft-combi casts are an ideal cast to use for reducing unnecessary hospital attendances in the current climate. As such, we have shared our casting technique for the soft-combi cast below in figure i.
The small size of this study may mean that it does not have enough power to detect statistically significant differences between the two groups.
Only radiological outcomes, and not functional outcomes, were looked at in this study.
Cast complications are not always recorded in the notes and so we could not collect any meaningful data regarding this.
37.5% of the participants never had radiographs out of the cast which affects the mean parameters at final follow-up reported in our results.
Twice as many participants underwent operative fixation in the soft-combi casts, suggesting a more unstable set of DRFs which may affect any comparisons made between the groups.