While anatomic reduction is ideal, some patients will tolerate residual deformity. Patients who are unlikely to undergo surgical intervention will require near anatomic reduction. When orthopedics is involved, I try to get a feel if the intention is ultimately to operate or not. Before reducing any fracture, anticipate the ultimate treatment goal. Patients with multiple co-morbidities, whether old or young, are less likely to undergo surgical intervention, so achieving near anatomic reductions is more important because reduction is definitive treatment. That said, some older patients, especially those dependent on a cane or walker, may require aggressive interventions to maintain weight bearing through the wrist. Older patients with few functional demands can tolerate greater deformity. Profession or trade and hand dominance affect tolerance to anything other than anatomic reduction. The most common determinants of care are age, hand dominance, profession, co-morbidities, and activity level. Similar or identical fracture patterns may warrant different treatment in different patients. Other complex fractures warranting orthopedics consultation include any pattern of carpal instability manifest by obvious widening of the scaphoid-lunate or luno-triquetral space, or obvious displacement of the lunate suggesting lunate or peri-lunate dislocation. Obviously any open fracture requires orthopedic consultation as well as any fractures that potentially involve instability of the carpal bones such as dorsal or volar Barton’s fractures in which the carpal bones displace with the fracture fragment. Highly comminuted intra-articular fractures are unstable in anyone’s hands and will require surgery. When distal radius fractures are not simple fracture patterns, reduction may best be performed in the hands of an orthopedist or hand surgeon. Document that you have involved the orthopedist and document concrete physical exam findings which may increase the urgency for reduction such as obvious deformity, skin tenting, change in capillary refill, impending conversion to open fracture, significant swelling, numbness and tingling, or decreased motor function.įractures requiring ED orthopedic consultation
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