DISTAL RADIAL FRACTURES TREATED WITH VOLAR LOCKING PLATES: WHO DOES THE OPERATING AND DOES IT AFFECT THE OUTCOME?

Abstract

In recent years volar locking plates (VLP) have revolutionised the treatment of more complex distal radial fractures, but doubt still exists as to whether this is an operation for all suitably qualified orthopaedic surgeons, in particular experienced trainees, or remains the domain of consultants or better still upper limb surgeons.

Aims: To assess changes in a Level 1 Trauma Unit’s practice over a 5 year period and to compare the clinical outcomes of patients operated upon by experienced orthopaedic trainees and consultant surgeons.

Methods: Two prospective cohort studies were undertaken using (a) the Synthes VLP (January 2003–January 2005), and (b) the Periloc (Smith & Nephew) VLP (January 2007–February 2008). All patients were assessed at 6 months following surgery for range of movement, grip and pinch strength, and subjective levels of pain and function using Visual Numerical Scales. 65 and 36 patients were available for 6 month review in the Synthes and Periloc groups respectively. Operations undertaken by, or assisted directly by, the consultant were considered to be ‘consultant’ procedures, with all others being undertaken by trainees.

Results: No significant patient demographical differences, or differences in fracture type were identified for the two cohorts. Clinical outcomes for the two cohorts were likewise similar at 6 months although there was a suggestion that pain, pinch and grip strength were marginally better in the Periloc group although this was not statistically significant. In the Synthes VLP cohort, 32 operations were undertaken by consultants and 33 by trainees, compared with 9 and 27 operations being undertaken by consultants and trainees respectively in the Periloc group. Although there was a tendency for the more difficult fractures to be operated upon by consultants, especially in the earlier cohort, trainees were left to deal with many of the more complex injuries in the Periloc cohort. The incidence of minor complications requiring further surgery (all relating to prominent metalwork) was also low in both groups (7 in the first group and 2 in the second group) with all but one of the index operations having been performed by a trainee.

Discussion: Despite the complexity of many distal radial fractures, VLP treatment of distal radial fractures has become a common place procedure that, in our unit, are frequently left to experienced trainees to operate upon without supervision. Our prospectively cohort studies clearly show that, over time, experienced trainees obtain clinical results that are similar to their consultant colleagues with respect to clinical outcome and incidence of complications.

Conclusions: As our unit’s experience of treating patients with distal radial fractures with VLPs has grown, experienced trainees appear to obtain clinical results that are similar to consultants.