ORIGINAL ARTICLE

Regional Anesthesia Improves Outcome After Distal

Radius Fracture Fixation Over General Anesthesia
Kenneth A. Egol, MD,* Michael G. Soojian, MD,† Michael Walsh, PhD,‡ Jonathan Katz, MD,§
Andrew D. Rosenberg, MD,* and Nader Paksima, DO, MPH*

Level of Evidence: Therapeutic Level III. See Instructions for

Objective: To compare the efficacy of anesthetic type on clinical Authors for a complete description of levels of evidence.
outcomes after operative treatment of distal radius fractures.
(J Orthop Trauma 2012;26:545–549)
Design: Retrospective review of prospectively collected data.
Setting: Academic medical center. INTRODUCTION
Patients: One hundred eighty-seven patients with a distal radius Anatomic reduction with stable fixation is the preferred
fracture (OTA type 23) were identified within a registry of 600 treatment for displaced unstable fractures of the distal radius.1–3
patients. Historically, unstable fractures of the distal radius that failed
closed management were treated with percutaneous pinning
Intervention: Patients with operative distal radius fractures and/or external fixation.1,4 Open reduction with internal
underwent open reduction and internal fixation with a volarly applied fixation of the distal radius is gaining popularity, particularly
plate and screws under regional or general anesthesia. for the majority of displaced injuries.1,5
Main Outcome Measurements: Clinical, radiographic, and Many factors have been identified in recovery after
patient-based functional outcomes were recorded at routine post-
fracture of the distal radius. These include whether the fracture
operative intervals. Complications were recorded.
is intra- or extra-articular, fracture characteristics, the age of
the patient, quality of reduction, and associated soft tissue
Results: One hundred eighty-seven patients met inclusion criteria injuries. Theoretically, reduced postoperative pain levels would
and had a minimum of 1-year follow-up. There were no differences allow patients to participate more actively in their rehabilita-
between the groups with regard to patient demographics or fracture tion and thus potentially attain a quicker and greater recovery
types treated. At both 3 and 6 months post surgery, pain was compared with those unable to participate secondary to higher
diminished among those patients who received a regional block. levels of pain. Early pain-free therapy has several potential
Wrist and finger range of motion for patients who received regional benefits in the treatment of joint fractures. Early motion has
versus general anesthesia was improved at all follow-up points. been shown to promote healing of full-thickness articular
Patients who received regional anesthesia also had higher functional cartilage defects in animal models.6 Dias et al7 examined the
scores as measured by the Disabilities of the Arm, Shoulder and Hand clinical effect of early mobilization of distal radius fractures
at 3 months (P = 0.04) and 6 months (P = 0.02). treated nonoperatively and noted rapid recovery of motion and
strength and reduced swelling in the wrist and hand. Early
Conclusion: Patients who are candidates should be offered regional therapy protocols for these injuries are further supported by
anesthesia when undergoing repair of a displaced distal radius Gruber et al8 who reported that surgical correction of the
fracture. anatomy of the distal radius, followed by rehabilitation, are
Key Words: distal radius, fracture, regional anesthesia, block, both critical elements in achieving good functional results.
outcome Other authors have failed to show a relationship between early
therapy protocols and improved wrist range of motion (ROM)
at 3 and 6 months.9 This suggests that outcome after distal
radius fracture is multifactorial.
Accepted for publication September 20, 2011. On initial presentation, most patients who have
From the *NYU Hospital for Joint Diseases; †Norwalk Hospital, sustained a displaced fracture of the distal radius are treated
Conn; †SUNY Downstate Medical School; and §Beth Israel Medical with closed reduction and immobilization. A large meta-
Center, New York, NY.
The authors declare no conflict of interest.
analysis examining the use of different types of anesthesia
No benefits in any form have been received or will be received from (including hematoma block, Bier block, regional block,
a commercial party related directly or indirectly to the subject of this article. conscious sedation, and general anesthesia) in the treatment
Dr. K. A. Egol as a departmental administrator receives funding support of distal radius fractures in the emergency room setting failed
from Stryker for residency enhancement and education. He holds stock in to find evidence to support the use of any single method over
Johnson and Johnson. Dr N. Paksima is a paid consultant for Stryker Corp.
Reprints: Kenneth A. Egol, MD, 301 East, 17th Street, New York, NY 10003 another.10 A separate study suggested that Bier block was
(e-mail: [email protected]). superior in terms of efficiency and economic burden.11
Copyright Ó 2012 by Lippincott Williams & Wilkins However, there has not been any published literature that

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Egol et al J Orthop Trauma  Volume 26, Number 9, September 2012

has studied the effect of different types of anesthesia on the In this report, all operative procedures were performed in
outcome of operatively treated distal radius fractures. Regional a similar manner. Fractures were exposed via an anterior Henry
anesthesia has several potential benefits with regard to upper approach and were fixed with 1 of 2 types of volar locking
extremity surgery. These include pain relief after the surgical plates (Hand Innovations, Miami, FL, or Stryker, Mahwah, NJ).
intervention and potential for sympathetic blockade, which All patients received either general anesthesia or brachial plexus
may be protective against the development of complex (infraclavicular) block before their operation.
regional pain syndrome. Our null hypothesis was that All blocks were performed using the infraclavicular
anesthetic type would have no effect on clinical and patient- nerve block technique, which is the regional anesthetic
reported functional outcomes. technique used at our institution for orthopaedic surgical
The purpose of this study was to examine both clinical procedures performed distal to the midshaft of the humerus.14,15
and functional results after distal radius fracture surgery in 2 The infraclavicular block is preferred for these procedures
similar cohorts of patients who differed only in the type of because at the infraclavicular level, all the nerves supplying
anesthesia they received at the time of surgery. motor and sensory innervation to the upper extremity course
together. In contrast, if an axillary block is performed,
a separate injection into the coracobrachialis muscle is required
to anesthetize the musculocutaneous nerve.
MATERIALS AND METHODS Immediately post surgery, patients were placed in
This was a retrospective review of a prospectively a plaster volar wrist splint with the fingers free at the level
collected database of patients treated for distal radius fractures of the metacarpal joints. This splint was removed after 1 week
at our university hospital system. All patients presented to at which time patients were fitted with a removable splint and
either the emergency department or outpatient clinic with enrolled into a physical/occupational therapy program under
a distal radius fracture. Those patients who signed informed the supervision of a therapist. The standard protocol consisted
consent were enrolled into an institutional review board– of early wrist, finger, and forearm ROM supplemented by
approved database. All patients were examined by an a home exercise program.
orthopaedic surgeon, and radiographs of the affected and All patients were seen at standard follow-up intervals of
nonaffected wrist were obtained to assess for preinjury 1, 6, 12, 24, and 52 weeks. At each visit, ROM of the wrist and
anatomic parameters such as ulnar variance. These parameters the digits were measured with a handheld goniometer. Pain
were then used to assess fracture reduction adequacy at was reported on a visual analog scale from 1 to 10. Grip
surgery. All fractures were classified according to the system strength was measured with a torque dynamometer with the
of the Orthopaedic Trauma Association.12 injured hand compared with the uninjured side. Complications
All patients were examined, and baseline functional and at any point were recorded. Radiographs of the operated wrist
demographic data were obtained. Patients with nondisplaced were obtained and reviewed for healing and maintenance of
fractures were splinted and discharged. Those with displaced reduction.
fractures were closed reduced and splinted. Patients who Two subjective functional outcome questionnaires were
achieved and maintained an acceptable reduction were treated also used: the Short Form 36 Version 2 and the Disabilities of
to healing in a cast. Patients were treated surgically by 1 the Arm, Shoulder and Hand (DASH) surveys.16,17 The DASH
of 4 fellowship-trained orthopaedic surgeons. Surgery was and Short Form 36 Version 2 have been carefully designed and
indicated immediately in patients with an open fracture or validated and include detailed administration and scoring
those with an inherently unstable fracture pattern (generally systems.18
defined by at least 3 of the following criteria as discussed by Over a 5-year period, 600 distal radius fractures were
Lafontaine et al13: initial dorsal angulation . 20 degrees, presented to our institution and were enrolled in the database.
initial shortening . 10 mm, .50% dorsal comminution, an Exclusion criteria for this study included nonoperative
intra-articular fracture, or age . 60 years with an associated treatment, operative treatment other than volar plate fixation,
ulnar fracture), a shear fracture, or a fracture–dislocation of the use of combined block and general anesthesia, failure to
wrist. Other patients who initially had closed reduction with an complete all follow-up visits, and incomplete data.
adequate reduction based on a set of agreed-upon criteria Continuous t tests and categorical Fisher exact tests were
including less than 10 degrees of residual dorsal angulation used to perform the statistical analysis of data collected at the
(from neutral), less than 2 mm difference in ulnar variance 3-, 6-, and 12-month follow-up intervals. Patients’ baseline
compared with the contralateral side, 1 mm or less articular pain and functional status and ROM and grip strength
step-off, no dorsal or volar subluxation of the distal radioulnar (uninjured side) were controlled for in the statistical analysis.
joint on the true lateral radiograph, and no widening of the An analysis of variance was performed to assess the effect of
distal radioulnar joint on the posteroanterior (PA) radiograph surgeon and anesthetic type on the various outcome measures.
were followed as outpatients. Patients who sustained a loss of
reduction at any outpatient follow-up visit were indicated for
surgical repair, and a discussion was held between patient and RESULTS
surgeon to establish a treatment plan. To eliminate confound- Two hundred sixteen patients received a volar locked
ing variables related to fixation type and soft tissue conditions, plate for fixation of their fracture. One hundred eighty-seven
we excluded all fracture fixation techniques other than volar patients (86%) met all eligibility requirements for the study
locked plating and all fractures with associated open wounds. and form the basis of this report. One hundred twenty-two

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J Orthop Trauma  Volume 26, Number 9, September 2012 Regional Anesthesia Versus General Anesthesia

patients (65%) received general anesthesia and 65 (35%)

TABLE 2. Pain, ROM, DASH, and Radiographic Outcomes at
received a regional block for their operative procedure in
3 Months by Anesthesia Type
a nonrandomized manner. There was a greater proportion of
Outcomes General Regional P
women in the block group (72%) compared with the general
group (55%). Furthermore, there was a difference in body Pain (SD), mm 2.5 (2.3) 1.4 (1.9) 0.001
mass index (BMI) between the groups. The general anesthesia Extension (SD), degrees 45.6 (16.8) 50.5 (19.6) 0.09
group had a BMI of 26.8 compared with the block group’s Flexion (SD), degrees 40.0 (14.5) 48.5 (16.8) 0.0006
BMI of 24.9 (P = 0.008). Although statistically significant, this Supination (SD), degrees 64.4 (24.6) 75.5 (15.0) 0.002
difference was not felt to be clinically significant, as both are Pronation (SD), degrees 76.7 (12.9) 80.5 (14.2) 0.08
close to 25. More importantly, there was no difference in the Ulnar deviation (SD), degrees 23.0 (11.2) 26.9 (10.2) 0.04
American Society of Anesthesiologists’ classification between Radial deviation (SD), degrees 15.8 (14.4) 17.1 (9.4) 0.55
the groups. There was no difference in the distribution of Grip strength (SD), lbs 31.1 (33.2) 33.1 (22.8) 0.72
fracture patterns between the 2 groups, and thus, the severity of Index finger TAM (SD), degrees 232.3 (47.9) 251.4 (28.5) 0.005
fracture was felt to be the same between the 2 groups (Table 1). Middle finger TAM (SD), degrees 236.1 (44.9) 252.0 (28.2) 0.01
At 3 months post surgery (Table 2), patients who Ring finger TAM (SD), degrees 235.4 (47.7) 252.9 (28.0) 0.01
received regional block showed significant improvement in Little finger TAM (SD), degrees 235.0 (43.4) 251.4 (29.7) 0.01
reported pain (P = 0.001), as measured by the visual analog Thumb TAM (SD), degrees 146.7 (41.6) 151.8 (34.0) 0.43
scale, and functional scores, as measured by the DASH Index finger DPC (SD), cm 0.94 (1.8) 0.16 (0.58) 0.002
(P = 0.04). In addition, this group also experienced significant Middle finger DPC (SD), cm 0.87 (1.9) 0.16 (0.58) 0.005
improvement in palmar flexion, pronation, supination, and Ring finger DPC (SD), cm 0.90 (1.9) 0.13 (0.49) 0.003
ulnar deviation compared with those who received general Little finger DPC (SD), cm 0.79 (1.6) 0.15 (0.51) 0.004
anesthesia. Finally, finger ROM, as measured by total active DASH (SD) 26.3 (27.6) 18.4 (19.6) 0.04
motion and finger to palm distance, was significantly better in DPC, distal palmar crease; TAM, total active motion.
all digits except the thumb in patients receiving regional
anesthesia.
At 6 months post surgery (Table 3), patients who
received regional block continued to show significant impro- Moreover, when the association was statistically adjusted for
vement in reported pain (P = 0.004) and functional scores surgeon, the results remained statistically significant for all
(P = 0.02), as measured by the DASH, compared with those outcomes except for finger ROM. The change in the association
who received general anesthesia. Improved wrist ROM was for finger ROM was not substantive but only statistical. The
seen with extension, palmar flexion, supination, and radial magnitude of the difference in finger ROM across anesthesia
deviation. Finally, finger ROM, as measured by total active types remained unchanged, even though the results were no
motion and finger to palm distance, was significantly better longer statistically significant. The lack of significance for finger
in all digits except the thumb in patients receiving regional ROM when adjusted for surgeon was due to a lack of statistical
anesthesia. power when adjusting for surgeons, which essentially stratifies
Finally at 12 months (Table 4), pain scores and DASH
scores were similar and the majority of wrist ROM normalized.
At this interval, wrist palmar and dorsal flexion maintained TABLE 3. Pain, ROM, DASH, and Radiographic Outcomes at
a significant improvement for those who received regional 6 Months by Anesthesia Type
anesthesia compared with those who received general Outcomes General Regional P
anesthesia. Finger motion was better in those who received Pain (SD), mm 2.4 (2.3) 1.3 (2.0) 0.004
regional anesthesia as well.
Extension (SD), degrees 50.4 (14.8) 56.9 (19.3) 0.02
The analysis of variance examined the association
Flexion (SD), degrees 46.8 (14.3) 52.4 (17.7) 0.04
between anesthesia type and all functional outcomes by each Supination (SD), degrees 73.9 (18.0) 78.5 (11.7) 0.10
surgeon and found no substantive change in the relationship. Pronation (SD), degrees 78.8 (13.0) 82.7 (7.2) 0.04
Ulnar deviation (SD), degrees 25.7 (10.3) 28.5 (8.5) 0.11
Radial deviation (SD), degrees 15.5 (6.7) 19.6 (9.3) 0.004
TABLE 1. Patient Demographic Characteristics by Grip strength (SD), lbs 41.6 (31.5) 46.2 (22.5) 0.39
Anesthesia Status Index finger TAM (SD), degrees 247.9 (26.6) 258.5 (7.9) 0.005
Patient Characteristic General (n = 122) Regional (n = 65) P Middle finger TAM (SD), degrees 249.9 (22.6) 258.5 (7.9) 0.008
Age (SD), y 53.5 (15.7) 55.3 (15.6) 0.50 Ring finger TAM (SD), degrees 248.3 (30.8) 258.5 (7.9) 0.02
BMI (SD), kg/m2 26.8 (4.4) 24.9 (3.7) 0.008 Little finger TAM (SD), degrees 247.3 (33.4) 258.5 (7.9) 0.02
Female sex, % 67 (55) 47 (72) 0.04 Thumb TAM (SD), degrees 156.2 (39.0) 163.1 (27.2) 0.26
ASA score (SD) 1.8 (0.61) 1.7 (0.61) 0.10 Index finger DPC (SD), cm 2.3 (1.8) 3.1 (2.0) 0.83
OTA classification, % Middle finger DPC (SD), cm 0.35 (0.9) 0.05 (0.2) 0.02
A 42 (34) 19 (29) 0.71 Ring finger DPC (SD), cm 0.37 (1.0) 0.05 (0.2) 0.02
B 15 (12) 10 (15) 0.71 Little finger DPC (SD), cm 0.38 (1.1) 0.05 (0.2) 0.02
C 56 (46) 26 (40) 0.71 DASH (SD) 17.8 (20.7) 10.2 (18.2) 0.02

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Egol et al J Orthop Trauma  Volume 26, Number 9, September 2012

distal radius fractures and type of anesthetic technique. We

TABLE 4. Pain, ROM, DASH, and Radiographic Outcomes at
found that at both 3 and 6 month postoperative followup,
12 Months by Anesthesia Type
patients who underwent regional anesthesia had significantly
Outcomes General Regional P
less pain and better functional scores as measured by the
Pain (SD), mm 2.0 (2.3) 1.5 (2.2) 0.18 DASH. In addition, wrist ROM was significantly improved in
Extension (SD), degrees 52.8 (13.6) 58.6 (22.1) 0.03 those patients who received regional anesthesia. We recognize
Flexion (SD), degrees 49.8 (12.9) 56.0 (19.1) 0.01 that these improvements, although statistically significant, may
Supination (SD), degrees 80.2 (12.4) 79.3 (10.9) 0.64 not be clinically significant.
Pronation (SD), degrees 83.2 (5.9) 83.7 (5.2) 0.60 One possible explanation for the improved outcomes in
Ulnar deviation (SD), degrees 29.1 (9.0) 29.6 (9.2) 0.79 patients receiving regional anesthesia is concomitant blockade
Radial deviation (SD), degrees 20.6 (12.5) 22.5 (9.6) 0.33 of the sympathetic nervous system at the time of surgery. Such
Grip strength, lbs 54.9 (42.0) 64.3 (47.3) 0.22 sympathetic blockade may result in a lower rate of complex
Index finger TAM (SD), degrees 255.4 (17.2) 260.0 (,0.001) 0.04 regional pain syndrome or at the very least act as an early
Middle finger TAM (SD), degrees 257.1 (12.9) 259.6 (2.6) 0.15 intervention to interrupt the course of a developing pain
Ring finger TAM (SD), degrees 257.0 (12.4) 259.6 (2.6) 0.12 syndrome. A second explanation is that successful brachial
Little finger TAM (SD), degrees 255.0 (19.5) 260.0 (,0.001) 0.06 plexus blockade provides complete paralysis of the forearm
Thumb TAM (SD), degrees 157.6 (30.3) 164.7 (19.5) 0.11 musculature, which may obviate the need for extensive
Index finger DPC (SD), cm 0.19 (0.6) 0.46 (0.4) 0.16 dissection and stripping of fracture fragments to obtain
Middle finger DPC (SD), cm 0.16 (0.7) 0.01 (0.04) 0.08 satisfactory fracture reduction. A third explanation may be that
Ring finger DPC (SD), cm 0.18 (0.7) 0.01 (0.04) 0.05 the regional block prevents afferent pain signals from reaching
Little finger DPC (SD), cm 0.12 (0.5) 0 (,0.001) 0.06 the central nervous system, thus lessening neurogenic
DASH (SD) 12.0 (18.0) 11.0 (20.5) 0.72 inflammation and the central windup that occurs with injury
DPC, distal palmar crease; TAM, total active motion. and surgery. Simply put, the nerve block decreases the number
of pain impulses reaching the brain, lessens the amount of pain
the patient experiences, provides for better analgesia, and
the sample by 3 additional categories, thus reducing the power ultimately leads to better long-term outcome.
for any given test within the surgeon. When comparing general with regional anesthesia, there
There was no significant difference in grip strength in are theoretical advantages to each technique. However, before
patients who underwent regional block versus those who this report, these advantages had not been borne out in
underwent general anesthesia at any point during follow-up. scientific literature. Other investigators have looked at the
Radiographically, there was only a 3-degree improvement in volar effects of anesthetic type in fracture care. Koval et al19 reported
tilt in those who received a regional block at 3 months compared no difference in functional outcome in hip fracture patients
with those who received general anesthesia (0.02) (Table 5). All receiving either general or regional anesthesia. The theoretical
fractures healed, and there were no differences between the lower incidence of deep vein thrombosis associated with
groups with respect to postoperative complications. There were a regional anesthetic did not translate into a difference in
no complications related to anesthetic choice and no complica- mortality. Koval et al20 repeated these findings in a second
tions related specifically to the use of regional anesthesia. study, which also reported no differences in complication or
mortality rate in a similar group of patients undergoing surgery
with different types of anesthesia. As shown by our study, the
DISCUSSION theoretical advantages of regional block appear to have clinical
This is the first study, to our knowledge, to investigate relevance in upper extremity surgery.
the relationship between outcome after operative fixation of This study does have some limitations. Patients were not
randomized as to what type of anesthesia they would receive.
The type of anesthesia selected was based upon both the
TABLE 5. Radiographic Results at Each Follow-up preference of the attending anesthesiologist and the individual
Parameter General Regional patient. There may have been some selection bias with this
approach; however, we feel the fact that there was no
3 mo
difference between the 2 groups with respect to American
Tilt, degrees 3.4 6.4 (P = 0.02)
Society of Anesthesiologists’ classification lessens the effect
Length, mm 10.2 12.5
of selection bias. Furthermore, although there was a statistical
Inclination, degrees 20.6 20.8
difference between the 2 groups with regard to BMI, both were
6 mo
within 1 unit of the ‘‘ideal’’ BMI and neither group fell within
Tilt, degrees 5.8 7.4
the obese category, thus not factoring into the complexity of
Length, mm 10.3 10.7
anesthetic choice. Four different attending orthopaedic
Inclination, degrees 20.9 20.7
surgeons treated patients in this study: 3 fellowship-trained
12 mo
orthopaedic traumatologists and 1 fellowship-trained ortho-
Tilt, degrees 6.6 6.5
paedic hand surgeon. However, all 4 surgeons are similarly
Length, mm 10.2 10.8
experienced in the treatment of distal radius fractures. When
Inclination, degrees 19.7 20.6
we tried to break down the results controlling for each surgeon

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and type of anesthesia, all the results were held. However, the 4. Dicpinigaitis P, Wolinsky P, Hiebert R, et al. Can external fixation
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