current care guidelines in practice
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Current care guidelines in practice
Piia Vuorela
MD, PhD, BSc
Current Care guideline editor
Conflicts of interest
• Employer: Finnish Medical Society Duodecim
• Presentations: community / goverment based hospitals,
non-profit organisations
• G-I-N Nordic Chair
• Asssociate professor at University of Helsinki, Finland
• Private practitioner, Diacor Terveyspalvelut Oy
• Student at the Helsinki School of Economics, Aalto
University, Finland
Content
A. Two examples of clinical questions, evidence &
recommendations
- Wrist fracture
B. How to find more evidence &
recommendations?
- EBMG
Part A
Two examples of clinical questions,
evidence & recommendations
Example:
Wrist fractures (distal radius)
Wrist fractures (distal radius)
• The most common fracture type of the arm.
• Murtuma syntyy tavallisesti ojennetun yläraajan
varaan kaatumisen seurauksena.
• Incidence grows with age
– Teenaged boys
– Postmenopausal women
• Diagnosis: typical anamnesis (falling on straight
arm), clinical examination, x-ray
Wrist fractures (distal radius)
• Conservative treatment may be given at primary
care
– Cast for 4-5 weeks, X-ray at 1, 2 and 5 weeks
• Surgical treatment for working aged in case
– closed repositioning is not succesful
– position does not hold in cast in x-ray at 1-2 wk
– or fraction has features that are not suitable for
conservative treatment
• Recovery takes 6-12 months
Clinical question:
In those > 65 years olds, is it better to
choose operative or conservative treatment
for nonstable, extra-articular distal radius
fractures?
> 65 years olds,
surgery or conservative treatment?
Study 1
• Austria, n=73, age >65 yr
• RCT (randomised controlled trial)
• Volar locking plate (n=36)
– Cast for 10 days + removable support 7 days
• Closed reduction and a cast, neutral position
(n=37)
– Cast for 5 weeks
Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trail comparing
nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in
patients sixty-five years of age and older. J Bone Joint Surg Am 2011;93:2146-53; PMID: 22159849*
> 65 years olds,
surgery or conservative treatment?
Study 1, results at 1 year follow-up
• No difference: the range of motion, the level of
pain, PRWE (Patient-Related Wrist Evaluation)
or DASH (Disabilities of the Arm, Shoulder and
Hand) scores
• Difference: operative group had better grip
strength and radiological outcome but also more
complications
Study quality: high Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trail comparing
nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in
patients sixty-five years of age and older. J Bone Joint Surg Am 2011;93:2146-53; PMID: 22159849*
> 65 years olds,
surgery or conservative treatment?
Study 2, Azzopardi et al. 2011
• Scotland (UK), n= 57, lottery by throwing a coin
• Aged mean 71 yr, range 60-88 years
• Surgery, percutaneous pinning + cast (n=30)
• Cast alone (n=27)
Azzopardi T, Ehrendorfer S, Coulton T, Abela M. Unstable extra-articular fractures of the distal
radius: a prospective, randomised study of immobilisation in a cast versus supplementary
percutaneous pinning. J Bone Joint Surg Br 2005;87:837-40; PMID: 15911669*
> 65 years olds,
surgery or conservative treatment?
Study 2, Azzopardi et al. 2011, results at 1 year
• No difference: functional outcome in terms of
pain, range of movement, grip strength, activities
of daily living and the SF-36 score except
• Difference: radiological paremeters were better
in surgical group
Study quality: moderate (due to suboptimal
randomization)
Azzopardi T, Ehrendorfer S, Coulton T, Abela M. Unstable extra-articular fractures of the distal
radius: a prospective, randomised study of immobilisation in a cast versus supplementary
percutaneous pinning. J Bone Joint Surg Br 2005;87:837-40; PMID: 15911669*
Recommendation from working group:
With > 65-year old patients it is probably
preferable to choose conservative rather
than surgical treatment
• Level of evidence: B
• Argument: Surgery results in better anatomical
outcome, but there is no or only little difference
in functional outcome. Surgery also causes more
complications.
– Possible exceptions: active ones with great demands
on arm function
Clinical question:
Neutral flexion-extension or dorsiflexion in
cast immobilization following distal radius
facture?
Neutral flexion-extension vs. dorsiflexion.
Research data
5 studies
• Switzerland, N=50, follow-up 2-7 yr
• USA, n=156, age mean 49, follow-up 15 wk
• Sweden, N=38, age mean 65 yr, follow-up 4-5
wk
• Scotland, N=41, age=?, follow-up 4 wk
• Cochrane review, included 37 studies with a
total of 4215 patients
Neutral flexion-extension vs. dorsiflexion.
Results
• Switzerland: Neutral position resulted in more
functional problems
– Study quality: weak
– Method of randomization was not stated, all results
were not fully reported
• USA: Function depended on initial fracture type,
not cast position
– Study quality: weak
– 1/3 of patients were lost to follow-up, randomization
method was weak, reporting of results was not clear
Neutral flexion-extension vs. dorsiflexion.
Results
• Sweden: evaluated position, not function
– Stude quality: weak
– Randomization method unclear, follow-up time was
short, only radiological results were given
• Scotland: evaluated position, not function
– Study quality: weak
– Data on patient population was limited, follow-up time
was short
• Cochrane review: did not find difference, studies
were too heterogenous
Recommendation from working group:
With cast treatment, it might be of benefit to
use a functional position (metacarpal bones
0-20 degrees to flexion from radius)
• Level of evidence: C
• Comment: There appears to be no major
difference between 0-20 degrees. Extreme
positions are not recommended, as they might
cause problems in mobilization.
Part 2
How to find more evidence and
recommendations?
Example from EBMG
Thank you for your attention!
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