current care guidelines in practice

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)


• 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


• 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,


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,


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,


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


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


– 1/3 of patients were lost to follow-up, randomization

method was weak, reporting of results was not clear


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


– 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!

current care guidelines in practice

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