1. PRESENTERSSUPERVISOR Mickey Macatha, Sharon Ocholla.Dr. James Obondi Maseno University school of medicineChief orthopedic surgeon MBChB VDr. Steve Okello

2.  Distal radial fractures are common in children, adolescents and the elderly (above 65 years).  Typically occur due to falls on an outstretched hand.  Proper management of distal radius fractures requires good anatomical and functional results  Management of extra-articular distal radius fractures involves closed reduction by cast application, closed reduction by percutaneous pinning or open reduction and internal fixation.  The treatment modality should be able to hold the corrected deformity in place and take care of predicted or proven instability at the fracture site and the associated joint.

3.  Contemporary practice has not established a preferred choice of management for extra articular distal radius fractures using evidence based medicine.  In our training facility at JOOTRH, we noted that some of the cases do not even reach the Medical officer at casualty as the patients are shunted to the radiology department and plaster technicians by nurses during triaging  For this reasons we felt compelled to look into CRPP as treatment modality and see if we could recommend it for our facilities.

4. Broad objective  To evaluate the evidence on outcomes of CRPP as a management modality for distal radius fractures. Specific objectives  To compare the outcomes of CRPP as a management modality versus other management methods  To evaluate the cost effectiveness of CRPP as a management modality  To determine the risks associated with CRPP as a management modality

5.  A total of 11 studies were reviewed  The study with the least number of subjects had 29 participants.  All studies reviewed were done and published later than the year 2000 to focus on current practices  Google scholar and PubMed platforms were the main engines used to search for published articles  Studies focused on adolescents and young adults

6.  Focus was directed at articles describing the use of CRPP as a treatment modality for distal radial fractures  Other treatment methods also evaluated for comparison include the use of below elbow cast, ORIF by volar plating and ORIF by intramedullary nailing.

7. ANATOMIC REDUCTION AND STABILITY  Most studies indicated that CRPP was found to offer better stability and reduced incidences of re-displacement as opposed to plaster of Paris cast application  For unstable fractures, CRPP was found to have less favorable outcomes in anatomic reduction as volar tilt and radial inclination were not as properly achieved as with ORIF in volar plating

8. INFECTION RATES  Pin tract infections were found to be as high as 30% in some studies where CRPP had been done in cohorts.  The rates of infection were however found to be reduced if the pins used were buried beneath the skin or use of high doses of prophylactic antibiotics used.

9. COST  ORIF with volar plating did not offer significant advantage over CRPP in simple fractures but were much more costly.  ORIF was however found to offer better anatomical and functional results in unstable fractures and would therefore supersede CRPP even with the associated high cost.

10. SURGEON BIAS  One of the more interesting articles cited that younger surgeons less than 40 years old preferred to use ORIF as opposed to closed reduction as their treatment modality  This study did not expound on why younger surgeons preferred ORIF but noted that the outcomes were as good as those of CRPP

11.  CRPP when done with appropriate technique allows for proper distal radius fractures management without injuring the neurovascular bundle in proximity. It also decreases the amount of soft tissue injury thus facilitating faster healing.

12.  CRPP is very effective and efficient when used in the management of simple distal radius fractures(AO Type A and Type B fractures) as it is less invasive compared to ORIF thus minimizing the risks of infection. It is also cost effective and has a similar functional outcome as ORIF.  However, for Type C fractures, ORIF remains the modality of choice and if CRPP is to be employed, it has to be used adjunctively e.g in percutaneous distal radius ulna pinning,percutaneous wires and plasters or with external fixators for stability in case of osteoporotic bone.

13.  It is our conclusion that CRPP, where available, should be the first line treatment for stable distal radial fractures  Prophylactic antibiotic therapy should be administered to reduce the incidence of pin tract infections when CRPP is done  For unstable fractures, ORIF by volar plating is more effective as a treatment modality than CRPP.

14.  Novel techniques such as pin in plaster technique, burying of pins under the skin and radius-ulnar pinning should be evaluated to determine if they offer better outcomes than standard CRPP.