Orthopedics

Feature Article Supplemental Data

Acute Carpal Tunnel Syndrome in Inpatients With Operative Distal Radius Fracture

Kalpit N. Shah, MD; Avi D. Goodman, MD; Wesley Durand, BSc; Alan H. Daniels, MD; Arnold-Peter C. Weiss, MD

Abstract

Acute carpal tunnel syndrome (CTS) may occur concomitantly with distal radius fracture (DRF) and is often managed with carpal tunnel release (CTR). Carpal tunnel syndrome may also develop postoperatively after DRF fixation. The authors sought to determine the rate of CTS with DRF, prophylactic CTR, and postoperative development of CTS. Furthermore, they also sought to identify predictors of these. The Nationwide Inpatient Sample database was queried (2002 to 2014) to identify adult inpatients undergoing surgical fixation of DRFs. They were segregated by the presence of CTS and further stratified by the timing of CTR in relation to DRF fixation. Those with a CTS diagnosis undergoing CTR on the same day as or prior to DRF fixation were classified as having CTS concomitantly. Patients undergoing CTR without a CTS diagnosis were considered prophylactically released. Carpal tunnel releases on any day after fracture fixation were considered complications. The authors identified 275,052 inpatients who had fixation of DRFs. Of these, 11,816 patients (4.3%) had CTS concomitantly. A total of 530 patients developed CTS after their DRF fixation (0.3%). Of those without CTS, 4420 patients (1.6%) underwent prophylactic CTR. Male sex, age younger than 50 years, and polytrauma status were associated with concomitant CTS and prophylactic CTR. Age younger than 50 years and polytrauma status were associated with postoperative development of CTS. The authors identified the rate of concomitant CTS, prophylactic CTR, and CTS developing postoperatively in inpatients undergoing DRF fixation. As early recognition and treatment optimizes outcomes after acute CTS, these data draw attention to the high rate of CTS and may be useful to surgeons treating patients with DRFs. [Orthopedics. 2019; 42(4):227–234.]

Abstract

Acute carpal tunnel syndrome (CTS) may occur concomitantly with distal radius fracture (DRF) and is often managed with carpal tunnel release (CTR). Carpal tunnel syndrome may also develop postoperatively after DRF fixation. The authors sought to determine the rate of CTS with DRF, prophylactic CTR, and postoperative development of CTS. Furthermore, they also sought to identify predictors of these. The Nationwide Inpatient Sample database was queried (2002 to 2014) to identify adult inpatients undergoing surgical fixation of DRFs. They were segregated by the presence of CTS and further stratified by the timing of CTR in relation to DRF fixation. Those with a CTS diagnosis undergoing CTR on the same day as or prior to DRF fixation were classified as having CTS concomitantly. Patients undergoing CTR without a CTS diagnosis were considered prophylactically released. Carpal tunnel releases on any day after fracture fixation were considered complications. The authors identified 275,052 inpatients who had fixation of DRFs. Of these, 11,816 patients (4.3%) had CTS concomitantly. A total of 530 patients developed CTS after their DRF fixation (0.3%). Of those without CTS, 4420 patients (1.6%) underwent prophylactic CTR. Male sex, age younger than 50 years, and polytrauma status were associated with concomitant CTS and prophylactic CTR. Age younger than 50 years and polytrauma status were associated with postoperative development of CTS. The authors identified the rate of concomitant CTS, prophylactic CTR, and CTS developing postoperatively in inpatients undergoing DRF fixation. As early recognition and treatment optimizes outcomes after acute CTS, these data draw attention to the high rate of CTS and may be useful to surgeons treating patients with DRFs. [Orthopedics. 2019; 42(4):227–234.]

Acute carpal tunnel syndrome (CTS) is a known complication following a distal radius fracture (DRF) that may be managed with a timely carpal tunnel release (CTR).1–8 Carpal tunnel release may be performed as either treatment (if the symptoms are acute and worsening) or prophylaxis (in the setting of a high-energy mechanism, a concerning fracture pattern, or an obtunded patient).9 Carpal tunnel release may be done concurrently with open reduction and internal fixation of the DRF; however, CTS may also develop postoperatively and therefore require a subsequent release. Early recognition and management of acute CTS has been shown to be crucial for optimal outcomes.1,10

Lewis et al5 and Abbott11 first described acute median nerve injury in the setting of a DRF in 1922 and 1933, respectively. Lynch and Lipscomb6 further evaluated the occurrence of CTS in association with a Colles fracture and identified patients immobilized in the Cotton-Loder position (hand and wrist flexed) to maintain reduction as a risk factor for developing CTS. In 1984, McCarroll12 described an algorithm for treatment: for severe symptoms that do not improve with fracture reduction, operative exploration is justified. Dyer et al13 recently found the prevalence of acute CTS in patients with surgically treated DRFs to be 5.4% and fracture displacement of greater than 35% to be the only independent risk factor for the development of CTS in younger women. However, studies identifying risk factors for the development of CTS after a DRF are scarce.

The authors sought to determine the rate of CTS present concomitantly or following DRF surgery and also the rate at which CTR is performed as prophylaxis. Further, they sought to establish risk factors for these conditions.

Materials and Methods

Data Source

The Healthcare Cost and Utilization Project Nationwide/National Inpatient Sample (HCUP/NIS) is the largest publicly available all-payer database of inpatient care, and it is the most commonly used administrative database in clinical orthopedic research.14,15 It contains 7 to 8 million records per year of data, representing an approximately 20% sample of US inpatient discharges. Each record contains International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes and information regarding patient age, sex, hospital length of stay (LOS), and mortality; day on which each procedure occurred; charges; and hospital characteristics. Given the publicly available and de-identified nature of the NIS dataset, this study was exempt from institutional review board approval.

Patient Selection

Patient records from 2002 to 2014 were identified based on the presence of pre-specified ICD-9-CM diagnosis and procedure codes for DRF and fixation, respectively (Table A, available in the online version of this article). For all included patients, a primary DRF procedure was identified if multiple procedure codes were present. A liberal criterion was used to define a polytrauma patient: any other traumatic injury proximal to the wrist using ICD-9-CM codes (Table A). Pediatric patients (ie, younger than 18 years) and patients with missing data regarding timing of procedures were excluded from analysis.

Coding Scheme (ICD-9-CM)

Table A:

Coding Scheme (ICD-9-CM)

Dependent Variables

All DRF patients included in the analysis were stratified based on the presence of CTS diagnosis code (Table A). Figure 1 and Table 1 may help with understanding the following analysis. Patients in both groups (CTS and no CTS) were further stratified based on the presence and/or timing of the CTR code in relation to DRF fixation: no release, release prior, release on same day, or release after. Patients without a CTS diagnosis undergoing CTR on the same day as DRF fixation were considered to have been prophylactically released, whereas those undergoing CTR on a day after their DRF fixation were thought to have developed CTS postoperatively. Patients with a CTS diagnosis who did not have a release may represent those with CTS concomitant with their injury or those who had it develop postoperatively; however, in either scenario, the CTS resolved and did not require a CTR (possibly after closed reduction or nonoperative management such as icing and elevation). Data on when the diagnosis was assigned in relation to their injury were not available in the NIS database. Further, given the confounding possibilities that may describe this cohort, these patients were excluded from analysis. Patients with a diagnosis of CTS undergoing CTR on the day prior to or the same day as the DRF fixation were classified as having developed CTS concomitantly. Finally, patients with a CTS diagnosis undergoing CTR on a day after their DRF fixation were considered to have developed CTS postoperatively (Figure 1).

Flow diagram depicting the stratification of included patients and the interpretation of their carpal tunnel syndrome (CTS) based on timing of carpal tunnel release (CTR). Abbreviation: DR, distal radius.

Figure 1:

Flow diagram depicting the stratification of included patients and the interpretation of their carpal tunnel syndrome (CTS) based on timing of carpal tunnel release (CTR). Abbreviation: DR, distal radius.

Patients Included in the Analysis Separated by the Diagnosis of Carpal Tunnel Syndrome and Further Segregated by the Time and/or Presence of Carpal Tunnel Release

Table 1:

Patients Included in the Analysis Separated by the Diagnosis of Carpal Tunnel Syndrome and Further Segregated by the Time and/or Presence of Carpal Tunnel Release

Independent Variables

Patient age, sex, primary payer (Medicare, Medicaid, private, self-pay, no charge, or other), polytrauma status, DRF fixation technique, and CTS diagnosis status were considered potential risk factors during bivariate and multivariate analyses of patients with concomitant CTS, prophylactic CTR, and postoperative development of CTS. Twenty-nine Elixhauser comorbidity metrics were considered, as detailed in the HCUP/NIS documentation, as were hospital location/teaching status, ownership, and bed size; region; and treatment year.

Statistical Analyses

Statistical analysis was performed using SAS version 9.4 software (SAS Institute Inc, Cary, North Carolina). All analyses were weighted to produce national estimates. Descriptive statistics for dependent and independent variables were generated. Multiple logistic regression with forward variable selection was performed to assess independent risk factor effects, with a threshold of P<.1 for inclusion. These analyses were performed using the stepsvylog SAS macro created by Wang and Shin.16 Given limitations on options available in the stepsvylog macro, factors identified using this approach were subsequently placed into a separate model using the surveylogistic procedure. Risk factors with low numbers were excluded from consideration, as these variables tended to result in model overfitting. No significant collinearity between risk factors was noted, as assessed by variable tolerance in a generalized linear model. Statistical significance was defined as P<.05, a priori.

Results

Descriptive Statistics

A total of 343,842 patients met the inclusion criteria of having DRF diagnosis and operative procedure codes for fracture fixation. Pediatric patients (n=22,846) were excluded from the cohort, as were patients with missing data on the timing of the procedure (n=46,123). The resultant cohort of 275,052 patients were included in the analysis. Their distribution by age was as follows: 18 to 49 years (34.6%, n=94,862), 50 to 64 years (25.4%, n=69,625), 65 to 79 years (23.4%, n=64,086), and 80+ years (16.6%, n=45,377). Most patients were female (62.2%, n=169,766). Medicare (38.3%, n=104,988) and private (35.6%, n=97,641) were the most common types of insurance. Polytrauma (47.6%, n=130,984) was present in approximately half of the patients. The most common fixation technique was open reduction with internal fixation (74.0%, n=203,511) (Table 2).

Patient and Procedure Characteristics

Table 2:

Patient and Procedure Characteristics

Carpal Tunnel Syndrome and Release

A majority of the patients (n=262,705; 95.5%) who had surgical treatment of their DRFs did not develop CTS. A minority of these patients (n=12,347; 4.5%) developed CTS at some point during their inpatient stay. Most patients did not undergo CTR (n=257,966; 93.8%), whereas a minority underwent prophylactic release, defined as release on the same day as or prior to surgery for their DRF without having the diagnosis code of CTS (n=4549; 1.6%). Most patients with the CTS diagnosis underwent CTR on the same day as or prior to their fracture fixation, which the current authors identified as CTS concomitant to the DRF (n=11,115; 4.1%). Patients with a CTS diagnosis but no CTR (n=702; 0.3%) were excluded because it was not clear when they developed CTS (ie, concomitant to the DRF or postoperatively). A small proportion of patients (n=720; 0.3%) returned to the operating room for a CTR on a later day after DRF fixation, which the current authors labeled as CTS developing after DRF fixation (Table 1).

Variables Associated With Concomitant Carpal Tunnel Syndrome

On stepwise multiple logistic regression, the following variables were significantly associated with concomitant CTS: closed reduction with internal fixation technique (vs open reduction with internal fixation: odds ratio, 2.60, P<.0001; vs internal fixation without fracture reduction: odds ratio, 1.94, P=.0407; vs external fixation: odds ratio, 1.28, P=.0490); age 18 to 49 years (vs 50 to 64 years: odds ratio, 1.22, P=.0002; vs 65 to 79 years: odds ratio, 1.59, P<.0001; vs 80+ years: odds ratio, 2.17, P<.0001); private payer (vs other: odds ratio, 1.94, P=.0009); polytrauma (odds ratio, 0.51, P<.0001); male sex (odds ratio, 1.28, P<.0001); year (trend to higher odds ratio in recent years); neurological disorders (odds ratio, 0.56, P<.0001); fluid and electrolyte disorders (odds ratio, 0.78, P=.0023); weight loss (odds ratio, 0.45, P=.0071); private, non-profit hospital (vs government, non-federal: odds ratio, 1.35, P=.0013); and urban, teaching hospital (vs rural: odds ratio, 1.38, P=.0027) (Table 3).

Variables Associated With Concomitant Carpal Tunnel Syndrome on Multiple Logistic Regression

Table 3:

Variables Associated With Concomitant Carpal Tunnel Syndrome on Multiple Logistic Regression

Variables Associated With Prophylactic Carpal Tunnel Release

On stepwise multiple logistic regression, the following variables were independently associated with the occurrence of prophylactic CTR: age 18 to 49 years (vs 50 to 64 years: odds ratio, 1.19, P=.0341; vs 65 to 79 years: odds ratio, 2.10, P<.0001; vs 80+ years: odds ratio, 3.08, P<.0001); male sex (odds ratio, 1.18, P=.0428); Medicare (vs private: odds ratio, 1.32, P=.0251); no charge patients (vs private: odds ratio, 2.18, P=.0050); surgical technique (application of external fixation vs closed reduction with internal fixation: odds ratio, 2.50, P=.0004; internal fixation without reduction vs closed reduction with internal fixation: odds ratio, 3.61, P=.0069; open reduction with internal fixation vs closed reduction with internal fixation: odds ratio, 5.55, P<.0001); non-profit (vs for-profit: odds ratio, 1.49, P=.0150); and polytrauma (odds ratio, 1.47, P<.0001) (Table 4).

Variables Associated With Prophylactic Carpal Tunnel Release on Multiple Logistic Regression

Table 4:

Variables Associated With Prophylactic Carpal Tunnel Release on Multiple Logistic Regression

Risk Factors for Developing Carpal Tunnel Syndrome Postoperatively

The following variables were independently associated with developing CTR postoperatively on stepwise logistic regression: age 18 to 49 years (vs 50 to 64 years: odds ratio, 2.08, P=.0003; vs 65 to 79 years: odds ratio, 14.49, P<.0001; vs 80+ years: odds ratio, 23.26, P<.0001); uncomplicated diabetes (odds ratio, 0.29, P=.0311); peripheral vascular disorders (odds ratio, 3.51, P=.0157); large hospital bed size (vs small: odds ratio, 3.34, P=.0185); urban, teaching hospital (vs urban, non-teaching: odds ratio, 1.82, P=.0067); rural hospital (vs urban, non-teaching: odds ratio, 2.26, P=.0066); and polytrauma (odds ratio, 1.70, P=.0018) (Table 5).

Variables Associated With Postoperative Development of Carpal Tunnel Syndrome on Multiple Logistic Regression

Table 5:

Variables Associated With Postoperative Development of Carpal Tunnel Syndrome on Multiple Logistic Regression

Discussion

This study examined a large, nationally representative US inpatient database indicating the rate of CTS in patients undergoing surgical fixation for DRF. The rate of developing CTS in conjunction with a DRF that requires operative fixation was 4.3%; another 0.3% of patients developed CTS after their DRF fixation. Approximately 1.6% of patients had a CTR prophylactically either before or at the same time as their DRF surgery. The current authors identified a variety of factors that were significantly associated with the different types of CTS and CTR; however, male sex, young age, and polytrauma status seemed to be associated with concomitant CTS, prophylactic release, and postoperative CTS development.

The rate of developing CTS in the setting of a DRF has been described previously, but mostly in case reports or a retrospective analysis of a small cohort of patients. Mack et al7 reviewed the literature and found that the rate of CTS in the setting of a DRF was reported to be between 0.2% and 21.3%. Recently, Dyer et al13 reported a rate of CTS in patients with operative DRFs of 5.4%. They performed a retrospective study of the billing database at 2 trauma centers with patients who had surgical fixation of their DRFs. They pointed out that all patients with CTS in their study had a manipulative reduction performed in the emergency department and developed CTS after the reduction. The current authors reported a similar, but slightly lower rate of 4.1% for concomitant CTS with an operative DRF. Data on reduction are lacking in the NIS database used for this study. It is possible that some of the current patients did not have a reduction performed prior to their surgery, leading to the slightly lower rate of concomitant CTS. Additionally, only inpatients with operative DRFs were included, which may have led to biasing the included patients to higher-energy injuries or more complex fracture patterns. Further, this study also reported on patient data collected from across the United States, and the number of patients included was far greater than that of the study by Dyer et al,13 which discussed patients from only two medical centers in the northeast United States.

When evaluating patient variables to identify factors associated with concomitant CTS, the authors noted that patients with CTS were male and younger, who are more likely to have a higher mechanism of injury. Dyer et al13 also found that male patients younger than 48 years were more likely to develop CTS. The current authors found that polytrauma patients were less likely to have concomitant CTS diagnosed (odds ratio, 0.51). It is unclear why polytrauma status would render these patients less likely to be diagnosed with CTS. Perhaps the other injuries act as a distraction and hinder providers from recognizing CTS in all polytrauma patients. The other association noted by the authors was that patients with concomitant CTS underwent open treatment of their DRF (odds ratio, 2.60) far more often than closed treatment with internal fixation. Given that the patient will likely need to undergo a CTR for the CTS, it seems reasonable for the surgeon to address and treat the DRF under the same anesthesia event. This association may also be supported by the trend to treat DRFs with plate fixation during the past decade.17–19 Similarly, the current authors noted that the diagnosis of concomitant CTS has significantly increased during the past decade when compared with the rate in 2002. This could be attributed to increasing numbers of patients captured in the NIS database every year and more awareness of the diagnosis among health care providers. Finally, urban, teaching hospitals had a higher ratio of patients with simultaneous CTS, which may represent the fact that many higher acuity trauma centers are urban, teaching hospitals and may receive more high-energy, polytrauma patients than rural hospitals.

In the current study, the rate of prophylactic CTR, defined by patients who had CTR without the diagnosis of CTS on the day prior to or the same day as surgical fixation of their DRF, was 1.6%. Similar to concomitant CTS, younger (18 to 49 years), male, and polytrauma patients had significantly higher odds of undergoing prophylactic CTR. When compared with closed reduction with internal fixation, all surgical techniques were significantly associated with prophylactic release. Interestingly, not-for-profit hospitals were affiliated with a prophylactic release compared with for-profit hospitals. Training programs and academic centers often tend to be not-for-profit and have resident physicians, who may have a lower threshold for suggesting a prophylactic release. There are no reports in the literature discussing the rate of prophylactic CTR in the setting of operative DRFs. However, many authors do advocate for release in the setting of substantial displacement or comminution.1,13,20

The rate of postoperative CTS was 0.3%. Similar to other analyses reported above, the current study found a significant association between younger, polytrauma, male patients and the development of CTS postoperatively. Vascular disease was a risk factor for developing CTS postoperatively, as was a large, urban, teaching hospital. Patients with vascular disease may have a tenuous blood supply to the median nerve, which may be affected by DRFs. Carpal tunnel syndrome has been known to develop after DRF fixation. Jupiter et al21 reported that 3 of 49 (6%) patients developed CTS up to 51 months postoperatively. Satake et al22 reported a CTS rate of approximately 2.6% within the average follow-up of 27 weeks. However, the purpose of this study was simply to report the development of CTS immediately postoperatively, during the same hospitalization.

This study had several potential limitations. Although the authors used one of the largest patient databases, the HCUP/NIS, it has shortcomings. The database provides information on inpatient admissions only, excluding patients who are treated in the emergency department and discharged home. This may produce selection bias and could potentially explain the high percentage of patients classified as polytrauma (47.6%) in the current study. However, the authors used a liberal criterion to consider a patient polytrauma: any other traumatic injury proximal to the wrist. This database would miss the many patients treated in the United States for isolated DRF by typically being immobilized and sent home and having surgical fixation of their DRF on an elective, outpatient basis. Despite these shortcomings, the authors were able to gather a large cohort meeting their inclusion criteria (n=275,052). To counter the loss of patients who were discharged home, the authors also chose to only focus on patients who had surgical treatment of their DRF who may have had a higher chance of being admitted due to the severity of their injury, polytrauma status, or other socioeconomic factors. Additionally, the authors believed that patients at the highest risk of developing CTS were most likely to be admitted to the hospital, making the NIS an ideal database to evaluate CTS in the setting of a DRF. Although the NIS database provides high-quality data on a variety of different domains of patient care, it does not provide radiographic data or information regarding mechanism of injury, presence of CTS prior to the injury, or timing of the diagnoses in relation to the injury, which might identify variables that are clinically significant. The database also does not provide any information on the functional outcome of the patient. Finally, the accuracy of the data depends greatly on the accuracy of the diagnosis and procedure coding for all of the included patients, which has been previously validated for this database. This accuracy is crucial to the many assumptions made and conclusions drawn based on the presence or absence of various codes.

Conclusion

This study systematically examined patients with DRFs requiring operative management and identified the presence of CTS through the different phases of care (ie, the preoperative and postoperative period). The authors also identified patients who received a prophylactic CTR along with their DRF fixation. Given the nature of the database and the information collected, the authors were able to identify a variety of variables associated with each group of patients. Male sex, polytrauma, and younger age were all associated with concomitant CTS, prophylactic CTR, and postoperative development of CTS.

References

  1. Rhee PC, Dennison DG, Kakar S. Avoiding and treating perioperative complications of distal radius fractures. Hand Clin. 2012;28(2):185–198. doi:10.1016/j.hcl.2012.03.004 [CrossRef]
  2. Davis DI, Baratz M. Soft tissue complications of distal radius fractures. Hand Clin. 2010;26(2):229–235. doi:10.1016/j.hcl.2009.11.002 [CrossRef]
  3. Jhattu H, Klaassen S, Ying C, Hussain MA. Acute carpal tunnel syndrome in trauma. Eur J Plast Surg. 2012;35(9):639–646. doi:10.1007/s00238-012-0732-0 [CrossRef]
  4. Gelberman RH, Szabo RM, Mortensen WW. Carpal tunnel pressures and wrist position in patients with Colles' fractures. J Trauma. 1984;24(8):747–749. doi:10.1097/00005373-198408000-00010 [CrossRef]
  5. Lewis D, Miller EM. Peripheral nerve injuries associated with fractures. Ann Surg. 1922;76(4):528–538. doi:10.1097/00000658-192210000-00018 [CrossRef]
  6. Lynch AC, Lipscomb PR. The carpal tunnel syndrome and Colles' fractures. JAMA. 1963;185(5):363–366. doi:10.1001/jama.1963.03060050041018 [CrossRef]
  7. Mack GR, McPherson SA, Lutz RB. Acute median neuropathy after wrist trauma: the role of emergent carpal tunnel release. Clin Orthop Relat Res. 1994;(300):141–146.
  8. Bienek T, Kusz D, Cielinski L. Peripheral nerve compression neuropathy after fractures of the distal radius. J Hand Surg Br. 2006;31(3):256–260. doi:10.1016/J.JHSB.2005.09.021 [CrossRef]
  9. Itsubo T, Hayashi M, Uchiyama S, Hirachi K, Minami A, Kato H. Differential onset patterns and causes of carpal tunnel syndrome after distal radius fracture: a retrospective study of 105 wrists. J Orthop Sci. 2010;15(4):518–523. doi:10.1007/s00776-010-1496-7 [CrossRef]
  10. Chauhan A, Bowlin TC, Mih AD, Merrell GA. Patient-reported outcomes after acute carpal tunnel release in patients with distal radius open reduction internal fixation. Hand (NY). 2012;7(2):147–150. doi:10.1007/s11552-012-9400-x [CrossRef]
  11. Abbott LC, Saunders JB. Injuries of the median nerve in fractures of the lower end of the radius. Surg Gynecol Obstet. 1933;57:507–516.
  12. McCarroll HR Jr, . Nerve injuries associated with wrist trauma. Orthop Clin North Am. 1984;15(2):279–287.
  13. Dyer G, Lozano-Calderon S, Gannon C, Baratz M, Ring D. Predictors of acute carpal tunnel syndrome associated with fracture of the distal radius. J Hand Surg Am. 2008;33(8):1309–1313. doi:10.1016/j.jhsa.2008.04.012 [CrossRef]
  14. Bohl DD, Singh K, Grauer JN. Nationwide databases in orthopaedic surgery research. J Am Acad Orthop Surg. 2016;24(10):673–682. doi:10.5435/JAAOS-D-15-00217 [CrossRef]
  15. Patel AA, Singh K, Nunley RM, Minhas SV. Administrative databases in orthopaedic research: pearls and pitfalls of big data. J Am Acad Orthop Surg. 2016;24(3):172–179. doi:10.5435/JAAOS-D-13-00009 [CrossRef]
  16. Wang F, Shin HC. SAS model selection macros for complex survey data using PROC SURVEYLOGISTIC/SURVEYREG. Presented at: MWSUG 2011 Conference. ; September 25–27, 2011. ; Kansas City, KS. . https://www.mwsug.org/proceedings/2011/stats/MWSUG-2011-SA02.pdf
  17. Koval KJ, Harrast JJ, Anglen JO, Weinstein JN. Fractures of the distal part of the radius: the evolution of practice over time. Where's the evidence?J Bone Joint Surg Am. 2008;90(9):1855–1861. doi:10.2106/JBJS.G.01569 [CrossRef]
  18. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment of distal radial fractures in the elderly. J Bone Joint Surg Am. 2009;91(8):1868–1873. doi:10.2106/JBJS.H.01297 [CrossRef]
  19. Wilcke MK, Hammarberg H, Adolphson PY. Epidemiology and changed surgical treatment methods for fractures of the distal radius: a registry analysis of 42,583 patients in Stockholm County, Sweden, 2004–2010. Acta Orthop. 2013;84(3):292–296. doi:10.3109/17453674.2013.792035 [CrossRef]
  20. Gwathmey FW Jr, Brunton LM, Pensy RA, Chhabra AB. Volar plate osteosynthesis of distal radius fractures with concurrent prophylactic carpal tunnel release using a hybrid flexor carpi radialis approach. J Hand Surg Am. 2010;35(7):1082–1088. doi:10.1016/j.jhsa.2010.03.043 [CrossRef]
  21. Jupiter JB, Fernandez DL, Toh CL, Fellman T, Ring D. Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am. 1996;78(12):1817–1828. doi:10.2106/00004623-199612000-00004 [CrossRef]
  22. Satake H, Hanaka N, Honma R, et al. Complications of distal radius fractures treated by volar locking plate fixation. Orthopedics. 2016;39(5):e893–e896. doi:10.3928/01477447-20160517-05 [CrossRef]

Patients Included in the Analysis Separated by the Diagnosis of Carpal Tunnel Syndrome and Further Segregated by the Time and/or Presence of Carpal Tunnel Release

CTS Diagnosis and Release StatusInterpretationNo. (%)
No CTS diagnosis262,705 (95.5)
  No releaseNo CTS257,966 (93.8)
  Release priorProphylactic CTR129 (0)
  Release on same day4420 (1.6)
  Release afterPostoperative development of CTS190 (0.1)
CTS diagnosis12,347 (4.5)
  No releaseResolved with conservative management702 (0.3)
  Release priorConcomitant CTS160 (0.1)
  Release on same day10,955 (4.0)
  Release afterPostoperative development of CTS530 (0.3)

Patient and Procedure Characteristics

CharacteristicNo. (%)
Age group, y
  18–4994,862 (34.6)
  50–6469,625 (25.4)
  65–7964,086 (23.4)
  80+45,377 (16.6)
Sex
  Male103,027 (37.8)
  Female169,766 (62.2)
Primary payer
  Medicare104,998 (38.3)
  Medicaid19,141 (7.0)
  Private97,641 (35.6)
  Self-pay22,678 (8.3)
  No charge2569 (0.9)
  Other27,100 (9.9)
Polytrauma
  No144,068 (52.4)
  Yes130,984 (47.6)
Distal radius fracture fixation technique
  Open reduction with internal fixation203,511 (74.0)
  Internal fixation without fracture reduction1742 (0.6)
  Application of external fixator device33,255 (12.1)
  Closed reduction with internal fixation36,543 (13.3)

Variables Associated With Concomitant Carpal Tunnel Syndrome on Multiple Logistic Regression

VariableOdds Ratio95% Confidence IntervalP
Technique (reference=closed reduction with internal fixation)
  Open reduction with internal fixation2.602.13–3.16<.0001
  Internal fixation without fracture reduction1.941.03–3.65.0407
  Application of external fixator device1.281.00–1.64.0490
Age group, y
  18–49 vs 50–641.221.10–1.36.0002
  18–49 vs 65–791.591.39–1.82<.0001
  18–49 vs 80+2.171.83–2.58<.0001
Polytrauma (reference=none)
  Yes0.510.46–0.56<.0001
Sex (reference=female)
  Male1.281.16–1.40<.0001
Year (reference=2002)
  20031.140.80–1.62.4666
  20041.090.78–1.52.6209
  20051.190.84–1.68.3348
  20061.330.92–1.93.1357
  20071.611.10–2.37.0150
  20081.711.20–2.42.0027
  20091.651.12–2.44.0122
  20101.581.16–2.16.0039
  20112.071.52–2.82<.0001
  20121.791.34–2.39<.0001
  20131.841.38–2.46<.0001
  20141.641.22–2.21.0011
Neurological disorder (reference=none)
  Yes0.560.44–0.72<.0001
Fluid and electrolyte disorders (reference=none)
  Yes0.780.66–0.92.0023
Weight loss (reference=none)
  Yes0.450.25–0.81.0071
Hospital control (reference=government, non-federal)
  Private, non-profit1.351.12–1.62.0013
  Private, for-profit1.210.97–1.52.0881
Hospital location/teaching status (reference=rural)
  Urban, non-teaching1.200.98–1.47.0792
  Urban, teaching1.381.12–1.70.0027

Variables Associated With Prophylactic Carpal Tunnel Release on Multiple Logistic Regression

VariableOdds Ratio95% Confidence IntervalP
Age group, y
  18–49 vs 50–641.191.01–1.39.0341
  18–49 vs 65–792.101.61–2.72<.0001
  18–49 vs 80+3.082.13–4.46<.0001
Sex (reference=female)
  Male1.181.01–1.38.0428
Primary payer (reference=private)
  Medicare1.321.04–1.68.0251
  Medicaid1.060.82–1.36.6578
  Self-pay0.970.75–1.27.8446
  No charge2.181.27–3.77.0050
  Other1.120.91–1.38.2968
Polytrauma (reference=none)
  Yes1.471.26–1.72<.0001
Technique (reference=closed reduction with internal fixation)
  Open reduction with internal fixation5.553.68–8.38<.0001
  Internal fixation without fracture reduction3.611.42–9.17.0069
  Application of external fixator device2.501.51–4.14.0004
Hypertension (reference=none)
  Yes0.800.68–0.94.0081
Hospital ownership (reference=private, for-profit)
  Government, non-federal1.370.93–2.01.1080
  Non-profit1.491.08–2.05.0150
Hospital region (reference=South)
  Northeast1.090.84–1.40.5343
  Midwest1.331.03–1.71.0286
  West1.421.13–1.78.0028

Variables Associated With Postoperative Development of Carpal Tunnel Syndrome on Multiple Logistic Regression

VariableOdds Ratio95% Confidence IntervalP
Age group, y
  18–49 vs 50–642.081.41–3.09.0003
  18–49 vs 65–7914.495.15–41.67<.0001
  18–49 vs 80+23.265.26–100.00<.0001
Primary payer (reference=private)
  Medicare1.020.54–1.94.9452
  Medicaid0.900.50–1.65.7426
  Self-pay0.650.36–1.19.1628
  No charge1.350.44–4.09.5998
  Other1.941.31–2.87.0009
Polytrauma (reference=none)
  Yes1.701.22–2.36.0018
Peripheral vascular disorders (reference=none)
  Yes3.511.27–9.73.0157
Hypothyroidism (reference=none)
  Yes1.840.94–3.59.0731
Diabetes (uncomplicated) (reference=none)
  Yes0.290.09–0.89.0311
Hospital bed size (reference=small)
  Medium2.080.72–6.01.1745
  Large3.341.22–9.10.0185
Hospital location/teaching status (reference=urban, non-teaching)
  Rural2.261.26–4.06.0066
  Urban, teaching1.821.18–2.79.0067

Coding Scheme (ICD-9-CM)

Distal Radius Fracture Fixation codes
78.13
78.53
79.32
79.12

Distal Radius Fracture Diagnosis Codes
813.41
813.42
813.43
813.44
813.45
813.47

Carpal Tunnel Syndrome
354

Carpal Tunnel Release
04.43

Polytrauma
800.00 to 813.33
818.0 to 832.2
835.00 to 841.9
843.0 to 881.01
881.10 to 881.11
881.20 to 881.21
884.0 to 904.9
925.1 to 927.11
927.8 to 957.9
Authors

The authors are from the Department of Orthopaedics, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island.

Dr Shah, Dr Goodman, Mr Durand, and Dr Weiss have no relevant financial relationships to disclose. Dr Daniels is a paid consultant for Orthofix, Stryker, Spineart, and EOS and has received grants from Orthofix and Southern Spine.

Correspondence should be addressed to: Kalpit N. Shah, MD, Department of Orthopaedics, Brown University, Warren Alpert School of Medicine 593 Eddy St, Providence, RI 02903 ( kalpit210@gmail.com).

Received: December 04, 2018
Accepted: April 26, 2019
Posted Online: May 28, 2019

10.3928/01477447-20190523-04

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