Surgical Treatment of Upper Limb Fractures - An Evidence-based Approach

Abstract

Yläraajojen murtumat ovat yleisimpiä aikuisten murtumia. Perinteisesti näitä vammoja, kuten värttinäluun, olkaluun tai solisluun murtumia, on totuttu hoitamaan ilman leikkausta esimerkiksi kipsin tai kantositeen avulla. Viime vuosina on kuitenkin herännyt epäily, että leikkausinto näitä murtumia kohtaan olisi kasvanut. Korkeatasoista tutkimusnäyttöä uudempien leikkaustekniikoiden paremmuudesta verrattuna vanhempiin hoitomuotoihin eri yläraajamurtumien kohdalla on niukalti. Tutkimuksen tavoitteena oli selvittää, onko Suomessa tapahtunut muutoksia tavallisimpien yläraajan murtumien leikkaushoidossa.

Tutkimuksen aineisto saatiin kansallisesta hoitoilmoitusrekisteristä. Tutkimus koostui viidestä osatyöstä, joista neljässä selvitettiin leikkaushoidoissa tapahtuneita muutoksia värttinäluun, olkaluun ja solisluun murtumien osalta. Yhdessä osatyössä arvioitiin lisäksi hoitoilmoitusrekisterin luotettavuutta tämänkaltaisessa tutkimuksessa.

Arvioitaessa hoitoilmoitusrekisterin luotettavuutta murtumien leikkaushoidon osalta todettiin, että hoitoilmoitusrekisteriin on luotettavasti ja kattavasti kirjattu murtuman diagnoosi, suoritettu toimenpide ja tapaturmaan vaikuttaneet ulkoiset tekijät. Näin ollen rekisterin tietoja voidaan käyttää arvioitaessa eri murtumien leikkaushoidoissa tapahtuneita muutoksia. Muissa osatöissä todettiin eri yläraajan murtumien osalta, että leikkaushoito on lisääntynyt huomattavasti viime vuosina. Värttinäluun ja olkaluun murtumien osalta leikkaushoito on lisääntynyt etenkin vanhemmilla naisilla. Uudempi leikkaustekniikka käyttäen levyä murtuman vakauttamiseksi on syrjäyttänyt perinteisempiä leikkaustekniikoita. Solisluun murtumien leikkaus on sen sijaan yleistynyt miehillä nuoremmissa ikäryhmissä.

Tämän hetkinen tutkimustieto ei tue tässä tutkimuksessa havaittuja leikkaushoitokäytäntöjen muutoksia. Huomattava leikkausmäärien kasvu viittaa siihen, että leikattavien potilaiden suhteellinen osuus on lisääntynyt. Tavallisimpien yläraajamurtumien osalta on selkeä tarve korkealaatuisille potilastutkimuksille, joissa verrataan eri leikkaustekniikoita toisiinsa ja toisaalta leikkaushoitoa hoitoon ilman leikkausta.

The purpose of this thesis study was to investigate the trends and incidence rates of operative treatment of upper limb fractures in Finland. A further purpose of the study was to evaluate the reliability of the Finnish National Hospital Discharge Register. The thesis consists of five separate studies. The first part of the thesis evaluated the reliability of the Finnish National Hospital Discharge Register. The study popu-lation consisted of all adult patients diagnosed with a pertrochanteric hip fracture in three Finnish hospitals between 2008 and 2010. Accuracy of diagnosis as well as accuracy and coverage of procedural coding and external cause of injury were as-sessed. The following four studies were based on data obtained from the Finnish National Hospital Discharge Register. The second study assessed the trends and incidence rates of surgically treated clavicle fractures consisting of all surgically treated adult patients with a clavicle fracture in Finland between 1987 and 2010. The third and fourth studies assessed trends and incidence rates of surgically treat-ed humeral fractures. The study population consisted of all surgically treated adult patients with a fracture of proximal part or shaft of the humerus in Finland be-tween 1987 and 2009. The fifth study assessed trends and incidence rates of surgi-cally treated distal radius fractures. The study population consisted of all surgically treated patients 20 years and older with a distal radius fracture in Finland between 1998 and 2009. In the first part of this thesis, the accuracy of diagnosis in the Finnish National Hospital Discharge register was 96%, coverage of external cause of injury was 95% and accuracy 90%. The coverage of procedural coding was 98% and accuracy 88%. According to the results of this thesis, surgical treatment of common upper limb fractures has increased markedly. As with other upper limb fractures in this thesis, the rate of surgically treated clavicle fractures increased between 1987 and 2010. The magnitude of the change that was observed in this study was surprising; the overall incidence rate of clavicle fractures increased about ninefold. The change was even stronger in men under 60 years of age, where the incidence of surgical activity increased almost elevenfold. The rate of proximal humeral fractures that were surgically treated between 1987 and 2009 nearly quadrupled. The continuous increase in the surgical activity coincided with the actual fracture rate remaining quite constant, indicating that an increasing proportion of fractures are being treat-ed surgically. The increase in the rate of surgical treatment, especially in plating was greatest in women older than 60 years of age. Between 1987 and 2009 the number and incidence rate of surgically treated humeral shaft fractures increased signifi-cantly, especially in older women. There was a clear shift towards plating, mostly at the expense of nailing, in the surgical treatment of humeral shaft fractures. Be-tween 1998 and 2008 the incidence rate of surgically treated distal radius fractures doubled. A clear change in the type of surgical technique was also evident, as plat-ing surpassed external fixation as the most popular procedure. These changes were especially notable in older women. According to the first study, the Finnish National Hospital Discharge Register is a very reliable source of information, and can be used on assessing trends in the surgical treatment of fractures. For one reason or another, surgical treatment of common upper limb fractures has increased markedly during recent years. Concerning distal radius, and proximal as well as humeral shaft fractures, plate fixation has increased, thus diminishing the rate of other surgical techniques. Current scientific evidence on the treatment of these upper limb fractures does not support the changes observed in this thesis. There is an urgent and evident need for more high-quality prospective research comparing non-operative and surgical treatment of these fractures. Additionally, different surgical methods need to be compared in a high-quality setting before major changes in the treatment protocols of common injuries are adopted.