Quotes of the Day
Do you really need an operation?
"...she took the kids ice skating... fell pretty hard. They told her it's a bad break. Would you mind taking a look at the x-rays? I'm attaching them. It's the right wrist."
The wrist in question belonged to Carol, a super-busy young mom, married to Peter, one of my best buds from college. Late-spawning academic types, they live in a city of world-famous hospitals. The picture with the e-mail was a familiar x-ray to every orthopedist. Carol's wrist was sporting a nasty fracture of the distal radius — the larger of the two long bones in the forearm, just at the joint. The bone was in a few pieces (the fracture was "comminuted"), and it broke into the joint (it was "intra-articular") but none of the pieces were too far separated from the others ( it wasn't very "displaced"). The "correct" or generally accepted way to treat a fracture like this has changed quite radically in the course of my career. We hardly ever operated on them when I started in the late '80s; now we operate on them all the time. Mine was now the job of explaining wrist fractures to my very intelligent friend Peter, a Ph.D. in biochemistry, who despite all his smarts, had one big question on his mind: does my wife really need an operation?
From a thousand years B.C right up to the Clinton years, we've treated fractures like Carol's with closed reduction and casting. "Treating it closed" meant we set it ("reduced the fracture"), i.e. pulled and twisted (hopefully with some anesthesia) to get the pieces into the best position possible, then we held the wrist still in a plaster cast for a month and a half — 40 days and 40 nights being the magic healing time for most things orthopedic. Done well (and soon) closed reduction works quite well; an experienced orthopedist with good hands can take some horrible-looking fractures and usually end up with a good-looking x-ray, a painless wrist and close-to-perfect function. If you're older than 40 you know this from personal experience; this fracture is so common (they represent a fifth of all fractures seen in U.S. emergency departments) that you surely know at least a couple of people who have had one.
Bone-setting was a doctor's skill borne of necessity. In the days when any surgery meant great pain and usually an infection, closed treatment was the only sensible option. A good closed reduction still makes any bone doctor worth his salt proud. Walk up to some poor guy looking forward to a life of pain, deformity and stiffness, pick up his wrist, give it just the right yank and wham! he's cured. Makes you feel like Fonzi kicking the Coke machine.
Now there is also a surgical approach to fixing a broken wrist; it's had its place for decades. It was always a judgment call though: back in the day we sometimes would operate if the fracture was really bad. It generally worked out satisfactorily, but tellingly, many had learned not to operate when the fracture was really, really bad. The surgical results when the wrist was truly blown to bits often seemed to be worse than the results with closed treatment. The body can get it right — or at least more right than a surgeon can — once in a while.
A statistical case for doing the surgery much more frequently has been made of late in various research papers. It may be on account of this research or maybe on account of other, less scientific factors, (read: lots more money for doctor, hospital and surgical parts company) but one way or another American orthopedists have gone from hardly every operating on these common wrist fractures to almost always operating on them. Somewhat better outcomes have been reported in large studies of many broken wrists treated surgically, but there are so many different surgical techniques and the level of skill (and effort) put into closed treatment is so variable that the "statistical evidence" comparing surgical to closed treatment is easy to challenge. I explained this to Peter — and also let him know that he actually lives down the block from a professor who made his career studying, and mostly operating on, these wrist fractures. But I had to give Peter what he expected from a friend "in the business": the inside skinny.
To begin, the very worst outcomes I personally have seen with these fractures have been with the operated ones. I reminded Peter that my father, an orthopedist himself whom Peter knows well, had this fracture, and he treated it closed. I reminded him that closed treatment was not perfect — but neither were the results with surgery. I would expect Carol's wrist to be somewhat stiff and occasionally achy either way. A scientist could appreciate that there is ultimately very little pure data here. Surgery would be my choice if and only if the doctor couldn't get (and hold) good position with a closed reduction and casting — and I thought he probably could. Finally I told Peter that in 20 years I had operated on only about 200 fractures like Carol's, while the justifiably famous professor down the block had done more than 3,000.
Carol had the operation. Then another one to take out the metal and loosen up scar tissue. A year of therapy. Lots of pain meds. Now it's two years out and she's all right, but not perfect. I honestly think her condition is about the same as it would have been with closed treatment, minus some scars, some scary days in the hospital and a good bit of pain. Yet had she opted for closed treatment, any pain or stiffness at all would invariably bring up that doubt: "wouldn't I have done better with the surgery? Everybody's doing it." The bottom line is that we can rely on statistics (sometimes) but in any individual case no one can ever knows how a given treatment will work, or how a different one would have. People must put their practical trust in something: progress or "science," friends, institutions, the government, sometimes maybe even their doctor. Today there seem to be many who just trust the money — that the more expensive must be the better choice. Faith in the marketplace, when ultimately commercial factors define good medicine, is a reality of modern medicine — a reality that can cheat patients out of the best treatment.
- Dr. Scott Haig