Feasibility of Distal Radius Fracture Fixation With or Without a Tourniquet Under General or Regional Anesthesia: A Retrospective Comparative Study

Feasibility of Distal Radius Fracture Fixation With or Without a Tourniquet Under General or Regional Anesthesia: A Retrospective Comparative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Feasibility of Distal Radius Fracture Fixation With or Without a Tourniquet Under General or Regional Anesthesia: A Retrospective Comparative Study Min Young Kim, Young jae Kim, Ki Yong An This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8005851/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Tourniquets provide a bloodless field but may increase ischemic complications and postoperative pain. We compared perioperative and clinical outcomes of distal radius fracture (DRF) fixation with versus without a tourniquet under general or regional anesthesia. Methods We retrospectively reviewed 93 consecutive adults who underwent volar plate open reduction and internal fixation for DRF from January 2020 to September 2023. Patients were grouped by intraoperative tourniquet use (Group I, n = 54) versus no tourniquet (Group II, n = 39). Outcomes included operative time, perioperative hemoglobin (Hgb) change, hospital stay, pain on postoperative day 1 (VAS), 1-year QuickDASH, standardized opioid consumption in morphine milligram equivalents (MME), and radiographic parameters (radial height, radial inclination, volar tilt). Multivariable linear regression adjusted for age, sex, BMI, and anesthesia type. Results All no-tourniquet cases were completed without conversion. Operative time and 1-year QuickDASH were similar between groups. Hgb drop was greater in the tourniquet group (mean 1.27 ± 0.92 vs 1.03 ± 0.38 g/dL, p = 0.03). The no-tourniquet group showed lower opioid use (mean 20.3 ± 15.5 vs 38.7 ± 6.2 mg MME, p < 0.05) and a shorter hospital stay (mean 11.1 ± 5.4 vs 15.8 ± 10.7 days, p < 0.05). VAS tended to be lower without tourniquet (4.9 ± 0.7 vs 5.1 ± 0.8, p = 0.11). Radiographic restoration (volar tilt, radial height, radial inclination) was comparable. Minor skin abrasions occurred only at tourniquet sites (n = 3), resolving conservatively. In adjusted analyses, tourniquet use was not an independent predictor of MME, Hgb change, or hospital stay (all p > 0.05). Conclusions No-tourniquet DRF fixation is feasible and associated with less opioid consumption and shorter hospitalization without compromising reduction quality or functional recovery. These data support a pragmatic tourniquet-free workflow for upper-extremity trauma surgery. distal radius fracture tourniquet no-tourniquet morphine milligram equivalents postoperative pain volar tilt QuickDASH Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Distal radius fractures are among the most frequently encountered injuries in orthopedic practice, accounting for a substantial proportion of upper-extremity fractures. These injuries affect all age groups, typically resulting from high-energy trauma in younger individuals and low-energy falls—often associated with osteoporosis—in the elderly population [ 1 ]. Optimal management of these fractures is essential to preserve wrist function, prevent post-traumatic arthritis, and enable an early return to daily activities. Open reduction and internal fixation (ORIF) using volar locking plates has become the standard method for treating unstable or displaced distal radius fractures [ 2 ]. This technique provides anatomical alignment, restores joint congruity, and ensures rigid fixation, thereby facilitating early mobilization and functional recovery. However, due to the rich vascularity of the wrist area, ORIF is associated with a risk of intraoperative bleeding, which can obscure the surgical field and complicate the procedure [ 3 ]. To address intraoperative bleeding, tourniquet use has been an established practice in extremity surgeries for over a century, dating back to the late 19th century when Esmarch first introduced elastic bandage techniques [ 4 ]. Subsequently, pneumatic tourniquets were developed to provide more controlled and consistent pressure [ 5 ], resulting in a clearer operative field. However, several studies have reported that tourniquet application may lead to ischemic nerve injury, muscle damage, delayed wound healing, skin abrasions, and increased postoperative pain due to reperfusion injury [ 6 ]. The upper extremities are anatomically more vulnerable than the lower limbs, due to superficial nerves, less muscle mass, and thinner soft-tissue layers, increasing the risk of tourniquet-induced nerve or ischemic injury [ 7 , 8 ]. Although the wide-awake local anesthesia no tourniquet (WALANT) technique has shown feasibility in selected upper-limb procedures, its applicability to long-bone fixation remains limited. Unlike WALANT, our study focuses on patients undergoing distal radius ORIF under general or regional anesthesia, allowing for a direct evaluation of the independent effect of tourniquet use on perioperative outcomes. This study aimed to compare key clinical outcomes—including operative time, perioperative hemoglobin change, hospital stay, pain (VAS), functional recovery (QuickDASH), radiographic parameters and standardized postoperative opioid use quantified as morphine milligram equivalents (MME) [ 9 ]—between two groups performed with and without a tourniquet. Material and Methods This retrospective comparative study was approved by the Kwangju Christian Hospital Institutional Review Board (KCH IRB)(IRB No. KCHIRB-M-2024-5). Given the retrospective design, the requirement for written informed consent was waived. A total of 106 patients underwent ORIF using volar plate fixation for distal radius fractures between January 2020 and September 2023. Among them, 93 patients who had complete clinical data and a minimum follow-up period of two years were included in the final analysis (Fig. 1 ). Patients were retrospectively assigned to one of two groups based on whether a tourniquet was used during surgery. Group I (tourniquet group) consisted of 54 patients. Among them, 19 received general anesthesia, 35 received brachial plexus block (BPB) anesthesia under ultrasound guidance. A pneumatic tourniquet of 200 mmHg was applied in all cases. Group II (no-tourniquet group) included 39 patients, of whom 10 underwent general anesthesia and 29 received ultrasound-guided brachial plexus block. Fractures were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification system[ 10 ]. In Group I and Group II, operations were performed by different single experienced orthopedic surgeons, respectively. Patients with open or pathological fractures, polytrauma, prior ipsilateral wrist surgery, or incomplete clinical or radiologic records were excluded. All 93 included patients had complete datasets for clinical and radiographic variables; no imputation was performed. Prophylactic antibiotics (1 g cefazolin) were administered one hour before incision. Tranexamic acid was not administered in either group to avoid its potential influence on perioperative hemoglobin changes. In patients with chronic kidney disease, dosage adjustment was made according to renal function. Sutures were removed at two weeks postoperatively. A wrist brace was applied for four weeks postoperatively in both groups. Postoperative assessments included operative time, pain score using VAS, length of hospital stay, QuickDASH score at one year, changes in Hgb level (preoperative vs. within 5 days postoperative), and opioid consumption. Opioid use was quantified using MME based on the National Institutes of Health Helping to End Addiction Long-term Initiative (NIH HEAL) standard calculator. The use of MME as a research metric has been recommended by the NIH HEAL to harmonize pain-related data in orthopedic and anesthetic literature [ 11 ]. All intravenous Patient-Controlled Analgesia (PCA) doses and tramadol prescriptions were converted to MME to allow standardized cross-comparison of opioid burden. All brachial plexus blocks were performed under ultrasound guidance to ensure accurate nerve localization. All patients received standardized postoperative care, including identical analgesic protocols, rehabilitation schedules, and discharge criteria, to ensure comparability between groups. The discharge plan and rehabilitation timeline (including initiation of wrist motion after four weeks of immobilization) were consistent across both groups, minimizing the influence of postoperative management differences on pain and opioid consumption. Intraoperative blood loss was not directly quantified because of variations in irrigation and difficulty in accurately counting absorbed gauze or suction volume. Therefore, the perioperative change in hemoglobin level was used as a surrogate marker for bleeding, providing a more reliable and objective comparison between groups. Radiographic parameters included radial height(RH), radial inclination(RI), and volar tilt(VT) measured on standardized anteroposterior and lateral radiographs. Normal reference ranges (VT 10–15°, RI 21–25°, RH 11–13 mm) were adopted from Palmer AK [ 12 ]. Statistical analysis was conducted using Predictive Analytics Software(PASW) Statistics version 18.0(SPSS Inc.). For continuous variables, independent t-tests were applied when normality assumptions were met, and the Mann-Whitney U test was used as a non-parametric alternative when assumptions were violated. Categorical variables were analyzed using chi-square or Fisher’s exact tests. A p-value of < 0.05 was considered statistically significant. To minimize potential bias, all patients received standardized perioperative management and identical rehabilitation protocols. Differences in surgeon experience were acknowledged as a possible confounder. No formal sample size calculation was performed due to the retrospective design of the study. Multivariable linear regression analyses were conducted to evaluate the independent associations of tourniquet use, anesthesia type, and patient factors (age, sex, BMI) with postoperative opioid consumption (MME), perioperative hemoglobin change, and hospital stay. Results Demographic characteristics and AO fracture classifications were comparable between the two groups (Table 1 and Table 2 ). No significant differences were noted in age, sex distribution, BMI, or fracture classification. Table 1 Demographic characteristics of patients in Group I and II Variable Group I (with Tourniquet) Group II (without Tourniquet) P value Number 54 (M:6, F:48) 39 (M:6, F:33) - Age (years) 62.1 ± 11.4 61.9 ± 12.2 0.84 BMI (kg/m²) 22.1 ± 4.5 22.7 ± 3.0 0.47 BMD (g/cm²) -3.4 ± 0.7 -2.8 ± 0.7 0.13 Table 2 Comparison of AO Classification of distal radius fracture Between Group I and II AO classification Group I (N) Group II (N) χ² P-value A type 28 (51.9%) 14 (35.9%) 0.75 0.69 B type 13 (24.1%) 9 (23.1%) C type 13 (24.1%) 16 (41.0%) The mean operative time was 61.6 ± 18.9 minutes in Group I and 57.8 ± 12.5 minutes in Group II (p = 0.19). All cases in the no-tourniquet group were completed without intraoperative conversion to tourniquet use, indicating full adherence to the assigned protocol. Mean postoperative volar tilt (VT), radial height (RH), and radial inclination (RI) did not differ significantly between the two groups (all p > 0.05), and all were within the accepted normal ranges. In a sensitivity analysis using simulated contralateral normals, side-to-side differences in VT, RH, and RI were small and comparable between groups (VT: 3.95 ± 2.74° vs. 4.30 ± 2.92°; RH: 1.82 ± 1.41 mm vs. 1.94 ± 1.37 mm; RI: 2.10 ± 1.65° vs. 2.24 ± 1.52°, all negligible effect sizes), supporting radiographic comparability of reduction quality. Postoperative hemoglobin drop was greater in Group I (1.27 ± 0.92 g/dL) than in Group II (1.03 ± 0.38 g/dL), with statistical significance (p = 0.03)(Fig. 2 ). On postoperative day 1, VAS was 4.9 ± 0.7 without a tourniquet and 5.1 ± 0.8 with a tourniquet (p = 0.11), indicating no significant differencein early pain. QuickDASH at 1 year was 2.2 ± 0.5 vs 2.1 ± 0.5 (p = 0.62), consistent with comparable long-term function.(Fig. 3 ) Opioid consumption was significantly lower in the no-tourniquet group. Group I had a mean total opioid use of 38.7 ± 6.2 mg MME, whereas Group II used 20.3 ± 15.5 mg MME (p < 0.05)(Fig. 4 ). Hospital stay was significantly shorter in Group II (11.1 ± 5.4 days) compared to Group I (15.8 ± 10.7 days) (p < 0.05). No major complications such as infections or neurovascular injuries occurred in either group. No intraoperative complications were reported. However, three patients in Group I experienced minor skin abrasions at the tourniquet site, which resolved conservatively. No tourniquet-related complications were noted in Group II. All 93 patients completed clinical and radiographic follow-up, and no missing data were identified. In multivariable linear regression adjusting for age, sex, BMI, and anesthesia type, tourniquet use was not independently associatedwith postoperative opioid consumption, perioperative hemoglobin change, or hospital stay (all p > 0.05). Discussion Traditionally, tourniquets have been used to secure a bloodless field and facilitate exposure. However, with the refinement of surgical instruments, bipolar coagulation, and meticulous soft-tissue handling, adequate hemostasis can be achieved without tourniquet assistance. Although tourniquet use is often justified by improved visualization, our findings suggest that modern hemostatic techniques provide sufficient exposure without increasing complications [ 13 , 14 ]. Although patients in the no-tourniquet group showed lower postoperative opioid consumptionand shorter hospital stays in unadjusted comparisons, pain scores and 1-year functional outcomes were comparablebetween groups (p = 0.11 for VAS; p = 0.62 for QuickDASH). Importantly, our multivariable modelsindicated that tourniquet use was not independently associatedwith opioid consumption, hemoglobin change, or hospital stay after adjusting for age, sex, BMI, and anesthesia type. Thus, the observed differences likely reflect clinical and perioperative contextrather than a direct, causal effectof the tourniquet itself. From a practical standpoint, tourniquet-free fixation appears feasiblewithout compromising visualization or reduction quality in routine cases, while selective or low-pressure use may remain reasonable for specific scenarios with problematic bleeding. The lower MME use in Group II aligns with prior evidence suggesting that ischemia–reperfusion injury from prolonged tourniquet inflation can exacerbate postoperative pain through peripheral nociceptor sensitization [ 15 ]. The use of standardized MME conversion based on NIH HEAL Initiative guidelines [ 9 ] enabled robust and comparable evaluation of postoperative opioid burden, enhancing the generalizability of our results. While operative time and long-term functional outcomes (QuickDASH at one year) were comparable between groups, a greater perioperative hemoglobin drop was noted in Group I (1.27 ± 0.92 vs. 1.03 ± 0.38 g/dL, p = 0.03), despite the presumed benefit of intraoperative hemostasis. This may be related to reactive hyperemia and concealed bleeding following tourniquet deflation [ 16 ]. From a patient-centered perspective, omitting the tourniquet offers additional benefits, including improved intraoperative comfort, avoidance of ischemic pain, and a lower risk of nerve or skin injury, particularly under regional anesthesia. Radiographic alignment parameters, especially volar tilt, were comparable between groups, confirming that reduction quality was not compromised by the absence of a tourniquet. Volar tilt has been recognized as a key radiographic determinant of wrist kinematics and functional recovery, with restoration of normal tilt closely correlated with improved range of motion and grip strength [ 17 ]. The comparable postoperative VT observed in both groups therefore reinforces that omitting the tourniquet did not compromise the essential radiographic endpoint for wrist function. Multivariable analyses were performed to identify independent factors associated with postoperative opioid use, perioperative hemoglobin change, and hospital stay. After adjustment for demographic and perioperative factors (age, sex, BMI, anesthesia type), tourniquet use was not significantly associated with higher MME (β = 0.07, p = 0.51) or greater hemoglobin change (β = 0.12, p = 0.26). Similarly, hospital stay did not differ between groups (β = −0.05, p = 0.63). These results indicate that tourniquet use itself was not an independent determinant of these postoperative outcomes. Certain clinical scenarios, such as extensive soft-tissue trauma, uncontrolled bleeding from metaphyseal vessels, or revision cases, may still justify temporary or low-pressure tourniquet use [ 16 ]. Conversely, patients with peripheral vascular disease, neuropathy, or pre-existing skin compromise may benefit more from no-tourniquet fixation. In such cases, inflation time and pressure should be minimized, and multimodal analgesia employed to mitigate ischemic sequelae [ 14 , 18 ]. Moreover, no intraoperative conversion to tourniquet use occurred in the no-tourniquet group, suggesting that adequate visualization and hemostasis can be reliably achieved without tourniquet assistance. This further supports that the tourniquet itself exerts no positive or necessary influence on surgical performance. Finally, the principles of Enhanced Recovery After Surgery (ERAS) support minimizing intraoperative interventions that delay recovery. Evidence from total knee arthroplasty shows that omitting the tourniquet reduces postoperative pain and thromboembolic risk without compromising fixation [ 19 ]. These findings parallel our results and further support the feasibility of no-tourniquet approaches in upper-extremity trauma surgery. Despite these strengths, limitations must be acknowledged. First, the retrospective design introduces potential selection bias, and randomization was not feasible. Second, unequal group sizes may have affected statistical power. Third, anesthesia type was not standardized and could influence postoperative pain or opioid use. Fourth, although each group was operated on by a single experienced surgeon, unmeasured differences in surgical technique and intraoperative decision-making could have influenced certain perioperative outcomes. Lastly, long-term complications beyond two years were not assessed. Future prospective, randomized trials with larger cohorts are needed to confirm these findings and better define indications for no-tourniquet fixation. Conclusion Open reduction and internal fixation of distal radius fractures withouta tourniquet was feasiblein our cohort, with comparable pain and functional outcomesto tourniquet use, and with lower postoperative opioid consumptionand shorter hospitalizationon unadjusted analyses. Radiographic restoration was similar between groups. However, after adjustmentfor patient and perioperative factors, tourniquet use itself was not independently associatedwith opioid use, hemoglobin change, or length of stay. These findings support a pragmatic, tourniquet-free optionin appropriate cases, while underscoring the need for prospective, adequately powered studiesto confirm causal effects. Declarations Ethics approval and consent to participate This retrospective study was approved by the Kwangju Christian Hospital Institutional Review Board (KCH IRB)(IRB No. KCHIRB-M-2024-5). The requirement for informed consent was waivedby the IRB owing to the retrospective design and the use of de-identified data. The study was conducted in accordance with the Declaration of Helsinkiand its later amendments. Consent for publication Not applicable.This manuscript contains no individual person’s identifiable data(including images, videos, or clinical details) requiring consent for publication. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly availabledue to institutional restrictions but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research received no specific funding. Author Contributions Min Young Kim, MD (First author):Conceptualization; Methodology; Investigation; Data curation; Formal analysis; Visualization; Writing original draft. Young Jae Kim, MD: Investigation; Data curation; Validation; Formal analysis (verification); Visualization; Review & editing. Ki Yong An, MD, PhD (Corresponding author):Conceptualization; Methodology; Supervision; Project administration; Resources; Validation; Review & editing. References Nellans KW, Kowalski E, Chung KC. The epidemiology of distal radius fractures. Hand Clin. 2012;28(2):113–25. American Academy of Orthopaedic Surgeons. Management of distal radius fractures [Internet]. Rosemont (IL): AAOS; 2019. Ahmad AA, Yi LM, Ahmad AR. Plating of distal radius fracture using the wide-awake anesthesia technique. J Hand Surg Am. 2018;43(11):e10451–5. Wakai A, Winter DC, Street JT, Redmond PH. Pneumatic tourniquets in extremity surgery. J Am Acad Orthop Surg. 2001;9(5):345–51. Noordin S, McEwen JA, Kragh CJ Jr, Eisen A, Masri BA. Surgical tourniquets in orthopaedics. J Bone Joint Surg Am. 2009;91(12):2958–67. Estebe JP, Davies JM, Richebé P. The pneumatic tourniquet: mechanical, ischaemia-reperfusion and systemic effects. Eur J Anaesthesiol. 2011;28(6):404–11. Horlocker TT, Hebl JR. Regional anesthesia essentials: upper and lower extremity tourniquet use. Reg Anesth Pain Med. 2003;28(6):508–17. Huang YC, Hsu CJ, Renn JH, et al. WALANT for distal radius fracture: open reduction with plating fixation via wide-awake local anesthesia with no tourniquet. J Orthop Surg Res. 2018;13:195. Adams MCB, Sward KA, Perkins ML, Hurley RW. Standardizing research methods for opioid dose comparison: NIH HEAL MME calculator. Pain. 2025;00(00):1–9. Meinberg EG, Agel J, Roberts CS, et al. AO/OTA Fracture and Dislocation Classification Compendium–2018. J Orthop Trauma. 2018;32(Suppl 1):S1–170. Ong CK, Seymour RA, Lirk P, Merry AF. Combining morphine consumption and pain scores. Br J Anaesth. 2010;105(4):446–53. Palmer AK. Radiographic measurement of the distal radius. J Hand Surg Am. 1981;6(4):376–81. Tai TW, Chang CW, Lai KA, et al. Effects of tourniquet use on blood loss and soft-tissue damage in total knee arthroplasty. J Bone Joint Surg Am. 2012;94(24):2209–15. Lu Y, Wang D, Li T, et al. Tourniquet-induced nerve compression injuries caused by high pressure gradients. BMC Biomed Eng. 2020;2:6. Daniels SE, Upmalis D, Okamoto A, et al. Tapentadol vs oxycodone for acute postoperative pain. Clin J Pain. 2011;27(4):336–43. Drew B, Bird D, Matteucci M, Keenan S. Tourniquet conversion: a recommended approach. J Spec Oper Med. 2015;15(3):81–5. Medoff RJ. Essential radiographic evaluation for distal radius fractures: keys to successful management. J Hand Surg Am. 2013;38(12):2431–2445. doi:[10.1016/j.jhsa.2013.09.006]. Nicholson LT, Copeland LA, Zeber JE, et al. Hemoglobin and hematocrit changes after orthopedic surgery. Mil Med. 2011;176(12):1350–6. Wainwright TW, Gill M, McDonald DA, et al. Enhanced recovery after surgery (ERAS) and its applicability for major orthopedic surgery. Best Pract Res Clin Anaesthesiol. 2016;30(1):91–102. Additional Declarations No competing interests reported. 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11:27:46","extension":"xml","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":54349,"visible":true,"origin":"","legend":"","description":"","filename":"cd78397cfc7b40f593f746e43d1f7e031structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8005851/v1/adb73c1b93ca6ef1f536aa21.xml"},{"id":97894346,"identity":"7a6350f8-cfda-4340-8a48-11b99ed787f6","added_by":"auto","created_at":"2025-12-10 15:32:21","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":62568,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8005851/v1/1a588d55700e2c176c2fcd2e.html"},{"id":97694894,"identity":"6e8d6cf6-3660-468b-a307-438b2a52ab06","added_by":"auto","created_at":"2025-12-08 11:27:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":921729,"visible":true,"origin":"","legend":"\u003cp\u003eFlow of participants through the study\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8005851/v1/97313e55b65fe3d29fb7dc3c.png"},{"id":97894005,"identity":"ae781f7d-ae20-4ada-bfc2-397e1f47c2eb","added_by":"auto","created_at":"2025-12-10 15:31:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":66521,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of Hemoglobin change between group I and II\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8005851/v1/20f2160d1ee8a90960b35d0a.png"},{"id":97893293,"identity":"b0ad75df-0bc4-4db3-8a86-cfbb71ee007f","added_by":"auto","created_at":"2025-12-10 15:29:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":87968,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of VAS and QuickDASH score between groups I and II\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8005851/v1/70551a42e9335a6730bd7a6f.png"},{"id":97893799,"identity":"0bd7c445-d4c7-4145-8ab4-640e4e24d99e","added_by":"auto","created_at":"2025-12-10 15:31:14","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":69682,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of Opioid consumption between groups I and II\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8005851/v1/5392e935f91216d52d4548af.png"},{"id":103781667,"identity":"ec37c61b-5293-403d-ae9d-e3956c59c3ed","added_by":"auto","created_at":"2026-03-02 20:54:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1295495,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8005851/v1/7a2a8182-593a-4960-873a-0ae6768a0775.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Feasibility of Distal Radius Fracture Fixation With or Without a Tourniquet Under General or Regional Anesthesia: A Retrospective Comparative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDistal radius fractures are among the most frequently encountered injuries in orthopedic practice, accounting for a substantial proportion of upper-extremity fractures. These injuries affect all age groups, typically resulting from high-energy trauma in younger individuals and low-energy falls\u0026mdash;often associated with osteoporosis\u0026mdash;in the elderly population [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Optimal management of these fractures is essential to preserve wrist function, prevent post-traumatic arthritis, and enable an early return to daily activities.\u003c/p\u003e\u003cp\u003eOpen reduction and internal fixation (ORIF) using volar locking plates has become the standard method for treating unstable or displaced distal radius fractures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This technique provides anatomical alignment, restores joint congruity, and ensures rigid fixation, thereby facilitating early mobilization and functional recovery. However, due to the rich vascularity of the wrist area, ORIF is associated with a risk of intraoperative bleeding, which can obscure the surgical field and complicate the procedure [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo address intraoperative bleeding, tourniquet use has been an established practice in extremity surgeries for over a century, dating back to the late 19th century when Esmarch first introduced elastic bandage techniques [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Subsequently, pneumatic tourniquets were developed to provide more controlled and consistent pressure [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], resulting in a clearer operative field. However, several studies have reported that tourniquet application may lead to ischemic nerve injury, muscle damage, delayed wound healing, skin abrasions, and increased postoperative pain due to reperfusion injury [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe upper extremities are anatomically more vulnerable than the lower limbs, due to superficial nerves, less muscle mass, and thinner soft-tissue layers, increasing the risk of tourniquet-induced nerve or ischemic injury [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Although the wide-awake local anesthesia no tourniquet (WALANT) technique has shown feasibility in selected upper-limb procedures, its applicability to long-bone fixation remains limited. Unlike WALANT, our study focuses on patients undergoing distal radius ORIF under general or regional anesthesia, allowing for a direct evaluation of the independent effect of tourniquet use on perioperative outcomes.\u003c/p\u003e\u003cp\u003eThis study aimed to compare key clinical outcomes\u0026mdash;including operative time, perioperative hemoglobin change, hospital stay, pain (VAS), functional recovery (QuickDASH), radiographic parameters and standardized postoperative opioid use quantified as morphine milligram equivalents (MME) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u0026mdash;between two groups performed with and without a tourniquet.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003e This retrospective comparative study was approved by the Kwangju Christian Hospital Institutional Review Board (KCH IRB)(IRB No. KCHIRB-M-2024-5). Given the retrospective design, the requirement for written informed consent was waived. A total of 106 patients underwent ORIF using volar plate fixation for distal radius fractures between January 2020 and September 2023. Among them, 93 patients who had complete clinical data and a minimum follow-up period of two years were included in the final analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003ePatients were retrospectively assigned to one of two groups based on whether a tourniquet was used during surgery. Group I (tourniquet group) consisted of 54 patients. Among them, 19 received general anesthesia, 35 received brachial plexus block (BPB) anesthesia under ultrasound guidance. A pneumatic tourniquet of 200 mmHg was applied in all cases. Group II (no-tourniquet group) included 39 patients, of whom 10 underwent general anesthesia and 29 received ultrasound-guided brachial plexus block.\u003c/p\u003e\u003cp\u003eFractures were classified according to the Arbeitsgemeinschaft f\u0026uuml;r Osteosynthesefragen (AO) classification system[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In Group I and Group II, operations were performed by different single experienced orthopedic surgeons, respectively. Patients with open or pathological fractures, polytrauma, prior ipsilateral wrist surgery, or incomplete clinical or radiologic records were excluded. All 93 included patients had complete datasets for clinical and radiographic variables; no imputation was performed.\u003c/p\u003e\u003cp\u003eProphylactic antibiotics (1 g cefazolin) were administered one hour before incision. Tranexamic acid was not administered in either group to avoid its potential influence on perioperative hemoglobin changes. In patients with chronic kidney disease, dosage adjustment was made according to renal function. Sutures were removed at two weeks postoperatively. A wrist brace was applied for four weeks postoperatively in both groups. Postoperative assessments included operative time, pain score using VAS, length of hospital stay, QuickDASH score at one year, changes in Hgb level (preoperative vs. within 5 days postoperative), and opioid consumption. Opioid use was quantified using MME based on the National Institutes of Health Helping to End Addiction Long-term Initiative (NIH HEAL) standard calculator. The use of MME as a research metric has been recommended by the NIH HEAL to harmonize pain-related data in orthopedic and anesthetic literature [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. All intravenous Patient-Controlled Analgesia (PCA) doses and tramadol prescriptions were converted to MME to allow standardized cross-comparison of opioid burden.\u003c/p\u003e\u003cp\u003eAll brachial plexus blocks were performed under ultrasound guidance to ensure accurate nerve localization. All patients received standardized postoperative care, including identical analgesic protocols, rehabilitation schedules, and discharge criteria, to ensure comparability between groups. The discharge plan and rehabilitation timeline (including initiation of wrist motion after four weeks of immobilization) were consistent across both groups, minimizing the influence of postoperative management differences on pain and opioid consumption.\u003c/p\u003e\u003cp\u003eIntraoperative blood loss was not directly quantified because of variations in irrigation and difficulty in accurately counting absorbed gauze or suction volume. Therefore, the perioperative change in hemoglobin level was used as a surrogate marker for bleeding, providing a more reliable and objective comparison between groups.\u003c/p\u003e\u003cp\u003eRadiographic parameters included radial height(RH), radial inclination(RI), and volar tilt(VT) measured on standardized anteroposterior and lateral radiographs. Normal reference ranges (VT 10\u0026ndash;15\u0026deg;, RI 21\u0026ndash;25\u0026deg;, RH 11\u0026ndash;13 mm) were adopted from Palmer AK [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStatistical analysis was conducted using Predictive Analytics Software(PASW) Statistics version 18.0(SPSS Inc.). For continuous variables, independent t-tests were applied when normality assumptions were met, and the Mann-Whitney U test was used as a non-parametric alternative when assumptions were violated. Categorical variables were analyzed using chi-square or Fisher\u0026rsquo;s exact tests. A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant. To minimize potential bias, all patients received standardized perioperative management and identical rehabilitation protocols. Differences in surgeon experience were acknowledged as a possible confounder. No formal sample size calculation was performed due to the retrospective design of the study. Multivariable linear regression analyses were conducted to evaluate the independent associations of tourniquet use, anesthesia type, and patient factors (age, sex, BMI) with postoperative opioid consumption (MME), perioperative hemoglobin change, and hospital stay.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDemographic characteristics and AO fracture classifications were comparable between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). No significant differences were noted in age, sex distribution, BMI, or fracture classification.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic characteristics of patients in Group I and II\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup I (with Tourniquet)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGroup II (without Tourniquet)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54 (M:6, F:48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39 (M:6, F:33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62.1\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61.9\u0026thinsp;\u0026plusmn;\u0026thinsp;12.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.84\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg/m\u0026sup2;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMD (g/cm\u0026sup2;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of AO Classification of distal radius fracture Between Group I and II\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAO classification\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup I (N)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGroup II (N)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eχ\u0026sup2;\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28 (51.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14 (35.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eB type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13 (24.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (23.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13 (24.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16 (41.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe mean operative time was 61.6\u0026thinsp;\u0026plusmn;\u0026thinsp;18.9 minutes in Group I and 57.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.5 minutes in Group II (p\u0026thinsp;=\u0026thinsp;0.19). All cases in the no-tourniquet group were completed without intraoperative conversion to tourniquet use, indicating full adherence to the assigned protocol.\u003c/p\u003e\u003cp\u003eMean postoperative volar tilt (VT), radial height (RH), and radial inclination (RI) did not differ significantly between the two groups (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), and all were within the accepted normal ranges. In a sensitivity analysis using simulated contralateral normals, side-to-side differences in VT, RH, and RI were small and comparable between groups (VT: 3.95\u0026thinsp;\u0026plusmn;\u0026thinsp;2.74\u0026deg; vs. 4.30\u0026thinsp;\u0026plusmn;\u0026thinsp;2.92\u0026deg;; RH: 1.82\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41 mm vs. 1.94\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37 mm; RI: 2.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.65\u0026deg; vs. 2.24\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52\u0026deg;, all negligible effect sizes), supporting radiographic comparability of reduction quality.\u003c/p\u003e\u003cp\u003ePostoperative hemoglobin drop was greater in Group I (1.27\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92 g/dL) than in Group II (1.03\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38 g/dL), with statistical significance (p\u0026thinsp;=\u0026thinsp;0.03)(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eOn postoperative day 1, VAS was 4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 without a tourniquet and 5.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 with a tourniquet (p\u0026thinsp;=\u0026thinsp;0.11), indicating no significant differencein early pain. QuickDASH at 1 year was 2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 vs 2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 (p\u0026thinsp;=\u0026thinsp;0.62), consistent with comparable long-term function.(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eOpioid consumption was significantly lower in the no-tourniquet group. Group I had a mean total opioid use of 38.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2 mg MME, whereas Group II used 20.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15.5 mg MME (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)(Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eHospital stay was significantly shorter in Group II (11.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4 days) compared to Group I (15.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.7 days) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No major complications such as infections or neurovascular injuries occurred in either group. No intraoperative complications were reported. However, three patients in Group I experienced minor skin abrasions at the tourniquet site, which resolved conservatively. No tourniquet-related complications were noted in Group II. All 93 patients completed clinical and radiographic follow-up, and no missing data were identified.\u003c/p\u003e\u003cp\u003eIn multivariable linear regression adjusting for age, sex, BMI, and anesthesia type, tourniquet use was not independently associatedwith postoperative opioid consumption, perioperative hemoglobin change, or hospital stay (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTraditionally, tourniquets have been used to secure a bloodless field and facilitate exposure. However, with the refinement of surgical instruments, bipolar coagulation, and meticulous soft-tissue handling, adequate hemostasis can be achieved without tourniquet assistance. Although tourniquet use is often justified by improved visualization, our findings suggest that modern hemostatic techniques provide sufficient exposure without increasing complications [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough patients in the no-tourniquet group showed lower postoperative opioid consumptionand shorter hospital stays in unadjusted comparisons, pain scores and 1-year functional outcomes were comparablebetween groups (p\u0026thinsp;=\u0026thinsp;0.11 for VAS; p\u0026thinsp;=\u0026thinsp;0.62 for QuickDASH). Importantly, our multivariable modelsindicated that tourniquet use was not independently associatedwith opioid consumption, hemoglobin change, or hospital stay after adjusting for age, sex, BMI, and anesthesia type. Thus, the observed differences likely reflect clinical and perioperative contextrather than a direct, causal effectof the tourniquet itself. From a practical standpoint, tourniquet-free fixation appears feasiblewithout compromising visualization or reduction quality in routine cases, while selective or low-pressure use may remain reasonable for specific scenarios with problematic bleeding.\u003c/p\u003e\u003cp\u003eThe lower MME use in Group II aligns with prior evidence suggesting that ischemia\u0026ndash;reperfusion injury from prolonged tourniquet inflation can exacerbate postoperative pain through peripheral nociceptor sensitization [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The use of standardized MME conversion based on NIH HEAL Initiative guidelines [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] enabled robust and comparable evaluation of postoperative opioid burden, enhancing the generalizability of our results.\u003c/p\u003e\u003cp\u003eWhile operative time and long-term functional outcomes (QuickDASH at one year) were comparable between groups, a greater perioperative hemoglobin drop was noted in Group I (1.27\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92 vs. 1.03\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38 g/dL, p\u0026thinsp;=\u0026thinsp;0.03), despite the presumed benefit of intraoperative hemostasis. This may be related to reactive hyperemia and concealed bleeding following tourniquet deflation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFrom a patient-centered perspective, omitting the tourniquet offers additional benefits, including improved intraoperative comfort, avoidance of ischemic pain, and a lower risk of nerve or skin injury, particularly under regional anesthesia. Radiographic alignment parameters, especially volar tilt, were comparable between groups, confirming that reduction quality was not compromised by the absence of a tourniquet. Volar tilt has been recognized as a key radiographic determinant of wrist kinematics and functional recovery, with restoration of normal tilt closely correlated with improved range of motion and grip strength [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The comparable postoperative VT observed in both groups therefore reinforces that omitting the tourniquet did not compromise the essential radiographic endpoint for wrist function.\u003c/p\u003e\u003cp\u003eMultivariable analyses were performed to identify independent factors associated with postoperative opioid use, perioperative hemoglobin change, and hospital stay. After adjustment for demographic and perioperative factors (age, sex, BMI, anesthesia type), tourniquet use was not significantly associated with higher MME (β\u0026thinsp;=\u0026thinsp;0.07, p\u0026thinsp;=\u0026thinsp;0.51) or greater hemoglobin change (β\u0026thinsp;=\u0026thinsp;0.12, p\u0026thinsp;=\u0026thinsp;0.26). Similarly, hospital stay did not differ between groups (β = \u0026minus;0.05, p\u0026thinsp;=\u0026thinsp;0.63). These results indicate that tourniquet use itself was not an independent determinant of these postoperative outcomes.\u003c/p\u003e\u003cp\u003eCertain clinical scenarios, such as extensive soft-tissue trauma, uncontrolled bleeding from metaphyseal vessels, or revision cases, may still justify temporary or low-pressure tourniquet use [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Conversely, patients with peripheral vascular disease, neuropathy, or pre-existing skin compromise may benefit more from no-tourniquet fixation. In such cases, inflation time and pressure should be minimized, and multimodal analgesia employed to mitigate ischemic sequelae [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Moreover, no intraoperative conversion to tourniquet use occurred in the no-tourniquet group, suggesting that adequate visualization and hemostasis can be reliably achieved without tourniquet assistance. This further supports that the tourniquet itself exerts no positive or necessary influence on surgical performance.\u003c/p\u003e\u003cp\u003eFinally, the principles of Enhanced Recovery After Surgery (ERAS) support minimizing intraoperative interventions that delay recovery. Evidence from total knee arthroplasty shows that omitting the tourniquet reduces postoperative pain and thromboembolic risk without compromising fixation [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These findings parallel our results and further support the feasibility of no-tourniquet approaches in upper-extremity trauma surgery.\u003c/p\u003e\u003cp\u003eDespite these strengths, limitations must be acknowledged. First, the retrospective design introduces potential selection bias, and randomization was not feasible. Second, unequal group sizes may have affected statistical power. Third, anesthesia type was not standardized and could influence postoperative pain or opioid use. Fourth, although each group was operated on by a single experienced surgeon, unmeasured differences in surgical technique and intraoperative decision-making could have influenced certain perioperative outcomes. Lastly, long-term complications beyond two years were not assessed. Future prospective, randomized trials with larger cohorts are needed to confirm these findings and better define indications for no-tourniquet fixation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOpen reduction and internal fixation of distal radius fractures withouta tourniquet was feasiblein our cohort, with comparable pain and functional outcomesto tourniquet use, and with lower postoperative opioid consumptionand shorter hospitalizationon unadjusted analyses. Radiographic restoration was similar between groups. However, after adjustmentfor patient and perioperative factors, tourniquet use itself was not independently associatedwith opioid use, hemoglobin change, or length of stay. These findings support a pragmatic, tourniquet-free optionin appropriate cases, while underscoring the need for prospective, adequately powered studiesto confirm causal effects.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis retrospective study was approved by the Kwangju Christian Hospital Institutional Review Board (KCH IRB)(IRB No. KCHIRB-M-2024-5). The requirement for informed consent was waivedby the IRB owing to the retrospective design and the use of de-identified data. The study was conducted in accordance with the Declaration of Helsinkiand its later amendments.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.This manuscript contains no individual person’s identifiable data(including images, videos, or clinical details) requiring consent for publication.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly availabledue to institutional restrictions but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research received no specific funding.\u003c/p\u003e\n\u003cp\u003eAuthor Contributions\u003c/p\u003e\n\u003cp\u003eMin Young Kim, MD (First author):Conceptualization; Methodology; Investigation; Data curation; Formal analysis; Visualization; Writing original draft.\u003c/p\u003e\n\u003cp\u003eYoung Jae Kim, MD: Investigation; Data curation; Validation; Formal analysis (verification); Visualization; Review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eKi Yong An, MD, PhD (Corresponding author):Conceptualization; Methodology; Supervision; Project administration; Resources; Validation; Review \u0026amp; editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNellans KW, Kowalski E, Chung KC. The epidemiology of distal radius fractures. Hand Clin. 2012;28(2):113\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmerican Academy of Orthopaedic Surgeons. Management of distal radius fractures [Internet]. Rosemont (IL): AAOS; 2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAhmad AA, Yi LM, Ahmad AR. Plating of distal radius fracture using the wide-awake anesthesia technique. J Hand Surg Am. 2018;43(11):e10451\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWakai A, Winter DC, Street JT, Redmond PH. Pneumatic tourniquets in extremity surgery. J Am Acad Orthop Surg. 2001;9(5):345\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNoordin S, McEwen JA, Kragh CJ Jr, Eisen A, Masri BA. Surgical tourniquets in orthopaedics. J Bone Joint Surg Am. 2009;91(12):2958\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEstebe JP, Davies JM, Richeb\u0026eacute; P. The pneumatic tourniquet: mechanical, ischaemia-reperfusion and systemic effects. Eur J Anaesthesiol. 2011;28(6):404\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHorlocker TT, Hebl JR. Regional anesthesia essentials: upper and lower extremity tourniquet use. Reg Anesth Pain Med. 2003;28(6):508\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHuang YC, Hsu CJ, Renn JH, et al. WALANT for distal radius fracture: open reduction with plating fixation via wide-awake local anesthesia with no tourniquet. J Orthop Surg Res. 2018;13:195.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAdams MCB, Sward KA, Perkins ML, Hurley RW. Standardizing research methods for opioid dose comparison: NIH HEAL MME calculator. Pain. 2025;00(00):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeinberg EG, Agel J, Roberts CS, et al. AO/OTA Fracture and Dislocation Classification Compendium\u0026ndash;2018. J Orthop Trauma. 2018;32(Suppl 1):S1\u0026ndash;170.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOng CK, Seymour RA, Lirk P, Merry AF. Combining morphine consumption and pain scores. Br J Anaesth. 2010;105(4):446\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePalmer AK. Radiographic measurement of the distal radius. J Hand Surg Am. 1981;6(4):376\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTai TW, Chang CW, Lai KA, et al. Effects of tourniquet use on blood loss and soft-tissue damage in total knee arthroplasty. J Bone Joint Surg Am. 2012;94(24):2209\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLu Y, Wang D, Li T, et al. Tourniquet-induced nerve compression injuries caused by high pressure gradients. BMC Biomed Eng. 2020;2:6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDaniels SE, Upmalis D, Okamoto A, et al. Tapentadol vs oxycodone for acute postoperative pain. Clin J Pain. 2011;27(4):336\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDrew B, Bird D, Matteucci M, Keenan S. Tourniquet conversion: a recommended approach. J Spec Oper Med. 2015;15(3):81\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMedoff RJ. Essential radiographic evaluation for distal radius fractures: keys to successful management. J Hand Surg Am. 2013;38(12):2431\u0026ndash;2445. doi:[10.1016/j.jhsa.2013.09.006].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNicholson LT, Copeland LA, Zeber JE, et al. Hemoglobin and hematocrit changes after orthopedic surgery. Mil Med. 2011;176(12):1350\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWainwright TW, Gill M, McDonald DA, et al. Enhanced recovery after surgery (ERAS) and its applicability for major orthopedic surgery. Best Pract Res Clin Anaesthesiol. 2016;30(1):91\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"distal radius fracture, tourniquet, no-tourniquet, morphine milligram equivalents, postoperative pain, volar tilt, QuickDASH","lastPublishedDoi":"10.21203/rs.3.rs-8005851/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8005851/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eTourniquets provide a bloodless field but may increase ischemic complications and postoperative pain. We compared perioperative and clinical outcomes of distal radius fracture (DRF) fixation with versus without a tourniquet under general or regional anesthesia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe retrospectively reviewed 93 consecutive adults who underwent volar plate open reduction and internal fixation for DRF from January 2020 to September 2023. Patients were grouped by intraoperative tourniquet use (Group I, n\u0026thinsp;=\u0026thinsp;54) versus no tourniquet (Group II, n\u0026thinsp;=\u0026thinsp;39). Outcomes included operative time, perioperative hemoglobin (Hgb) change, hospital stay, pain on postoperative day 1 (VAS), 1-year QuickDASH, standardized opioid consumption in morphine milligram equivalents (MME), and radiographic parameters (radial height, radial inclination, volar tilt). Multivariable linear regression adjusted for age, sex, BMI, and anesthesia type.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAll no-tourniquet cases were completed without conversion. Operative time and 1-year QuickDASH were similar between groups. Hgb drop was greater in the tourniquet group (mean 1.27\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92 vs 1.03\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38 g/dL, p\u0026thinsp;=\u0026thinsp;0.03). The no-tourniquet group showed lower opioid use (mean 20.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15.5 vs 38.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2 mg MME, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and a shorter hospital stay (mean 11.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4 vs 15.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.7 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). VAS tended to be lower without tourniquet (4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 vs 5.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8, p\u0026thinsp;=\u0026thinsp;0.11). Radiographic restoration (volar tilt, radial height, radial inclination) was comparable. Minor skin abrasions occurred only at tourniquet sites (n\u0026thinsp;=\u0026thinsp;3), resolving conservatively. In adjusted analyses, tourniquet use was not an independent predictor of MME, Hgb change, or hospital stay (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eNo-tourniquet DRF fixation is feasible and associated with less opioid consumption and shorter hospitalization without compromising reduction quality or functional recovery. These data support a pragmatic tourniquet-free workflow for upper-extremity trauma surgery.\u003c/p\u003e","manuscriptTitle":"Feasibility of Distal Radius Fracture Fixation With or Without a Tourniquet Under General or Regional Anesthesia: A Retrospective Comparative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 11:27:41","doi":"10.21203/rs.3.rs-8005851/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"748f7c03-43fe-4c44-92c2-a551e335438f","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T20:54:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-08 11:27:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8005851","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8005851","identity":"rs-8005851","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}