4 Distal Radius Fracture: The Evidence
Abstract
Distal radius fractures are common injuries and, as such, a large number of studies focusing on both nonoperative and operative treatment have been published. A review of level one studies reveals that nonoperative management can be performed in either a cast or functional brace with equivalent results. The decision on whether to proceed with operative treatment remains controversial. In terms of surgical management, open reduction internal fixation (ORIF), closed reduction and pinning (CRPP), and external fixation produce similar results at 1 year although an earlier return to function favors ORIF with a volar plate. Treating surgeons should evaluate patients with fragility fractures for underlying osteoporosis and initiate treatment when appropriate.
4.1 Introduction
Distal radius fractures (DRFs) are the most common fracture of the upper extremity, accounting for 2% of all emergency room visits and one-sixth of all fractures. There are more than 600,000 DRFs in the United States annually. 1 Furthermore, the overall incidence of DRFs has been increasing. DRFs have a bimodal age distribution, affecting young people with high-energy injuries and older patients with osteoporotic fractures. Given the common nature of DRF, there is a wide spectrum of existing literature examining the treatment and outcomes of these injuries. High-quality, randomized studies, however, are rare. This chapter reviews the existing evidence guiding the surgical management of DRF.
The Canadian task force originally described levels of evidence in 1979. They developed a system of grading evidence to optimize internal validity based on the study’s level of bias. 2 Randomized controlled trials (RCTs) and meta-analyses of RCTs are considered level 1 evidence. This review focuses on level 1 studies examining the treatment of DRF.
4.2 Methods
We reviewed the 2009 American Academy of Orthopaedic Surgeons (AAOS) Guidelines on the Treatment of Distal Radius Fractures 3 and included all RCTs that were deemed high-quality studies. We next searched PubMed for newer RCTs published after the clinical guidelines were released. Keywords used included distal radius, radius, fracture, open reduction internal fixation (ORIF), external fixation, operative, nonoperative, percutaneous pinning, osteoporosis, therapy, and RCT. All studies reviewed were published after 1996, included at least 30 patients, and were published in the English language.
4.3 Nonoperative Fracture Treatment
Nonoperative treatment remains the most common method of treatment of DRFs. 1 When treating patients conservatively, fractures can be managed in a splint, cast, or functional brace. Splints can be removed for hygiene but provide less support. Functional braces provide circumferential support but require active motion producing muscle contractions to function correctly. 4
To investigate the optimal method of immobilization for nondisplaced DRFs, O’Connor performed an RCT of 66 patients randomized to removable splint versus casting. Patients with nondisplaced DRFs had better outcomes when treated in a removable splint versus a cast when comparing patient satisfaction, complications related to the cast, functional assessment, and range of motion (ROM) at 6 weeks. However, at 12 weeks, their functional assessment and ROM were no longer significantly different. 5
Tumia et al randomized 339 displaced and nondisplaced DRFs into treatment with a traditional plaster casts versus Colles prefabricated fracture braces after reduction. There were similar results in both study arms in regard to maintenance of fracture reduction and pain scores. The fracture brace group had better early grip strength at 5 weeks for both manipulated and nonmanipulated fractures. There was no difference in functional outcome between treatment groups. 6 DRFs that have satisfactory reduction either with or without manipulation can thus be treated in a plaster cast or a functional brace.
4.4 Surgery versus Immobilization for Displaced Distal Radius Fracture
The first decision in managing a displaced DRF is determining whether the patient should be treated conservatively or operatively. Normal radiographic parameters of acceptable reduction include 23° of radial inclination, 12 mm of radial height, and 11° of volar angulation. Measuring these radiographic parameters has been found to be reliable and reproducible. 7 The 2009 AAOS clinical guidelines suggested operative fixation for fractures with a postreduction radial shortening greater than 3 mm, dorsal tilt greater than 10°, or greater than 2 mm of intraarticular step-off. Although radiographic criteria exist, 3 there is a continuous debate in the literature on which patients benefit the most from operative management.
McQueen evaluated patients with displaced DRF initially treated with closed reduction. They randomized 120 patients to 4 groups: rereduction and casting, ORIF with a single K-wire and a corticocancellous iliac crest bone graft placed dorsally, spanning external fixation, and a hinged spanning external fixation with early wrist ROM. They found no difference in patient outcome (activities of daily living [ADL], grip strength, and ROM) between the groups although the ORIF arm had superior radiographic results. Carpal malalignment, defined as displacement on the lateral view of the longitudinal axis of the capitate in reference to the longitudinal axis of the radius, was associated with worse ROM, grip strength, and pinch strength, but the overall carpal malalignment was not significantly different between groups. 8 Although this study is well designed and executed, with four study arms, the techniques and technology of ORIF have evolved, leading us to question the current clinical relevance of the results.
Several studies have compared outcomes for displaced DRFs treated with casting versus external fixation. Young randomized 85 displaced DRFs to reduction and casting versus reduction and external fixation. At 7 years postinjury, there was no difference in functional outcome and patient satisfaction between groups. Radiographic malunion was significantly higher in the casted group but this did not correlate with functional outcome. 9 Kreder et al randomized 113 patients with displaced extraarticular fractures to casting versus external fixation with supplemental K-wires. There was a trend towards better function, clinical and radiographic outcomes in the operative group; however, this was not statistically significant. They found no difference in ROM, grip strength, or pinch strength between groups. 10
Together, these studies suggest that similar functional outcomes can be obtained with surgical and nonsurgical management. However, the groups are heterogeneous and conclusions are difficult to generalize. As such, the decision as to whether to proceed with surgery or not should be shared between the patients and the treating physician.
4.5 The Management of Elderly Patients
DRFs often occur in elderly patients from a fall from a standing height. For the purpose of this chapter, we define elderly as patients older than 60 years. Underlying decreases in bone mineral density (BMD) puts them at higher risk for these low-energy fractures. Their demands and fracture morphology differ from younger patients with high-energy injuries. As such, the optimal treatment of DRFs in the elderly deserves special mention.
Two studies have compared casting to closed reduction percutaneous pinning (CRPP) of displaced extra-articular fractures in patients over the age of 60. A randomized controlled study of 60 patients over 65 years of age with displaced extra-articular DRFs (greater than 20° of dorsal angulation and 5-mm shortening) found no difference in Mayo wrist scores, quality of life, healing time, or complications in those treated with casting versus CRPP. Radiographic outcomes were significantly better in the CRPP group. 11 A similar study performed by Azzopardi et al randomized 57 patients over the age of 60 years with unstable extra-articular DRFs to closed reduction and casting in the operating room versus CRPP. They also reported an improvement in radiographic alignment but no difference in functional outcomes (pain, ROM, grip strength, and ADL). The CRPP group did have improved ulnar deviation, although this was of uncertain significance. 12
When determining how to optimize the function of elderly patients, it is important to consider ORIF in addition to casting and CRPP. ORIF allows earlier return to activities, which may improve patient function. Arora randomized 73 patients over 65 years of age to ORIF versus casting. The operative group had significantly better radiographic parameters and grip strength. However, there was no difference in ROM or pain at any time point. They also found that functional outcomes were better at 6 and 12 weeks in the operative group but there was no significant difference at 6 and 12 months. 13
In summary, nonoperative and operative management of DRF in patients over the age of 60 appears to have similar outcomes at 1 year. Operative treatment results in better radiographic alignment and may allow an earlier return of function. As our aging population becomes more active, it is important to individualize treatment for these patients when choosing operative versus nonoperative fracture management.
4.6 Operative Treatment for Displaced Distal Radius Fracture: Method of Fixation
Operative treatment is designed to restore anatomic alignment and maximize a patient’s functional outcomes. Multiple options exist ranging from external fixation (bridging versus nonbridging), CRPP, a combination of external fixation with CRPP, and ORIF via multiple different surgical approaches.
4.6.1 Bridging versus Nonbridging External Fixation
External fixation can be used as a temporizing treatment or as definitive fixation. When placing an external fixator, the construct can span the wrist joint, achieving distal fixation in the metacarpals or it can be a nonbridging external fixator, allowing wrist ROM. McQueen et al randomized 60 patients to nonbridging and bridging external fixation and found that patients with nonbridging external fixators had significantly greater grip strength and flexion as well as better maintenance of volar tilt and carpal alignment at 6 weeks, 3 months, 6 months, and 1 year. 14 However, in another RCT of 60 patients, Krisnan found that there was no difference between bridging external fixation and nonbridging external fixator for intra-articular DRFs when comparing postoperative ROM, grip strength, and complications. 15 Although these two studies investigate the same question, they support different conclusions.
4.6.2 Closed Reduction Percutaneous Pinning versus Open Reduction Internal Fixation
CRPP for DRFs has been performed for almost a century with excellent results. ORIF using plate fixation has been gaining in popularity, particularly since the advent of volar plating.
An RCT of 180 patients found no difference in ROM, grip strength, pinch strength, or restoration of radiographic parameters at 2 years postoperatively in patients who underwent ORIF with a dorsal approach versus CRPP. 16 Volar locking plates (VLP) were introduced in 2001 and have had a large impact on the management of displaced DRF. In some parts of the world, this is now the most common approach in the surgical treatment of these injuries. 1 Rozental performed a two-institution RCT comparing ORIF with VLP to CRPP with a specific emphasis on early functional outcomes. They found that patients treated with VLP had significantly improved outcome by disabilities of the arm, shoulder, and hand (DASH) score at 6, 9, and 12 weeks postoperatively as well as significantly improved wrist ROM at 6 and 9 weeks. There was no difference in ROM or functional outcome at 1 year postoperatively. Patients treated with VLP reported better satisfaction with their treatment than patients managed by CRPP. 17 Since then, several RCTs have been performed with similar findings. A large RCT involving 461 patients across 18 trauma centers in the United Kingdom reported no difference in the patient-rated wrist evaluation in the VLP and CRPP groups at 3, 6, or 12 months. Additionally, they did not find a clinically relevant difference in the quality of life at these time points. 18
Two recent meta-analyses of 7 RCTs including 875 fractures examined the outcomes in patients treated with VLPs versus CRPP. Chaudhry et al concluded that patients treated with VLPs had slightly better function than those treated with CRPP at 3 and 12 months postoperatively. However, at both of these time points, there was less than 10-point difference on DASH, a predetermined value demonstrated to be a clinically significant difference. At 3 months, those treated with VLP had improved flexion and supination, but at 1 year, there was no difference. The authors reported that superficial wound infection requiring oral antibiotics was more common in CRPP group. 19 In analyzing the same seven RCTs, Zong et al concluded that patients with VLPs had significantly improved grip strength, wrist flexion, and supination at 6 months compared to CRPP. They also noted that ORIF with VLP had statistically significantly lower DASH and less postoperative complications including postoperative infections when compared to CRPP. 20
In conclusion, both VLP and CRPP are viable options in the treatment of displaced DRF although VLP may allow an earlier improvement in function.
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