Boris A. Zelle MD and Riikkaa E. Nomides MD UT Health San Antonio, Department of Orthopaedics, San Antonio, TX, USA Unstable intra‐articular distal radius fractures frequently undergo surgical fixation. Surgical fixation options include the concepts of internal fixation versus external fixation. Temporary spanning external fixation with or without supplementary percutaneous pin fixation is a widely used standard treatment method. Similarly, open reduction and internal plate (dorsal or volar) represents a commonly used standard treatment method. External fixation relies on indirect reduction of the fracture, but it can be applied in a minimally invasive fashion. Open reduction and internal fixation (ORIF) offers the benefit of a direct reduction with appropriate visualization of the fracture site. However, it also represents a more invasive treatment method as compared to external fixation. In 2013, Esposito et al. published a meta‐analysis of all randomized clinical trials that were published prior to January 2011 (level I evidence).1 A total of nine randomized clinical trials were included in their analysis. Since then an additional four level I studies comparing temporary spanning external fixation with or without supplementary pin fixation versus ORIF with a plate have been published in the literature.2–5 In their meta‐analysis, Esposito et al. reported on the pooled results from nine publications with a total of 707 distal radius fractures treated with ORIF with a plate (n = 356) versus external fixation (n = 351).1 These authors reported favorable functional results regarding upper extremity function as measured by the Disability of the Arm, Shoulder, and Hand (DASH) score in patients undergoing ORIF with a plate (mean difference [MD]: −5.92; 95% confidence interval (CI): −9.89 to −1.96; p <0.01). Moreover, they reported favorable radiographic results as measured by ulnar variance in patients undergoing ORIF with a plate (MD: −0.70, 95% CI: −1.20 to −0.19; p = 0.006). In addition, the risk of infection was lower in the ORIF with a plate group (risk ratio [RR] = 0.37; 95% CI: 0.19–0.73; p <0.01). Subsequent randomized clinical trials confirmed these findings. Jeudy et al. reported on 75 patients undergoing ORIF with a plate (n = 36) versus spanning external fixation (n = 39).2 Patients undergoing ORIF were found to have improved wrist function, as measured by the Green and O’Brien rating scale, at six months after surgery. Moreover, the ulnar variance trended toward superior results in the ORIF group, but this trend was not statistically significant. Williksen et al. reported on 91 patients who were followed for a minimum of five years.5 They reported significantly less radial shortening in the ORIF group. Moreover, a subgroup analysis showed favorable functional outcomes, as measured by the Mayo Wrist Score, in patients with C2 type fractures. Roh et al. reported on 74 patients, who were randomized to ORIF with a plate versus external fixation, with a 12‐month follow‐up.4 These authors reported improved functional outcomes in the ORIF group at three months after surgery, as measured by the Michigan Hand Questionnaire score. At 12 months after surgery the difference between the two groups was no longer significant. However, the ORIF group showed superior radiographic outcomes as measured by the ulnar variance. Recently, Mellstrand Navarro et al. reported on 140 patients, who were randomized to the two treatment groups.3
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Distal Radius Fractures
Clinical scenario
Top three questions
Question 1: In patients with displaced intra‐articular distal radius fractures, does open reduction and internal fixation (ORIF) with a plate result in improved outcomes as compared to temporary spanning external fixation with or without supplementary pin fixation?
Rationale
Clinical comment
Available literature and quality of the evidence
Findings
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