Key Points
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Treatment is based on radiographical fracture pattern, bone quality, and functional demand.
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Evidence suggests that functional recovery may be faster in volar locking plating compared to conservative treatment, whereas there is not enough study of external fixation and percutaneous pinning compared to conservative treatment regarding patient-reported outcome.
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Evidence suggests that regarding the complication rate, which needed secondary surgery, there is no statistical difference in percutaneous pinning and volar plating compared to conservative treatment. The risk of having secondary surgery may be lower in external fixation compared to conservative treatment.
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When performing the surgical treatment, care should be taken to prevent nerve and tendon injury.
A 48-year-old, right-handed female who works in the agricultural industry visited the orthopedics clinic with a swollen and deformed right wrist after a fall on the outstretched hand while riding a bicycle. Radiographs showed an extraarticular distal radius fracture with 25 degrees of dorsal tilt ( Fig. 1 ). What is the most effective approach for the treatment of her fracture?
Importance of the Problem
Distal radius fracture (DRF) is one of the most common types of fracture, and the pediatric and geriatric population have a higher risk of sustaining this injury. Most of the fractures can be treated by closed reduction and casting. However, conservative treatment can be associated with redisplacement and subsequent malunion of the distal radius, which may lead to the pain and disability. Besides, especially among the elderly population, there is a growing need for faster recovery of limb function.
As surgical treatment of distal radius fractures, percutaneous pinning by K-wires, external fixation, or internal fixation by a volar locking plate (VLP) are widely performed. Conservative treatment is more cost-effective, and there is no risk of complication associated with surgery but can be complicated by malunion or wrist contracture. On the other hand, patients can start the range of motion exercises earlier with a stable surgical fixation, especially with VLP. However, it can be complicated with other adverse events such as tendonitis and tendon ruptures.
The objective of this chapter is to clarify the current evidence comparing surgical treatment and conservative treatment of distal radius fractures.
Main Question
What is the relative effect of conservative treatment versus surgical treatment on functional outcome and complication rates in the management DRFs?
P: patient with distal radius fracture.
I: surgical treatment (percutaneous pinning, volar locking plating, external fixation).
C: conservative treatment (reduction and fixation by cast).
O: patient-reported outcome and complications.
Current Opinion
Surgical indication differs based on the patient’s age, demand, and type of fracture. Generally, surgical treatment is recommended if there is the following one or more parameters on radiographs after reduction.
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More than 10 degrees of dorsal angulation on the lateral view
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Ulnar variance (UV) of more than 2 mm
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Articular step-off or gap of more than 2 mm
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Incongruity of the distal radioulnar joint
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Dorsal loss of substance and comminution of the fracture
Finding the Evidence
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Cochrane search: “Distal radius fracture,” “Distal radial fracture”
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Pubmed (Medline):
((((((((“radius fractures”[MeSH Terms] OR “forearm injuries”[MeSH Terms] OR “wrist injuries” [MeSH Terms]))) OR ((distal radius fracture*[tiab]) OR distal radial fracture*[tiab])))) OR (“Broken wrist*”[tiab] OR “Colles fracture*” [tiab])) AND (((conservative treatment[tiab] OR nonoperative treatment[tiab]) OR nonoperative treatment[tiab] OR splint[tiab] OR cast[tiab] OR casting[tiab] OR closed treatment[tiab] OR closed management[tiab] OR “closed reduction”[tiab])))
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Articles that were not in English were excluded.
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For the pooled analysis of the functional outcome, data from studies that reported the mean and standard deviation of the validated patient-reported outcomes such as Disability of the Arm, Shoulder, and Hand questionnaire (DASH), Patient-Rated Wrist Evaluation (PRWE), Short Form Health Survey-36 (SF-36). If these outcomes were not reported, a result of other functional outcomes that report the functional grade such as Gartland and Werley system were extracted.
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For the article which reported only median and interquartile, mean, and standard deviation were estimated using the method by developed by Wan.
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For percutaneous pinning and external fixation, the complication was defined as the redisplacement of fracture which required the surgery.
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For volar plating, the complication was defined as the condition which requires the surgery, such as carpal tunnel release for carpal tunnel syndrome, tendon rupture, tendonitis which requires plate removal, refixation of the fracture due to redisplacement or malposition of the plate, osteotomy due to malunion, infection requiring lavage, and debridement.
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Data abstraction for the metaanalysis was based on the published studies.
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Due to the nature of the intervention, all studies lacked blinding of the study population and health care providers, as such an overall risk of bias was high.
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Metaanalysis was conducted using StataCorp 2019 ( Stata Statistical Software: Release 16 . College Station, TX: StataCorp LLC).
Percutaneous Pinning vs Conservative Treatment
Quality of the Evidence
Level I:
1A: Metaanalyisis: 1
1B: Randomized controlled trials: 3
Level II:
2B: Randomized controlled trials with methodological limitations: 3
Findings
There is no study that reported DASH or PRWE regarding pinning versus conservative treatment. Only one study reported the SF-36. This study reported a mean physical score of SF-36 at 4 months as 42.2 (SD 9.7) for pinning and 38.2 (SD 11.2) for conservative treatment. For the mental health component score at 4 months, the mean score was 51 (SD 13.2) for pinning and 50.4 (SD 8.6) for conservative treatment. The difference was not statistically significant. Several studies reported the functional grading, the risk ratio of developing fair or poor grading was 0.45 in favor of percutaneous pinning (95% CI: 0.21–0.97, I 2 = 13.9%) ( Fig. 2 ). For the complication rate, there was no difference in the rate of redisplacement requiring surgical treatment (RR 0.09, 95% CI: 0.01–1.03, I 2 = 25.5%) ( Fig. 3 ).
External Fixation vs Conservative Treatment
Quality of the Evidence
Level I:
1A: Metaanalysis: 1
1B: Randomized controlled trials: 1
Level II:
2B: Randomized controlled trials with methodological limitations: 12
Findings
Most studies were randomized controlled trials comparing conservative treatment and external fixation but did not mention the randomization protocol, hence were categorized as level 2B. In addition, none of the studies included DASH or PRWE as an outcome. Moroni et al. reported that the mean SF-36 score was 66.2 (SD 13.1) for conservative treatment and 67.1 (SD 13.1) for external fixation, and the result was not statistically significant. The risk ratio of developing fair or poor grading was not statistically significant (RR 0.73, 95% CI: 0.45–1.18, I 2 = 60.1%) ( Fig. 4 ). For the complication rate, the risk ratio of redisplacement, which needed surgical treatment was 0.24 (95% CI: 0.08–0.68, I 2 = 37.6%) in favor of external fixation ( Fig. 5 ) ( Figs. 6 and 7 ).
Volar Locking Plating vs Conservative Treatment
Quality of the Evidence
Level I:
1A: Systematic Reviews/Metaanalyses: 1
1B: Randomized controlled trials: 6
Level II:
2B: Randomized controlled trials with methodological limitations: 2
Findings
Most of the studies which compared volar plating and conservative treatment included only elderly patients, except for two studies. In addition, there is heterogeneity in the inclusion criteria of the fracture type. Studies by Arora et al., Mulders et al., and Saving et al. excluded patients with an intraarticular fracture, whereas an inclusion criteria of the studies from Bartl et al., and Marinez-Mendez et al. were patients with AO type C fractures. Sirniö et al. excluded C3 type fractures.
Regarding the pooled analysis of patient-reported outcome, five out of eight selected studies reported the mean score of either PRWE or DASH. The study from Mulders et al. reported the median of the functional outcome. In terms of PRWE, 3 months postoperatively, the analysis revealed a significant weighted mean difference (WMD) in favor of volar plating, and the result was clinically significant (WMD = − 16.29, 95% CI: − 21.82 to − 10.76, I 2 = 0%) ( Fig. 2 ). At the final follow up (12–24 month postoperatively), the difference was still statistically significant, but smaller compared to the result of 3 months (WMD = − 8.78, 95% CI: − 12.50 to − 5.06, I 2 = 0%) ( Fig. 3 ). The analysis showed the statistically significant difference of the DASH score in favor of volar plating both at 3 month postoperatively (WMD = − 6.81, 95% CI: − 10.18 to − 3.45, I 2 = 0%) and at the final follow up (12–24 month, postoperatively) (WMD = − 6.26, 95% CI: − 8.97 to − 3.55, I 2 = 31.2%) ( Figs. 8 and 9 ). Six studies reported the rate of overall complications requiring surgery. The result was not statistically significant and substantially heterogeneous (RR 0.74, 95% CI: 0.27–2.02, I 2 = 76.9%) ( Fig. 10 ).
