Comparison of outcomes between nonsurgical and surgical treatment of distal radius fracture: a systematic review update and meta-analysis

Delayed fixation of distal radial fractures beyond three weeks after initial failed closed reduction increases the odds of reoperation

Aims

We aimed to compare reoperations following distal radial fractures (DRFs) managed with early fixation versus delayed fixation following initial closed reduction (CR).

Methods

We used administrative databases in Ontario, Canada, to identify DRF patients aged 18 years or older from 2003 to 2016. We used procedural and fee codes within 30 days to determine which patients underwent early fixation (≤ seven days) or delayed fixation following CR. We grouped patients in the delayed group by their time to definitive fixation (eight to 14 days, 15 to 21 days, and 22 to 30 days). We used intervention and diagnostic codes to identify reoperations within two years. We used multivariable regression to compare the association between early versus delayed fixation and reoperation for all patients and stratified by age (18 to 60 years and > 60 years).

Results

We identified 14,960 DRF patients, 8,339 (55.7%) of whom underwent early surgical fixation (mean 2.9 days (SD 1.8)). In contrast, 4,042 patients (27.0%) underwent delayed fixation between eight and 14 days (mean 10.2 days (SD 2.2)), 1,892 (12.7%) between 14 and 21 days (mean 17.5 days (SD 1.9)) and 687 (4.6%) > 21 days (mean 24.8 days (SD 2.4)) post-fracture. Patients who underwent delayed fixation > 21 days post-fracture had a higher odds of reoperation (odds ratio (OR) 1.33 (95% CI 1.11 to 1.79) vs early fixation). This worsened for patients aged > 60 years (OR 1.69 (95% CI 1.11 to 2.79)). We found no difference in the odds of reoperation for patients who underwent delayed fixation within eight to 14 or 15 to 21 days post-fracture (vs early fixation).

Conclusion

These data suggest that DRF patients with fractures with unacceptable reduction following CR should be managed within three weeks to avoid detrimental outcomes. Prospective studies are required to confirm these findings.

Protocol for a prospective randomized trial of surgical versus conservative management for unstable fractures of the distal radius in patients aged 65 years and older

Aims

The primary aim of this study is to quantify and compare outcomes following a dorsally displaced fracture of the distal radius in elderly patients (aged ≥ 65 years) who are managed conservatively versus with surgical fixation (open reduction and internal fixation). Secondary aims are to assess and compare upper limb-specific function, health-related quality of life, wrist pain, complications, grip strength, range of motion, radiological parameters, healthcare resource use, and cost-effectiveness between the groups.

Methods

A prospectively registered (ISRCTN95922938) randomized parallel group trial will be conducted. Elderly patients meeting the inclusion criteria with a dorsally displaced distal radius facture will be randomized (1:1 ratio) to either conservative management (cast without further manipulation) or surgery. Patients will be assessed at six, 12, 26 weeks, and 52 weeks post intervention. The primary outcome measure and endpoint will be the Patient-Rated Wrist Evaluation (PRWE) at 52 weeks. In addition, the abbreviated version of the Disabilities of Arm, Shoulder and Hand questionnaire (QuickDASH), EuroQol five-dimension questionnaire, pain score (visual analogue scale 1 to 10), complications, grip strength (dynamometer), range of motion (goniometer), and radiological assessments will be undertaken. A cost-utility analysis will be performed to assess the cost-effectiveness of surgery. We aim to recruit 89 subjects per arm (total sample size 178).

Discussion

The results of this study will help guide treatment of dorsally displaced distal radial fractures in the elderly and assess whether surgery offers functional benefit to patients. This is an important finding, as the number of elderly distal radial fractures is estimated to increase in the future due to the ageing population. Evidence-based management strategies are therefore required to ensure the best outcome for the patient and to optimize the use of increasingly scarce healthcare resources.

Factors influencing study outcomes in recent literature on distal radial fracture treatment

The main tools used by an orthopaedic surgeon for managing distal radial fracture treatment are recent literature and treatment guidelines. The aim of the present study was to find which factors within the study design influence study outcomes the most. Trials in three major databases (PubMed, Scopus, Embase) comparing surgical and non-surgical treatment options for adolescent and adult distal radial fractures with their original data, between 2013 and 2021, were included. The selected 47 studies were classified according to their outcomes. The relationship between study characteristics and outcomes was statistically analysed. It was more likely to find no difference in outcomes between volar locking plate and less invasive treatments when the sample size was above 100, follow-up was more than 1 year and functional assessments were used. A small sample size and short follow-up time affect study outcomes in favour of a volar locking plate. Readers should focus on the design criteria and read the full text of the studies before making any conclusions.

LEVEL OF EVIDENCE

III.

Factors Associated with Re-Displacement after Nonsurgical Treatment of Distal Radius Fractures in Adults: A Retrospective Study

OBJECTIVE

Closed reduction combined with external fixation is a frequently utilized approach for treating distal radial fractures in adults. Nonetheless, the potential for re-displacement following external fixation remains. Analyzing the factors influencing re-displacement after nonsurgical treatment of distal radial fractures in adults is vital for preventing re-displacement and making prognostic assessments.

METHODS

A retrospective analysis was performed on 884 patients who underwent nonsurgical treatment for distal radius fractures in the reduction room of the Orthopedics and Traumatology Department of Integrated Traditional Chinese and Western Medicine at Tianjin Hospital, Tianjin, China, between July 2019 and December 2022. Patients were categorized into two groups, namely displaced and nondisplaced, based on radiographic outcomes. Factors affecting fracture re-displacement were examined, including sex, age, side, AO/OTA type, external fixation, and radiographic outcomes at pre-reduction and immediate reduction. Logistic regression analysis was employed to identify the risk factors for fracture re-displacement, and ROC curves were constructed.

RESULTS

Among the 884 patients, 563 (63.69%) experienced re-displacement after fracture reduction. There were no statistically significant differences (p > 0.05) between the two groups in terms of gender, external fixation method, and palmar tilt angle at pre-reduction and immediate reduction, while significant differences (p < 0.05) were observed in age, side, AO/OTA type, and radial inclination, radial length, and radiographic outcomes of ulnar variance at pre-reduction and immediate reduction. Multifactorial logistic regression analysis revealed that age (odds ratio [OR] = 1.027, p < 0.001), AO/OTA type (OR = 2.327, p = 0.005), ulnar variance at pre-reduction (OR = 1.142, p = 0.048), and ulnar variance at immediate reduction (OR = 1.685, p < 0.001) were significant factors (p < 0.05) associated with re-displacement following nonoperative treatment of adult distal radius fractures. For patients aged ≥60 years, the amount of missing radiographic outcomes was positively correlated with age. The receiver operating characteristic curve demonstrated that age ≥65.5 years, ulnar variance >3.26 mm at pre-reduction, and ulnar variance >2.055 mm at immediate reduction were high-risk factors for fracture re-displacement.

CONCLUSIONS

Nonsurgical treatment of distal radius fractures exhibits a higher rate of re-displacement. Age, AO/OTA type, pre-reduction, and immediate reduction ulnar variance are key factors predicting fracture re-displacement.

The Minimum Clinically Important Difference for the Patient-Rated Wrist Evaluation in Surgical Fixation of Distal Radius Fractures: Does Hand Dominance Make a Difference?

BACKGROUND

Distal radius fractures (DRFs) are common orthopaedic injuries. They can be treated in many ways, but the volar locking plate (VLP) is more frequent. Currently, there is limited information regarding the minimum clinically important difference (MCID) in surgically treated DRFs. The purpose of this study was to calculate MCID values for the Patient-Reported Wrist Evaluation (PRWE) in the setting of VLP-treated DRFs.

METHODS

A retrospective review was conducted for patients with isolated, surgically-treated DRFs with a VLP. Exclusions included any concomitant procedure other than a carpal tunnel release, skeletal immaturity, polytrauma, open fracture, or missing PRWE data. MCID was calculated using PRWE, an overall health question, and the anchor-based method.

RESULTS

A total of 131 patients were identified. Approximately 54.2% injured their dominant hand. AO/OTA classification 23C was the most common (n=89, 67.9%). Average baseline, 6-week, and 12-week PRWE were 71.8 ± 19.6, 34.3 ± 20.1, and 21.2 ± 18.0 respectively. This corresponds to an average change from baseline PRWE at 6 weeks and 12 weeks of -37.5 ± 23.4 and -50.6 ± 22.3, respectively. Average MCID values for 6 weeks and 12 weeks were 43.1 ± 18 and 56.0 ± 20.0, respectively (p<0.001). Hand dominance did not correlate with MCID value (rs = 0.084 at six weeks, rs = 0.099 at 12 weeks). MCID value additionally did not correlate with sex, AO/OTA classification, smoking status, ASA score, or BMI. Treatment at a level 1 trauma center and diagnosis of anxiety and/or depression correlated with a higher 6-week MCID value (rs = 0.308 and rs = 0.410, respectively). Increasing age weakly correlated with higher 12-week MCID value (rs = 0.352).

CONCLUSIONS

This study demonstrated an MCID calculation using an overall health anchor. MCID value varied with follow-up time and correlated weakly with age, diagnosis of anxiety and/or depression, and treatment facility, but it did not correlate with injury of the dominant hand. Future research should analyze how to apply MCID and identify successful treatment in the setting of DRF care.

Wearable rehabilitation wristband for distal radius fractures

Background

Distal radius fractures are a common type of fracture. For patients treated with closed reduction with splinting, a period of rehabilitation is still required after the removal of the splint. However, there is a general lack of attention and low compliance to rehabilitation training during this period, so it is necessary to build a rehabilitation training monitoring system to improve the efficiency of patients' rehabilitation.

Methods

A wearable rehabilitation training wristband was proposed, which could be used in the patient's daily rehabilitation training scenario and could recognize four common wrist rehabilitation actions in real-time by using three thin film pressure sensors to detect the pressure change curve at three points on the wrist. An algorithmic framework for classifying rehabilitation training actions was proposed. In our framework, an action pre-detection strategy was designed to exclude false detections caused by switching initial gestures during rehabilitation training and wait for the arrival of the complete signal. To classify the action signals into four categories, firstly an autoencoder was used to downscale the original signal. Six SVMs were then used for evaluation and voting, and the final action with the highest number of votes would be used as the prediction result.

Results

Experimental results showed that the proposed algorithmic framework achieved an average recognition accuracy of 89.62%, an average recognition recall of 88.93%, and an f1 score of 89.27% on the four rehabilitation training actions.

Conclusion

The developed device has the advantages of being small size and easy to wear, which can quickly and accurately identify and classify four common rehabilitation training actions. It can easily be combined with peripheral devices and technologies (e.g., cell phones, computers, Internet) to build different rehabilitation training scenarios, making it worthwhile to use and promote in clinical settings.

Three Column Fixation Through a Single Incision in Distal Radius Fractures

Purpose  The purpose of this study was to evaluate the clinical and functional results of 67 patients with distal radius fracture (DRF), treated with a modified surgical technique that allows three-column fixation through the same palmar approach. Patients and Methods  Between 2014 and 2019, we treated 67 patients using a particular surgical technique. All patients suffered DRF, classified using the universal classification system. Two different intervals were developed palmary: the first ulnarly to the flexor carpi radialis tendon for direct visualization of the distal radius and the second one radially to the radial artery for direct visualization of the styloid process. An anatomic volar locking compression plate was applied to all patients. The radial styloid process was fixed and stabilized either with Kirschner-wires or an anatomic plate through the same incision. Functional results were evaluated based on the Disabilities of the Arm, Shoulder and Hand and Mayo wrist scores. Range of motion and grip strength of the injured wrist were statistically compared with the opposite side. Results  The mean follow-up was 47 months (13-84). All fractures were united, and all patients recovered to the preinjury level of activity. The mean flexion-extension range was 73.8° to 55.2° and the supination-pronation range 82.8° to 67°. No infection or nonunion occurred. No major complications were reported. Conclusion  Open reduction and internal fixation, under specific indications, is the best treatment option in DRF. The described technique provides excellent visualization to the distal radius surfaces and allows the internal fixation of the radial columns through the same skin incision. Therefore, it can constitute an efficient choice in the treatment armamentarium of DRF.

Can elderly patients regain their preoperative functional level after distal radius fracture type A? Results from a fracture register study using PROM

Introduction

Although distal radius fractures (DRFs) are the most common fractures of the human body, there are still ongoing debates concerning the treatment for type A fractures, especially in elderly patients. In spite of good clinical outcomes, it remains unclear whether elderly patients, especially, could regain the preoperative functional level of the wrist. Therefore, we have quantified wrist function within a retrospective study design using patient-reported outcome measures (PROM) and we have analyzed the influence of age between control and patient collective and young vs. old, respectively.

Patients and methods

The retrospective study included all patients with a surgically treated DRF type A and a control group of healthy patients, age and gender matched. The function of the wrist was examined by using a self-assessment questionnaire called the Munich Wrist Questionnaire (MWQ) according to the patient-related outcome measurements PROM.

Results

We could enroll 110 patients and controls, and the average follow-up was 66 months. Subgroup matching induced similar age group distribution: in both groups, 7 individuals &lt;30 years, 67 between 31 and 64 years, 29 between 65 and 79 years, and 7 individuals &gt;80 years, were enrolled, respectively. In the fracture group, women were significantly older than men (59 ± 15 vs. 47 ± 17 (M ± SD). There was no significant difference between the control and the patient groups (96 ± 6 vs. 95 ± 7). The function was significantly different between controls and patients &lt;30 years (100 ± 1 vs. 98 ± 2). In the control group, there was a functional difference in the age group &lt;30 compared with 65–79 and &gt;80 and in the age group 30–64 compared with 65–79 and &gt;80. In the control group, the function was found to be significantly decreasing with advancing age, whereas in the patient group, this influence was absent. A correlation analysis showed a worse function with increasing age in the control group and therefore a negative correlation. In the fracture group, a similar result could not be obtained.

Discussion

Age has a relevant influence on wrist function. Although the wrist function decreases significantly with aging, in the patient group, this influence is absent, and the functional results after surgery are excellent. Even elderly patients can regain their preoperative functional level.

Association between perceived and objective hand-wrist function in distal radius fracture

The relationship between patient-reported outcome measures and objective measures is important for understanding patient expectations. The aim of this study was to investigate the relationship of each section of the Michigan Hand Outcomes Questionnaire (MHQ) to objective measurements in patients with distal radius fracture (DRF). Eighty-four patients who were treated operatively or non-operatively for DRF were included. Injury severity was assessed by the Modified Hand Injury Severity Score. Joint motion was assessed at 6 and 12 weeks and grip strength at 12 weeks after non-operative treatment or surgery. The MHQ was used to assess hand functionality. The relationships between measurements were analyzed by Spearman correlation analysis. Statistical significance was set at p &lt; 0.05. Fifty-one patients (60.7%) were women and 33 (39.3%) men. Mean age was 48.17 ± 12.26 (range, 20-64) years. Fifty-two (61.9%) patients were treated surgically and 32 (38.1%) non-operatively. Forearm pronation-supination and wrist flexion and ulnar deviation at week 6 and forearm pronation-supination, wrist extension and radial deviation at week 12 correlated with MHQ scores, unlike wrist extension and radial deviation at week 6 and flexion and ulnar deviation at week 12. Gross and fine grip strength at week 12 correlated with MHQ, except for the overall hand function, work performance and pain subsections. The MHQ subsections correlated with joint motion and grip strength in the early period after DRF. These findings clarified patient expectations in the early period.

Effectiveness of surgical versus conservative treatment of distal radius fractures in elderly patients: A systematic review and meta-analysis

BACKGROUND

The aim of this study was to determine whether surgical treatment is more effective than conservative treatment in terms of functional outcomes in elderly patients with distal radius fractures (DRFs).

METHODS

An electronic search of the Medline, Central, Embase, PEDro, Lilacs, CINAHL, SPORTDiscus, and Web of Science databases was performed, from inception until July 2021. The eligibility criteria for selecting studies were randomized clinical trials that compared surgical versus conservative treatment in subjects older than 60 years with DRFs. Two authors independently performed the search, data extraction, and assessed risk of bias (RoB) using the Cochrane RoB tool.

RESULTS

Twelve trials met the eligibility criteria, and nine studies were included in the quantitative synthesis. For volar plate versus cast immobilization at 1-year follow-up, the mean difference (MD) for PRWE was -5.36 points (p=0.02), for DASH was -4.03 points (p=0.02), for grip strength was 8.32% (p=0.0004), for wrist flexion was 4.35 degrees (p=0.10), for wrist extension was -1.52 degrees (p=0.008), for pronation was 2.7 degrees (p=0.009), for supination was 4.88 degrees (p=0.002), and for EQ-VAS was 2.73 points (p=0.0007), with differences in favor of volar plate. For K-wire versus cast immobilization at 12 months, there were no statistically significant differences in wrist range of motion (p>0.05).

CONCLUSIONS

There was low to high evidence according to GRADE ratings, with a statistically significant difference in functional outcomes in favor of volar plate versus conservative treatment at 1-year follow-up. However, these differences are not minimally clinically important, suggesting that both types of management are equally effective in patients older than 60 years with DRFs.

LEVEL OF EVIDENCE

I; Therapeutic (Systematic review and meta-analysis of randomized clinical trials).

Standard radiographic assessments of distal radius fractures miss involvement of the distal radioulnar joint: a diagnostic study

INTRODUCTION

Distal radius fractures account for one-fifth of all fractures in the emergency department. Their classification based on standard radiographs is common practice although low inter-observer reliabilities and superiority of computer tomography (CT) scanning in evaluation of joint congruency have been reported.

MATERIALS AND METHODS

We retrospectively analyzed 96 displaced distal radius fractures scheduled for open reduction and internal fixation using standard radiographic assessment. The radiographs were classified with the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA), Fernandez and Frykman classifications by three observers and inter-rater reliabilities were calculated. Additional CT scanning was performed in all cases and the following parameters were assessed: radiocarpal joint involvement, fracture extent into the radial sigmoid notch, i.e. the distal radio-ulnar joint, comminution of the metaphysis, and concomitant ulnar styloid fracture. The CT scans were used as a reference standard to determine sensitivity and accuracy of standard radiographic assessment in evaluation of distal radius fractures.

RESULTS

The inter-rater agreement for the AO classification was 35.4%, 68.8% for the Fernandez and 38.5% for the Frykman classification. Fracture extension into the radiocarpal joint was present in 81 cases (84.4%). Sigmoid notch involvement was found in 81 fractures (84.4%). Involvement of both joints was present in 72 cases (75%). The sensitivity of standard radiographs regarding radiocarpal joint involvement was 93.8%. Considering involvement of the distal radio-ulnar joint the false-negative rate using standard radiographs was 61.7% and the test's accuracy for sigmoid notch involvement was 45.8%.

CONCLUSION

This study demonstrates that involvement of the sigmoid notch is frequently missed in standard radiographs. The presented data support the frequent use of CT imaging to allow the holistic illustration of a fracture's complexion and to ensure optimal pre-operative planning.

A comparative study of variable angle volar plate and bridging external fixator with K-wire augmentation in comminuted distal radius fractures

PURPOSE

Comminuted intraarticular distal radial fractures are difficult to treat conservatively and require operative treatment. This study compared the functional outcomes between variable angle volar plating and external fixator with K-wire augmentation in open reduction and internal fixation.

METHODS

A total of 62 adult patients with comminuted intraarticular distal radius fracture were randomized into 2 groups: volar plate group and external fixator group. These patients aged between 18 and 60 years had unilateral fractures, and agreed to be included in the study. Patients with a history of fracture, bilateral fracture, associated other injuries, delayed injury for more than 2 weeks, open fracture, pre-existing arthrosis or disability, psychiatric illness and pathological fracture were excluded. Patients were followed up at 6 weeks, 3 months, 6 months and 1 year. The assessment of pain, functional activity, range of motion and grip strength was done at each stage of follow-up. The pain and functional activities were assessed by patient rated wrist evaluation (PRWE) score and disabilities of the arm, shoulder and hand (DASH) score.

RESULTS

Patients in volar plate group had superior PRWE score and DASH score at each stage of follow-up. At 1 year follow-up, the mean PRWE score were 7.48 for volar plate group and 7.35 for external fixator group; while the mean DASH score was 4.65 for volar plate group and 5.61 for external fixator group. They had better flexion and extension range of movement. They also had better pronation and supination range of motion at initial follow-up, however the difference get attenuated by 1 year. Volar plate group had significantly better grip strength than external fixator group. Complication rates were higher in external fixation group.

CONCLUSION

Fixation with variable angle volar plate results in early wrist mobilization, better range of movement, less pain and disability and early return of function.

The external fixation can be a good alternative to plate-screw treatment in the surgical treatment of bilateral distal radius fractures: A retrospective cohort study

Objectives

We aimed to compare the outcomes of two surgical treatment options, external fixator (EF) or open reduction and internal fixation (ORIF), in patients with bilateral distal radius fractures (DRFs).

Patients and methods

Twenty-one patients (11 males 10 females; mean age: 40.0±16.0 years; range, 20 to 67 years) who underwent ORIF (n=10) or EF (n=11) due to bilateral DRF at between January 2011 and December 2019 were retrospectively analyzed. The Quick Disability of the Arm, Shoulder and Hand (Q-DASH) was used to calculate functional and symptomatic evaluation. The MAYO wrist scores were used to evaluate pain, functional status, ROM, and grip strength and the Michigan Hand Outcomes Questionnaire (MHOQ) was used to measure hand performance in daily life.

Results

The operation time was statistically significantly longer in the ORIF group, compared to the EF group (p<0.001). Radial shortening was statistically significantly greater in the EF group, compared to the ORIF group (p<0.001). While the Q-DASH score was lower in the EF group on Day 15 and at one and two months (p<0.001, for each), it was similar between the groups at one year (p=0.507). The MAYO wrist score was higher in the EF group on Day 15 and at one and two months and one year (p<0.05, for each). While the MHOQ score was higher in the EF group on Day 15 and at one and two months (p<0.001, for each), it was similar between the groups at one year (p=0.557).

Conclusion

In bilateral DRF cases, hand functions in the first two months after treatment were better in the EF group, compared to the ORIF group. This functional difference between the two groups gradually decreased in the first year and reached similar levels. Our results demonstrate that EF can be a good alternative in the surgical treatment of bilateral DRFs owing to its acceptable results, particularly in the short-term.

Operative vs conservative treatment in distal radius fractures: A protocol

BACKGROUND

Given this lack of conclusive outcome data, there are currently no clear guidelines to direct the treatment of displaced distal radius fractures in the elderly. This retrospective clinical trial was performed to compare the outcomes of two methods that were used for the treatment of displaced and unstable distal radial fractures in patients 65 years of age or older: METHODS:: This study was performed and reported in accordance with the Strengthening the Reporting of Observational studies in Epidemiology checklist. Between January 2017 and May 2018, a total of 184 patients who presented to Huzhou Traditional Chinese Medicine Hospital with distal radius fractures were extracted from the hospital database and evaluated for eligibility. This retrospective cohort study was approved by the institutional review board in our hospital. Outcome measures included Patient-Related Wrist Evaluation score, patient satisfaction, complications, and radiographic outcomes. SPSS software package (version 21.0; SPSS Inc, Chicago, IL) was used for all statistical analyses.

RESULTS

The hypothesis was that the two groups would achieve similar functional scores and complications in distal radial fractures.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5689).