Early palmar plate fixation of distal radius fractures may benefit patients aged 50 years or older: a randomized trial comparing 2 different treatment protocols

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Abstract

Background and purpose — There is no consensus regarding optimal treatment of displaced distal radius fractures (DRFs). We compared the results of 2 treatment protocols: early palmar plating vs. primary nonoperative treatment of displaced DRFs.

Patients and methods — We performed a prospective randomized controlled study including 80 patients aged ≥ 50 years with dorsally displaced DRFs, excluding AO type C3 fractures. Patients were randomized to undergo either immediate surgery with palmar plating (n = 38), or initial nonoperative treatment (n = 42) after successful closed reduction in both groups. Delayed surgery was performed in nonoperatively treated patients showing early loss of alignment (n = 16). The primary outcome measure was Disabilities of the Arm, Shoulder, and Hand (DASH) score.

Results — Mean DASH scores at 24 months in the early surgery group were 7.9 vs. 14 in the initial nonoperative group (difference between means 6, 95% CI 0.1–11, p = 0.05). Delayed operation was performed on 16/42 of patients due to secondary displacement in the initial nonoperative group. In “as treated” analysis, DASH scores were 7 in the early surgery group, 13 in the nonoperative group, and 17 after delayed surgery (p = 0.02). The difference in DASH scores between early and delayed surgery was 9 points (CI 0.3–19, p = 0.02)

Interpretation — Treatment of DRFs with early palmar plating resulted in better 2-year functional outcomes for ≥50-year-old patients compared with a primary nonoperative treatment protocol. Delayed surgery in case of secondary displacement was not beneficial in terms of function.

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Most cited references 18

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A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older.

Martin Lutz, Moritz C Deml, Rohit Arora … (2011)

Despite the recent trend toward the internal fixation of distal radial fractures in older patients, the currently available literature lacks adequate randomized trials examining whether open reduction and internal fixation (ORIF) with a volar locking plate is superior to nonoperative (cast) treatment. The purpose of the present randomized clinical trial was to compare the outcomes of two methods that were used for the treatment of displaced and unstable distal radial fractures in patients sixty-five years of age or older: (1) ORIF with use of a volar locking plate and (2) closed reduction and plaster immobilization (casting). A prospective randomized study was performed. Seventy-three patients with a displaced and unstable distal radial fracture were randomized to ORIF with a volar locking plate (n = 36) or closed reduction and cast immobilization (n = 37). The outcome was measured on the basis of the Patient-Rated Wrist Evaluation (PRWE) score; the Disabilities of the Arm, Shoulder and Hand (DASH) score; the pain level; the range of wrist motion; the rate of complications; and radiographic measurements including dorsal radial tilt, radial inclination, and ulnar variance. There were no significant differences between the groups in terms of the range of motion or the level of pain during the entire follow-up period (p > 0.05). Patients in the operative treatment group had lower DASH and PRWE scores, indicating better wrist function, in the early postoperative time period (p < 0.05), but there were no significant differences between the groups at six and twelve months. Grip strength was significantly better at all times in the operative treatment group (p < 0.05). Dorsal radial tilt, radial inclination, and radial shortening were significantly better in the operative treatment group than in the nonoperative treatment group at the time of the latest follow-up (p < 0.05). The number of complications was significantly higher in the operative treatment group (thirteen compared with five, p < 0.05). At the twelve-month follow-up examination, the range of motion, the level of pain, and the PRWE and DASH scores were not different between the operative and nonoperative treatment groups. Patients in the operative treatment group had better grip strength through the entire time period. Achieving anatomical reconstruction did not convey any improvement in terms of the range of motion or the ability to perform daily living activities in our cohorts.

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Trends in the United States in the treatment of distal radial fractures in the elderly.

J Birkmeyer, Melissa Shauver, Arthur Chung (2009)

Traditionally, distal radial fractures in the elderly have been treated nonoperatively with casting. However, since the introduction of the volar locking plating system in 2000, there has been an interest in the use of more aggressive treatment methods. The purpose of the present study was to assess changing trends in the treatment of distal radial fractures in elderly patients in the United States. We evaluated a 5% sample of Medicare data from 1996 to 1997 and a 20% sample from 1998 to 2005. Information on four treatment methods (closed treatment, percutaneous pin fixation, internal fixation, and external fixation) was extracted from the dataset. Other available data were diagnosis, physician specialty, and patient age, sex, and race. We calculated frequencies and rates to compare the utilization of different treatments over time. Over the ten-year time period examined, the rate of internal fixation of distal radial fractures in the elderly increased fivefold, from 3% in 1996 to 16% in 2005. Closed treatment, however, remained the predominant method (used for 82% of the fractures in 1996 and 70% in 2005). Fractures in patients with an age of eighty-five years or more were significantly more likely to be treated in a closed fashion (p < 0.0001). There was a large variation among physician specialties with regard to the fixation methods that were used. Orthopaedic surgeons were significantly more likely to use closed treatment than hand surgeons were, whereas hand surgeons were significantly more likely to use internal fixation than orthopaedic surgeons were. Since 2000, although the majority of distal radial fractures are still treated nonoperatively, there has been an increase in the use of internal fixation and a concurrent decrease in the rate of closed treatment of distal radial fractures in the elderly in the United States.

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A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly.

Takashi Oda, Arthur Chung, Javier Ramiro Garcia … (2011)

As the population in developed countries continues to age, the incidence of osteoporotic distal radius fractures (DRFs) will increase as well. Treatment of DRF in the elderly population is controversial. We systematically reviewed the existing literature for the management of DRFs in patients aged 60 and over with 5 common techniques: the volar locking plate system, nonbridging external fixation, bridging external fixation, percutaneous Kirschner wire fixation, and cast immobilization (CI). We reviewed articles retrieved from MEDLINE, Embase, and CINAHL Plus that met predetermined inclusion and exclusion criteria in 2 literature reviews. Outcomes of interest included wrist arc of motion, grip strength, functional outcome measurements, radiographic parameters, and the number and type of complications. We statistically analyzed the data using weighted means and proportions based on the sample size in each study. We identified 2,039 papers and selected 21 papers fitting the inclusion criteria in the primary review of articles with a mean patient age of 60 and older. Statistically significant differences were detected for wrist arc of motion, grip strength, and Disabilities of the Arm, Shoulder, and Hand score, although these findings may not be clinically meaningful. Volar tilt and ulnar variance revealed significant differences among groups, with CI resulting in the worst radiographic outcomes. The complications were significantly different, with CI having the lowest rate of complications, whereas the volar locking plate system had significantly more major complications requiring additional surgical intervention. This systematic review suggests that despite worse radiographic outcomes associated with CI, functional outcomes were no different from those of surgically treated groups for patients age 60 and over. Prospective comparative outcomes studies are necessary to evaluate the rate of functional recovery, cost, and outcomes associated with these 5 treatment methods. Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

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Author and article information

Journal

Journal ID (nlm-ta): Acta Orthop

Journal ID (iso-abbrev): Acta Orthop

Journal ID (publisher-id): IORT

Journal ID (publisher-id): iort20

Title: Acta Orthopaedica

Publisher: Taylor & Francis

ISSN (Print): 1745-3674

ISSN (Electronic): 1745-3682

Publication date (Print): April 2019

Publication date (Electronic): 23 January 2019

Volume: 90

Issue: 2

Pages: 123-128

Affiliations

[a ] Department of Surgery, Division of Orthopaedic and Trauma Surgery, Oulu University Hospital , Oulu;

[b ] Department of Anesthesiology, Surgery, and Intensive Care, Oulu University Hospital , Oulu, Finland

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Correspondence: Kai.Sirnio@ 123456ppshp.fi

Article

Publisher ID: 1561614

DOI: 10.1080/17453674.2018.1561614

PMC ID: 6461076

PubMed ID: 30669897

SO-VID: fce1dca3-1dc2-4f00-9e89-e7f59cbb8de3

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution-Non-Commercial License ( https://creativecommons.org/licenses/by/4.0)

Early palmar plate fixation of distal radius fractures may benefit patients aged 50 years or older: a randomized trial comparing 2 different treatment protocols

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Most cited references 18

A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older.

Trends in the United States in the treatment of distal radial fractures in the elderly.

A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly.

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