Cast immobilization is non-inferior to volar locking plates in relation to QuickDASH after one year in patients aged 65 years and older: a randomized controlled trial of displaced distal radius fractures

Abstract

Aims To compare operative and nonoperative treatment for displaced distal radius fractures in patients aged over 65 years. Methods A total of 100 patients were randomized in this non-inferiority trial, comparing cast immobilization with operation with a volar locking plate. Patients with displaced AO/OTA A and C fractures were eligible if one of the following were found after initial closed reduction: 1) dorsal angulation > 10°; 2) ulnar variance > 3 mm; or 3) intra-articular step-off > 2 mm. Primary outcome measure was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) after 12 months. Secondary outcome measures were the Patient-Rated Wrist and Hand Evaluation (PRWHE), EuroQol-5 dimensions 5-level questionnaire (EQ-5D-5L), range of motion (ROM), grip strength, “satisfaction with wrist function” (score 0 to 10), and complications. Results In all, 89 women and 11 men were included. Mean age was 74 years (65 to 91). Nonoperative treatment was non-inferior to operation with a five-point difference in median QuickDASH after 12 months (p = 0.206). After three and six months QuickDASH favoured the operative group (p = 0.010 and 0.030). Median values for PRWHE were 19 (interquartile range (IRQ) 10 to 32) in the operative group versus ten (IQR 1 to 31) in the nonoperative group at three months (p = 0.064), nine (IQR 2 to 20) versus five (IQR 0 to 13) (p = 0.020) at six months, and two (IQR 0 to 12) versus zero (IQR 0 to 8) (p = 0.019) after 12 months. Range of motion was similar between the groups. The EQ-5D-5L index score was better (mean difference 0.07) in the operative group at three and 12 months (p = 0.008 and 0.020). The complication rate was similar (p = 0.220). The operated patients were more satisfied with wrist function (median 8 (IQR 6 to 9) vs 6 (IQR 5 to 7) at three months, p = 0.002; 9 (IQR 7 to 9) vs 8 (IQR 6 to 8) at six months, p = 0.002; and 10 (IQR 8 to 10) vs 8 (IQR 7 to 9) at 12 months, p < 0.001). Conclusion Nonoperative treatment was non-inferior to operative treatment based on QuickDASH after one year. Patients in the operative group had a faster recovery and were more satisfied with wrist function. Results from previous trials comparing operative and nonoperative treatment for displaced distal radius fractures in the elderly vary between favouring the operative group and showing similar results between the treatments. This randomized trial suggests that most elderly patients may be treated nonoperatively. Cite this article: Bone Joint J 2021;103-B(2):247–255.

Objective Outcome Measures Continue to Improve from 6 to 12 Months after Conservatively Treated Distal Radius Fractures in the Elderly—A Prospective Evaluation of 50 Patients

“…In addition, the qDASH may even be more sensitive and responsive to functional impairments than the DASH (Disabilities of Shoulder and Hand) [ 24 , 25 ]. In our study, ROM also progressed from six until 12 months and normalized, which is corroborated by Hassellund et al [ 26 ].…”

“…Nonetheless, the functional recovery and complication rate were not compromised in this group. Additionally, in this group there is a growing body of evidence in support of non-operative treatment in the long-term and a suggestion to reserve surgery for patients in need of fast recovery [ 15 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ].…”

A New Year and some good opportunities

“…I would like to reflect on some of the highlights of the past year: 2021 saw a particular focus on the diagnosis and management of periprosthetic infection, [1][2][3][4][5][6][7][8] as well as continued enthusiasm for enhanced technologies, such as robotics, [9][10][11][12][13][14][15][16] and some outstanding trauma studies. [17][18][19][20][21][22][23][24] There was, as ever, a danger of an imbalance towards the hip and the knee due to the large quantity and excellent quality and impact of papers in those areas; 25 we hope to rebalance this year by encouraging high-quality submissions across the full depth and breadth of trauma and orthopaedics.…”

Surgical treatment is not cost-effective compared to nonoperative treatment for displaced distal radius fractures in patients 65 years and over

“…persistent pain, loss of wrist motion, and reduced grip strength. 3 The burden to society is mainly in acute costs of treating the fracture and aiding the recovery, but for patients with marked sequelae the need for healthcare resources may continue. Non-displaced fractures are usually treated nonoperatively, whereas surgery may improve the functional results in displaced fractures, at a potentially higher cost.…”

“…The main conclusion was that nonoperative treatment was noninferior to operation, and that most elderly patients can be treated nonoperatively. 3 Despite this, operative treatment is increasing in number and invasiveness, also in elderly patients. 9 The total healthcare provider costs are high due to the incidence of these fractures, and the choice of treatment influence the costs.…”