Surgical Plating vs Closed Reduction for Fractures in the Distal Radius in Older Patients

Abstract

IMPORTANCEThe burden of injury and costs of wrist fractures are substantial. Surgical treatment became popular without strong supporting evidence.OBJECTIVE To assess whether current surgical treatment for displaced distal radius fractures provided better patient-reported wrist pain and function than nonsurgical treatment in patients 60 years and older. DESIGN, SETTING, AND PARTICIPANTSIn this multicenter randomized clinical trial and parallel observational study, 300 eligible patients were screened from 19 centers in Australia and New Zealand from December 1, 2016, until December 31, 2018. A total of 166 participants were randomized to surgical or nonsurgical treatment and followed up at 3 and 12 months by blinded assessors. Those 134 individuals who declined randomization were included in a parallel observational cohort with the same treatment options and follow-up. The primary analysis was intention to treat; sensitivity analyses included as-treated and per-protocol analyses. INTERVENTION Surgical treatment was open reduction and internal fixation using a volar-locking plate (VLP). Nonsurgical treatment was closed reduction and cast immobilization (CR).MAIN OUTCOMES AND MEASURES The primary outcome was the Patient-Rated Wrist Evaluation score at 12 months. Secondary outcomes were Disabilities of Arm, Shoulder, and Hand questionnaire score, health-related quality of life, pain, major complications, patient-reported treatment success, bother with appearance, and therapy use. RESULTS In the 300 study participants (mean [SD] age, 71.2 [7.5] years; 269 [90%] female; 166 [81 VLP and 85 CR] in the randomized clinical trial sample and 134 [32 VLP and 102 CR] in the observational sample), no clinically important between-group difference in 12-month Patient-Rated Wrist Evaluation scores (mean [SD] score of 19.8 [21.1] for VLP and 21.5 [24.3] for CR; mean difference, 1.7 points; 95% CI −5.4 to 8.8) was observed. No clinically important differences were found in quality of life, wrist pain, or bother at 3 and 12 months. No significant difference was found in total complications between groups (12 of 84 [14%] for the CR group vs 6 of 80 [8%] for the VLP group; risk ratio [RR], 0.53; 95% CI, 0.21-1.33). Patient-reported treatment success favored the VLP group at 12 months (very successful or successful: 70 [89%] vs 57 [70%]; RR, 1.26; 95% CI, 1.07-1.48; P = .005). There was greater use of postoperative physical therapy in the VLP group (56 [72%] vs 44 [54%]; RR, 1.32; 95% CI, 1.04-1.69; P = 0.02).CONCLUSIONS AND RELEVANCE This randomized clinical trial found no between-group differences in improvement in wrist pain or function at 12 months from VLP fixation over CR for displaced distal radius fractures in older people.

Non-operative treatment or volar locking plate fixation for dorsally displaced distal radius fractures in patients over 70 years – a three year follow-up of a randomized controlled trial

“…Randomized trials similar to ours comparing non-operative treatment with volar locking plates in elderly patients have been carried out in the last decade but few studies present data beyond 1 year of follow-up. In contrast to our findings, most authors do not report any significant benefit of surgical treatment [ 9 , 20 , 22 , 23 , 25 ]. The inclusion criteria however differ between studies in both age range and degree of fracture displacement, making comparisons complicated.…”

“…Arora et al present no differences between groups at 12 months, but the fractures in their study healed in nearly anatomical positions, even in the non-operative group [ 20 ]. Lawson et al showed no benefit as measured in PRWE in the RCT with patients > 60 years including fractures with more than 10-degrees of dorsal displacement [ 22 ]. At 12-months follow-up Egol et al did not find surgery to be superior according to DASH, in a case control study of patients aged > 65 years.…”

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

“…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 ].…”

Nonsurgical Management of Distal Radius Fractures in the Elderly: Approaches, Risks and Limitations

“… 3 Multiple trials and studies have also demonstrated nonsurgical treatment of distal radius fractures to be equivocal to surgical treatment. 3 , 5 , 7 , 13 , 22 For patients considering percutaneous operative intervention as opposed to traditional fixation with a volar locking plate, percutaneous pinning of unstable extra-articular fractures of distal radius shows marginal improvement in radiological outcomes compared to cast alone. Despite this, there was no difference in functional outcomes.…”