• Hand & Wrist Conditions
• Orthopaedic Procedures
• Orthopaedics Clinical Trials

• Hand & Wrist Conditions
• Orthopaedic Procedures
• Orthopaedics Clinical Trials
• Orthopaedics

Closed reduction and cast immobilization appear to be just as effective as surgery on health-related quality of life and functional measures in older patients with displaced intra-articular distal radial fractures. This was the main finding of a randomized controlled trial [ISRCTN76120052] presented by Christoph Bartl, MD, Ulm University, Ulm, Germany.

Fractures of the distal radius are the most common fracture in older patients and may be an indicator of the onset of osteoporosis. Treatment options include (1) closed reduction and plaster casting and (2) open reduction and internal fixation with volar locking plate fixation.

Angle-stable volar locking plates have been especially advocated for use in the surgical fixation of distal radial fractures in osteoporotic bone, with the proposed rationale being that threaded screws in the screw hole of the plate reduce shear forces to prevent loosening of the surgical construct, although the benefits have not been proven. Closed reduction and cast stabilization for 6 weeks is simple, convenient, and readily available, whereas surgical management requires hospitalization but allows for early mobilization and functional rehabilitation. The superior strategy remains controversial, said Prof Bartl.

In this multicenter clinical trial, 185 patients aged ≥ 65 years with an intra-articular distal radius fracture agreed to participate: 94 were assigned to surgical management with volar locking plate fixation and 91 were assigned to closed reduction and cast immobilization for 6 weeks. The primary outcome was the Short Form-36 (SF-36) Physical Component Summary score 1 year after randomization. Other outcomes assessed were the Disabilities of the Arm, Shoulder, and Hand (DASH) score, the EuroQol-5D (EQ-5D) visual analog scale and utility index, and wrist range of motion (ROM), in addition to radiographic evaluation of the wrist at 3 and 12 months.

Baseline characteristics—age, sex, fracture severity, general health status, and activity status—were similar between the 2 groups. Thirty-seven patients (41%) assigned to cast immobilization had subsequent surgery due to significant loss of reduction in the cast. After 1 year, in the intention-to-treat population, surgery showed a marginal nonsignificant advantage when compared to cast treatment (SF-36 Physical Component Summary mean difference, 3.3 in favor of surgery; 95% CI, −0.2 to 6.8). The mean difference in DASH scores (5.0 in favor of surgery; 95% CI, 1.0 to 11.0), EQ-5D visual analog scale scores (3.0 in favor of surgery; 95% CI, −1.9 to 7.9), and EQ-5D utility index (0.0 in favor of surgery; 95% CI, −0.06 to 0.06) were also not significantly different between the treatment groups.

In both treatment groups, patients returned to their preinjury activity statuses without significant differences between them. Although the group that underwent surgery had a faster improvement in wrist ROM at 3 months (P < .05), there was no significant difference in wrist ROM in all planes between groups at the 1-year follow-up. Although anatomic restoration of the distal radius in palmar tilt, ulnar variance, and radial height was significantly superior in the group that received surgery (each P < .05), these improvements did not translate into better function, said Prof Bartl.

The outcomes were similar when the analysis was conducted according to the actual treatment received. Patients in the group with secondary conversion to surgical management achieved equivalent scores when compared to those with primary surgery. Patients with a higher fracture comminution grade (AO/OTA C3) in the cast group had a 2-fold increased risk for conversion to secondary surgical management vs patients with AO/OTA type C1/C2 fractures. Both procedures are safe, as the researchers did not observe cases of infection in the surgical group or relevant cast pressure marks. There was only 1 case of complex regional pain syndrome overall.

Prof Bartl concluded that closed reduction and cast immobilization remain a valid first-line treatment option for elderly patients with displaced intra-articular distal radial fractures. If cast treatment fails, conversion to secondary surgery within 3 weeks does not compromise final outcome results. Patients with high fracture comminution grades and those in high-demand populations may benefit from primary surgical management.

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