Surgical Versus Conservative Interventions for Displaced Distal Radius Fractures

Importance of the Problem

Distal radius fracture (DRF) is one of the most common types of fracture, and the pediatric and geriatric population have a higher risk of sustaining this injury. Most of the fractures can be treated by closed reduction and casting. However, conservative treatment can be associated with redisplacement and subsequent malunion of the distal radius, which may lead to the pain and disability. Besides, especially among the elderly population, there is a growing need for faster recovery of limb function.

As surgical treatment of distal radius fractures, percutaneous pinning by K-wires, external fixation, or internal fixation by a volar locking plate (VLP) are widely performed. Conservative treatment is more cost-effective, and there is no risk of complication associated with surgery but can be complicated by malunion or wrist contracture. On the other hand, patients can start the range of motion exercises earlier with a stable surgical fixation, especially with VLP. However, it can be complicated with other adverse events such as tendonitis and tendon ruptures.

The objective of this chapter is to clarify the current evidence comparing surgical treatment and conservative treatment of distal radius fractures.

Main Question

What is the relative effect of conservative treatment versus surgical treatment on functional outcome and complication rates in the management DRFs?

P: patient with distal radius fracture.

I: surgical treatment (percutaneous pinning, volar locking plating, external fixation).

C: conservative treatment (reduction and fixation by cast).

O: patient-reported outcome and complications.

Current Opinion

Surgical indication differs based on the patient's age, demand, and type of fracture. Generally, surgical treatment is recommended if there is the following one or more parameters on radiographs after reduction.

• (1)

  More than 10 degrees of dorsal angulation on the lateral view

• (2)

  Ulnar variance (UV) of more than 2 mm

• (3)

  Articular step-off or gap of more than 2 mm

• (4)

  Incongruity of the distal radioulnar joint

• (5)

  Dorsal loss of substance and comminution of the fracture

Finding the Evidence

• Cochrane search: “Distal radius fracture,” “Distal radial fracture”

• Pubmed (Medline):

  • ((((((((“radius fractures”[MeSH Terms] OR “forearm injuries”[MeSH Terms] OR “wrist injuries” [MeSH Terms]))) OR ((distal radius fracture*[tiab]) OR distal radial fracture*[tiab])))) OR (“Broken wrist*”[tiab] OR “Colles fracture*” [tiab])) AND (((conservative treatment[tiab] OR nonoperative treatment[tiab]) OR nonoperative treatment[tiab] OR splint[tiab] OR cast[tiab] OR casting[tiab] OR closed treatment[tiab] OR closed management[tiab] OR “closed reduction”[tiab])))

• Articles that were not in English were excluded.

• For the pooled analysis of the functional outcome, data from studies that reported the mean and standard deviation of the validated patient-reported outcomes such as Disability of the Arm, Shoulder, and Hand questionnaire (DASH), Patient-Rated Wrist Evaluation (PRWE), Short Form Health Survey-36 (SF-36). If these outcomes were not reported, a result of other functional outcomes that report the functional grade such as Gartland and Werley system were extracted.

• For the article which reported only median and interquartile, mean, and standard deviation were estimated using the method by developed by Wan.

• For percutaneous pinning and external fixation, the complication was defined as the redisplacement of fracture which required the surgery.

• For volar plating, the complication was defined as the condition which requires the surgery, such as carpal tunnel release for carpal tunnel syndrome, tendon rupture, tendonitis which requires plate removal, refixation of the fracture due to redisplacement or malposition of the plate, osteotomy due to malunion, infection requiring lavage, and debridement.

• Data abstraction for the metaanalysis was based on the published studies.

• Due to the nature of the intervention, all studies lacked blinding of the study population and health care providers, as such an overall risk of bias was high.

• Metaanalysis was conducted using StataCorp 2019 ( Stata Statistical Software: Release 16 . College Station, TX: StataCorp LLC).

Percutaneous Pinning vs Conservative Treatment