Early Mobilization Versus Splinting After Surgical Management of Distal Radius Fractures

Is Immobilization Necessary After Open Reduction and Internal Fixation of Distal Radius Fractures? A Meta-Analysis of Randomized Controlled Trials

Distal radius fractures (DRFs) are the most common fractures in adults. With the increased trend in open reduction and internal fixation (ORIF) using a volar locking plate, the postoperative rehabilitation course remains debated and whether or not a postoperative immobilization is necessary is unknown. PubMed, Cochrane, and Google Scholar (pages 1-20) were queried through August 2024. Inclusion criteria consisted of studies that compared patients undergoing immediate mobilization after ORIF for DRF with patients undergoing postoperative immobilization. Adverse events, patient-reported outcomes measures, and range of motion (ROM) were all compared between the 2 groups at various postoperative time points. Four randomized controlled trials were included in this study. No difference was seen in the risk of complications (odds ratio = 1.17, P = .70) and reoperations (odds ratio = 1.35, P = .53) between the 2 groups. The immediate mobilization group had lower pain scores at 6 months (mean difference = -0.46, P = .005) and lower Disabilities of the Arm, Shoulder, and Hand at 3 months (mean difference = -0.45, P = .002), and 6 months (mean difference = -0.46, P = .005). As for ROM, better forearm rotation was seen in the immediate mobilization group at 6 months (mean difference = 3.43, P = .004).

Literature Review of Postoperative Distal Radius Fracture Immobilization Recommendations

Distal radius fractures (DRFs) are a commonly treated injury in orthopedics. DRFs have a high incidence across patient demographics, including pediatrics, young patients in high-energy trauma, and geriatric patients in low-energy trauma. While DRFs occur across a large range of age groups, they are especially consequential in geriatric patients with osteoporosis. Management of DRFs has extensive variability, ranging from conservative casting to surgical interventions, such as open reduction and internal fixation surgical procedures. The diversity of treatment options for DRFs is due to a consideration of factors, such as fracture characteristics, time to presentation with an orthopedic surgeon, age of the patient, and medical comorbidities of the patient. Despite being a common fracture type, there remain discrepancies in the non-pediatric literature regarding postoperative recommendations, such as the timing and methods of immobilization. There is also debate regarding whether postoperative immobilization in adult DRFs has clinical benefit. Some of this variability depends on the type of fixation utilized, such as a volar locking plate, dorsal locking plate, and dorsal wrist-spanning fixation. This literature review examines recommendations and outcomes of postoperative splinting (supination, pronation, or neutral rotation of the forearm) versus removable wrist brace versus soft dressings only for DRFs with both intra-articular and extra-articular fracture patterns with operative fixation. Postoperative care is imperative to study as it carries long-term effects on patients' quality of life, as their range of motion and strength can be dictated by the methodology of this care. Studies have been conducted comparing the outcomes of early mobilization versus prolonged immobilization after surgical intervention. This literature review analyzes these studies to understand which methods carry better outcomes with respect to the range of motion and quality of life of patients for operatively treated DRFs in non-pediatric patients.

The Treatment of Closed Finger and Metacarpal Fractures

BACKGROUND

Fractures of the fingers and metacarpal bones are the most common fracture type in the upper limb, with an incidence of 114 to 1483 per 100 000 persons per year. The clinical importance of closed finger and metacarpal fractures is often underestimated; inadequate diagnostic and therapeutic measures may result in serious harm. This review concerns the basic elements of the diagnosis and treatment of finger and metacarpal fractures.

METHODS

This review of the incidence, diagnosis and treatment of finger and metacarpal fractures is based on pertinent publications retrieved by a selective search of the literature.

RESULTS

The main focus of treatment lies on restoration of hand function in consideration of the requirements of the individual patient. The currently available evidence provides little guidance to optimal treatment (level II evidence). Although most closed fractures can be managed conservatively, individualized surgical treatment is advisable in comminuted fractures and fractures with a relevant degree of torsional malposition, axis deviation, or shortening, as well as in intra-articular fractures. Minimally invasive techniques are, in principle, to be performed wherever possible, yet open surgery is sometimes needed because of fracture morphology. Postsurgical complication rates are in the range of 32-36%, with joint fusion accounting for 67-76% of the complications. 15% involve delayed fracture healing and pseudarthrosis.

CONCLUSION

Individualized treatment for finger and metacarpal fractures can improve patients' outcomes, with major socioeconomic and societal benefits. Further high-quality studies evaluating the relative merits of the available treatments are needed as a guide to optimized therapy.

[Ulnar Shortening Osteotomy - Two Weeks of Immobilization Sufficient]

BACKGROUND

Diaphyseal ulnar shortening osteotomy (USO) as surgical treatment of ulnar impaction syndrome is standardized nowadays with good to very good results. In contrast, a wide spectrum of different postoperative treatment regimens can be found in the current literature. The results after USO with modern, angular stable implants with immobilization for 2 weeks are presented.

PATIENTS AND METHODS

A retrospective database analysis identified 49 patients (31 women, 18 men, mean age 37.6 years) with a total of 51 USO over a 13-year period and were followed up for 73.5 (15.9-192.9). All USO were obliquely sawed and stabilized with palmar locking implants. The wrist was immobilized postoperatively in 30° extension in a dorsal forearm splint for 2 weeks.

RESULTS

All USO showed load-stable consolidation signs after an average of 7.0 (SD 1.9; 4.9-14.1) weeks. Wrist range of motion was significantly improved in extension/flexion from 107.6° (60-155) preoperatively to 123.7° (80-160) postoperatively and in ulnar/radial deviation from 55.1° (25-90) to 60.8° (30-90) (p<0.05). Pain level was significantly reduced from 3.2 (0-8) to 0.1 (0-2) at rest and from 7.3 (4-10) to 1.2 (0-9) under weight bearing (p<0.01). A total of 5 complications (9.8%) were noted. Nonunion was not found.

CONCLUSION

By using angular stable implants to stabilize a USO, the duration of immobilization can be reduced to 2 weeks without compromising bone healing.

Comparative clinical and radiographic outcomes between early and delayed wrist mobilization after volar fixed-angle plate fixation of distal radius fracture

Postoperative immobilization protocols after volar fixed-angle plate fixation of distal radius fractures (DRF) vary among surgeons. This study aimed to compare functional outcomes, radiographic parameters, and complications between early and delayed mobilization after volar fixed-angle plate fixation of DRF. This study is a randomized controlled trial. The early group was allowed to perform wrist motion exercise immediately after surgery and the delayed group was allowed to perform it after 2 weeks of external immobilization. Postoperative patient-rated wrist evaluation (PRWE), disabilities of arm, shoulder, and hand (DASH), wrist range of motion, visual analog scale (VAS) pain score, and grip strength were evaluated. Forty-eight patients with DRF were enrolled and randomly allocated to the early or delayed mobilization groups. The PRWE, DASH, VAS pain score, grip strength, and wrist motion of both groups significantly improved over time. However, there were no significant differences between groups at any timepoint. Radiographic parameters were not different between groups. There were no significant differences in functional outcomes, radiographic parameters, and complications between early and delayed mobilization after volar fixed-angle plate of DRF. Immediate postoperative wrist range-of-motion exercise can be safely initiated after volar fixed-angle plate fixation of DRF without external immobilization.Clinical trial registration: Thaiclinicaltrials.org identifier: TCTR20180927005. Registered 27/09/2018-retrospectively registered. https://www.thaiclinicaltrials.org/show/TCTR20180927005 .

Arthroscopic debridement of the dorsal capsule in intraarticular distal radius fractures: does it provide superior outcomes?

INTRODUCTION

Distal radius fractures (DRFs) are very common. One of the most significant complications after intraarticular DRF is arthrofibrosis with loss of wrist motion and pain. Wrist arthroscopy has become increasingly popular in the treatment of DRF with the advantage of good visualization of the joint surface and soft tissue injuries. In intraarticular DRFs injuries of the dorsal capsule are a characteristic finding which potentially cause loss of wrist motion. In this study, we investigated if arthroscopic debridement of dorsal capsule injuries at time of surgical fixation provides superior outcomes compared to the same treatment without debridement.

MATERIALS AND METHODS

Between 2013 and 2017, we included 42 patients who underwent arthroscopy-assisted palmar plating for intraarticular DRFs in a prospective randomized controlled study. In group A (intervention group), the dorsal capsule tears were debrided during primary surgery, while in group B these were left in place. Active range of motion (AROM), grip strength, subjective outcomes and radiographic results were assessed 3, 6 and 12 months after primary surgery. A subgroup analysis was performed for patient age, fracture severity and duration of immobilization.

RESULTS

Arthroscopic debridement of the dorsal capsule improved AROM in patients over 60 years of age, more severe fractures (AO 23 C2/C3) and prolonged postoperative immobilization for more than two weeks, while it was not relevant for younger patients with simple fractures and short immobilization.

CONCLUSIONS

Debridement of the injured dorsal capsule in arthroscopic-assisted surgical treatment of intraarticular DRFs can improve surgical performance and optimize patient outcomes in a specific subgroup of patients.

In adults, early mobilization may be beneficial for distal radius fractures treated with open reduction and internal fixation: a systematic review and meta-analysis

Objectives

It remains debatable if early mobilization (EM) yields a better clinical outcome than the late mobilization (LM) in adults with an acute and displaced distal radial fracture (DRF) of open reduction internal fixation (ORIF). Therefore, we aimed to perform a systematic review and meta-analysis of randomized controlled trials (RCTs), comparing clinical results with the safety of EM with LM following ORIF.

Methods

Databases such as Medline, Cochrane Central Register, and Embase were searched from Jan 1, 2000, to July 31, 2021, and RCTs comparing EM with LM for DRF with ORIF were included in the analysis. The primary outcome of study included disabilities of the Arm, Shoulder, and Hand (DASH) score at different follow-up times. Wherever the secondary outcomes included patient-rated wrist evaluation (PRWE), grip strength (GS), visual analog scale (VAS), wrist range of motion (WROM), and associated complications, the two independent reviewers did data extraction for the analysis. Effect sizes of outcome for each group were pooled using random-effects models; thereafter, the results were represented in the forest plots.

Results

Nine RCTs with 293 EM and 303 LM participants were identified and included in the study. Our analysis showed that the DASH score of the EM group was significantly better than LM group at the six weeks postoperatively (− 10.15; 95% CI − 15.74 to − 4.57, P < 0.01). Besides, the EM group also had better outcomes in PRWE, GS and WROM at 6 weeks. However, EM showed potential higher rate for implant loosening and/or fracture re-displacement complication (3.00; 95% CI 1.02–8.83, P = 0.05).

Conclusion

Functionally, at earlier stages, EM for patients with DRF of ORIF may have a beneficial effect than LM. The mean differences in the DASH score at 6 weeks surpassed the minimal clinically important difference; however, the potentially higher risk of implant loosening and/or fracture re-displacement cannot be ignored. Due to the lack of definitive evidence, multicenter and large sample RCTs are required for determining the optimal rehabilitation protocol for DRF with ORIF.

PROSPERO registration number: CRD42021240214 2021/2/28.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02837-0.