Comparison of treatment results between surgical and conservative treatment of distal radius fractures in adults: A meta-analysis of randomized controlled trials

Protocol for a prospective randomized trial of surgical versus conservative management for unstable fractures of the distal radius in patients aged 65 years and older

Aims

The primary aim of this study is to quantify and compare outcomes following a dorsally displaced fracture of the distal radius in elderly patients (aged ≥ 65 years) who are managed conservatively versus with surgical fixation (open reduction and internal fixation). Secondary aims are to assess and compare upper limb-specific function, health-related quality of life, wrist pain, complications, grip strength, range of motion, radiological parameters, healthcare resource use, and cost-effectiveness between the groups.

Methods

A prospectively registered (ISRCTN95922938) randomized parallel group trial will be conducted. Elderly patients meeting the inclusion criteria with a dorsally displaced distal radius facture will be randomized (1:1 ratio) to either conservative management (cast without further manipulation) or surgery. Patients will be assessed at six, 12, 26 weeks, and 52 weeks post intervention. The primary outcome measure and endpoint will be the Patient-Rated Wrist Evaluation (PRWE) at 52 weeks. In addition, the abbreviated version of the Disabilities of Arm, Shoulder and Hand questionnaire (QuickDASH), EuroQol five-dimension questionnaire, pain score (visual analogue scale 1 to 10), complications, grip strength (dynamometer), range of motion (goniometer), and radiological assessments will be undertaken. A cost-utility analysis will be performed to assess the cost-effectiveness of surgery. We aim to recruit 89 subjects per arm (total sample size 178).

Discussion

The results of this study will help guide treatment of dorsally displaced distal radial fractures in the elderly and assess whether surgery offers functional benefit to patients. This is an important finding, as the number of elderly distal radial fractures is estimated to increase in the future due to the ageing population. Evidence-based management strategies are therefore required to ensure the best outcome for the patient and to optimize the use of increasingly scarce healthcare resources.

Development of a testing device for external wrist bridging dynamic fixators used for distal radius fractures

BACKGROUND

Stabilization of extra-articular distal radius fractures by wrist joint bridging (WB) dynamic fixation allows for early motion of the wrist, but relies on exact positioning of the device. In fact, physiological movement appeared to be compromised with even distinctly aberrant positioning of such device. To investigate this issue in more detail, we developed an in-vitro testing apparatus suitable for assessing the forces required for flexion and extension of the wrist.

METHODS

The experimental set-up enables the transmission of the translational movement of the traverse of a universal testing machine into the main physiological movement (flexion and extension) of the wrist. An external WB dynamic fixator was assembled to an artificial saw bone wrist model prior and after performing a wedge-shaped osteotomy on the distal radius about 1.5 cm proximal to the joint line, i.e. generation of a fracture model. The functionality of the fixator was evaluated under either condition and the effect of misalignment of the external WB dynamic fixator was quantified by purposeful violation of the manufacture's instructions. Results were statistically analyzed using the generalized linear mixed model.

FINDINGS

Significantly higher loading was noted as the degree of misalignment increased. The normalized force was significantly higher at a misalignment of 20° compared to 10° (10°: 4.13; 20°: 6.93, P < 0.001).

INTERPRETATION

The proposed set-up turned out to allow highly reproducible and sensitive recording of the reaction forces during flexion and extension of the wrist and thus is feasible for the evaluation and comparison of different external WB devices.

Efficacy of cast immobilization versus surgical treatment for distal radius fractures in adults: a systematic review and meta-analysis

This articl e includes high-quality randomized controlled trials in recent years and updates the past meta-analysis. It has been proved that cast immobilization can achieve similar functional results, reduce economic burden in the long-term compared with surgery, and provide a basis for doctors to make treatment choices.

PURPOSE

The efficacy of conservative and surgical treatment of distal radius fractures (DRFs) in adults is still controversial. Recently, some high-quality randomized controlled trials (RCTs) evaluated the efficacy of both treatments. We hypothesized that treatment of DRFs with closed reduction and cast immobilization would achieve functional outcomes similar to surgery.

METHODS

This study is a systematic review and summary of RCTs comparing conservative and surgical management of DRFs from 2005 to March 2022. Patients were evaluated for functional and imaging outcomes and complications.

RESULTS

A total of 11 studies [1-11] included 1775 cases of DRFs. At 1-year follow-up, the cast group had lower mean differences (MDs) in DASH scores than the surgery group by - 2.55 (95% CI =  - 5.02 to - 0.09, P = 0.04); with an MD of 1.63 (95% CI = 1.08-2.45, P = 0.02), while the surgery group had a lesser complication rate than the cast group.

CONCLUSIONS

At 1-year follow-up, the lower DASH scores of the cast group showed advantages of this treatment, but the complication rate was higher than that of the surgery group. There was no massive distinction in other scoring methods.

Factors influencing self-perceived functioning after volar locking plate fixation of distal radius fractures: a scoping review protocol

OBJECTIVE

The objective of this review is to give an overview of the demographic, peri-, and postoperative factors that have been assessed for influence on self-perceived functioning at least 3 months after volar locking plate fixation of a distal radius fracture.

INTRODUCTION

Most patients treated with a volar locking plate for a distal radius fracture recover within months after surgery; however, a subgroup of patients experience complications and slow recovery. A variety of demographic, peri-, and postoperative factors may influence self-perceived functioning. To facilitate functioning after surgery, supervised rehabilitation can be offered by a hand therapist. In the decision-making process about which patients to offer supervised rehabilitation, demographic, peri-, and postoperative factors may provide additional information, but no updated overview of explored factors has been found.

INCLUSION CRITERIA

This review will consider all studies reporting on peri- and postoperative factors identified within 6 weeks after surgery, or demographic factors assessed for influence on self-perceived functioning experienced by patients at least 3 months after volar locking plate fixation of distal radius fractures.

METHODS

MEDLINE, CINAHL, Embase, Cochrane Library, PsycINFO, SPORTSdiscus, and Web of Science will be searched for eligible studies. The review will consider peer-reviewed studies published after 2005 in English and Scandinavian languages. Two reviewers will independently perform study selection and data extraction. Following a content analysis of each identified factor, the factors will be mapped to the International Classification of Functioning, Disability and Health (ICF) components by using the ICF linking rules. An overview will be depicted graphically or in tabular format for different timepoints based on assessment of the self-perceived functioning.

Effectiveness of surgical versus conservative treatment of distal radius fractures in elderly patients: A systematic review and meta-analysis

BACKGROUND

The aim of this study was to determine whether surgical treatment is more effective than conservative treatment in terms of functional outcomes in elderly patients with distal radius fractures (DRFs).

METHODS

An electronic search of the Medline, Central, Embase, PEDro, Lilacs, CINAHL, SPORTDiscus, and Web of Science databases was performed, from inception until July 2021. The eligibility criteria for selecting studies were randomized clinical trials that compared surgical versus conservative treatment in subjects older than 60 years with DRFs. Two authors independently performed the search, data extraction, and assessed risk of bias (RoB) using the Cochrane RoB tool.

RESULTS

Twelve trials met the eligibility criteria, and nine studies were included in the quantitative synthesis. For volar plate versus cast immobilization at 1-year follow-up, the mean difference (MD) for PRWE was -5.36 points (p=0.02), for DASH was -4.03 points (p=0.02), for grip strength was 8.32% (p=0.0004), for wrist flexion was 4.35 degrees (p=0.10), for wrist extension was -1.52 degrees (p=0.008), for pronation was 2.7 degrees (p=0.009), for supination was 4.88 degrees (p=0.002), and for EQ-VAS was 2.73 points (p=0.0007), with differences in favor of volar plate. For K-wire versus cast immobilization at 12 months, there were no statistically significant differences in wrist range of motion (p>0.05).

CONCLUSIONS

There was low to high evidence according to GRADE ratings, with a statistically significant difference in functional outcomes in favor of volar plate versus conservative treatment at 1-year follow-up. However, these differences are not minimally clinically important, suggesting that both types of management are equally effective in patients older than 60 years with DRFs.

LEVEL OF EVIDENCE

I; Therapeutic (Systematic review and meta-analysis of randomized clinical trials).