Management of dorsally displaced distal radius fractures: have we reached a consensus yet?
SICOT Associate Member & SICOT Newsletter Editorial Board Member - London, United Kingdom
Distal radius fractures are common. However, controversies remain in defining stable vs. unstable fractures, indications for nonoperative vs. operative treatment and the ideal fixation method when an operation is deemed necessary.
The majority of distal radius fractures can be treated with closed reduction and plaster immobilization which results in satisfactory outcomes in most cases . However, multiple studies suggested that age, shortening, dorsal comminution, loss of radial inclination and AO type 3 fractures (A3, B3, C3) are associated with an increased risk of displacement . In fact, a recent meta-analysis of 27 studies showed that dorsal comminution, female gender and age >60 years were particularly linked to unstable patterns. Such unstable fractures are often treated with either K-wires or a locking plate.
A number of studies attempted to evaluate predictors of outcomes in the operative group. For example, radiological predictors of high functional outcomes have been described as less than 2 mm of gap or step-off, restoration of the radius to within 2 mm of its normal length, and restoration of carpal alignment in McQueen's famous review article . On the other hand, some studies highlighted that the ultimate aim is to achieve a pain-free, mobile wrist without functional limitation and hence relied on functional rather than radiological outcomes to assess the success of an operation [4, 5].
Over the last few years, there has been a tendency towards using locking plates as opposed to K-wires in the treatment of unstable dorsally displaced distal radius fractures as they improve radiological outcomes and as a result may be associated with improved functional outcomes [6, 7]. However, there remains a high major complication rate associated with using locking plates . Therefore, a multicentred randomised controlled trial (RCT) including 18 centres and 461 patients from the United Kingdom was conducted recently to compare functional outcomes of K-wires vs. volar locking plates in the treatment of unstable dorsally displaced distal radius fractures . In contrary to evidence from single centered RCTs favouring the use of locking plates [6, 7], results from this study did not show any statistically significant difference in patient-reported outcome measures (PROMS), Patient-Rated Wrist Evaluation (PRWE) and Disabilities of the Arm, Shoulder and Hand (DASH) scores regardless of age and intra-articular fracture involvement. On the other hand, cost analysis showed that K-wires are less expensive and are, therefore, more cost effective for these injuries. It is important to highlight though that there has been subjectivity in patient selection in this RCT as it was at the surgeon’s discretion to include or exclude intra-articular fractures with no clear indication as to when it is still acceptable to do closed reduction and wiring as opposed to plating for those fractures. Additionally, follow-up remains short at one year but authors will continue following up and publishing the results of their findings accordingly.
A number of studies also compared operative and nonoperative treatment in elderly patients and concluded that only minor objective functional differences were achieved in the operative group which did not result in an impact on subjective function and quality of life [9, 10]. As a result, elderly sedentary patients with low demands may still be treated with closed reduction and plaster immobilization with good functional outcomes despite the presence of a residual deformity.
In summary, the majority of dorsally displaced distal radius fractures can be treated with closed reduction and plaster immobilization. Extra-articular fractures within 3 cm of the radiocarpal joint and some intra-articular fractures which are deemed unstable but can be reduced closed are preferably treated by K-wiring. However, where closed reduction is not achievable or the fracture is intra-articular and highly comminuted then a locking plate or other forms of treatment such as external fixators and bridging plates may be more appropriate. Elderly patients with low demands can be more tolerable to malunion with overall good functional outcomes when treated conservatively with closed reduction and plaster immobilization.
- Hobby JL. Cost effectiveness of percutaneous fixation with Kirschner wires versus locking plate for adult patients with a dorsally displaced fracture of the distal radius from the DRAFFT trial: a commentary. Bone Joint J. 2015 Aug;97-B(8):1015-6.
- Walenkamp MM, Aydin S, Mulders MA, Goslings JC, Schep NW. Predictors of unstable distal radius fractures: a systematic review and meta-analysis. J Hand Surg Eur Vol. 2015 Sep 29.
- Ng CY, McQueen MM. What are the radiological predictors of functional outcome following fractures of the distal radius? J Bone Joint Surg Br. 2011 Feb;93(2):145-50.
- Tubeuf S, Yu G, Achten J, Parsons NR, Rangan A, Lamb SE, et al. Cost effectiveness of treatment with percutaneous Kirschner wires versus volar locking plate for adult patients with a dorsally displaced fracture of the distal radius: analysis from the DRAFFT trial. Bone Joint J. 2015 Aug;97-B(8):1082-9.
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- Gehrmann SV, Windolf J, Kaufmann RA. Distal radius fracture management in elderly patients: a literature review. J Hand Surg Am. 2008 Mar;33(3):421-9.