Rohit Arora, Martin Lutz; Christian Deml, Dietmar Krappinger, Luzian Haug, Markus Gabl.

Department of Trauma Surgery and Sports Medicine, Medical University Innsbruck (MUI), Anichstrasse 35, A-6020 Innsbruck, Austria

J Bone Joint Surg Am. 2011 Dec 7;93(23):2146-53

Level 2, Randomised Control Trial

•  There has been a general trend towards ORIF as the treatment of choice for distal radial fractures in recent literature.

• Although there is general agreement that there is a close relationship between the restoration of anatomy and function in younger patients but such conclusions for elderly population is controversial.
• Stable fractures can be managed with cast immobilization but for unstable distal radial fractures, several authors suggest additional fixation while others advocate non-operative treatment citing that anatomic alignment on radiographs arenot correlated with better functional outcomes in older patients.
•  There is a lack of prospective study comparing these two methods of treatment in elderly patients. The present study was specifically designed on these grounds.

Materials

• Patients with stable fractures were excluded from the study. Seventy-three patients(18 men and 55 women) with a mean age of 76.7 years (range, 65-89 years) who had a displaced and unstable distal radial fracture met inclusion criteria and were randomized to the ORIF with a volar locked plate(n=36) or non-operative (n=37) groups and followed-up for 1 year.
• The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE) score, and secondary outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH)score, the level of pain, the range of wrist motion, and the rate of complications.

Results

• There wereno significant differences between the two groups in termsof the range of motion or the level of pain during the entirefollow-up period (p > 0.05)
• Operative group had lower DASH and PRWE scores at 6 and 12 weeks (p<0.05) but not at 6 and 12 months (p>0.05)
• Grip strength was significantly better atall times for the operative treatment group (p < 0.05)
• Although clinical deformity was evident in 78% patients in non-operative group as compared to none in operative group, however none of the patients with such deformity were dissatisfied with clinical appearance or function
• Satisfactory reduction was achieved intraoperatively for all fractures in the ORIF group. At the latest follow-up examination, malunion had occurred in all patients in the non-operative group
• Significantly more complications, including loss of reduction, fracture malunion, and fracture nonunion, as well as deep infection, neuropathy, tendon irritation, and tendon rupture, were found in the ORIF group than in the nonoperative group (13 vs 5; p < 0.05)

Conclusion

• Achieving anatomical reconstruction doesn’t convey any improvement in terms of the range of motion or the ability to perform daily living activities in elderly patient with unstable distal radial fracture
• There were no significant differences in elderly patients with unstable distal radial fractures treated with immobilisation and those treated by volar plate fixation.
• Given the higher incidence of post-traumatic arthritis in the non-operative group, it is conceivable that their results could deteriorate more rapidly over time. Further studies with longer follow-up may help answer that question

Ref:

1. http://www.jbjs.org/article.aspx?articleid=180948
2. http://www.myorthoevidence.com/#articleid=601

Chief Editor: Mohit Bhandari

• Surgical orthopedic procedures such as hip replacements, arthroscopy or knee replacements are surrounded by pre- and post-operative complications, and there are varying different methods for the procedures themselves.
• This book, for the first time, brings together the best evidence for treatments as well as any complications. Not only does it cover the evidence base for orthopedic surgery, but also orthopedic conditions requiring medical treatment, and pediatric orthopedics.
• Using the approved EBM methodology, and edited by teachers of evidence-based medicine, this is a genuine EBM textbook for all orthopedic specialists and trainees.