Review: Evidence on surgical interventions for distal radial fractures is inconclusivePDF
ACP J Club. 2002 May-Jun;136:112. doi:10.7326/ACPJC-2002-136-3-112
Handoll HH, Madhok R. Surgical interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2001(3):CD003209 (latest version 29 Mar 2001). [PubMed ID: 11687051] (All 2002 articles were reviewed for relevancy, and abstracts were last revised in 2008.)
In adults with fractures of the distal radius, is surgical treatment effective for improving clinical outcome?
Studies were identified by searching 6 databases; hand searching conference proceedings; and scanning reference lists.
Randomized or quasi-randomized controlled trials were selected if they compared surgical interventions with conservative interventions or other surgical interventions in adults with fracture of the distal radius.
Data were extracted on patient characteristics, intervention, and outcomes (including functional and anatomic outcomes and complications). The quality of studies was assessed.
44 studies (3193 mainly female and older patients with 3197 fractures) with 23 different comparisons met the selection criteria, with follow-up ranging from 6 weeks to 10 years. Summarizing the outcomes was impeded by the poor quality and variation in study methods, interventions, patient characteristics, and outcomes. Some anatomic and functional outcomes (Table) were better in the external-fixation group (7 studies), the pins-through-fracture group (4 studies), and the bone-scaffolding group (2 studies) than in the plaster-cast group; differences in function for open reduction and internal fixation or bone graft or substitute relative to plaster cast are not reported here because studies had excessive losses to follow-up or results were no longer significant when the random-effects model was used. External fixation and percutaneous pinning led to fewer patients with redisplacement that required secondary treatment than did a plaster cast; external fixation led to more patients with pin-track infection than did a plaster cast (Table). The evidence did not show clear superiority for 1 surgical intervention over another.
In patients with distal radial fractures, heterogeneity exists for patients, mechanism of fracture, and fracture type, and results are inconsistent. Some benefit in reduced deformity, reduced malunion, and better functional outcome is seen for external fixation and percutaneous pinning relative to plaster cast, but who will benefit sufficiently is unclear.
Sources of funding: East Riding and Hull Health Authority, UK.
For correspondence: Professor R. Madhok, University of Hull, Willerby, England, UK. E-mail email@example.com.
Table. Surgical interventions for fracture of the distal radius*
|Outcomes||Comparisons||Weighted event rates||RRR (95% CI)||NNT (CI)|
|Functional grading (FG) not excellent||Ext fix vs PC||55% vs 67%||18% (4 to 31)||9 (5 to 36)|
|PTF vs PC||43% vs 81%||47% (29 to 61)||3 (2 to 5)|
|Bone scaf vs PC||54% vs 78%||31% (13 to 45)||5 (3 to 10)|
|RRI (CI)||NNH (CI)|
|PSF vs PC||100% vs 84%†||19% (5.7 to 39)||7 (4 to 13)|
|RRR (CI)||NNT (CI)|
|FG fair or poor||PTF vs PC||12% vs 37%||69% (36 to 85)||4 (3 to 9)|
|Redisplacement needing secondary treatment||Ext fix vs PC||0.9% vs 22%||89% (76 to 95)||5 (4 to 7)|
|PF vs PC||0% vs 20%||92% (63 to 98)||6 (4 to 8)|
|RRI (CI)||NNH (CI)|
|Pin track infection||Ext fix vs PC||11% vs 0%||648% (149 to 2148)||10 (7 to 16)|
*Bone scaf = bone scaffolding; Ext fix = external fixation; PC = plaster cast; PF
= percutaneous fixation; PSF = pins supporting fracture; PTF = pins through fracture.
Other abbreviations defined in Glossary; RRR, RRI, NNT, NNH, and CI calculated from data in article using a random-effects
†Event rates not weighted.
Debate exists about the degree to which normal anatomy needs to be restored after distal radial fracture. Most clinicians agree that the articular surface should be made congruous, that shortening should be minimized, and that palmar tilt should be restored to at least neutral (1). The methods to achieve and maintain reduction can be grouped into casting and percutaneous or open techniques, although many variations of each exist.
Most clinicians consider high-energy multifragmentary distal radial fractures with intra-articular displacement as distinct from low-energy fractures with a congruous joint when choosing appropriate treatment. Many of the studies in the review by Handoll and Madhok have inappropriately evaluated all injuries together. The myriad of treatment variations described, the wide range of outcomes evaluated, and the lack of injury discrimination have made it difficult to draw firm conclusions from the literature. Casting is associated with the highest probability of a poor anatomic result, especially in high-energy injuries and those with metaphyseal comminution. Alternatives to casting should be considered when acceptable reduction cannot be achieved or when residual joint incongruity and metaphyseal redisplacement is likely, especially in high-energy injuries. It seems reasonable to approach these high-energy injuries with minimally invasive techniques and to resort to open reduction if anatomic restoration is not possible. The role of arthroscopy and adjunctive bone grafting or substitution to obtain and maintain reduction has yet to be elucidated (2).
Large prospective trials with appropriate injury discrimination and consistent outcome evaluation are needed before firm recommendations can be made about the degree of anatomic restoration required, and the best treatment to use in a particular situation. Existing practices are based largely on expert opinion.
Hans J. Kreder, MD, MPH
University of Toronto
Toronto, Ontario, Canada
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2. Trumble TE, Culp RW, Hanel DP, Geissler WB, Berger RA. Intra-articular fractures of the distal aspect of the radius. Instr Course Lect. 1999;48:465-80. [PubMed ID: 10098077]
3. Handoll HH, Madhok R. Conservative interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003;(2):CD000314. [PubMed ID: 12804395]
4. Handoll HH, Madhok R. External fixation versus conservative treatment for distal radial fractures in adults. Cochrane Database Syst Rev. 2007;(3):CD006194. [PubMed ID: 17636832]
5. Handoll HH, Madhok R. Surgical interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003;(3):CD003209. [PubMed ID: 12917953]