Distal radius fracture (DRF) is the most common fracture we see,” said Aaron Nauth, MD, MSc, during an AAOS Annual Meeting symposium on Surgical versus Nonsurgical Treatment of Common Upper Extremity Injuries: An Evidence-Based Approach. “But what do we really know about it? We know that malunion is the most common treatment complication and that symptomatic malunion in active patients may require a corrective osteotomy.
“Ideally, we’d like to determine which fractures need to be addressed surgically,” he continued. “To answer that, we need to know what degree of malunion results in functional limitation, whether surgery prevents malunion, and whether we can improve functional outcomes with surgery. Further, we’d like to understand the influence of patient age and surgical technique on the management of DRF.”
Correlating findings to outcomes
Dr. Nauth pointed out that the 2009 AAOS Clinical Practice Guideline (CPG) on treatment of DRF attempted to answer several of these questions, and he noted that the Guideline offers a moderate recommendation in favor of surgical fixation for fractures with postreduction radial shortening of more than 3 mm, dorsal tilt greater than 10 degrees, or intra-articular displacement or step-off of more than 2 mm.
“The CPG is based on five randomized trials that met the work group’s inclusion criteria,” he explained. “Those studies include a mix of fracture types and age groups. Yet all of the studies show differences in pain, range of motion, and complication rates between surgical and nonsurgical treatment, and all favored surgical over nonsurgical management. As an aside, it is interesting to note that only one of the five studies found improved functional outcomes with surgery.”
Dr. Nauth cited several studies that investigated the issue of how radiographic findings may correlate to functional outcome. It was, he said, a 1996 prospective, randomized trial comparing four methods of treatment for DRF that introduced the concept of carpal malalignment.
“This is something I find very useful in my practice, because it’s a very simple tool that we can use to analyze radiographs,” he said. “You draw a line up the center of the radial shaft on the lateral radiograph, and look for that line to intersect the carpus. A dorsally angulated fracture will be apparent in dorsal subluxation of the carpus. Similarly, a volarly displaced fracture will display volar subluxation of the carpus. The study also noted a significant correlation between carpal malalignment and poorer key grip strength, grip strength, and rotational range of motion at 1 year.”
An earlier study he cited found that patients with residual articular step-off had a 91 percent rate of radiographic arthritis and a 57 percent rate of poor clinical result.
“This is in contrast to patients with no intra-articular incongruity, who had fairly good outcomes. Among patients with no intra-articular incongruity, the rate of radiographic arthritis was just 11 percent; only 7 percent of these patients had a poor clinical outcome,” said Dr. Nauth. “So the literature suggests that a young, active patient who has an intra-articular step both on radiograph and computed tomography would benefit from surgical intervention to restore the articular surface.”
Dr. Nauth argued in favor of a moderate recommendation for specific surgical indications for DRF, based on level II and level III studies for young, active patients in whom closed reduction failed to maintain alignment.
Age as an indicator
Dr. Nauth then addressed the issue of age as a factor. Again, he turned first to the AAOS CPG, which offers an inconclusive recommendation for or against surgical treatment for DRF among patients older than 55 years.
“This section of the Academy guideline is based on three randomized trials that met the inclusion criteria,” he said. “But I would argue that the literature is actually relatively conclusive on this, finding no differences in pain, range of motion, or function at any time point with surgical or nonsurgical intervention.”
Dr. Nauth cited a 2011 paper in which researchers reported on a prospective, randomized trial of 73 patients older than age 65 in whom closed reduction had been unsuccessful. The patients were randomized to nonsurigal treatment or to surgical treatment with locked volar plating.
“At 1-year, there was no difference in range of motion, strength, or functional outcomes across cohorts,” he said.
A study published this year examined the influence of activity level among patients older than 60 years. In that trial, the authors used a validated physical activity score to stratify 96 patients into high activity and low activity groups and to correlate their outcomes with malunion. The authors noted no influence of activity level on outcomes.
“I would argue that most DRF patients older than age 65 do not require surgery,” said Dr. Nauth.
Finally, Dr. Nauth addressed the issue of surgical technique for management of DRF.
“If you’ve decided the patient requires surgery, a variety of options are available, such as percutaneous pinning, spanning external fixation, nonspanning external fixation, and locked volar plating,” he said.
The AAOS CPG did not endorse any specific surgical technique, noted Dr. Nauth.
“This wasn’t for lack of trying,” he said. “Fourteen randomized trials met the CPG inclusion criteria. They looked at various fixation methods, and found no significant differences in outcomes. So the literature suggests that it’s really up to the physician and the patient to choose which surgical intervention to use.”
Dr. Nauth did not issue some caveats, however. According to one meta-analysis that looked at studies comparing external fixation and volar plating, plating was more advantageous in terms of DASH score, ulnar variance, and complication rates. A study of 461 patients randomized to volar locked plating or percutaneous pinning found no significant difference in functional outcomes or complication rates at mean 24-month follow-up.
“In summary, the evidence in the literature is insufficient to recommend a specific patient strategy for management of DRF,” said Dr. Nauth, “although I would argue that it is sufficient to tell us that there’s little or no difference between fixation strategies. Some evidence from level II and level III studies supports surgical intervention in young and active patients after closed reduction has failed, and some evidence shows that patients older than age 65 generally do not require surgery. Finally, insufficient evidence is available to support a specific fixation strategy, and I recommend leaving that decision to surgeon and patient preference.”
Dr. Nauth’s disclosures can be accessed electronically at www.aaos.org/disclosure
Peter Pollack is electronic content specialist for AAOS Now. He can be reached at firstname.lastname@example.org