The treatment of displaced intra-articular distal radius fractures in elderly patients

Abstract

Background: From 2000 to 2012, the annual incidence of inpatient treatment for distal radius fracture in Germany rose from 65 to 86 per 100 000 persons. It is unclear whether open reduction and volar angle-stable plate osteosynthesis (ORIF), a currently advocated treatment, yields a better functional outcome or quality of life than closed reposition and casting.

Methods: In the ORCHID multi-center trial, 185 patients aged 65 and older with an AO type C distal radial fracture were randomly assigned to ORIF or closed reposition and casting. Their health-related quality of life and hand/arm function were assessed 3 and 12 months afterward with the Short Form 36 (SF-36) questionnaire and the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. The radiological findings, range of movement of the wrist, and EuroQol-5D (EQ-5D) scores were documented as well.

Results: Among the 149 patients in the intention-to-treat-analysis, there was no significant difference in SF-36 scores between the two treatment groups at one year (mean difference, 3.3 points in favor of ORIF; 95% confidence interval, -0.2 +6.8 points; p = 0.058). The DASH scores showed moderately strong, but clinically unimportant effects in favor of ORIF, and there was no difference in EQ-5D scores. ORIF led to better radiological results and wrist mobility at 3 months, with comparable results at 12 months. 37 of the patients initially allotted to nonsurgical treatment underwent secondary surgery due to significant loss of reduction.

Conclusion: The findings with respect to mobility, functionality, and quality of life at 12 months provide marginal and inconsistent evidence for the superiority of volar angle-stable plate osteosynthesis over closed reduction and casting in the treatment of intra-articular distal radius fractures. Primary nonsurgical management is also effective in suitable patients.

Figure 1

Study profile according to CONSORT requirements. ORIF, open reduction and volar locking plate fixation

Figure 2

Physical components of health-related quality of life.

Figure 3

Pooled results of the available randomized trials. Left: DASH scores after 3 months; right: DASH scores after 12 months. ORIF, open reduction and volar locking plate fixation; DASH, Disabilities of the Arm, Shoulder and Hand questionnaire; WMD, mean weighted difference; 95% CI, 95% confidence interval

Figure 4

Results of the EQ-5D survey

eFigure 1

AO classification of intra-articular distal radius fractures. In the AO system the letter C signifies an intra-articular fracture. The suffixes 1 to 3 indicate increasing extent of fracture severity with increasing intra-articular involvement (extent of joint surface damage, number of fragments, extent of metaphyseal comminution zone) (14). Reproduced by kind permission of the AO Foundation (Copyright by AO Foundation, Switzerland; Müller AO Classification of Fractures—Long Bones [14])

eFigure 2

Radiological measurement of wrist joint anatomy Palmar inclination (PI): Angle between a perpendicular to the longitudinal axis of the radius and the line between the dorsal and volar margins of the joint. A positive value corresponds to palmar inclination, a negative value to dorsal inclination. Ulnar variance (UV): Measure of the relative length of the ulna and the radius at the wrist joint. UA (in mm) is the distance between two lines perpendicular to the axis of the radius, one at the level of the ulnar joint surface, the other at the level of the sigmoid notch of the radius. In the majority of the population UV is 0, i.e., the joint surfaces are at the same level. Ulnar variance with a prominent ulna is given with a plus sign. Radial inclination (RI): Angle between the radial joint surface line (a line between the styloid process of the radius and the ulnar corner of the lunate fossa) and a perpendicular to the longitudinal axis of the radius