Treatment of radius or ulna fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and current practice

Abstract

Background: The objective of the present study was to evaluate effectiveness, complications and cost-effectiveness of any surgical or non-surgical treatment for radius or ulna fractures in elderly patients. Secondary objectives were to analyze present treatment traditions of distal radius fractures (DRF) in Sweden and to calculate resource usage for its treatment.

Methods and findings: The assessment contains a systematic review of clinical and health economic studies comparing treatment options for radius or ulna fractures. The results regarding the effectiveness of the treatments are summarized in meta-analyses. In addition, the assessment contains a cost analysis for different treatment options commonly used for DRF care, and an analysis of registry data on the incidence and treatment of DRF. In total 31 randomized controlled trials were included in meta-analyses. When comparing functional outcome for plate fixation versus non-surgical treatment for DRF, there were no clinically important differences at one-year follow-up (mean difference [MD], -3.29, 95% CI, -7.03; 0.44). Similar results were found when comparing plating and percutaneous methods with respect to functional outcome (standardized mean difference [SMD], -0.07, 95% CI, -0.21; 0.07) and grip strength (MD, -3.47, 95% CI, -11.21; 4.28). There were no differences for minor complications, (risk difference [RD], -0.01, 95% CI, -0.07; 0.05) whereas major complications were less common for the percutaneous group, (RD, 0.02, 95% CI, 0.02; 0.03). Given the low number of studies, the evidence above was rated as moderate certainty. The cost for plate fixation versus plaster cast was estimated to 1698 compared to 137 US dollars. For DRF, plate fixation increased in Sweden between 2005 and 2013, and was the most common surgical method in 2013.

Conclusions: Surgical treatment of moderately displaced distal radius fractures in elderly patients offers no clear benefit compared to non-surgical treatment. Plating procedures have become more common during the second millennium and involve higher costs and higher risk of major complications than percutaneous options.

Fig 1. PRISMA flow-chart.

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Iterns for Systematic Reviews and Meta- Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi: 10.1371/journal.pmed.1000097 For more information, visit www.prisma-statement.org.

Fig 2. Meta-analysis of randomized controlled trials comparing plate fixation with plaster cast: Results of functional outcome, in elderly patients with distal radius fractures at one-year follow-up.

Fig 3. Meta-analysis of randomized controlled trials comparing percutaneous fixation methods with plaster cast: Results of functional outcome, in elderly patients with distal radius fractures at one-year follow-up.

Fig 4. Meta-analysis of randomized controlled trials comparing percutaneous fixation methods with plaster cast: Results of grip strength, in elderly patients with distal radius fractures at one-year follow-up.

Fig 5. Meta-analysis of randomized controlled trials comparing percutaneous fixation methods with plaster cast: Results of quality of life, in elderly patients with distal radius fractures at one-year follow-up.

Fig 6. Meta-analysis of randomized controlled trials comparing percutaneous fixation methods with plaster cast: Results of minor complications, in elderly patients with distal radius fractures at one-year follow-up.

Fig 7. Meta-analysis of randomized controlled trials comparing plate fixation with percutaneous fixation methods: Results of functional outcome, in elderly patients with distal radius fractures at one-year follow-up.

Fig 8. Meta-analysis of randomized controlled trials comparing plate fixation with percutaneous fixation methods: Results of grip strength, in elderly patients with distal radius fractures at one-year follow-up.

Fig 9. Meta-analysis of randomized controlled trials comparing plate fixation with percutaneous fixation methods: Results of quality of life, in elderly patients with distal radius fractures at one-year follow-up.

Fig 10. Meta-analysis of randomized controlled trials comparing plate fixation with percutaneous fixation methods: Results of minor complications, in elderly patients with distal radius fractures at one-year follow-up.

Fig 11. Meta-analysis of randomized controlled trials and one registry study comparing plate fixation with percutaneous fixation methods: Results of major complications, in elderly patients with distal radius fractures at one-year follow-up.

Fig 12. Meta-analysis of randomized controlled trials comparing percutaneous or plaster treatment with or without bone substitute: Results of functional outcome, in elderly patients with distal radius fractures at one-year follow-up.

Fig 13. Meta-analysis of randomized controlled trials comparing percutaneous or plaster treatment with or without bone substitute: Results of grip strength, in elderly patients with distal radius fractures at one-year follow-up.

Fig 14. Meta-analysis of randomized controlled trials comparing percutaneous or plaster treatment with or without bone substitute: Results of minor complications, in elderly patients with distal radius fractures at one-year follow-up.

Fig 15. Meta-analysis of randomized controlled trials comparing percutaneous or plaster treatment with or without bone substitute: Results of major complications, in elderly patients with distal radius fractures at one-year follow-up.

Fig 16. Incidence per 10,000 person-years of distal radius fractures in the Swedish population ≥50 years old, between 2005 and 2013.

Fig 17. The most common surgical treatments of distal radius fracture in women, ≥50 years old, between 2005–2013 in Sweden.

Fig 18. The most common surgical treatments of distal radius fracture in men, ≥50 years old, between 2005–2013 in Sweden.