OPTIONS

Numerous historical methods can be used to treat distal radius fractures; however, general categories are: (1) closed reduction and casting, (2) percutaneous pinning and casting, (3) external fixation, and (4) plate fixation. Subgroups exist within these general categories. External fixation may be bridging or nonbridging, uniplanar or multiplanar, and possibly augmented with percutaneous pins. Plate fixation may use an enormous variety of plate designs, approaches, and screw design and configurations. As one can imagine, this heterogeneity in treatment options is problematic when trying to design a study to evaluate treatment methods, as well as drawing conclusions from the various published studies.

Each treatment modality offers its own advantages and disadvantages. Closed reduction and casting avoids the general risks of surgery but requires routine follow-up and rehabilitation after bony healing. Percutaneous pinning offers treatment with minimal soft-tissue disruption but introduces risks for pin-tract infection. External fixation offers improved structural support than percutaneous pinning; however, problems of patient acceptance and pin-tract infection remain. Finally, open reduction and plate fixation allows direct manipulation and fixation of fracture fragments but requires soft-tissue disruption and risks late hardware problems.

It is unclear how each purported risk and benefit affects the overall outcome of each surgical technique. Prospective, randomized, controlled trials offer a global insight as to how much the cumulative risk and benefits differ between treatments.

EVIDENCE (LEVEL I AND II EVIDENCE)

Handoll and Madhok^1,2 performed a systematic review of the distal radius fracture literature before 2000. Significant methodologic deficiencies abounded: Most series had a small number of patients, allocation concealment was deficient in 42 of 44 studies, and a majority of outcomes were reported using a modified Gartland and Werley scheme, a nonvalidated surgeon-generated outcome measure. Despite these deficiencies, their systematic review suggests that external fixation and percutaneous pinning have better radiographic outcomes and may have improved functional outcomes compared with closed reduction and casting.

Studies after 2000 with improved methodology confirm results of previous studies. In a level I study, Kreder and colleagues³ compared spanning external fixation to closed reduction and casting in distal radius fractures without joint incongruity and found trends toward improved 36-Item Short Form Health Survey (SF-36) bodily pain scores and Musculoskeletal Functional Assessment (MFA) scores at 2 years; however, these trends did not reach statistical significance. Radiologic outcomes also showed a trend that approached significance that favored external fixation. Comparisons of percutaneous pinning to closed reduction using validated outcomes also found that radiographic parameters were significantly improved with pinning; however, there was no difference in the SF-36 score.⁴ Harley and colleagues’⁵ level I study also examined outcomes of augmented external fixation versus percutaneous pinning at 1 year. Although validated and functional outcomes were similar, external fixation demonstrated better articular congruity on radiographic follow-up.

External fixation has also been compared with internal fixation. When comparing dorsal pi plating with external fixation in a level II study, Grewal and investigators⁶ found no significant difference in Disabilities in Arm, Shoulder, and Hand (DASH) or SF-36 scores; however, the pi plate group had significantly weaker grip strengths and greater number of complications, especially tendonitis and the need for hardware removal. Kreder and colleagues⁷ in a multicenter level I study found that although MFA and SF-36 scores were similar at 2 years between both external fixation with indirect reduction and percutaneous pinning and open reduction, internal fixation was statistically equivalent, internal fixation yielded a better SF-36 bodily pain subscore, but external fixation yielded better grip strengths at the 6-month period.

Although many studies have confirmed previous conclusions, some newer studies have brought these conclusions under question. In a 1998 level II study, McQueen⁸ found that nonbridging external fixation yielded better radiographic results, grip strength, and flexion than bridging external fixation. However, Atroshi and colleagues⁹ found that in a level I study, although radiographic outcomes were improved in patients treated with nonbridging fixators, DASH scores were statistically equivalent.

Trials have also examined adjunctive bone graft substitutes. In a level II randomized, controlled trial by Sanchez-Sotelo and coauthors,¹⁰ Norian-treated wrists had better functional outcomes compared with wrists treated with closed reduction and casting. In the regression analysis, treatment without Norian increased the probability of a poor functional result by 12 and increased the probability of malunion by 11. Cassidy and colleagues¹¹ compared Norian SRS-treated wrists with external fixation in a level I study and found better subjective outcomes at 6 weeks; however, no significant clinical differences were observed at 1 year.

With regard to external fixation, Werber and researchers’¹² level II study demonstrated that use of a five-pin external fixator with one pin supporting the radial articular fragment yielded better radiographic and functional outcomes than a standard four-pin fixator. Egol and coworkers’¹³ level I study demonstrated no significant difference in the incidence of pin-site infection regardless of pin-site care using dry dressings, peroxide pin-site care, or chlorhexidine impregnated discs.