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Distal radial fractures: ORIF and external fixation provide similar grip strength and ROM
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August 2013
Distal radial fractures: ORIF and external fixation provide similar grip strength and ROM
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A
External or internal fixation in the treatment of non-reducible distal radial fractures?
Acta Orthop. 2011 Oct;82(5):610-3. Epub 2011 Sep 6Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
50 patients with unstable, irreducible, or comminuted distal radial fractures were randomized to either receive open reduction with internal fixation (ORIF) or closed reduction with bridging external fixation. The purpose of this trial was to compare grip strength and range of motion over a medium-term follow-up. The 1 year results indicated that there was a significant difference in grip strength and ROM between groups favoring ORIF. However, this difference was not maintained at 5 years with both groups approaching the normal grip strength and ROM values of the uninjured side.
Publication Funding Details
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Funding:
Non-Industry funded
Sponsor:
Swedish Research Council (project 2031), the Greta and Johan Kock Foundation, the Alfred Osterlund Foundation, the Maggie Stephens Foundation, the Thure Carlsson Foundation, and the Medical Faculty of Lund.
Conflicts:
None disclosed
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
1/4
Randomization
2/4
Outcome Measurements
1/4
Inclusion / Exclusion
2/4
Therapy Description
2/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Surgical treatment is typically recommended for patients with unstable, non-reducible distal radial fractures. The standard method of fixation is external fixation however, ORIF has increased in popularity due to introduction of the volar locking plate technique. A previous randomized study demonstrated superior grip strength and forearm rotation at year with ORIF compared to closed reduction and external fixation. This present study provided an evaluation of the same patients at a 3-7 year follow-up (mean 5). This study was needed to determine if the short term results found in the 1 year study persist over time.
What was the principal research question?
Does ORIF result in improved grip strength and forearm rotation compared to external fixation in the treatment of unstable distal radial fractures, measured at a mean follow up of 5 years?
Study Characteristics
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Population:
50 patients (36 women) with unstable, irreducible, or comminuted distal radial fractures.
Intervention:
Open reduction and internal fixation (n=26)
Comparison:
Closed reduction and bridging external fixation (n=24)
Outcomes:
Outcomes included the score on the QuickDASH questionnaire (assesses physical activities, severity of symptoms, effect on social activities) and general health (measured using SF-36). Grip strength and range of motion were recorded. As well, radial inclination, ulnar variance, dorsal angulation, and the presence of osteoarthritis were assessed using radiographs.
Methods:
RCT
Time:
Mean follow up of 5 years
What were the important findings?
- All 50 patients that were randomized completed the QuickDASH questionnaire, and 45 patients participated in the clinical and radiographic assessment.
- The mean grip strength (reported as a percentage of the uninjured side) was 95% (SD 12) in patients that underwent internal fixation, compared to 90% (SD 21) in the external fixation group (p=0.3, 95% CI:-4 to 16 percent units).
- QuickDASH scores, range of motion, general health and radiographic outcomes were similar between both groups.
What should I remember most?
At the 1 year follow up of the study, there were statistically significant differences between groups regarding grip strength and pronation-supination that favoured ORIF. However, this previously reported difference was lost at the 5 year follow-up, as both groups approached the normal grip strength and ROM values of the uninjured side.
How will this affect the care of my patients?
ORIF and external fixation appear to provide similar long-term strength and ROM outcomes for non-reducible distal radial fractures when compared to the uninjured arm. However, the short term outcomes should be considered when determining the best treatment option as ORIF may provided better strength and ROM outcomes over the first post-operative year.
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