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Volar locked plating of dorsally displaced fractures of the distal radius
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March 2013
Volar locked plating of dorsally displaced fractures of the distal radius
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A
Wrist function recovers more rapidly after volar locked plating than after external fixation but the outcomes are similar after 1 year
Acta Orthop. 2011 Feb;82(1):76-81.Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
63 patients with distal radius fractures were randomized to treatment with either volar locked plating or bridging external fixation, to compare functional and radiographic outcomes. Short-term outcomes at 3 and 6 months favored the volar locked plating group in terms of Disabilities of the Arm, Shoulder, and Hand (DASH) scores,Patient related wrist evaluation (PRWE) scores, grip strength and range of motion. However, by 12 months, many of the outcomes between the two groups had become similar.
Publication Funding Details
+
Funding:
Not Reported
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.
3/4
Randomization
3/4
Outcome Measurements
4/4
Inclusion / Exclusion
4/4
Therapy Description
4/4
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?
Recent studies have indicated promising patient outcomes for open reduction and internal fixation with volar locked plating of unstable distal radius fractures with dorsal displacement. Proposed benefits include adequate fracture stabilization and anatomic reduction, expediting early range of motion. However, the choice of internal fixation over external fixation remains unsupported in the literature. Thus, this study was required to investigate the functional and radiographic outcomes of volar locked plating.
What was the principal research question?
Does internal fixation with volar locked plating provide superior outcomes in terms of function and radiographic measures compared to external fixation, in patients with dorsally displaced fracture of the distal radius?
Study Characteristics
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Population:
63 patients aged 20-70 with a unilateral dorsally displaced fracture of the distal radius (AO class A extraarticular fractures and class CI fractures [one intraarticular fracture line], axial shortening [> or = 4 mm], or dorsal angulation [> or = 20 deg]).
Intervention:
Volar locked plate: Patients were operated on using a volar flexor capri radialis approach with a volar locked plate (Konigsee; Swemac, Sweden). Postoperatively, patients received a dorsal below-elbow plaster cast for 10-12 days. (n=33)
Comparison:
External fixation: Control group received external fixation using a Hoffmann device (Stryker, NJ) utilizing 2 pins in both the second metacarpal and proximal radius. Closed reduction was performed under fluoroscopic guidance. (n=30)
Outcomes:
The primary outcomes were the Disabilities of the Arm, Shoulder, and Hand (DASH) score and the Patient Related Wrist Evaluation (PRWE) score. Other outcomes included grip strength, range of motion, and anterior, posterior and lateral radiographs.
Methods:
RCT; Single-centered
Time:
Follow-up was conducted at 10 days, 5 weeks, and 3, 6, and 12 months postoperatively.
What were the important findings?
- Statistically significant improvements in DASH scores were observed in the volar-plated group versus the external fixation group at the 3 month (9 vs. 27; p<0.001) and 6 month follow-ups (6 vs. 14; p=0.008). This result failed to achieve significance at the 12 month follow-up (7 vs. 11; p=0.1).
- Statistically significant improvements in PRWE were similarly observed in the volar-plated group over the external fixation group at the 3 (12 vs. 31; p<0.001) and 6 month follow-ups (9 vs. 17; p=0.02). This result failed to achieve significance at the 12 month follow-up (11 vs. 15; p=0.3).
- Grip strength and range of motion (extension, supination, and pronation) were statistically superior in the volar plated group versus the external fixation group at the 3 month and 6 month follow-up points (p<0.05)
- The volar group demonstrated significantly reduced axial shortening (at all time points; p<0.001) and dorsal angulation (at 12 months; p=0.05) of the radius following radiographic analysis.
- 12 patients in the external fixation group and 7 patients in the volar locked plate group experienced complications over 1 year.
What should I remember most?
The volar plated group demonstrated superior patient perceived functional outcomes (DASH) and patient related wrist evaluation (PRWE) scores during early follow-up (up to 6 months); however, these benefits diminished in comparison to external fixation over time (12 months). Similar trends were observed for grip strength, whereas extension, supination, and pronation, and reduction in axial shortening remained significantly better at all follow-up periods.
How will this affect the care of my patients?
The authors conclude that volar plating should be preferentially implemented for patients seeking rapid recovery of wrist function. The use of an external method is still applicable and offers advantages, such as cost and invasiveness. However, the possibility of late future complications with plating needs to be investigated, and the small sample size of the study should be taken into consideration.
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