Introduction
Fractures of the distal radius account for an estimated 15-25% of all fractures diagnosed.1 The importance of distal radius injuries has increased in the recent time due to an increase in lifespan. There is a bimodal distribution noticed in the incidence of such fractures, with younger patients sustaining complicated, high-energy injuries while older patients sustain low energy fractures.
In 1814, Abraham Colle was the first to describe the dorsally displaced extra-articular distal radius fracture.2 He opined that unreduced fracture results in malunion which might be pain free and may even offer good range of movement, however more recent studies widely differ with this.3 The consequences of post-traumatic loss of function are comprehensive. Loss of function can impair the individual in performing his day-to-day tasks.
Extra-articular distal radius fractures are considered relatively harmless but inadequate treatment may result complications such as malunion which can severely impair the function of the individual4. Several treatment modalities to obtain and maintain reduction exist and decision-making is mainly based on patient age, compliance, fracture type, concomitant fractures, soft tissue status and surgeon’s preference.4, 5
Various treatment methods exist ranging from surgical management to a conservative approach. Good results have been reported with both modalities, but a clear consensus does not exist on the ideal treatment method.6 With advancements in surgical practices over the last 2 decades, there has been a shift in the management of distal radius fractures from conservative treatment to more operative management.7, 8, 9
Volar locking plates have become increasingly popular as it involves a relatively simple volar approach to the wrist, followed by fracture fixation using fixed angle implants. More importantly it allows the individual to be free from a cast thus allowing for earlier mobilization and return to daily tasks. Open reduction and internal fixation with locking plates allows more accurate reduction and immediate stable fixation.6, 7 The fracture stability allows for early mobilization and may therefore result in an improved recovery of function. K-wire fixation is a minimally invasive procedure between open reduction plate fixation and conservative treatment and numerous authors have reported good results with this technique.8, 9
In recent decades there has been a shift in how to assess the functional outcome after distal radius fractures. However, clinical parameters do not represent patients’ perspectives and seem less relevant for outcome evaluation. Patient-reported outcomes like DASH score and Modified Mayo wrist score seem to be more relevant and are used as standard for this purpose.10
Very few studies have been performed comparing conservative treatment with operative treatment in patients with extra-articular distal radius fractures.11, 12
The aim of this prospective cohort study is to compare the functional outcomes between the conservative and surgical methods, assessed using the Disability of the Arm Shoulder and Hand Score (DASH) and the Modified Mayo wrist score and to determine whether we are undertreating or overtreating these injuries.
Materials and Methods
This study was conducted in Kasturba medical college and its allied hospitals. The study population consists of consecutive patients diagnosed with displaced extra-articular distal radius fractures admitted to Kasturba Medical college hospital (n=90) from November 2018 to September 2019 and were followed up for at least 1 year. The studies were combined in September 2020 to reach the estimated sample size within a reasonable time frame. Ethical approval was obtained from the Ethics Committee.
Exclusion criteria
Age less than 18 years.
Intraarticular fractures of distal radius.
Pathological fractures.
Open fractures.
Patients with associated same side upper limb injuries.
Previous history of distal radius fractures.
Arthritic changes in joint.
A total of 90 patients were identified fulfilling our criteria. All of them were offered surgery based on the fracture configuration. After detailed discussion and counseling, 45 patients consented for surgery and underwent either closed reduction percutaneous K-wire fixation or open reduction and volar plating, while 45 patients declined surgery and were hence treated conservatively with cast immobilization. There was no randomization of the patients into the operative or nonoperative group.
Casting protocol
The casting protocol consisted of wrist immobilization in below elbow cast after the initial manipulation and reduction under hematoma block. X-rays were taken after the procedure to check the reduction and was found to be satisfactory. A repeat x-ray was taken after 2 weeks to check for collapse of the fracture. The cast was maintained for 4-5 weeks more with free mobilization of digits, elbow, and shoulder. After removal of the cast the patient was advised both active assisted and passive physiotherapy which they continued at home. Patient was advised to carry out day to day tasks.
Volar locking plate protocol
The radius was approached via a volar Henrys approach. We used standard 2.4mm fixed angle locking plates. Fracture reduction was verified with fluoroscopy. When feasible, the pronator quadratus muscle was repaired to protect the flexor tendons. The wrist was mobilized from day 2 post surgery. Regular follow up of the patients were done.
Percutaneous K-wire protocol
Fixation using K-wires was performed percutaneously after indirect fracture reduction. Two K-wires 1.5 mm were used to transfix the fracture site. They were passed in a Criss cross fashion. One was passed through radial styloid, and the second wires entry point was dorsolateral. The K-wires were not buried. A below elbow cast was applied for 4-6 weeks duration. The plaster and K-wires were then removed in the outpatient department at 4-6 weeks, and all patients were prescribed physiotherapy program involving active motion of wrist and grip strengthening.
ROM – The ROM was calculated in both the injured and normal hand with a goniometer. The ROM in the study is expressed as % with that of the normal hand.
Statistical analysis
Categorical and quantitative variables were expressed as frequency (percentage) and mean ± SD respectively. Independent t test was used to compare quantitative parameters between categories. Chi-square test was used to association between categorical variables. For all statistical interpretations, p<0.05 was considered the threshold for statistical significance. Statistical analyses was performed by using a statistical software package SPSS, version 20.0.
Results
Patient demographics
The study comprised 94 individuals who fulfilled the inclusion and exclusion criteria from November 2018 to September 2020. 4 patients were lost to follow up.
Both the operative and non-operative group consisted of 45 individuals.
It was noted that the female population was more susceptible than males to sustaining fractures of the distal radius (60% in non-operative & 66.7% in operative group). The study also noted that the non-dominant hand was injured more often in both the groups (60% in operative and 66% in non-operative).
Among the patients who underwent operative procedures most patients were treated with closed reduction and K-wire fixation (57.1%) and were maintained on a below elbow cast foe a period of 4-6 weeks.
Flexion-extension
Both flexion and extension were significantly better in patients who had undergone operative procedures. A mean extension and flexion of 84.7% and 83.6% were noted in the group which was managed conservatively which was significantly lesser than 88.1 and 89 degrees noted in the operative group. It was also noted that patients who underwent plating had significantly better extension and flexion when compared to patients who had undergone K – wiring. A mean extension of 91.8% and flexion of 93.9% was noted in the group which had undergone plating.
Pronation-supination
No statistically significant difference was noted between the two groups.
Radial-ulnar deviation: Both radial and ulnar deviation were statistically significant and better in the operative population.
Grip strength
At the end of 12 months follow up the grip strength was significantly better in patients who had undergone operative procedures.
Table 3
Comparison of ROM in both operative and non-operative groups
Table 4
Comparison of ROM in operative group
Functional outcomes
Both DASH and MAYO scores were calculated after 12 months.
The DASH score was calculated based on the questionnaire with higher scores denoting higher disability. Higher DASH scores were noted in patients who had undergone non- operative management.
Among the patients who had undergone operative management, patients who had undergone closed reduction and K-wire fixation were noted to have higher DASH scores when compared to patients with plate fixation (35.3 – operative group and 36.4 in non-operative group) (36.5 in patients who had undergone closed reduction with K- wiring and 33.4 in patients who had undergone plating).
Considering the Mayo wrist score, a mean score of 64.1 was noted in patients who had undergone non- operative management with 34% of the patients showing poor results.
A mean Mayo score of 75 was noted in patients who had undergone operative management. 14% of the patients showed excellent results while 37% of the patients showed good results. None of the patients in the operative group showed poor results. Mayo score is also significantly higher in the patients who have undergone plating when compared to patients who underwent K-wiring (82.3 and 69.5 respectively).
Table 5
Comparison of DASH scores
|
Group |
Mean |
SD |
N |
t |
P |
|
Non operative |
35.9 |
2.5 |
45 |
1.9 |
0.061 |
|
Operative |
35.0 |
2.3 |
45 |
Table 6
Comparison of MAYO scores in both groups
|
MAYO |
Non operative |
Operative |
||
|
Count |
Percent |
Count |
Percent |
|
|
Poor |
9 |
20.0 |
0 |
0.0 |
|
Satisfactory |
34 |
75.6 |
20 |
44.4 |
|
Good |
2 |
4.4 |
16 |
35.6 |
|
Excellent |
0 |
0.0 |
9 |
20.0 |
Table 7
Comparison of DASH and MAYO Scores based on procedure in operated cases
|
DASH score |
|
|
|
|
|
|
Procedure |
Mean |
SD |
N |
T |
P |
|
CRIF with K Wire |
36.1 |
2.2 |
26 |
4.53 |
p<0.01 |
|
ORIF with plating |
33.5 |
1.5 |
19 |
||
|
MAYO scores |
|
|
|
|
|
|
CRIF with K Wire |
71.9 |
7.2 |
26 |
5.73 |
p<0.01 |
|
ORIF with plating |
84.2 |
6.9 |
19 |
|
|
Figure 3
50 year old female treated conservatively with reduction and casting
(DASH score - 35.2, MAYO Score - 70)
Figure 4
76 year old male who had undergone closed reduction and K-wiring
(DASH score - 34 MAYO Score - 70)
Discussion
Some sort of discomfort and loss of function is seen in most patients with distal radius fractures up until 1 year. The first 2 months after injury, the patients reported problems with many daily activities, but after 1 year most patients were comfortable and had minimal complaints.13
We deliberately used patient derived functional outcome measures rather than radiographic assessments because we think that the patient’s own assessment of the result is more important.
We felt that the patient will be better able to comprehend the changes they have in their daily life and the functional differences they face. However, we acknowledge that radiographic assessments of the quality of the reduction may have a bearing on the long-term functional result, particularly in younger patients.9, 10
This prospective cohort study conducted in Kasturba medical college and its allied hospitals showed that extra-articular distal radial fractures demonstrated better functional outcomes after 12 months when treated surgically compared with nonoperative treatment when the Modified Mayo Wrist Score was considered. However, the DASH scores at 12 months are not significant though the scores are better in the operative group showing lesser disability. Significantly better DASH score and Modified Mayo Wrist Score were noted for ORIF with volar LCP group when compared with patients who had undergone K wiring.
In 2 randomized controlled trials, Arora et al. and Bartl et al. compared ORIF with plaster immobilization in elderly patients.14, 15 Neither study showed any difference in wrist function between the 2 treatment groups at 6 and 12 months. These results are consistent with results of 2 previous retrospective studies by Arora e al. and Egol et al.16, 17 However, all these studies were conducted in an elderly population and included both extra- and intra-articular fractures. In 2009, Koenig et al.18 evaluated whether ORIF was preferable to nonoperative treatment for acceptably reduced distal radial fractures. The authors concluded that ORIF was the preferred treatment, especially in young patients, and reported a long-term gain in quality-adjusted life years.17 The results of our study were like the trends observed in the above-mentioned studies where surgically treated patients tend to achieve greater motion and better grip strength during recovery and significantly better functional outcomes. In a recent RCT comparing surgical vs conservative treatment in extra-articular fractures by Mulders et al.,13 with follow up until 12 months, surgically managed patients had significantly better functional outcomes.12
Surgical treatment by closed reduction percutaneous k-wire fixation and with open reduction volar plate fixation showed better functional results at 1 year in the group who had undergone plating which contradicts previous identical studies.7, 8, 18
Over the last 2 decades, open reduction and volar plate fixation has been increasingly utilized. Although the true reasons for this increase are unknown, it has been suggested that functional outcomes are positively correlated with adequate reduction, especially in young patients.
A few limitations of our study should be noted. Firstly, this was a prospective cohort study and there was no randomization of treatment groups. Secondly, radiological outcomes were not assessed. Thirdly, only short-term outcomes (12 months) were measured in this study. Although the sample sizes in the operative and nonoperative groups (45 each) after the criteria were applied were by no means small, a larger and ideally, a prospective randomized trial looking into both the short- and long-term outcomes will provide more information and a higher level of evidence.
Conclusion
In patients 18 to 65 years old with an extra-articular distal radial fracture surgically managed patients had clinically relevant better Mayo wrist scores with nonoperatively managed patients. Better ROM and grip strength were also noted in patients who had undergone operative management. The DASH scores at the end of 12 months were comparable but a lesser level of disability was noted in the operative group. Therefore, we can conclude that surgery is the ideal treatment approach for displaced extra articular distal radius fractures.
Further prospective randomized controlled studies with larger numbers will be required to evaluate the potential long-term benefits of surgical treatment along with economic evaluation determining the cost-effectiveness of each treatment option.