Question: In patients with displaced fracture of the distal part of the radius, how does bridging external fixation compare with locked volar plate-and-screw fixation?
Design: Randomized (allocation concealed), unblinded controlled trial with 12-month follow-up.
Setting: The New York University Hospital for Joint Diseases, New York, NY, USA.
Patients: 88 patients (mean age 51 y, 53% women) with a fracture of the distal part of the radius requiring operative repair (a score of 3 of 5 possible points according to the instability criteria scoring system of LaFontaine et al.) that could consist of open reduction and internal fixation or external fixation and Kirschner (K)-wires. Exclusion criteria included volar and dorsal shear fractures and skeletal immaturity. All patients completed the study; 77 patients (88%) were included in the analysis.
Intervention: Patients were allocated to a bridging external fixation and K-wire construct (n = 44) or locked volar small-fragment plate-and-screw fixation (n = 44). External fixation involved closed reduction with K-wires placed to hold the reduction. If reduction could not be achieved, small incisions were made to reduce and fix the fracture fragments anatomically with K-wires. The standard volar approach involved a similar procedure, with all fractures reduced in an open manner but stabilized with a locked precontoured volar plate.
Main outcome measures: Range-of-movement parameters (extension, flexion, supination, pronation, ulnar deviation, and radial deviation), pain (10-point visual analog scale [0 = no pain]), function (Disabilities of the Arm, Shoulder and Hand [DASH] score), number of physiotherapy sessions, and grip strength. Radiographic measurements (volar tilt, radial inclination, radial length, and ulnar variance) were made to assess union of the fracture and loss of reduction.
Main results: Greater improvements in range of movement of the wrist were observed in the volar plating group than in the external fixation group. At 3 months, significant differences between groups were seen in pronation and radial deviation, with borderline significant differences in extension and supination (Table). The improvement in extension and pronation was sustained at 6 months, and in pronation at 12 months (Table). From 6 to 12 months, the external fixation group received more physiotherapy sessions than the volar plating group (43.5 vs 20.4, p = 0.02). The groups did not differ at any follow-up point with regard to pain scores, DASH scores, or grip strength. The groups did not differ with regard to radiographic parameters, with similar amounts of initial displacement and extent of reduction.
Conclusion: In patients with a displaced fracture of the distal part of the radius, locked volar plate-and-screw fixation (as compared with bridging external fixation) led to a more improved range-of-movement outcome and fewer physiotherapy visits soon after treatment, but only improved pronation was sustained over longer follow-up.
The trial by Egol et al. investigates a timely and relevant topic. Several observations should be noted.
First, given over 50 separate statistical comparisons, a correction for the number of tests (e.g., a Bonferroni correction) would have demonstrated no significant differences at 1 year.
Second, for important outcomes of self-reported disability (DASH), grip strength, or volar tilt, the 2 methods were similar. If one agrees with the authors' opinion that the differences in motion are clinically insignificant, then perhaps looking at pronation or extension is not a good primary question for the next study.
Third, despite mention of a difference in the reoperation rate in the original abstract of the study, the difference was not significant.
Fourth, there was incomplete or unclear description of how the 88 randomized patients dwindled to 77 analyzed patients, the exclusion of patients who crossed over or used both treatments, and the exclusion of patients who had a salvage procedure (wrist fusion). Analysis according to "intention to treat" would have been preferable—otherwise there is too much risk for introducing bias.
Fifth, despite randomization, there was a greater proportion of AO Type C than Type A fractures in the external fixation group.
To determine how this study applies to clinical practice, one should consider the reported indications for surgery, the inclusion of partially healed fractures (up to 3 weeks after injury), and the definition of external fixation that allows small incisions to realign fragments. My preliminary judgment is that the two treatments (locking volar plates and external fixation) are comparable for the treatment of fracture of the distal part of the radius. Until a clear advantage is shown consistently in clinical trials, the choice of treatment will remain a shared decision of the patient and the surgeon and will continue to be influenced by surgeon training and preferences, patient preferences, and available resources.