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Functional Outcomes for Unstable Distal Radial Fractures Treated with Open Reduction and Internal Fixation or Closed Reduction and Percutaneous FixationA Prospective Randomized Trial
Tamara D. Rozental, MD1; Philip E. Blazar, MD2; Orrin I. Franko, BS3; Aron T. Chacko, BS1; Brandon E. Earp, MD2; Charles S. Day, MD1
1 Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Stoneman 10, Boston, MA 02215. E-mail address for T.D. Rozental: trozenta@bidmc.harvard.edu
2 Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115
3 Harvard Medical School, 25 Shattuck Street, Boston, MA 02115
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Wright Medical. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Departments of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Aug 01;91(8):1837-1846. doi: 10.2106/JBJS.H.01478
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Abstract

Background: Despite the recent trend toward internal fixation of distal radial fractures, few randomized trials have examined whether volar plate fixation is superior to other stabilization techniques. The purpose of the present study was to compare (1) open reduction and internal fixation with use of a volar plate and early mobilization with (2) percutaneous fixation and casting or external fixation for the treatment of dorsally displaced unstable extra-articular and simple intra-articular fractures of the distal part of the radius, with a specific emphasis on early functional recovery.

Methods: A prospective randomized study was performed at two institutions. Forty-five consecutive patients with a displaced, unstable fracture of the distal part of the radius were randomized to closed reduction and pin fixation (n = 22) or open reduction and internal fixation with a volar plate (n = 23). Clinical and radiographic assessments were conducted at six, nine, and twelve weeks after surgery and at one year. Outcome was measured on the basis of range of motion; grip and pinch strength; and Disabilities of the Arm, Shoulder and Hand scores. A questionnaire was used to determine patient satisfaction, and a detailed analysis of complications was performed.

Results: Patients in the open reduction and internal fixation group had superior Disabilities of the Arm, Shoulder and Hand scores at six, nine, and twelve weeks. At six weeks, the average Disabilities of the Arm, Shoulder and Hand score was 27 in the open reduction and internal fixation group as compared with 53 in the closed reduction and pin fixation group (p < 0.01). At nine and twelve weeks, patients in the open reduction and internal fixation group continued to have lower scores (17 compared with 39 [p < 0.01] and 11 compared with 26 [p = 0.01], respectively). At one year, there was no significant difference between the two groups in terms of the Disabilities of the Arm, Shoulder and Hand scores. Patients in the open reduction and internal fixation group had greater range of motion and strength than patients in the closed reduction and pin fixation group at six and nine weeks, and more patients in the open reduction and internal fixation group were very satisfied with the overall wrist function and motion. Eight complications occurred, two in the open reduction and internal fixation group and six in the closed reduction and pin fixation group.

Conclusions: Both closed reduction with percutaneous pin fixation and open reduction with internal fixation with use of a volar plate are effective methods for the treatment of dorsally displaced, unstable, extra-articular or simple intra-articular fractures of the distal part of the radius. Better functional results can be expected in the early postoperative period in association with open reduction and internal fixation, and this form of treatment should be considered for patients requiring a faster return to function after the injury.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Tamara D. Rozental, MD
    Posted on October 21, 2009
    Dr. Rozental responds to Mr. Holmes and colleagues
    Harvard Medical School, Boston, MA

    We thank the authors for their thoughtful questions and remarks. We agree that post-operative immobilization likely plays an important role in explaining the lower DASH scores among patients treated with closed reduction and percutaneous pinning (and have included this as part of our title). Since post-operative immobilization is routinely employed following closed reduction and percutaneous pinning, we believe it is an important factor to consider when deciding on a treatment method for unstable fractures of the distal radius. Although our numbers were small, we were not able to detect any differences between age groups and believe that our study findings apply to young and elderly patients alike. Finally, the standard deviation in our return to work data is explained by the fact that several patients did not choose to take any time away from work during/after their treatment. We hope this helps to clarify the data and, once again, thank the authors for their comments.

    William JM Holmes, MBChB, MRCSEd
    Posted on October 10, 2009
    Group Homogeneity
    NULL

    To the Editor:

    We read the article by Rozental et al. (1) with great interest and welcome the authors' attempt to add more prospective studies to this highly controversial area of clinical practice (2). We also congratulate the authors on the regular and thorough follow up. We note from their introduction that they had a specific emphasis on "early functional recovery". One point we would like to make is that plaster immobilization is likely to affect the 6-week DASH score in the closed reduction and percutaneous fixation group when compared to those with ORIF and post-operative splinting. This makes it difficult to study early outcomes without inadvertently measuring the effect of plaster vs. splint, rather than the specific intervention desired.

    Furthermore, one of the difficulties encountered in all studies that attempt to compare interventions is that, in order to get sufficient numbers to provide statistical analysis, large age ranges exists for each group (19-77 years versus 24-79 years). This often makes it difficult to draw significant conclusions as age has a large bearing on patients perceived outcomes and functional ability - the requirements of a 17 year old are very different from those of a 79 year old. Furthermore, since occupation was not studied in the paper, it furthermore highlights the difficulty in grouping together such a heterogeneous population.

    Lastly, we admire the attempt look at return to work as this provides good patient-orientated outcome measure, but the statistics in this paper implied that return to work was 17+/-21 days versus 26+/-27 days. This would indicate that some patients returned to work 4 days prior to their injury, making the analysis difficult to interpret. Can the authors explain these numbers?

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References

    1. Rozental TD, Blazar PE, Franko OI, Chacko AT, Earp BE, Day CS. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial. J Bone Joint Surg Am. 2009;91:1837-46.

    2. Henry MH. Distal radius fractures: current concepts. J Hand Surg Am. 2008;33:1215-27.

    Tamara D. Rozental, MD
    Posted on August 28, 2009
    Dr. Rozental responds to Dr. Kumar
    Harvard Medical School, Boston, MA

    We thank Dr. Kumar for his comments.

    The age and fracture distribution among both patients groups was similar. Furthermore, given that reductions were maintained in both patient groups, we did not feel that age or the presence of osteoporotic bone significantly affected our results. For these reasons, we did not conduct a separate analysis by age.

    As is our standard protocol, patients with fragility fractures and those with other risk factors for osteoporosis were referred for bone mineral density testing. Treatment for underlying osteopenia and osteoporosis was then determined on a case-by-case basis.

    All closed reductions and percutaneous pinnings were performed under regional anesthesia with sedation and/or general anesthesia. We obtained an adequate closed reduction in all cases and there was no cross-over to the open reduction group after randomization (see Figure 1).

    The technique for placement of Kirschner wires is described in our Methods section. Wires were placed through small stab incisions in the radial styloid and along the dorsal-ulnar aspect of the distal radius. No wires were placed volarly.

    Sudeep Kumar, MBBS, MS(Ortho)
    Posted on August 20, 2009
    Letter to the Editor
    All India Institute Of Medical Sciences, New Delhi, India

    To the Editor:

    I read with interest the paper by Rozental et al. (1) and would like to raise some points and put forward a few questions to the authors:

    1). There was no mention of which age group was affected most by which type of fracture. There are high chances of failure of Kirschner wire fixation in A1 and A2 fractures in elderly osteoporotic population. Thus the result could vary according to patient age. Therefore, it is difficult to generalize the results without taking patient age into consideration. An age-wise differentiation of the fractures and the analysis of the results should have been done.

    2). What were the criteria used to define osteoporosis and was screening for osteoporosis done in any age group or were any additional precautions taken or drug supplementation given preoperatively and postoperatively in these patients?

    3). There was no mention in your paper regarding the type of anesthesia or sedation used for the closed reduction group. Many times under hematoma block consideration, it is very difficult to achieve a good closed reduction. So, if the fractures were manipulated under general anesthesia and the reduction obtained was not satisfactory, did the surgeon proceed with open reduction or accept the unsatisfactory reduction?

    4). Were the wires placed dorsally or volarly? If the wires were inserted dorsally, how were the tendons protected and, if they were placed volarly, what was the method used to protect the neurovascular structures?

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    Reference

    1. Rozental TD, Blazar PE, Franko OI, Chacko AT, Earp BE, Day CS. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial. J Bone Joint Surg Am. 2009;91:1837-46.

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