Surgery
The baseline functional demands of the patient, the consequences of mal-union, and the potential risks of surgery need to be considered when assessing the role of surgical intervention. The following factors are considered:
- Early surgical intervention.
- Non-operative management.
- The outcome following mal-union.
- The indications and benefits of various surgical techniques.
- The effect of a concomitant distal ulnar styloid fracture.
Timing of Surgery
Introduction
It is possible that a delay in surgery for a DRF may lead to complications e.g. pain or CRPS, and subsequently an inferior outcome for the patient. The aim is to review whether the timing of surgical intervention for a DRF influences the patient reported outcome score. A time cut-off of two weeks was chosen by consensus with the GDG.
Review Question
How does early surgical intervention (up to 2 weeks following injury) compare with delayed surgical intervention (>2 weeks following injury) in terms of the PROMs?
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Population
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Adults ≥16yrs of age or older requiring surgical intervention for a fracture of the distal radius
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Intervention
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Surgery more than 2 weeks following injury
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Comparison
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Surgery up to 2 weeks following injury
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Outcomes
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PROMs
Functional outcome
Complications
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Study Designs
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Meta-analyses, systematic reviews, RCTs, cohort studies
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Evidence
No randomised controlled trials or cohort studies or case series were found for this review question.
Evidence Statement
No evidence was found on the effect of timing of surgical intervention and the functional or patient reported outcome following a DRF.
The NICE Guidelines recommend surgical intervention is performed within 72 hours of injury for intra-articular fractures and within one week for extra-articular fractures. When operative management is required for re-displacement following manipulation, surgery should be undertaken within 72 hours of the decision to operate. (NICE Non-complex Fracture Guidelines https://www.nice.org.uk/guidance/NG38/chapter/Recommendations#ongoing-orthopaedic-management )
Recommendation
Best Practice Point:
When surgery is indicated the patient is best served by prompt intervention by the appropriate surgeon, as delay confers no benefit to the patient’s recovery. The patient is to be fully involved and informed of all options, recommended guidelines and potential risks.
Non-operative versus operative management
Introduction
The aim is to review how non-operative management compared with surgery for a dorsally displaced fracture of the distal radius in terms of the patient reported outcome. Studies were categorised according to age following discussion within the committee – up to 50 years of age and over 50 years of age were the two categories.
Review Question
How does surgical intervention (volar plate fixation, (non-) bridging external fixation, K-wires) compare with non-operative management (including closed reduction) in terms of the patient reported outcome?
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Population
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Adults ≥16yrs of age who have sustained a dorsally displaced fracture of the distal radius
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Intervention
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Surgery (volar plate fixation, (non-)bridging external fixation, K-wires)
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Comparison
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Non-operative management (including closed reduction)
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Outcomes
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PROMs
Functional outcome
Complications
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Study Designs
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Meta-analyses, systematic reviews, RCTs, cohort studies
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Evidence
A total of 27 papers were reviewed for this question, including 20 RCTs and seven cohort studies. Of these, five met our inclusion criteria and were graded acceptable. View here.
Evidence Statement
Level 1+:
Based on the current literature, there is no evidence supporting any treatment option for the population under the age of 50 years and up to 65 years. However, for patients over the age of 65 years, there is evidence that operative intervention does not provide a superior outcome to non-operative management when measured by PROMs at one year.
Recommendation
Grade of Recommendation: Grade A
In patients 65 years of age or older, non-operative treatment can be considered as a primary treatment for displaced DRFs. However, other factors such as pre-injury function, medical comorbidities and fracture characteristics should be considered and options discussed with the patient.
Manipulation under Anaesthesia + K-wires versus open reduction internal fixation
Introduction
The aim is to review how manipulation and K-wire fixation compared with open reduction internal fixation for a dorsally displaced DRF in terms of the PROMs. Studies were categorised according to age following discussion within the committee – up to 50 years of age and over 50 years of age.
Review Question
How does surgical intervention with manipulation and K-wire fixation compare with open reduction internal fixation in terms of the PROM?
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Population
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Adults ≥16yrs of age who have sustained a dorsally displaced fracture of the distal radius
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Intervention
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Manipulation and K-wire fixation
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Comparison
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Open reduction internal fixation
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Outcomes
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PROMs
Functional outcome
Complications
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Study Designs
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Meta-analyses, systematic reviews, RCTs, cohort studies
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Evidence
A total of 16 papers were reviewed for this question, including one meta-analysis, nine RCTs, five cohort studies and one economic evaluation. Of these, three were high quality and three were acceptable and met the inclusion criteria. However, as four of these studies were included as part of the high-quality meta-analysis, the details of only two studies can be reviewed. View here.
Evidence Statement
Level 1+:
In dorsally displaced DRFS that can be reduced closed and where surgery might be considered, there is evidence that open reduction internal fixation does not provide a superior outcome to K-wire fixation when measured by PROMs at one year. There is insufficient evidence to draw conclusions about the best management of unstable DRFs which cannot be satisfactorily reduced closed.
Recommendation
Grade of Recommendation: Grade A
When surgery is needed for dorsally displaced DRFs that can be reduced closed, offer K-wire fixation and cast.
Best Practice Point:
For DRFs that require open reduction, or for those with an intra-articular step or gap which is unable to be satisfactorily reduced closed, open reduction and fixation can be considered.
External fixation versus open reduction internal fixation
Introduction
The aim is to review how external fixation compared with open reduction internal fixation for a dorsally displaced DRF in terms of the PROM. Studies were categorised according to age following discussion within the committee – up to 50 years of age and over 50 years of age.
Review Question
How does surgical intervention with external fixation compare with open reduction internal fixation in terms of the patient reported outcome?
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Population
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Adults ≥16yrs of age who have sustained a dorsally displaced fracture of the distal radius
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Intervention
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External fixation
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Comparison
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Open reduction internal fixation
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Outcomes
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PROMs
Functional outcome
Complications
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Study Designs
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Meta-analyses, systematic reviews, RCTs, cohort studies
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Evidence
A total of 25 papers were reviewed for this question, including 13 RCTs, seven cohort studies, four meta-analyses/systematic reviews and one economic evaluation. Of these, three were high quality and ten were acceptable and met the inclusion criteria. However, as five of these studies were included as part of the high-quality meta-analyses, the details of only eight studies can be reviewed. View here.
Evidence Statement
Level 1+++:
Open reduction and internal fixation is associated with better early functional outcomes and a lower risk of complications when compared with external fixation.
Recommendation
Grade of Recommendation: Grade A
External fixation should not be used as the definitive treatment of closed DRFs where open reduction and internal fixation of the fracture fragments is possible.
Concomitant Distal Ulnar Styloid Fracture Management
Introduction
The aim is to review how non-operative management compared with surgery for a concomitant fracture of the distal ulna in patients with a surgically managed DRF in terms of the PROM.
Review Question
How does concomitant distal ulnar styloid fracture fixation compare with no treatment in terms of the PROM?
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Population
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Adults ≥16yrs of age with a surgically managed distal radius fracture and a concomitant fracture of the distal ulna
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Intervention
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Non-operative management
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Comparison
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Surgery
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Outcomes
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PROMs
Functional outcome
Complications
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Study Designs
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Meta-analyses, systematic reviews, RCTs, cohort studies
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Evidence
A total of four papers were reviewed for this question, all of which were cohort studies. Of these, two met the inclusion criteria. View here.
Evidence Statement
Level 2:
Non-operative treatment of an ulnar styloid fracture associated with a DRF and a stable DRUJ produces the same outcome as an isolated DRF.
Recommendation
Grade of Recommendation: Grade D
In the presence of a DRF with a stable DRUJ it is not necessary to fix an ulnar styloid fracture.
Best Practice Point:
Stability of the DRUJ should be assessed and recorded after surgical treatment of DRFs.
References:
NON-OPERATIVE VERSUS OPERATIVE MANAGEMENT
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Study
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Intervention/ comparison
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Patients
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PROM(s)
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Comments
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Arora et al. (2009)
Retrospective cohort
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Non-operative vs ORIF
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Adults (n=114)
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DASH
PRWE
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Elderly patients (≥70yrs)
No difference in DASH and PRWE at mean final follow-up of 4.5yrs
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Aktekin et al. (2010)
Retrospective cohort
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Non-operative vs external fixation
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Adults (n=46)
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DASH
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Elderly patients (≥65yrs)
No difference in DASH at mean final follow-up of 2.1yrs
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Egol et al. (2010)
Retrospective cohort
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Non-operative vs surgery
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Adults (n=90)
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DASH
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Elderly patients (≥65yrs)
No difference in DASH at 3, 6 and 12 months post injury
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Arora et al. (2011)
PRCT
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Non-operative vs ORIF
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Adults (n=73)
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DASH
PRWE
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Elderly patients (≥65yrs)
ORIF group had superior DASH and PRWE scores at 6 weeks and 3 months but no difference seen at 6 and 12 months
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Bartl et al. (2014)
PRCT
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Non-operative vs ORIF
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Adults (n=185)
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DASH
EQ-5D
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Elderly patients (≥65yrs)
No difference in DASH at 3, 6 and 12 months follow-up
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Back
MANIPULATION UNDER ANAESTHESIA + K-WIRES VERSUS OPEN REDUCTION INTERNAL FIXATION
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Study
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Intervention/ comparison
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Patients
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PROM(s)
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Comments
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Hull et al. (2011)
Retrospective cohort
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MUA+K-wire vs ORIF
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Adults (n=71)
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PWRE
DASH
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No difference at 1 and 2 years post surgery for both PWRE and the DASH
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Chaudhry et al. (2015)
Meta-analysis
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MUA+K-wire vs ORIF
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Adults (n=875)
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DASH
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ORIF found to have superior DASH scores at 3 and 12 months but not clinically significant
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Back
EXTERNAL FIXATION VERSUS OPEN REDUCTION INTERNAL FIXATION
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Study
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Intervention/ comparison
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Patients
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PROM(s)
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Comments
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Cui et al. (2011)
Meta-analysis
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External fixation vs ORIF
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Adults (n=738)
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DASH
ROM
Grip Strength
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Pooled results suggest ORIF superior DASH score at 3 months and 1 year
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Landgren et al. (2011)
Retrospective cohort
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External fixation vs ORIF
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Adults (n=50)
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QuickDASH
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Long-term follow-up of previous PRCT. At a mean follow-up of 5 years, no difference in QuickDASH between groups.
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Richard et al. (2011)
Retrospective cohort
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External fixation vs ORIF
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Adults (n=115)
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DASH
ROM
Grip Strength
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Superior DASH score following ORIF at 1 year
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Jeudy et al. (2012)
PRCT
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External fixation vs ORIF
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Adults (n=75)
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PRWE
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No difference in PRWE at 3 and 6 months post surgery
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Wei et al. (2012)
Meta-analysis
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External fixation vs ORIF
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Adults (n=1011)
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DASH
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Pooled results suggest ORIF superior DASH score
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Esposito et al. (2013)
Meta-analysis
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External fixation vs ORIF
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Adults (n=707)
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DASH
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Pooled results suggest ORIF gives superior DASH score
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Williksen et al. (2013)
PRCT
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External fixation vs ORIF
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Adults (n=111)
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QuickDASH
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No difference in QuickDASH score at 1-year post surgery
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Xie et al. (2013)
Meta-analysis
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External fixation vs ORIF
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Adults (n=772)
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DASH
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Pooled results suggest ORIF gives superior DASH score at 12 months. Independent analysis of studies suggests superior DASH score at 3 and 6 months for ORIF, but not at 12 months.
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Back
CONCOMITANT DISTAL ULNAR STYLOID FRACTURE MANAGEMENT
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Study
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Intervention/ comparison
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Patients
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PROM(s)
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Comments
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Souer et al. (2009)
Retrospective cohort
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No fixation versus no fracture
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Adults (n=76)
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DASH
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No difference in DASH score at 1 and 2 years post injury
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Kim et al. (2010)
Prognostic retrospective cohort
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No fixation versus no fracture
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Adults (n=138)
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DASH
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No difference in DASH at mean final follow-up of 1.5yrs
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