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Unstable distal radial fractures managed with external fixation require fewer reoperations

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Author Verified

Unstable distal radial fractures managed with external fixation require fewer reoperations

Vol: 2| Issue: 3| Number:51| ISSN#: 2564-2537
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A

Bridging external fixation and supplementary Kirschner-wire fixation versus volar locked plating for unstable fractures of the distal radius: A RANDOMISED, PROSPECTIVE TRIAL

J Bone Joint Surg Br. 2008 Sep;90(9):1214-21

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Synopsis

88 patients with distal radius fracture were selected for surgical fixation. This group was randomized to be managed with either bridging external fixation with supplementary Kirschner-wire (K-Wire) fixation or volar locked plating with screws. The patients treated by volar plating had a significant early improvement in the range of movement of the wrist; this advantage diminished with time, and in absolute terms the difference in range of movement was clinically non-relevant. No clinically significant differences in the reductions was observed on radiographs. Both groups had comparable function at one year. No definitive advantage of either treatment could be established; however, fewer re-operations were required in the external fixation group.

Publication Funding Details +
Funding:
Not Reported
Conflicts:
None disclosed

Risk of Bias

6/10

Reporting Criteria

17/20

Fragility Index

N/A

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

2/4

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?

Distal radius fractures are a common injury, especially in the bones weakened by osteoporosis in post-menopausal women. As with any other fractures the anatomic reduction and immobilization is the key management principle. A wide variety of options are available ranging from conservative management in a cast to closed reduction and pinning, bridging and non-bridging external fixation, and open reduction with plate and screw fixation through a variety of approaches. Each technique has its own sets of merits and demerits.This study aimed to compare the clinical outcomes of bridging external fixation and supplementary Kirschner-wire fixation to volar locked plating.

What was the principal research question?

Does the bridging external fixation and supplementary Kirschner-wire fixation has better clinical outcomes at 1 year than volar locked plating for unstable fractures of the distal radius?

Study Characteristics -
Population:
88 consecutive patients (age range 18-87 yr, mean age 51.05 yr) with unstable fractures of the distal radius requiring surgical fixation
Intervention:
External Fixation Group: Bridging external fixation and K-wires construct (Mean age: 49.9, n=38, F=22)
Comparison:
Plate Group: Open reduction and Internal fixation with locked volar small-fragment plate-and-screw fixation (Mean age: 52.2, n=39, F=25)
Outcomes:
Mechanism of injury, Functional assessment by the Disabilities of Arm, Shoulder and Hand (DASH) score, range of movement of the wrist, Radiographic assessment of fracture union and alignment by anteroposterior (AP), lateral and oblique x-rays and re-operation rate.
Methods:
RCT; Prospective, Single-center
Time:
Baseline and post-operative 2 week, 6 week, 3, 6 and 12 months evaluations

What were the important findings?

  • No differences in the mean DASH scores at any of the follow-up assessments were observed between the groups and compared to the patients self-reported baseline levels. A trend towards significantly improved DASH scores was, however, found at 6 months, in favour of the external fixation group (p=0.06)
  • Patients treated by volar plating had a statistically significant improvement in the range of movement of the wrist at 3 months: pronation (p<0.001), supination (p=0.05), extension (p=0.05) and radial deviation (p=0.002). This improvement diminished at 6 months and 1 year.
  • Radiologically, there were no clinically significant differences in the reductions, although more patients with AO/OTA (Orthopaedic Trauma Association) type C fractures were allocated to the external fixation group.
  • Radiologically, all the fractures united except one. Complication rate was comparable with 7 patients (18.4%) in the external fixation group having 7 complications compared with 8 (20.5%) in the plate group.

What should I remember most?

The patients treated by volar plating had a statistically significant early improvement in the range of movement of the wrist, which diminished with time and was clinically non-relevant. No clinically significant differences in the reductions was observed on radiographs. Both groups had comparable function at one year. No definitive advantage of either treatment could be established; however, fewer re-operations were required in the external fixation group.

How will this affect the care of my patients?

Each method has its own sets of merits and demerits, which must be considered for each patient's profile, and appropriate method should be chosen based on thorough assessment. Further research with larger populations is needed.

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