Many papers have been published on the treatment of distal radius fractures , but the quality of the studies is variable. A general problem is that they often include very heterogeneous groups. The patients may range from 18 to 100 years of age without differentiation between younger and older patient groups. This is consistent with current practice at centres like Haukeland University Hospital and Oslo University Hospital, where more emphasis is placed on biological than on chronological age in cognitively healthy patients.
There are also many different classification systems for distal radius fractures, and the fractures are grouped somewhat differently. Several of the classification systems are not sufficiently reproducible, either
(22, 23). Different measuring methods are used for outcomes in some of the comparisons. Grading systems commonly used for functional testing frequently include anatomical and clinical outcomes, and modified versions of existing grading systems are often used. According to the authors of the reviews, this meant that the results could not be pooled.
Heterogeneity reduces the strength of the outcomes and conclusions are difficult to draw. This is the reason why none of the included studies was able to provide an unambiguous answer to our question of which patient groups benefit from surgical rather than conservative treatment.
A large percentage of patients with distal radius fractures can be treated conservatively
(18). This applies to those with fractures with little or no displacement. The challenge lies in deciding which fractures require surgery (3) – (7). The review does not point to any change in the anatomical limits for instability that will better capture those fractures that displace during the course of treatment than those referred to in the introduction to this paper (3) – (6).
When it comes to the question of which types of surgical treatment result in the best outcome for unstable, displaced fractures, there is some documentation. Both pinning combined with stabilising bandaging
(17) and external fixation (18) give better outcomes than conservative treatment. However, there is no documentation regarding their relative efficacy. Nor are there any differences between different types of external fixation (19).
Adjuvant treatment with bone graft or bone substitute does not improve the results
(20). Existing evidence indicates that plate osteosynthesis provides a better functional outcome than external fixation (21). This is supported by other literature (24, 25) A systematic review of low quality (25), which included both the old plate type and the newer, volar locking plates, found better DASH scores, supination and restoration of volar tilt in the plate group, while there was a tendency for external fixation to give better grip strength. Once studies of lower quality than randomised, controlled trials had been excluded, subgroup analyses showed that only the volar locking plates gave better results than external fixation. However, there are no studies of long-term results.
The review article of Cui et al.
(21) showed fewer complications with plate osteosynthesis than with external fixation, but that the difference disappears if pin infections are disregarded. Complications have also been reported with the new, volar locking plates (24, 26). There are also fewer complications with these than with external fixation (24). The complications are partly attributable to poor surgical technique, because implants may be incorrectly placed, causing damage to tendons or cartilage. The complications may also be attributable to the method itself. For example, many distal radius fractures may be accompanied by damage to ligaments in the capus (27) and stabilising structures of distal radio-ulnar joint (28).
We have so far no overview of consequences of the short-term or lack of immobilisation used with the newer volar locking plates for these ligament injuries. In addition, cost-benefit analyses may necessitate the introduction of surgical methods that also take into account use of resources in terms of operation time, implant cost, post-operative follow-up and risk of complications. We do not yet know whether these analyses favour the new volar locking plates.
The studies tend not to differentiate between younger and older patient groups. They accordingly provide no answers as to how best to treat young patients with displaced extra- or intra-articular fractures, or how best to treat older patients with osteoporotic bones. The review of the evidence provides little new data on how much residual displacement is tolerated. Thus there is a need for good studies that show where the anatomical limits for functional impairment are, and whether there are patient groups that may tolerate a larger residual displacement than others.
Limitations of the evidence-based method
Limitations of the evidence-based method
There are limitations inherent in using evidence-based practice for establishing treatment guidelines. One important factor is the time it takes before a systematic review of randomised trials is available after a new method is introduced. A systematic review will often not include the treatment methods currently in use to a sufficient degree. This also the case when it comes to treatment of distal radius fractures.
An example is the large-scale use of volar locking plates for the past ten years. When these plates were first introduced, there was no documentation of its use. Even after several years of use, there is only one systematic review article of more than moderate quality that includes this type of treatment
(21). Since October 2008, the Cochrane database has contained a protocol for a review with the title Internal fixation and comparisons of different fixation methods for treating distal radial fractures in adults (29), which is very relevant to our subject. Four years later, the report has still not been completed.
The length of time before systematic reviews are available adds to the tendency for the individual surgeon to choose a method based on personal preference and experience rather than available evidence-based literature. However, it should be mentioned that evaluation of operations and the treatment of distal radius fractures has gained greater attention as a result of the focus applied by the Norwegian Orthopaedic Association. Distal radius fractures are no longer merely a task for house doctors. This is an exciting field for highly specialised orthopaedic specialists and hand surgeons. It is to be hoped that the increased attention will be reflected in the treatment results and in fewer claims for damages.
Need for further research
Need for further research
Despite the many papers on distal radius fractures, there is still a great need for further research. It is important initially to identify research topics and prioritise among them. It would be desirable to assess the outcomes in the various age and fracture groups. This has not been done in any of the systematic reviews included in this review.
There are a number of different classification systems for distal radius fractures. Unfortunately they are all of limited practical use when it comes to selecting the optimal treatment. We need research on criteria that predict with greater certainty which fractures will re-displace, given conservative treatment, and which should therefore receive surgical treatment. The relationship between fracture position and function is well known, but what are the limits for an acceptable position? And what follow-up should be employed to ensure healing in a satisfactory position? We continue to see a substantial number of fractures that heal in malunion that causes symptoms.
Rather than yet more small, single-centre studies that do not satisfy the requirements for high quality evidence, good prospective randomised, controlled, multi-centre trials are needed. There is also a need to establish registers and analyse register data to capture changes in the incidence of complications when new methods are introduced.
The emphasis in this article is on the
treatment of distal radius fractures. It is important nonetheless to be aware of the importance of preventing these fractures. This offers considerable scope for research. Which measures work, how can resources be used most efficiently to prevent distal radius fractures, and can distal radius fractures provide an indirect measure of bone density and be a predictor of other types of fractures?
New treatment guidelines?
New treatment guidelines?
The evidence base for treatment of distal radius fractures was intended for use in preparing guidelines for treatment. Many questions remain unanswered, and good prospective, randomised multi-centre trials are needed to provide the best possible foundation for recommending treatments for patients.
Despite the limited documentation with respect to choice of treatment for different patient groups and fracture types, we know a good deal about treatment of distal radius fractures. We should use this knowledge as a basis for establishing treatment guidelines to reduce the variation in treatment practice and the number of claims for damages from patients.