Trauma Are intra-articular distal radius fractures best managed with volar locking plates or bridging external fixation?

Introduction Distal radius fractures are the sixth most commonly occurring fracture. Controversy surrounds the optimal method of fixation with both volar locking plate and bridging external fixation being advocated. This systematic review aims to compare these techniques in the treatment of intra-articular fractures. Materials and methods The electronic databases Medline and EMBASE were searched on the 6th December 2013. Clinical comparative trials comparing bridging wrist external fixator with or without Kwire augmentation and open reduction and internal fixation with any volar locking plate were included. Studies were excluded if no patient reported outcome measure was measured, extra-articular fractures were included or alternative fixation techniques were utilised. Results Four studies were included in the review. One randomised controlled trial was identified and demonstrated a significant improvement in only one of two functional outcomes measured following plate fixation. Two of three further retrospective studies reported significant improvements in outcomes following volar locking plate fixation, however these were of lower methodological quality. Conclusion The studies reviewed are insufficient to definitively conclude whether either treatment is optimal for intraarticular distal radius fractures. Further robust RCTs are required that focus on patient reported outcomes. Introduction Distal radius fractures (DRF) are the sixth most commonly occurring fracture1 and have an incidence of 9/10,000 in men and 37/10,000 in women in the UK2. The injury has a significant social impact with patients treated surgically taking over 13 weeks to return to work3,4. The amount of acceptable fracture displacement or angulation is not universally agreed, some previous studies have reported that imperfect reduction does not necessarily lead to osteoarthritis or worsening of patient satisfaction5,6. In contrast, others stress the importance of restoring radial length, alignment7,8 and articular congruency9,10,11. Even when surgery is indicated, controversy surrounds the ideal method of fixation12. Open reduction and internal fixation with dorsal or volar plates can yield successful results13,14,15. However plate fixation is associated with complications that include tenosynovitis, tendon rupture, complex regional pain syndrome, carpal tunnel syndrome and intraarticular penetration of screws16,17. Tendon complications are higher with dorsal plating15,18. Newer locking plates (LP) have higher resistance than the non-locking alternatives in biomechanical studies19 and their use in clinical practice has been advocated20,21. The successful use of external fixation (EF) for DRF has also been described22,23 and improved anatomical and functional results have been demonstrated when compared to casting alone24. EF acts by maintaining length whilst neutralising compressive, torsional and bending forces across the fracture site25. The ability of EF to restore palmar angulation has been questioned, the more expansile dorsal capsular ligaments are unable to control palmar angulation through ligamenttotaxis alone26. The addition of K-wires to the EF construct has been reported to increase rigidity in biomechanical studies27 whilst giving good clinical results28,29. EF can be associated with a number of complications that include malreduction, wrist and finger stiffness, pin tract infection, nerve injury and complex regional pain syndrome16,30,31. Reviews from the American Academy of Orthopaedic Surgeons and the Cochrane Database conclude that current evidence is insufficient to recommend for or against one specific method of fixation in DRF32,33. The aim of this systematic review is to compare volar locking plates and bridging external fixators in solely intraarticular fractures in terms of patient reported functional outcomes. Materials and methods The electronic databases Medline and EMBASE were searched on the 6th December 2013. The search strategy used for the Medline search is illustrated in table 1 and this strategy was modified for the EMBASE search. The studies were reviewed by both authors independently with any disagreements resolved through discussion. Only clinical comparative trials in humans (randomised or not randomised) were included. No papers were excluded by limiting search dates but only papers available in English were considered for review. Inclusion criteria were applied. Participants must be skeletally mature and have suffered an intra-articular DRF amenable to either plate or external fixation, described by the AO classification as C1-C3. The intervention could be any type of bridging wrist external fixator with or without K-wire augmentation or bone grafting. A comparative group must be included that underwent open reduction and internal fixation with any *Corresponding author Email: robert.jordan@doctors.org. uk 1 Birmingham Heartlands Hospital, Birmingham,