Plating vs Closed Reduction for Fractures in the Distal Radius in Older Patients
Authors: Andrew Lawson, Justine Naylor, Rachelle Buchbinder, Rebecca Ivers, Zsolt J. Balogh, Paul Smith, Wei Xuan, Kirsten Howard, Arezoo Vafa, Diana Perriman, Rajat Mittal, Piers Yates, Bertram Rieger, Geoff Smith, Sam Adie, Ilia Elkinson, Woosung Kim, Jai Sungaran, Kim Latendresse, James Wong, Sameer Viswanathan, Keith Landale, Herwig Drobetz, Phong Tran, Richard Page, Sally Beattie, Jonathan Mulford, Ian Incoll, Michael Kale, Bernard Schick, Trent Li, Andrew Higgs, Andrew Oppy, Ian A. Harris
Journal: JAMA Surgery (2022)

<h3>Importance</h3> Distal radius fractures are common and are managed with or without surgery. Current evidence indicates surgical treatment is not superior to nonsurgical treatment at 12 months. <h3>Objective</h3> Does surgical treatment for displaced distal radius fractures in patients 60 years or older provide better patient-reported wrist pain and function outcomes than nonsurgical treatment at 24 months? <h3>Design, Setting, and Participants</h3> In this secondary analysis of a combined multicenter randomized clinical trial (RCT) and a parallel observational study, 300 patients were screened from 19 centers in Australia and New Zealand. Of these, 166 participants were randomized to surgical or nonsurgical treatment. Participants who declined randomization (n = 134) were included in the parallel observational group with the same treatment options and follow-up. Participants were followed up at 3, 12, and 24 months by a blinded assessor. The 24-month outcomes are reported herein. Data were collected from December 1, 2016, to December 31, 2020, and analyzed from February 4 to October 21, 2021. <h3>Interventions</h3> Surgical treatment consisting of open reduction and internal fixation using a volar-locking plate (VLP group) and nonsurgical treatment consisting of closed reduction and cast immobilization (CR group). <h3>Main Outcomes and Measures</h3> The primary outcome was patient-reported function using the Patient-Rated Wrist Evaluation (PRWE) questionnaire. Secondary outcomes included health-related quality of life, wrist pain, patient-reported treatment success, patient-rated bother with appearance, and posttreatment complications. <h3>Results</h3> Among the 166 randomized and 134 observational participants (300 participants; mean [SD] age, 71.2 [7.5] years; 269 women [89.7%]), 151 (91.0%) randomized and 118 (88.1%) observational participants were followed up at 24 months. In the RCT, no clinically important difference occurred in mean PRWE scores at 24 months (13.6 [95% CI, 9.1-18.1] points for VLP fixation vs 15.8 [95% CI, 11.3-20.2] points for CR; mean difference, 2.1 [95% CI, −4.2 to 8.5];<i>P</i> = .50). There were no between-group differences in all other outcomes except for patient-reported treatment success, which favored VLP fixation (33 of 74 [44.6%] in the CR group vs 54 of 72 [75.0%] in the VLP fixation group reported very successful treatment;<i>P</i> = .002). Rates of posttreatment complications were generally low and similar between treatment groups, including deep infection (1 of 76 [1.3%] in the CR group vs 0 of 75 in the VLP fixation group) and complex regional pain syndrome (2 of 76 [2.6%] in the CR group vs 1 of 75 [1.3%] in the VLP fixation group). The 24-month trial outcomes were consistent with 12-month outcomes and with outcomes from the observational group. <h3>Conclusions and Relevance</h3> Consistent with previous reports, these findings suggest that VLP fixation may not be superior to CR for displaced distal radius fractures for patient-rated wrist function in persons 60 years or older during a 2-year period. Significantly higher patient-reported treatment success at 2 years in the VLP group may be attributable to other treatment outcomes not captured in this study. <h3>Trial Registration</h3> ANZCTR.org Identifier:ACTRN12616000969460