Is Early Internal Fixation Preferred to Cast Treatment for Well-Reduced Unstable Distal Radial Fractures?

Author(s): Koenig KM, Davis GC, Grove MR, Tosteson AN, Koval KJ

Source: J Bone Joint Surg Am 9:2086-93, 2009.

It can be difficult to determine optimal treatment for potentially unstable distal radius fractures, especially when an initial reduction has been performed and the patient’s alignment is adequate.  The decision to continue with non-operative treatment or to pursue internal fixation balances the risk of late fracture collapse against the risks of surgery.  In this article the authors develop a decision analytical model and used data from the available literature to evaluate which treatment option (open vs. closed) would be preferred and how the treatment would affect quality of life.  They also analyze what variables would change treatment decisions.
The authors determine that in most cases early internal fixation with a volar plate is the preferred treatment option (as it provided a higher probability of painless union).  However, the difference in outcomes was very small and in their analysis and the older patient (mean age 58 years) can only expect 0.08 more quality-adjusted life years (29 days) if treated with internal fixation rather than being treated non-operatively.  The benefit from operative treatment was even smaller for patients 65 years or older who in this analysis would have a benefit of 0.01 quality-adjusted life years (4 days). 
The authors suggest that patients (especially elderly) who have low functional demands (and thus have lower disutility for malunion and painful malunion) may prefer non-operative treatment for distal radius fractures that initially have an adequate reduction.