EVIDENCE-BASED MEDICINE Evidence-Based Medicine
Distal Radius Fractures: Percutaneous Treatment Versus Open Reduction With Internal Fixation Patrick O. Lang, MD, Kyle D. Bickel, MD CME INFORMATION AND DISCLOSURES The Review Section of JHS will contain at least 3 clinically relevant articles selected by the editor to be offered for CME in each issue. For CME credit, the participant must read the articles in print or online and correctly answer all related questions through an online examination. The questions on the test are designed to make the reader think and will occasionally require the reader to go back and scrutinize the article for details. The JHS CME Activity fee of $30.00 includes the exam questions/answers only and does not include access to the JHS articles referenced. Statement of Need: This CME activity was developed by the JHS review section editors and review article authors as a convenient education tool to help increase or affirm reader’s knowledge. The overall goal of the activity is for participants to evaluate the appropriateness of clinical data and apply it to their practice and the provision of patient care. Accreditation: The ASSH is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. AMA PRA Credit Designation: The American Society for Surgery of the Hand designates this Journal-Based CME activity for a maximum of 2.00 “AMA PRA Category 1 Credits”. Physicians should claim only the credit commensurate with the extent of their participation in the activity. ASSH Disclaimer: The material presented in this CME activity is made available by the ASSH for educational purposes only. This material is not intended to represent the only methods or the best procedures appropriate for the medical situation(s) discussed, but rather it is intended to present an approach, view, statement, or opinion of the authors that may be helpful, or of interest, to other practitioners. Examinees agree to participate in this medical education activity, sponsored by the ASSH, with full knowledge and awareness that they waive any claim they may have against the ASSH for reliance on any information presented. The approval of the US Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed or reviewed during this educational activity may not yet have received FDA approval.
THE PATIENT A 38-year-old, right-handed lawyer presents to the emergency department with right wrist pain and swelling after falling onto an outstretched right hand. His hand is swollen and tender over the distal radius. From the Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, Maryland, and the Hand Center of San Francisco, San Francisco, California. Received for publication February 28, 2013; accepted in revised form November 24, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Patrick O. Lang, MD, The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD 21218; e-mail: [email protected]. 0363-5023/14/3903-0026$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.11.039
546
r
2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
Provider Information can be found at http://www.assh.org/Pages/ContactUs.aspx. Technical Requirements for the Online Examination can be found at http://jhandsurg. org/cme/home. Privacy Policy can be found at http://www.assh.org/pages/ASSHPrivacyPolicy.aspx. ASSH Disclosure Policy: As a provider accredited by the ACCME, the ASSH must ensure balance, independence, objectivity, and scientific rigor in all its activities. Disclosures for this Article Editors David C. Ring, MD, PhD, has no relevant conflicts of interest to disclose. Authors All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page. Planners Ghazi M. Rayan, MD, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose. Learning Objectives Appraise the evidence regarding treatment of an unstable distal radius fracture. Discuss the available literature relevant to percutaneous pin fixation for a distal radius fracture. Review the literature related to external fixation for a distal radius fracture. Assess the literature pertinent to internal fixation for a distal radius fracture. Compare treatment outcomes for external versus internal fixation for a distal radius fracture. Deadline: Each examination purchased in 2014 must be completed by January 31, 2015, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each month’s JHS CME activity is up to 2 hours. Copyright ª 2014 by the American Society for Surgery of the Hand. All rights reserved.
Radiographs show a distal radius fracture with substantial dorsal displacement and a nondisplaced intraarticular extension. A closed reduction is performed and the wrist is stabilized with a sugar-tong splint. Repeat radiographs 2 days later show loss of reduction. Surgery is planned. THE QUESTION What is the optimal operative management of this unstable and displaced distal radius fracture? CURRENT OPINION There is no consensus on the optimal operative treatment for an unstable fracture of the distal radius.
Grewal et al8 randomized 53 patients to ORIF or external fixation. One third of patients (early recruitment) were treated with dorsal plates and the majority received VLP. The authors found lower Patient-Rated Wrist Evaluation (PRWE) scores early on in the ORIF group but no differences at 1 year. DASH scores were similar at all time points. Egol et al9 randomized 88 patients to either bridging external fixation or volar plating and found no differences in radiographic outcomes, range of motion, or function. Rozental et al10 randomized 45 consecutive patients to ORIF with volar plating or closed reduction with percutaneous pinning and showed early functional benefits in the ORIF group but no differences in DASH scores at 1 year. Williksen et al11 randomized 111 unstable distal radius fractures to external fixation with adjuvant pinning or VLP. At 1 year follow-up, the VLP group had better Mayo wrist scores on average (P ¼ .02). The VLP group had better supination at 1 year (P ¼ .03), but all other range of motion and grip strength comparisons were not significantly different between the 2 groups. QuickDASH scores at 1 year were comparable. Complications rates were about 30% in both groups. Fifteen percent of patients with VLP had a second surgery for plate removal.
An evidenced-based guideline from the American Academy of Orthopaedic Surgeons (AAOS)1 failed to establish the superiority of any one treatment. The current trend in the management of distal radius fractures is toward open reduction with internal fixation (ORIF), most recently with the use of volar locking plates (VLP).2 The rationale for this trend is that VLP facilitates restoration and maintenance of alignment while allowing early wrist motion, but the best evidence to date shows little difference in symptoms, disability, complications, or cost effectiveness compared with external fixation and percutaneous pinning. THE EVIDENCE Percutaneous pinning versus ORIF McFadyen et al3 randomized 56 extra-articular fractures to either VLP or percutaneous pinning and found that the VLP group fared better in both functional outcome and postoperative radiographic assessment. External fixation versus ORIF In 2005, an analysis of pooled data from retrospective case series found no significant differences between ORIF (dorsal and volar) and external fixation in subjective, objective, or radiographic outcomes.4 Richard et al5 retrospectively compared external fixation with VLP for comminuted intra-articular distal radius fractures and found significantly higher mean Disabilities of the Arm, Shoulder, and Hand (DASH) scores in the external fixation group, compared with the VLP group, at final follow-up an average of 12 months after surgery (32 vs 17; P ¼ .002). In addition, the VLP group had significantly more wrist flexion and extension and significantly less pain. The complication rate was higher in the external fixation group (P ¼ .021), but there were no differences in the rates of tendon and median nerve complications. Leung et al6 randomized 144 AO type C distal radius fractures to ORIF with nonlocking stainless steel T-plates (volar, dorsal, or combined) or external fixation with small AO/ASIF external fixators and percutaneous Kirschner wires. At the 24-month (but not the 12-month) evaluation point, they found superior Gartland and Werley scores and less radiographic arthritis in the ORIF group (primarily among C2 fractures) and no differences on the modified Green and O’Brien score. Kreder et al7 randomized 179 patients to ORIF (mostly dorsal) or external fixation and found early benefits in the external fixation group but no significant differences between the 2 groups in functional assessment scores (musculoskeletal functional assessment score) or radiographic outcomes 2 years after surgery. J Hand Surg Am.
547
SHORTCOMINGS OF THE EVIDENCE Many studies do not specify a primary outcome. If we assume that symptoms and disability (as measured by the DASH or musculoskeletal function assessment instruments) are the most important measure of treatment outcomes, then there is no difference between treatments. Given that symptoms and disability do not correlate precisely with pathophysiology, it is debatable whether or not that is indeed the best outcome measure. For instance, higher-demand individuals might benefit from a better radiographic alignment. Current data evaluate short-term outcomes only and cannot comment on arthrosis in the long term. Prospective trials to date have not assessed the convenience or cost effectiveness of percutaneous and open fixation. DIRECTIONS FOR FUTURE RESEARCH Future studies should address the convenience/burden of various treatment options from the patient’s and surgeon’s perspective. Studies of arthroscopic or 3-dimensional computed tomographic assessment of the articular reduction after reduction and fixation of the fracture might help clarify the relationship between articular alignment and functional outcome with r
Vol. 39, March 2014
Evidence-Based Medicine
TREATMENT OF DISTAL RADIUS FRACTURES
548
TREATMENT OF DISTAL RADIUS FRACTURES
Evidence-Based Medicine
stratification for levels of physical activity or demand. Ideally, this would be assessed after 5 to 10 years to determine the influence on arthrosis. In addition, studies that address the value (quality per cost) of various treatments would be helpful.
4.
5.
OUR CURRENT CONCEPTS FOR THIS PATIENT In our opinion, current evidence suggests an advantage to VLP over pinning or external fixation with regard to final radiographic alignment and for comminuted intra-articular fractures (AO group C), but the findings are inconsistent. Because external fixation and VLP are both good options, we generally follow the patient’s treatment preference. The patient under consideration chose ORIF with a VLP because he favored the risks of internal fixation over the inconveniences of having an external device.
6.
7.
8.
9.
REFERENCES 10.
1. American Academy of Orthopaedic Surgeons. The treatment of distal radius fractures: guideline and evidence report. 2009. Available at: http://www.aaos.org/research/guidelines/drfguideline.pdf. Accessed Feb 15, 2013. 2. Koval KJ, Harrast JJ, Anglen JO, Weinstein JN. Fractures of the distal part of the radius. The evolution of practice over time. Where’s the evidence? J Bone Joint Surg Am. 2008;90(9):1855e1861. 3. McFadyen I, Field J, McCann P, Ward J, Nicol S, Curwen C. Should unstable extra-articular distal radial fractures be treated with
11.
fixed-angle volar-locked plates or percutaneous Kirschner wires? A prospective randomised controlled trial. Injury. 2011;42(2):162e166. Margaliot Z, Haase SC, Kotsis SV, Kim HM, Chung KC. A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg Am. 2005;30(6):1185e1199. Richard MJ, Wartinbee DA, Riboh J, Miller M, Leversedge FJ, Ruch DS. Analysis of the complications of palmar plating versus external fixation for fractures of the distal radius. J Hand Surg Am. 2011;36(10):1614e1620. Leung F, Tu YK, Chew WY, Chow SP. Comparison of external and percutaneous pin fixation with plate fixation for intra-articular distal radial fractures. A randomized study. J Bone Joint Surg Am. 2008;90(1): 16e22. Kreder HJ, Hanel DP, Agel J, et al. Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: a randomised, controlled trial. J Bone Joint Surg Br. 2005;87(6):829e836. Grewal R, MacDermid JC, King GJ, Faber KJ. Open reduction internal fixation versus percutaneous pinning with external fixation of distal radius fractures: a prospective, randomized clinical trial. J Hand Surg Am. 2011;36(12):1899e1906. Egol K, Walsh M, Tejwani N, McLaurin T, Wynn C, Paksima N. 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;90(9):1214e1221. Rozental TD, Blazar PE, Franko OI, Chacko AT, Earp BE, Day CS. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial. J Bone Joint Surg Am. 2009;91(8):1837e1846. Williksen JH, Frihagen F, Hellund JC, Kvernmo HD, Husby T. Volar locking plates versus external fixation and adjuvant pin fixation in unstable distal radius fractures: a randomized, controlled study. J Hand Surg Am. 2013;38(8):1469e1476.
JOURNAL CME QUESTIONS Distal Radius Fractures: Percutaneous Treatment Versus Open Reduction With Internal Fixation
e. External fixation and volar plating are acceptable options, with evidence giving slight advantage to volar plating
Which of the following statements is most plausible regarding the surgical treatment of distal radius fracture as construed from current literature? a. Percutaneous pinning offers more superior results than internal fixation for extra-articular fractures b. External fixation treatment outcome is consistently better than internal fixation c. Disabilities of the Arm, Shoulder, and Hand (DASH) scores are reported in all studies to be better among patients treated with volar plating than external fixation d. There is consensus in the literature on the optimal operative treatment for an unstable fracture of the distal radius
Randomized studies comparing external fixation and volar plate fixation have concluded that: a. Significant differences are expected between the 2 groups in all functional assessment scores b. Radiographic outcomes are expected to be significantly different 2 years after surgery c. Significant differences are expected in range of motion and grip strengths d. Postoperative complications are the same for both but second surgery is expected for the volar plating group e. DASH, Gartland and Werley, and musculoskeletal functional assessment scores were consistently better after internal fixation
To take the online test and receive CME credit, go to http://www.jhandsurg.org/CME/home.
J Hand Surg Am.
r
Vol. 39, March 2014
Distal Radius Fractures: Percutaneous Treatment Versus Open Reduction With Internal Fixation Patrick O. Lang, MD, Kyle D. Bickel, MD CME INFORMATION AND DISCLOSURES The Review Section of JHS will contain at least 3 clinically relevant articles selected by the editor to be offered for CME in each issue. For CME credit, the participant must read the articles in print or online and correctly answer all related questions through an online examination. The questions on the test are designed to make the reader think and will occasionally require the reader to go back and scrutinize the article for details. The JHS CME Activity fee of $30.00 includes the exam questions/answers only and does not include access to the JHS articles referenced. Statement of Need: This CME activity was developed by the JHS review section editors and review article authors as a convenient education tool to help increase or affirm reader’s knowledge. The overall goal of the activity is for participants to evaluate the appropriateness of clinical data and apply it to their practice and the provision of patient care. Accreditation: The ASSH is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. AMA PRA Credit Designation: The American Society for Surgery of the Hand designates this Journal-Based CME activity for a maximum of 2.00 “AMA PRA Category 1 Credits”. Physicians should claim only the credit commensurate with the extent of their participation in the activity. ASSH Disclaimer: The material presented in this CME activity is made available by the ASSH for educational purposes only. This material is not intended to represent the only methods or the best procedures appropriate for the medical situation(s) discussed, but rather it is intended to present an approach, view, statement, or opinion of the authors that may be helpful, or of interest, to other practitioners. Examinees agree to participate in this medical education activity, sponsored by the ASSH, with full knowledge and awareness that they waive any claim they may have against the ASSH for reliance on any information presented. The approval of the US Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed or reviewed during this educational activity may not yet have received FDA approval.
THE PATIENT A 38-year-old, right-handed lawyer presents to the emergency department with right wrist pain and swelling after falling onto an outstretched right hand. His hand is swollen and tender over the distal radius. From the Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, Maryland, and the Hand Center of San Francisco, San Francisco, California. Received for publication February 28, 2013; accepted in revised form November 24, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Patrick O. Lang, MD, The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD 21218; e-mail: [email protected]. 0363-5023/14/3903-0026$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.11.039
546
r
2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
Provider Information can be found at http://www.assh.org/Pages/ContactUs.aspx. Technical Requirements for the Online Examination can be found at http://jhandsurg. org/cme/home. Privacy Policy can be found at http://www.assh.org/pages/ASSHPrivacyPolicy.aspx. ASSH Disclosure Policy: As a provider accredited by the ACCME, the ASSH must ensure balance, independence, objectivity, and scientific rigor in all its activities. Disclosures for this Article Editors David C. Ring, MD, PhD, has no relevant conflicts of interest to disclose. Authors All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page. Planners Ghazi M. Rayan, MD, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose. Learning Objectives Appraise the evidence regarding treatment of an unstable distal radius fracture. Discuss the available literature relevant to percutaneous pin fixation for a distal radius fracture. Review the literature related to external fixation for a distal radius fracture. Assess the literature pertinent to internal fixation for a distal radius fracture. Compare treatment outcomes for external versus internal fixation for a distal radius fracture. Deadline: Each examination purchased in 2014 must be completed by January 31, 2015, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each month’s JHS CME activity is up to 2 hours. Copyright ª 2014 by the American Society for Surgery of the Hand. All rights reserved.
Radiographs show a distal radius fracture with substantial dorsal displacement and a nondisplaced intraarticular extension. A closed reduction is performed and the wrist is stabilized with a sugar-tong splint. Repeat radiographs 2 days later show loss of reduction. Surgery is planned. THE QUESTION What is the optimal operative management of this unstable and displaced distal radius fracture? CURRENT OPINION There is no consensus on the optimal operative treatment for an unstable fracture of the distal radius.
Grewal et al8 randomized 53 patients to ORIF or external fixation. One third of patients (early recruitment) were treated with dorsal plates and the majority received VLP. The authors found lower Patient-Rated Wrist Evaluation (PRWE) scores early on in the ORIF group but no differences at 1 year. DASH scores were similar at all time points. Egol et al9 randomized 88 patients to either bridging external fixation or volar plating and found no differences in radiographic outcomes, range of motion, or function. Rozental et al10 randomized 45 consecutive patients to ORIF with volar plating or closed reduction with percutaneous pinning and showed early functional benefits in the ORIF group but no differences in DASH scores at 1 year. Williksen et al11 randomized 111 unstable distal radius fractures to external fixation with adjuvant pinning or VLP. At 1 year follow-up, the VLP group had better Mayo wrist scores on average (P ¼ .02). The VLP group had better supination at 1 year (P ¼ .03), but all other range of motion and grip strength comparisons were not significantly different between the 2 groups. QuickDASH scores at 1 year were comparable. Complications rates were about 30% in both groups. Fifteen percent of patients with VLP had a second surgery for plate removal.
An evidenced-based guideline from the American Academy of Orthopaedic Surgeons (AAOS)1 failed to establish the superiority of any one treatment. The current trend in the management of distal radius fractures is toward open reduction with internal fixation (ORIF), most recently with the use of volar locking plates (VLP).2 The rationale for this trend is that VLP facilitates restoration and maintenance of alignment while allowing early wrist motion, but the best evidence to date shows little difference in symptoms, disability, complications, or cost effectiveness compared with external fixation and percutaneous pinning. THE EVIDENCE Percutaneous pinning versus ORIF McFadyen et al3 randomized 56 extra-articular fractures to either VLP or percutaneous pinning and found that the VLP group fared better in both functional outcome and postoperative radiographic assessment. External fixation versus ORIF In 2005, an analysis of pooled data from retrospective case series found no significant differences between ORIF (dorsal and volar) and external fixation in subjective, objective, or radiographic outcomes.4 Richard et al5 retrospectively compared external fixation with VLP for comminuted intra-articular distal radius fractures and found significantly higher mean Disabilities of the Arm, Shoulder, and Hand (DASH) scores in the external fixation group, compared with the VLP group, at final follow-up an average of 12 months after surgery (32 vs 17; P ¼ .002). In addition, the VLP group had significantly more wrist flexion and extension and significantly less pain. The complication rate was higher in the external fixation group (P ¼ .021), but there were no differences in the rates of tendon and median nerve complications. Leung et al6 randomized 144 AO type C distal radius fractures to ORIF with nonlocking stainless steel T-plates (volar, dorsal, or combined) or external fixation with small AO/ASIF external fixators and percutaneous Kirschner wires. At the 24-month (but not the 12-month) evaluation point, they found superior Gartland and Werley scores and less radiographic arthritis in the ORIF group (primarily among C2 fractures) and no differences on the modified Green and O’Brien score. Kreder et al7 randomized 179 patients to ORIF (mostly dorsal) or external fixation and found early benefits in the external fixation group but no significant differences between the 2 groups in functional assessment scores (musculoskeletal functional assessment score) or radiographic outcomes 2 years after surgery. J Hand Surg Am.
547
SHORTCOMINGS OF THE EVIDENCE Many studies do not specify a primary outcome. If we assume that symptoms and disability (as measured by the DASH or musculoskeletal function assessment instruments) are the most important measure of treatment outcomes, then there is no difference between treatments. Given that symptoms and disability do not correlate precisely with pathophysiology, it is debatable whether or not that is indeed the best outcome measure. For instance, higher-demand individuals might benefit from a better radiographic alignment. Current data evaluate short-term outcomes only and cannot comment on arthrosis in the long term. Prospective trials to date have not assessed the convenience or cost effectiveness of percutaneous and open fixation. DIRECTIONS FOR FUTURE RESEARCH Future studies should address the convenience/burden of various treatment options from the patient’s and surgeon’s perspective. Studies of arthroscopic or 3-dimensional computed tomographic assessment of the articular reduction after reduction and fixation of the fracture might help clarify the relationship between articular alignment and functional outcome with r
Vol. 39, March 2014
Evidence-Based Medicine
TREATMENT OF DISTAL RADIUS FRACTURES
548
TREATMENT OF DISTAL RADIUS FRACTURES
Evidence-Based Medicine
stratification for levels of physical activity or demand. Ideally, this would be assessed after 5 to 10 years to determine the influence on arthrosis. In addition, studies that address the value (quality per cost) of various treatments would be helpful.
4.
5.
OUR CURRENT CONCEPTS FOR THIS PATIENT In our opinion, current evidence suggests an advantage to VLP over pinning or external fixation with regard to final radiographic alignment and for comminuted intra-articular fractures (AO group C), but the findings are inconsistent. Because external fixation and VLP are both good options, we generally follow the patient’s treatment preference. The patient under consideration chose ORIF with a VLP because he favored the risks of internal fixation over the inconveniences of having an external device.
6.
7.
8.
9.
REFERENCES 10.
1. American Academy of Orthopaedic Surgeons. The treatment of distal radius fractures: guideline and evidence report. 2009. Available at: http://www.aaos.org/research/guidelines/drfguideline.pdf. Accessed Feb 15, 2013. 2. Koval KJ, Harrast JJ, Anglen JO, Weinstein JN. Fractures of the distal part of the radius. The evolution of practice over time. Where’s the evidence? J Bone Joint Surg Am. 2008;90(9):1855e1861. 3. McFadyen I, Field J, McCann P, Ward J, Nicol S, Curwen C. Should unstable extra-articular distal radial fractures be treated with
11.
fixed-angle volar-locked plates or percutaneous Kirschner wires? A prospective randomised controlled trial. Injury. 2011;42(2):162e166. Margaliot Z, Haase SC, Kotsis SV, Kim HM, Chung KC. A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg Am. 2005;30(6):1185e1199. Richard MJ, Wartinbee DA, Riboh J, Miller M, Leversedge FJ, Ruch DS. Analysis of the complications of palmar plating versus external fixation for fractures of the distal radius. J Hand Surg Am. 2011;36(10):1614e1620. Leung F, Tu YK, Chew WY, Chow SP. Comparison of external and percutaneous pin fixation with plate fixation for intra-articular distal radial fractures. A randomized study. J Bone Joint Surg Am. 2008;90(1): 16e22. Kreder HJ, Hanel DP, Agel J, et al. Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: a randomised, controlled trial. J Bone Joint Surg Br. 2005;87(6):829e836. Grewal R, MacDermid JC, King GJ, Faber KJ. Open reduction internal fixation versus percutaneous pinning with external fixation of distal radius fractures: a prospective, randomized clinical trial. J Hand Surg Am. 2011;36(12):1899e1906. Egol K, Walsh M, Tejwani N, McLaurin T, Wynn C, Paksima N. 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;90(9):1214e1221. Rozental TD, Blazar PE, Franko OI, Chacko AT, Earp BE, Day CS. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial. J Bone Joint Surg Am. 2009;91(8):1837e1846. Williksen JH, Frihagen F, Hellund JC, Kvernmo HD, Husby T. Volar locking plates versus external fixation and adjuvant pin fixation in unstable distal radius fractures: a randomized, controlled study. J Hand Surg Am. 2013;38(8):1469e1476.
JOURNAL CME QUESTIONS Distal Radius Fractures: Percutaneous Treatment Versus Open Reduction With Internal Fixation
e. External fixation and volar plating are acceptable options, with evidence giving slight advantage to volar plating
Which of the following statements is most plausible regarding the surgical treatment of distal radius fracture as construed from current literature? a. Percutaneous pinning offers more superior results than internal fixation for extra-articular fractures b. External fixation treatment outcome is consistently better than internal fixation c. Disabilities of the Arm, Shoulder, and Hand (DASH) scores are reported in all studies to be better among patients treated with volar plating than external fixation d. There is consensus in the literature on the optimal operative treatment for an unstable fracture of the distal radius
Randomized studies comparing external fixation and volar plate fixation have concluded that: a. Significant differences are expected between the 2 groups in all functional assessment scores b. Radiographic outcomes are expected to be significantly different 2 years after surgery c. Significant differences are expected in range of motion and grip strengths d. Postoperative complications are the same for both but second surgery is expected for the volar plating group e. DASH, Gartland and Werley, and musculoskeletal functional assessment scores were consistently better after internal fixation
To take the online test and receive CME credit, go to http://www.jhandsurg.org/CME/home.
J Hand Surg Am.
r
Vol. 39, March 2014
