Better functional outcomes seen with volar plate fixation vs nonoperative treatment for distal radial fractures

Michael D. McKee, MD, FRCS(C)

This well-designed RCT by Mulders and colleagues compared volar plate fixation vs. closed reduction and casting for displaced extra-articular distal radial fractures. Consistent with prior similar studies, and as common sense would dictate, the authors found that early functional outcome was significantly better in the operative group. In contrast to prior RCTs, this study also found that these improvements persisted at a year (although the clinical relevance of a 6- to 7-point improvement in a DASH score could be debated). Additionally, a higher percentage of patients (42%) in the closed reduction group required surgical intervention for loss of reduction or symptomatic malunion. This was unexpected given the results of prior studies in which this rate was lower. 

There are a few cautionary notes with this study; it comprised only 98 patients from 3,679 distal radius fracture patients screened (including 200 eligible patients who were not included). It was a healthy group (only one patient in the operative group had diabetes, for example) and the surgical complication rate could be higher in patients with comorbidities. The decision to proceed with volar plate fixation in the closed reduction group that had “loss of reduction” was not clearly defined, and this is a notoriously subjective decision. Lastly, close to 60% of patients in the closed reduction group healed their fracture promptly in an acceptable position and did well functionally (mean DASH 9 points at a year).

In summary, as with most surgery/non-surgery RCTs, this excellent study should not be used to dictate one treatment regimen over another. Rather, it is reliable and useful data that can be used to tailor treatment for a specific patient group based on their expectations, functional requirements and appetite for risk.