Journal Club Presentation

Presented by: Dr Sikandar Kumar Mahto

PG 2nd Year, Orthopaedic
Moderator: Dr Garav Gupta
 Original article

Accepted: 19 September 2024

Published: 01 October 2024
 Introduction
• Distal radius fracture is the most common fracture

• usually in elderly.

• Classifed as : AO 23-C1+C2, there is no consensus on treatment in older

patients due to inconsistent study results.
• Treatment : Conservatively by plaster immobilization or surgical
therapy by valar plating
• Advanced age is often associated with osteoporosis, diabetes and
frailty and plays a pivotal role in fracture assessment and subsequent
treatment decisions.
 AIM

• To compare conservative therapy and surgical therapy of 23-

C1 + C2 DRF in terms of patient satisfaction and wrist function

in patients older than 65 years.

 Patients and methods
Calculation:
• Prior to study initiation a sample size calculation was
performed.
• The standard deviation as well as the difference of the
mean values of the patient-rated wrist evaluation (PRWE)
score was derived from the publication by Walenkamp et al.
• Considering a Wilcoxon test with non-normal data
distribution, an α of 0.05%, power of 80%, a difference in
means of 11 points and a standard deviation of 14, which
was published by Walenkamp et al. a minimum of n = 31
patients in each group was required for this study.
• Thus, on the basis of the sample size calculations performed,
including a drop-out rate of 30%, a case number of 40
patients per group was calculated.
• The study was designed according to the Consolidated
Standards of Reporting Trials (CONSORT) principles.
Ethics: The study was approved by the local regional ethical
committee.
Patients:
• In a prospective manner, 80 patients older than 65 years
between January 2021 and March 2022 with an isolated distal
radius fracture AO classification type C1 or C2 were included
in our study.
• After confirmation through x-ray, every patient was treated by
primary closed reduction under hematoma block and with a
forearm cast.
• Study-specific informed consent and written consent was
obtained.
• Patients were assigned to one of two groups (n = 40) – the
surgery group and the conservative group – using permuted
block randomization with blocks of 10 patients.
• Data were collected: age, sex, dominant hand, classification of
the fracture, side of injury, computed tomography (CT)
assessment.
• PRWE score , DASH score and ROM including dorsal extension,
palmar flexion, ulnar deviation and radial deviation, and grip
strength were compared with non-injured wrist.
 Conservative group

• Immobilization with a forearm cast for 5–6 weeks and regular

follow-up examinations including x-ray controls.
• After cast removal, mobilization started through occupational
therapy sessions.
 Surgery group
• Volar plate osteosynthesis after adequate decongestion,
typically 1 week post-traumatically.
• A dorsal plaster splint was applied for another 2 weeks.
• After completed wound healing and suture removal,
occupational therapy was started.
• Intraoperative data such as surgery date, implant, surgery
duration, and complications were recorded.
 Follow-up regimen
• At 6 weeks and 3, 6 and 12 months.
• Wrist function was assessed using
[Link] scale (1 – very satisfied, 2 – satisfied, 3 – neither satisfied nor dissatisfied,
4 – dissatisfied, 5 – not satisfied at all),
[Link],
[Link] strength and
[Link] measured by VAS ranging from 0 to 10.
• At 3, 6 and 12 months post-interventionally : patient reported
outcome measures (PROMs) including PRWE score and DASH
score were evaluated.
• Any complications that occurred were documented.
 Inclusion Criteria
• >65 years
• Isolated distal radius fracture
• AO classification type C1 or C2
 Exclusion criteria
• Open fractures and absolute indication for surgery,
• Pathologic fractures,
• Re-fractures,
• Patients with terminal illness,
• Advanced dementia,
• Pre-existing limitation of motion of the affected limb and
• Patient preference against surgical treatment.
 Data.
• Data collection was done using the proforma.
• Data were acquired from interviews with the patients and
review of their medical records.
• Approval for the study was taken from the Institutional
Review Board.
 Statistical data analysis
• Statistical analysis was performed using IBM SPSS Statistics
29.0 (Chicago, IL, USA).
• All demographic and pre-, intra-, and post-interventional data
were considered.
 Statistical data analysis…
• Data are presented using standard methods of descriptive
statistics:
 Normal distribution are presented as mean ± standard
deviation (SD) and
 Non-normal distribution as median (interquartile range [IQR]).
• The primary hypothesis was tested using
 Unpaired t-test in the case of normal data distribution
 Mann–Whitney U test in the case of non-normal distribution.
 Statistical data analysis…
• Nominal parameters were compared using the chi-squared
test.
• If the requirements of this test were not fulfilled, the Fisher’s
exact test was performed.
• A significance value of p < 0.05 was deemed to be statistically
significant for assessing the primary hypothesis.
• Other p-values smaller than 0.05 indicate a statistically
relevant difference between groups.
 Results
• Total of 80 patients, comprising 67 female (83.6%) and 13
male (16.4%) patients.
• Patients with mean age of 77.3 years (± 6.1 years) in the
conservative group and 72.5 years (± 5.3 years) in the surgery
group (p < 0.001).
• Comparing the conservative and surgical groups, fracture type
23-C1 occurred in 24 patients (60.0%) versus 9 patients
(22.5%), and fracture type 23-C2 in 16 patients (30.0%) versus
31 patients (77.5%; p < 0.001).
• Regarding the non-injured wrist, PRWE score was 0.8 (0–17) in
conservatively treated patients and 0.8 (0–2.0) in the surgical
group (p = 0.598).
• Mean pre-trauma DASH score was 0.5 in the surgical group
and 1.7 in the conservative group (p = 0.216; Table 1).
• Drop-out rate was 2.5% (two patients).
• At 3, 6 and 12 months post-interventionally, the PRWE score
and DASH scores showed a significant difference between
both groups (p < 0.001; Figs. 1 and 2).
• Satisfaction was significantly higher in surgically treated
patients at 6 weeks (p < 0.001), 6 months (p = 0.004), and
12 months (p < 0.001).
• There was no difference in pain between the two groups at all
stages (Table 2).
• Dorsal extension : significantly better in surgically group (p =
0.004) at 12 months.
• Palmar flexion : significantly better in the surgical group (p <
0.001) at 6wk
• Ulnar deviation : No significant difference.
• Radial deviation: significantly better in the conservative group
(p = 0.029) at 6 months
• Grip strength: significantly lower in conservative group at the
6-week follow-up (p = 0.046; Figs. 3, 4, 5, 6 and 7).
• No complications occurred during surgery.
• No combined surgical procedure (i.e. k-wire or an additional
screw) or an additional dorsal approach were necessary.
• Mean surgical time was 72 min (± 20 min).
• Five patients presented with post-operative complications
(12.5%):
 Intra-articular screw position occurred in 3 patients (7.5%),
and
 screw-loosening was seen in 1 patient (2.5%).
• All of them had revision surgery within 18 days.
• 1 patient developed carpal tunnel syndrome 3 months
postoperatively (2.5%).
• 1 patient in the conservative group presented ROM restriction
of the 4th and 5th finger after removing the forearm cast
(2.5%), and successfully treated using occupational therapy.
• At 6-month examination 2 patients showed clinical signs of
incipient carpal tunnel syndrome (5%).
• 2 patients (5%) in the conservative group presented early (<
6 days) secondary displacement.
• Both were treated with a 2nd closed reduction and no further
displacement occurred.
• None (0%) of all patients developed a post-interventional
complex regional pain syndrome (CRPS).
 Discussion
• Patients older than 65 years with C1 or C2 distal radius
fracture show better mid-term clinical and functional
outcome when treated surgically.
• The null hypothesis of this study was rejected because the
PRWE score showed significantly higher values in the surgery
group compared with the conservative group.
• There are a few prior randomized controlled studies
comparing conservative and surgical treatment of DRF.
• PROMs as the main outcome variable comparing these two
treatment options, several previous authors arrive at
divergent conclusions compared with this study.
• In 2011, Arora et al. found no difference of either PRWE or
DASH score after 6 and 12 months.
• Distinctly from this study, they also included patients with DRF
of AO classifications A2, A3 and C3 in addition to C1 and C2.
• Similar results were published by Bartl et al., with no
difference of the DASH score at 3 and 12 months post-
interventionally.
• The CROSSFIRE study group as well as Tahir et al. could not
show any difference of the PRWE and DASH score after 3 and
12 months.
• Mulders et al. as well as Selles et al. could present comparable
results in multicentre randomized control trials showing
significantly better PRWE and DASH scores at 3, 6 and
12 months post-interventionally in the surgical group.
• In 2019, Saving et al. involving 140 patients with A2, A3 and
C1–3 fractures with >75 years that surgery results in superior
PRWE and DASH scores at 3- and 12-months f/u.
• Hassellund et al. showed significantly better PRWE scores
after 6 and 12 months as well as significantly better DASH
scores after 3 and 6 months in the surgery group.
• At the 2-year follow-up , both Martinez-Mendez and Sirniö et
al. presented superior PRWE and DASH scores in patients
treated with plate osteosynthesis compared with conservative
treatment.
• In 2022, Oldrini et al. published a systematic review and meta-
analysis involving 12 RCTs that showed significantly better
DASH scores in patients treated with palmar plate
osteosynthesis after a short-term period of 3 months.
• PRWE scores showed no significant difference after 3 and
12 months (p = 0.17 and p = 0.12).
• Alongside clinical scores, patient satisfaction is rendered as
one of the most important parameters in any treatment.
• Apart from this study, Hassellund et al. was – to the best of
our knowledge – the only study that assessed patient
satisfaction concerning the resulting function of their injured
wrist.
• This study group corroborated the results by reporting
superior satisfaction at 6 and 12 months in the surgical group.
• While Martinez-Mendez et al. and Tahir et al. presented no
significant difference concerning grip strength between
conservatively and surgically treated patients.
• Arora et al. and Saving et al. published comparable outcomes
to our data because they showed better grip strength in the
surgical group.
• In this respect, the meta-analysis by Oldrini et al. again was
not able to show any statistical significance
• Regarding complication rates, the literature reports a range
between 8% and 39% in palmar plate osteosynthesis
treatment which aligns with the 12.5% post-operative
complications observed in the surgery group.
 Strength
• Prospective randomized trial as well as
• >65 years with an isolated AO-classified C1 or C2 DRF.
 Limitations
• Firstly, the randomization process resulted in a difference in
age and distribution of fracture subtypes between both
cohorts.
• Furthermore, although every patient was referred to
occupational therapy and was encouraged to exercise, we
were not able to control and quantify the intensity.
• Although this was definitely not the focus of our study,
another limiting factor is the missing assessment of
correlation of radiological and functional outcomes
 conclusion
• Surgical treatment proved to be superior to conservative
treatment in terms of the primary outcome variable, PRWE
score.
• Satisfaction was significantly better in the surgical group.
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