Session X - Upper Extremity

A Randomized Controlled Trial of Closed Reduction and Casting versus Closed Reduction and External Fixation for Distal Radius Fractures with Metaphyseal Displacement but Without Joint Incongruity

Hans J. Kreder, MD, FRCS(C); Douglas P. Hanel, MD; Julie Agel, MA, ATC; Michael D. McKee, MD, FRCS(C); Thomas E. Trumble, MD; University of Toronto, Toronto, Ontario, Canada; Harborview Medical Center, Seattle, Washington, USA; University of Minnesota, Minneapolis, Minnesota, USA (-OREF Grant)

Purpose: We compared closed reduction and casting with closed reduction and external fixation for repair of distal radius fractures with metaphyseal displacement but without joint incongruity in a multicenter randomized clinical trial.

Methods: We randomized 113 eligible patients with distal radius fractures with metaphyseal displacement but without joint incongruity to repair with either closed reduction and casting (N = 59) or closed reduction and external fixation (N = 54). For five patients randomized to cast treatment, an open procedure was required within the first 3 weeks because of significant loss of correction. One patient randomized to external fixation underwent open reduction and internal fixation because of displacement of a previously undisplaced partial articular fracture. The patients were evaluated at 6 weeks, 6 months, and 1 and 2 years. Upper extremity function, as measured by using the upper extremity module of the Musculoskeletal Function Assessment, represented the primary endpoint. Pain, Jebsen Taylor functional test score, range of motion, and grip and pinch strength were evaluated as secondary outcomes. Repeated measures analysis of variance was used to compare outcome between the two study groups. We compared the results at each time interval by using the Student's t-test or chi square test to evaluate the outcome data.

Results: By 2 years, Jebsen Taylor scores and pain scores were similar to population age- and sex-matched control scores in both study groups. At all evaluation time points, there was a trend toward better function in the external fixation group; however, this did not reach statistical significance (P<0.05). The mean difference in upper extremity function scores at 2 years (the primary endpoint) was 5.5 in favor of external fixation (power = 0.161). Results of approximately 896 patients would have been required to obtain 80% statistical power.

There were six pin site infections in the external fixation group (14%), with one deep infection requiring curettage (2%). One patient in the external fixation group (2%) and two in the cast group (6%) developed a reflex sympathetic dystrophy (P = 0.585). There was no statistically significant difference in the radiographic restoration of anatomic parameters, although there was a trend toward better length and palmar tilt restoration with use of external fixation (P>0.05).

Discussion and Conclusions: Upper extremity function, Jebsen Taylor, and pain scores, and grip strength improved significantly the 1st year of the study for all patients. There was a trend toward better functional, clinical, and radiographic outcomes with use of immediate external fixation for distal radius fractures with metaphyseal displacement and a congruous joint.