Session X - Upper Extremity

A Randomized Controlled Trial of Indirect Reduction and Percutaneous Fixation versus Open Reduction and Internal Fixation for Displaced Intraarticular Distal Radius Fractures

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 indirect reduction and percutaneous fixation with open reduction and internal fixation for repair of displaced intraarticular distal radius fractures in a multicenter randomized clinical trial.

Methods: A total of 179 skeletally mature patients 16 to 75 years of age who had displaced intraarticular distal radius fractures received either indirect percutaneous reduction and external fixation (N = 88) or open reduction internal fixation (ORIF) (N = 91). Each fracture was reduced to a standard of acceptable radiographic parameters. Patients were evaluated at 6 weeks, 6 months, and 1 and 2 years. Function was measured by using the upper extremity module of the Musculoskeletal Function Assessment to represent the primary endpoint. Pain, the Jebsen-Taylor functional test score, range of motion, and grip and pinch strength were secondary outcomes. Repeated measures analysis of variance was used to compare outcomes between the two study groups over time.

Results: Primary and secondary outcome measures improved significantly the 1st year. By 2 years, the mean Jebsen Taylor and pain scores were within half a standard deviation of the control population scores for both study groups. Upper extremity function improved more rapidly after indirect reduction as compared with ORIF; a 13-point score difference was noted in favor of indirect reduction at the 6-month evaluation (P = 0.037). After adjusting for repeated measures over the 2-year study period, indirect reduction resulted in significantly better upper extremity function compared with ORIF (P = 0.014). Pinch strength was also significantly better after indirect reduction (P = 0.020), with similar trends for grip strength (P = 0.448) and Jebsen Taylor scores (P = 0.059). There was no statistically significant difference in the radiographic restoration of anatomic parameters (P>0.05). Twelve patients (14%) healed with residual intraarticular step deformity in the indirect reduction group compared with 13 patients (14%) in the open reduction group (P = 1.0). Only three patients (3%) in the indirect group and two patients (2%) in the ORIF group had step deformity of more than 2 mm at union (P = 0.679). Residual step and gap deformity were associated with development of radiographic osteoarthritis and also with poor function scores (P<0.05).

Discussion: Indirect reduction and percutaneous fixation results in more rapid return to function and superior functional outcome within 2 years from injury as compared with ORIF for repair of displaced intraarticular distal radius fractures, provided that intraarticular step and gap deformity is minimized.

Conclusion: This is the first study with results showing that ORIF of intraarticular distal radius fractures should be preceded by attempts at closed reduction, percutaneous stabilization, and external fixation. Only if the reduction cannot be obtained with closed percutaneous methods should the fracture be opened and internally secured.