Operative Treatment More Beneficial than Nonoperative for Distal Fractures

Yassine Ochen, MD

Operative treatment of distal radius fractures improved the medium-term Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score and grip strength over nonoperative treatment in adults, new study findings showed.

Because no consensus has been made about whether operative or nonoperative treatment was better for such fractures, the findings suggested that operative treatment might be the preferred treatment option for the most common injury among adults.

A team of investigators, led by Yassine Ochen, MD, conducted a meta-analysis of 2254 unique patients from 23 studies to compare functional, clinical, and radiologic outcomes after operative versus nonoperative treatment of distal radius fractures in adults.

Ochen, from the Department of Orthopedic Surgery at Harvard Medical School Orthopedic Trauma Initiative, and colleagues searched PubMed/MEDLINE, Embrase, CENTRAL, and CINAHL databases from inception to June 15, 2019 for studies that compared operative and nonoperative treatment of distal radius fractures. Inclusion criteria for the studies were: acute distal radius fracture; operative treatment versus nonoperative treatment; patients >18 years old; and reported on functional outcome.

The investigators extracted the first author; year of publication; study design; country the study was performed; study and follow-up periods; number of patients included; age groups; operative or nonoperative method; and AO fracture classification.

The primary study outcomes were medium-term functional outcome, which was measured with the DASH questionnaire, and the overall complication rate after operative and nonoperative treatment. DASH consisted of patient-reported outcomes to measure upper extremity disability and symptoms, resulting in a score from no disability (0) to most severe disability (100).

Additional outcomes included the Patient-Rated Wrist Evaluation score, grip strength, range of wrist extension and flexion, and ulnar deviation.

Ochen and the team included 23 unique studies—8 randomized controlled trials and 15 observational studies—with 2254 unique patients. A majority of the patients were women (80.6%) and the mean weighted age was 67 (range, 22-90) years old.

There was a significant improvement in medium term (<1 year) DASH score after operative treatment compared with nonoperative treatment (MD, −5.22; 95% CI, −8.87 to −1.57; P=.005). For complication rate, there was no difference observed between both treatment options (RR, 1.03; 95% CI, .69-1.55; P=.87).

Patients who underwent operative treatment had significant improvement in grip strength, measured in kilograms (MD, 2.73; 95% CI, .15-5.32; P=.04) and as a percentage of the unaffected side (MD, 8.21; 95% CI, 2.26-14.15); P=.007).

In a subgroup of patients of adults >60 years old, there was no improvement in medium-term DASH score (MD, -.98; 95% CI, -3.52 to 1.57; P=.45), compared with a large improvement after operative treatment in studies that included patients >18 years old (MD, -7.5; 95% CI, -12.4 to -2.5; P=.003). The difference between the subgroups was statistically significant (P=.02).

Having an operative treatment was associated with increased improvements over nonoperative treatment for distal radius fractures in adults. The results could support the international increase of operative treatment for such injuries.

Additional research could focus on the nonelderly population because many studies are performed on older populations. What’s more, future research could help investigators better understand optimal treatment methods and outcomes for generally health and young individuals.

The study, “Operative vs Nonoperative Treatment of Distal Radius Fractures in Adults,” was published in JAMA Network Open.