You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.


Do Outcomes Differ Between Casting and Surgery for Wrist Fractures?

  • Authors: News Author: Nancy A. Melville; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 8/5/2021
  • Valid for credit through: 8/5/2022
Start Activity

Target Audience and Goal Statement

This activity is intended for primary care clinicians, orthopedists, emergency medicine specialists, nurses and other clinicians on the healthcare team who care for adults with distal radial fracture (DRF).

The goal of this activity is to compare surgical and nonsurgical approaches to the treatment of DRF.

Upon completion of this activity, participants will:

  • Assess outcomes of malunion among adults with DRF
  • Compare surgical and nonsurgical treatment approaches to DRF
  • Outline implications for the healthcare team


As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.

News Author

  • Nancy A. Melville

    Freelance writer, Medscape


    Disclosure: Nancy A. Melville has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California


    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: GlaxoSmithKline; Johnson & Johnson


  • Hazel Dennison, DNP, RN, FNP-BC, CHCP, CPHQ, CNE

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Hazel Dennison, DNP, RN, FNP-BC, CHCP, CPHQ, CNE, has disclosed no relevant financial relationships.

CME Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.

Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC, CHCP

    Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Amy Bernard, MS, BSN, RN-BC, CHCP, has disclosed no relevant financial relationships.

Medscape, LLC staff have disclosed that they have no relevant financial relationships.

Accreditation Statements

In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

    Contact This Provider

    For Nurses

  • Awarded 0.25 contact hour(s) of nursing continuing professional development for RNs and APNs; 0 contact hours are in the area of pharmacology.

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.


Do Outcomes Differ Between Casting and Surgery for Wrist Fractures?

Authors: News Author: Nancy A. Melville; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 8/5/2021

Valid for credit through: 8/5/2022


Clinical Context

Distal radial fracture (DRF) is a common traumatic condition, particularly among older adults, and several studies have highlighted long-term outcomes of DRF. Muhanned and colleagues followed a small cohort of adults with DRF for up to 14 years, with particular interest in the rate of malunion of fracture and its consequences. Their research was published in the April 18, 2018 issue of the Journal of Bone and Joint Surgery.[1]

Researchers followed 63 patients, 25 of whom who met criteria for malunion. Not surprisingly, malunion was associated with higher disability scores at 2 years after fracture, and this remained true at 12 to 14 years after fracture as well. Malunion was also associated with a mean 10-point increase in a 100-point visual analog scale pain score vs full union of the distal radius; however, malunion did not significantly affect motion or grip strength. In addition, the presence of osteoarthritis and styloid nonunion had no significant effect on pain or functional outcomes.

These findings suggest that surgical correction of DRF may provide better outcomes vs casting in cases at risk for malunion. The current study by Chung and colleagues provides uses a randomized design, with outcomes measured to 2 years to address this possibility.

Study Synopsis and Perspective

For older patients with distal radius wrist fractures, there are no significant differences in outcomes after 2 years when treated with nonsurgical casting compared with the 3 other most common treatment strategies -- all surgical, new research shows.

"The insight from these 24-month data is that older patients who chose nonoperative treatment adapted to their deformity and functioned similarly to those who chose an operative treatment, despite malunion," reported the authors of the study, which was published on June 1 in JAMA Network Open.[2]

"This effect was maintained at 2 years, which assures the lack of deterioration of overall function over time," they wrote.

Commenting on the study, Jason Michael Johanning, MD, of the department of surgery, University of Nebraska Medical Center, Omaha, Nebraska, said the findings should reassure clinicians that casting is usually an effective option for older patients.

"Given that for many years, surgical therapy was a mainstay for the majority of patients, I suspect that the current study will tip the scales towards nonoperative management for a significant number of patients in the future as the work is disseminated," Johanning, who also authored a commentary on the study,[3] told Medscape Medical News.

Despite the fact that distal radius wrist fractures are among the most common fractures in adults, evidence-based guidelines to management of the fractures are lacking, and options for treatment vary widely.

To investigate the longer-term outcomes of the most common approaches, first author Kevin C. Chung, MD, of the Michigan Medicine Comprehensive Hand Center, University of Michigan, in Ann Arbor, Michigan, and his colleagues conducted the Wrist and Radius Injury Surgical Trial (WRIST), an international, multicenter study that included 304 adults aged ≥ 60 years with isolated, unstable distal radius wrist fractures.

The patients, who were recruited between April 2012 and December 2016, were randomly assigned to undergo any one of the four primary management strategies: volar locking plate system (VLPS) (n = 65); external fixation with or without pinning (EFP) (n = 64); closed reduction with percutaneous pinning (CRPP) (n = 58); and nonsurgical closed reduction and casting (n = 117).

Assessments of 182 of the patients at 24 months, after a multivariate adjustment, showed no significant differences between the four groups in the primary outcome of summary scores on the Michigan Hand Outcomes Questionnaire. The mean scores were 88 for VLPS, 83 for EFP, and 85 each for CRPP and casting (P = .7), all representing good overall hand function.

The groups had low pain subscores, good return of activities to daily living, and good satisfaction scores that were not significantly different. The 12-month and 24-month outcomes were similar.

"Even though most patients recover from wrist fractures within 6 months, we hypothesized that outcomes such as radiographic and anatomic appearance could be different at 24 months, possibly changing the outcomes, but fortunately, that was not the case," Chung told Medscape Medical News.

Of note, the similar outcomes were observed despite a substantially higher rate of malunion in the casting group (59%) in comparison with the other groups (8% to 17%; < .001).

The fractures in the casting group were of equal severity as the fractures in the surgical patients.

In his commentary, Johanning underscored the additional benefits of a nonsurgical approach: "[There is] the advantage of avoiding general anesthesia and operative complication rates of 15% to 20%, which are low but present nonetheless."

Johanning told Medscape that the findings should help advance decision making on the treatment options, and he acknowledged the benefits of surgical options for some patients.

"I do believe there are still patients who will benefit from surgical therapy," he said. "Now the goal of the research team should be to clearly delineate who will benefit from [a surgical approach]."

Key to that endeavor will be to take a more patient-centered perspective rather than simply relying on x-rays to guide decision making.

"It needs to be clearly emphasized that radiographic abnormalities do not relate to future functional outcome," Johanning said.

"The reflex of seeing a fracture with malalignment and the thought of needing to realign the fracture makes intuitive sense, but the study clearly shows that functional outcome does not correlate with radiographic appearance," he said.

Chung agreed: "There are no guidelines on this management, but if there is shared decision making, the patient will be more satisfied."

He noted that the trial showed that in the early months after surgery, patients in the VLPS group demonstrated greater improvements in the ability to perform activities of daily living and in satisfaction and recovered more strength and wrist motion in comparison with the other groups.

Although those differences had disappeared by 6 months, that option might be preferrable for patients who require rapid improvement.

"Older patients who are independent and are still quite active, for instance, may prefer a surgical option that could provide the opportunity to recover faster," Chung said. "Ultimately, the take-home message should be to treat the patient, not the x-ray."

The study received support from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Institute on Aging of the National Institutes of Health. Chung reports receiving book royalties from Wolters Kluwer and Elsevier and personal fees from Axogen Corporation and Integra LifeSciences. Johanning has disclosed no relevant financial relationships.

Study Highlights

  • This multinational study was completed between 2012 and 2016. Patients eligible for study participation were aged ≥ 60 years and had an isolated DRF that met criteria for possible surgical intervention with open reduction and internal fixation with a VLPS, closed reduction and external fixation with a bridging fixator with or without supplemental k-wire fixation (EFP), and closed reduction and k-wire fixation with percutaneous pinning (CRPP).
  • The study excluded patients with serious trauma, open fractures, or neurologic conditions affecting the upper extremities from participation.
  • Investigators randomly assigned study participants to VLPS, EFP, or CRPP and created an observation group that received casting for participants who did not want surgery.
  • Participants were followed regularly for 24 months after randomization. The main study outcome was the Michigan Hand Outcomes Questionnaire (MHQ). Participants were also followed for health-related quality of life (HRQoL) plus grip/lateral pinch strength.
  • Researchers adjusted study outcomes to account for age, race, smoking status, and physical activity level.
  • 304 participants were included in the trial, of whom 62% were randomly assigned to a surgical intervention. 38% of the cohort comprised the casting group.
  • 87% of participants were women, and the mean age of participants was 71.1 ± 8.9 years.
  • 182 participants had follow-up data at 24 months. Participants in the casting group were less likely to follow up at 24 months vs the surgical cohort.
  • The mean MHQ score for the total study cohort at 24 months was 85, indicating a low level of disability. Pain, function, and patient satisfaction were similar in all surgical groups and the casting group.
  • The total MHQ score remained stable between 12 and 24 months of follow-up. Pain scores specifically fell slightly during the second year of follow up.
  • Hand and wrist strength was nearly 100% in the affected arm vs contralateral arm by 24 months, regardless of treatment group. There was a slight improvement in strength measurements across the cohort between 12 and 24 months. The biggest improvement in grip strength was noted in the EFP group whereas the casting group had the largest improvement in pinch strength.
  • HRQoL scores were also similar in comparing treatment groups.
  • 23% of participants had malunion at 24 months. 59.1% of participants in the casting group experienced malunion compared with rates of 17%, 9.8%, and 8% in the EFP, CRPP, and VLPS groups, respectively.
  • Older age was associated with a higher risk for malunion.
  • Malunion was associated with a nonsignificant reduction in function vs full union, but it did not affect employment or levels of physical activity.

Clinical Implications

  • A previous study by Ali and colleagues that followed adults with DRF for up to 14 years demonstrated that pain and disability were more common in cases of malunion vs full union; however, motion and grip strength were not adversely affected by malunion.
  • The current study by Chung and colleagues finds no significant difference in pain, function, or objective strength in comparing treatment strategies of 3 different surgical procedures and casting among older adults with DRF.
  • Implications for the healthcare team: The healthcare team should counsel older adults with DRF that long-term outcomes appear similar regardless of treatment. Short-term outcomes should have more weight in decision making regarding treatment.


Earn Credit

  • Print