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%; P < .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.

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.

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