Daniel Herren

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Distal radius fractures - evidence based approach

MEETING ABSTRACT Open Access
Distal radius fractures - evidence based approach
Daniel Herren
From 10th Congress of the Asia-Pacific Federation of Societies of Surgery fo the Hand and the 6th Congress
of Asia-Pacific Federation of Societies of Hand Therapists
Kuala Lumpur, Malaysia. 2-4 October 2014
Distal radius fractures account for the most commonly
treated fracture of the upper extremity and are espe-
cially common in the elderly population. Despite new
treatment strategies many questions remain regarding
the optimal treatment regime. Controversies include the
treatment modalities and the expected outcome as well
as economical considerations. It is the goal of this pre-
sentation to discuss five common questions and state-
ments around distal radius fractures in the light of the
published evidence based literature.
Statement 1: Most distal radius fractures are
nowadays best treated with volar plating
Several studies, including those analyzing patient popu-
lation older than 65 years old, suggest that operative
treatment with volar plating does not provide better
clinical results compared to other treatment modalities,
especially conservative treatment with repositioning and
plaster immobilization. There is evidence that in the
earlier stage of fracture healing, there is a faster return
to activities of daily living provided by open reduction
and internal fixation (ORIF) but at 6 months follow-up
the results of different treatment modalities are similar.
More complex fractures seem to benefit from ORIF in
both radiographical and clinical results. In addition,
radiographical results are superior in ORIF but with no
significant influence on the clinical results.
Statement 2: In distal radius fractures concomitant
ulna styloid fractures need not to be fixed
There are several studies suggesting that distal radio-
ulnar joint function is not affected by whether the ulna
styloid is healed or not healed after the treatment of dis-
tal radius fractures. As long as the anatomy of the DRUJ
is well reconstructed, even in ulna styloid base fractures
DRUJ instability seems to be rare. However, there is no
standardized description of the assessment of DRUJ sta-
bility as well intra-as postoperatively and therefore no
recommendation can be given in this regard. In addition
it is unknown how much TFCC scarring contributes to
DRUJ re-stabilization of distal radio-ulnar joints. On the
other hand, ulna styloid re-fixation, regardless of the
technique used, has a relatively high potential of compli-
cations, especially DRUJ stiffness and disturbance
including painful neuroma formation of the sensory
branch of the ulnar nerve.
Statement 3: There is a clear tendency of
publication bias in the literature of distal radius
fractures and a lack of randomized controlled
studies
Together with the development of new treatment concepts
and especially new plating systems, the amount of articles
concerning the outcome of distal radius fracture treatment
has nearly exploded. According to the analysis of Sando et
al 2013, there is a clear tendency for publication bias in
distal radius fracture literature. Significantly more reports
about positive outcome are published (70%) compared to
only 5% of publications with negative outcomes. The
authors state that a more standardized approach to mea-
sure results and to judge possible publication bias should
be implemented. Especially in pathologies as frequent as
distal radius fractures, more randomized controlled studies
should be available, in order to enhance the level of evi-
dence to enlighten certain pending questions.
Statement 4: Intra-articular steps of > 2 mm in
intra-articular distal radius fractures have a
significant higher likelihood of cartilage
degeneration in the long-term
Since the publication of Knirk and Jupiter 1986 about
the outcome of distal radius fractures, the ‘magic’ >
2mm rule of inacceptable intra-articular step in the
treatment of distal radius fractures have been burnt into
Department of Hand Surgery, Schulthess Klinik, Zurich, 8008. Switzerland
Herren BMC Proceedings 2015, 9(Suppl 3):A35
http://www.biomedcentral.com/1753-6561/9/S3/A35
© 2015 Herren; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://
creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
the brains of hand surgeons. A later analysis of the
study by the authors themselves advocated significant
methodological flaws and they had to admit that the
conclusion drawn at the time do not withstand the prin-
ciples of evidence based medicine. Other publications
warn of the correlation between radiographical appear-
ance and functionality in the long-term. However there
are no studies with sufficient power to answer the ques-
tion on the amount of tolerable intra-articular step and
the long-term association.
Different reasons might be responsible for this lack of
scientific data. It might be speculated that with new treat-
ment concepts the level of fracture fixation improved sig-
nificantly in the last 30 years and less fractures with
articular steps are accepted. In addition, it seems unethical
to randomized patients in different groups with more or
less articular steps in order to answer this question.
Statement 5: Volar plating is associated with a
high number of complications
The increased use of volar plates in the treatment of dis-
tal radius fractures has led to more reports on its compli-
cations. The number of problems, which lead to further
treatment, is in most series between 5-10% for volar plat-
ing. Two major types of problems might be identified:
hardware associated complications and surgical approach
associated problems. Basically both can be summarized
as technical issues and in most cases avoidable. Several
studies therefore advocate, that with increasing surgeon’s
experience, fewer complications are to be expected. How-
ever, besides malunion, only non-operative treated distal
radius fractures seem to have less complications than all
other different type of operative procedures for this pro-
blem. Nevertheless for a fair comparison, there is a clear
lack of randomized controlled studies with enough statis-
tical power.
Published: 19 May 2015
doi:10.1186/1753-6561-9-S3-A35
Cite this article as: Herren: Distal radius fractures - evidence based
approach. BMC Proceedings 2015 9(Suppl 3):A35.
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Herren BMC Proceedings 2015, 9(Suppl 3):A35
http://www.biomedcentral.com/1753-6561/9/S3/A35
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Distal radius fractures - evidence based approach

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