COMMENTARY
A Randomized, Controlled Trial of Distal Radius Fractures
Kreder et al.
Journal of Orthopaedic Trauma; 2006:20(2):115–121.
The authors evaluated the outcomes of closed, extra-articular distal radius fractures with metaphyseal comminution and displacement treated with either closed reduction and casting or closed reduction and external fixation with or without K-wires. Primary outcome measures were functional.
Closed reduction and cast immobilization is often successful. Criteria to predict success include initial displacement, age of the patient, and metaphyseal comminution. General criteria that portend failure of closed treatment include dorsal displacement greater than 20º, articular displacement greater than 2 mm, shortening of more than 3 mm, and acute median nerve compression (OKU-T3). The fractures of this study are referred to as having metaphyseal comminution and displacement; this is the same description of the fractures that usually fail closed treatment. Therefore, this study’s finding of no functional outcomes difference between cast and external fixator is important information for discussion with patients. However, fractures with comminution >1/3 the anterior-posterior diameter of the radius and prereduction dorsal tilt of >10º were excluded. Thus, this is a study that examines a population that is generally treated well closed.
Ultimately, the authors establish that patients who do well with a cast can also do well with an external fixator. However, patients need to be informed of the additional risks associated with external fixators. The infection rate in this study is high: 2/59 (3.4%) suffered pin tract infections that required surgical curettage. The authors note that in order to find any differences between the groups examined in this study, a huge population (@600/arm) would have to be enrolled.
This further supports that these two treatment methods have quite similar results in this limited patient group.
Reviewed by Judith A. Siegel, M.D.
Department of Orthopaedic Surgery Boston University School of Medicine
Boston Medical Center; Boston, Massachusetts
