Description of the condition
Fractures of the distal radius, often referred to as "wrist fractures", are common injuries in both children and adults. They represent 15% of fractures in adults dealt with in the emergency department (Sanders 1996). They are usually defined as fractures occurring in the distal radius within three centimetres of the radiocarpal joint. The majority are 'closed' injuries, with the overlying skin remaining intact.
Distal radial fractures in adults occur predominantly in white and older populations in the developed world (Sahlin 1990; Singer 1998; Van Staa 2001). There is a bimodal age distribution of these fractures although with a difference between the sexes. In women, the incidence of these fractures increases with age, more rapidly from the age of 40 years onwards (McQueen 2003); in people under 40 years of age, the incidence is higher in men (Singer 1998). A multicentre study in the United Kingdom of people aged 35 years and above with distal radius fracture reported an annual incidence of 9 per 10,000 men and 37 per 10,000 women (O'Neill 2001). It has been estimated that at 50 years of age, a white woman in the USA or Northern Europe has a 15% lifetime risk of a distal radius fracture, whereas a man has a lifetime risk of just over 2% (Cummings 1985). This has been supported by more recent estimates of lifetime risk of radius or ulna fracture at 50 years of age of 16.6% for women versus 2.9% for men (Van Staa 2001).
Younger people usually sustain this injury as a result of high-energy trauma, such as a traffic accident; whereas in older people, the fracture more often results from low-energy or moderate trauma, such as a fall from standing height. This reflects the greater fragility of the bone in older adults because of osteoporosis.
The symptoms of a distal radius fracture include pain, deformity, swelling and crepitus (crackling, grating or popping sounds and sensations). Imaging investigations are typically used to confirm the diagnosis and plan treatment. Radiographs (X-rays) are the most common investigation, but computerised tomography (CT) and, occasionally, magnetic resonance imaging (MRI) are also used.
A review of the costs of upper extremity injuries in adults has estimated the direct costs, adjusted to 2007 values, of wrist fractures to be 1890 Euro per case (Polinder 2013). This study showed higher costs in women (2440 Euro) than men (1150 Euro). It is suggested that the higher average age and consequent osteoporosis associated with these injuries in females may predispose to a higher rate of surgery and complications and hence costs. Around 20% of people (mainly older people) with these fractures are estimated to require hospital admission (Cummings 1985; O'Neill 2001). This figure includes all people receiving surgery. Indirect costs of hand and wrist injuries in terms of loss of productivity are estimated to be greater than the direct costs (De Putter 2012).
Surgeons have classified fractures by anatomical configuration and fracture pattern to aid communication, research and guide management. Simple classifications, named after those who described them, were based on clinical appearance. In the distal radius, the term 'Colles’ fracture' is still used to describe a fracture in which there is an obvious and typical clinical deformity (commonly referred to as a 'dinner fork deformity') of dorsal translation, dorsal angulation, dorsal comminution (fragmentation) and shortening. The introduction of X-rays and other imaging modalities made it clear that the characteristic deformity may be associated with a range of different fracture patterns, which may be important determinants of outcome and therefore fracture management. For example, the fracture through the distal radius may be extra-articular (leaving the articular surface of the radius intact) or intra-articular (the articular surface is disrupted, sometimes in a complex manner). Numerous classifications have been devised to define and group different fracture patterns (Chitnavis 1999). Brief descriptions of six commonly cited classification systems (Cooney 1993; Fernández 1993; Frykman 1967; Melone 1993; Müller 1991; Older 1965) are presented in Table 1.
|Name (reference ID)||Brief outline||Comment|
|AO (Arbeitsgemeinschaft fur Osteosynthesefragen)|
This system is organised in order of increasing fracture severity. It divides the fractures into three major groups:
These three groups are then subdivided, yielding 27 different fracture types.
|There is no assessment of the extent of fracture displacement.|
This system is based on the mechanisms of injury. There are five main groups:
These groups are further categorised by stability, displacement pattern, number of fragments (or comminuted) and associated lesions.
|The injury mechanism is not always apparent.|
There is no consideration of the extent of displacement.
|This system distinguishes between extra-articular fractures and intra-articular fractures of the radiocarpal and radio-ulnar joints, and the presence or absence of an associated distal ulnar (ulnar styloid) fracture.|
There are eight types labelled I to VIII (1 to 8): the higher the number, the greater complexity of the fracture.
|There is no assessment of the extent or direction of fracture displacement, or of comminution.|
|This system identifies five fracture types, based on four major fracture components: the radial shaft, the radial styloid, and the dorsal-medial and volar-medial fragments.||This is for intra-articular fractures only.|
|This system divides fractures into four types, labelled I to VI (1 to 4) of increasing severity.|
The types are defined according to extent of displacement (angulation and radial shortening) and comminution.
|There is no consideration of radio-ulnar joint involvement.|
|' Universal Classification' (Cooney 1993)||This system divides fractures into four main types, labelled I to VI (1 to 4), distinguishing between extra-articular and intra-articular fractures and displaced and non-displaced fractures. Displaced fracture types II and IV are further subdivided based on reducibility (whether the fracture can be reduced; that is whether the bone fragments can be put back in place) and stability (whether, once reduced, the fragments will remain so).||This does not distinguish between the radiocarpal and radio-ulnar joints. Additionally, there is a 'trial by treatment'.|
Complications from distal radius fractures are not uncommon and can occur from the injury itself or from its treatment. Concomitant soft tissue injury is common, with reports of ligament injury in up to 50% of cases (Geissler 1996; Lindau 1997), the triangular fibrocartilage complex (TFCC) in 40% to 70% of cases (Geissler 1996; Lindau 2000) and compromise to surrounding blood vessels. The median nerve can be injured by trauma or compressive neuropathy may develop later, with rates reported of 10% in surgically managed fractures (Ho 2011). Chronic regional pain syndrome type 1 (CRPS-1) is a poorly understood complication that occurs in approximately 1% of non-surgically managed fractures and 5% of surgically managed fractures (Atkins 2003). The severity of symptoms can vary but pain, swelling and stiffness can take months to resolve and prolonged therapy may be required. Tendon irritation and rupture have been reported with both non-surgical (conservative) and surgical intervention. Extensor pollicis longus (thumb extensor tendon) ruptures can occur in minimally displaced fractures treated in a cast, with rates reported at 3% (Bonatz 1996). Malunion, which may result from redisplacement of an initially reduced fracture, can result in changes in the radiocarpal, midcarpal and radioulnar joints that lead to pain (Patton 2004), loss of motion (Kazuki 1993) and reduction in grip strength (Patton 2004), along with the development of later degenerative changes (Park 2002; Taleisnik 1984).
Description of the intervention
In the last century, most distal radius fractures in adults were treated non-surgically ('conservatively') by reduction (the alignment of the bony fragments to original anatomical positions) of the fracture when displaced and stabilisation in a plaster cast or other external brace for several weeks (Charnley 2003). The results of such treatment, particularly in older people with bones weakened by osteoporosis, were not consistently satisfactory (Handoll 2003). This resulted in attempts to develop other strategies involving surgery aimed at more accurate reduction and more reliable stabilisation.
One method of surgery is internal fixation, which is usually preceded by open reduction, and generally involves open surgery where the fractured bone is exposed to direct view and the fixation device (such as a metal plate) applied directly. The three other main strategies for surgical treatment described in the literature (Fernandez 1995) are percutaneous pinning (this involves the percutaneous (through the skin) insertion of pins and wires); external fixation (metal pins or screws are inserted into bone, generally via small incisions of the skin, on either side of the fracture are fixed externally, such as by incorporation into a plaster cast or securing into an external fixator frame); and bone grafts or substitutes (these are inserted into bony defects). These three methods are covered in the following Cochrane Reviews: percutaneous pinning (Handoll 2007a), external fixation (Handoll 2007b; Handoll 2008a), and bone grafts or substitutes (Handoll 2008b). Given the invasive and technically demanding nature of open surgery, internal fixation is often reserved for more severe injuries. There is significant ongoing interest in the role of internal fixation as it continues to evolve with the development of new implant designs (Martineau 2007; Simic 2003).
Numerous techniques and devices are used for internal fixation. The surgical approach to the distal radius for plating may be volar (palm side of the forearm) or dorsal (back of the forearm). Intra-operative imaging in the form of X-rays is commonly used to aid visual assessment of reduction. Stabilisation with plates is the most common type of internal fixation and there are many different types on the market. These may be either locking (the screw heads themselves screw into the plate to act mechanically as one fixed-angle device) or non-locking. Fragment-specific fixation employs one or more smaller plates to stabilise defined fracture fragments rather than using one plate for all fragments (Gavaskar 2012). Intramedullary nails have been used to try to minimise disruption to the surrounding tendons by having the implant contained within the bone. Postoperative decisions include the use and duration of immobilisation, and the need for removal of implants.
How the intervention might work
Patient factors, including age, fracture pattern and bone quality (presence and extent of osteoporosis), influence the decision to undertake internal fixation and the method employed. Common to all surgical methods is the promise of stable fixation after reduction to restore the anatomy to as close to normal. Bone quality may, however, be insufficient to hold the screws while healing takes place and internal fixation has mainly been used in younger, more active patients (Knirk 1986). The advent of locking plates with their greater ability to maintain hold in osteoporotic bone has meant that internal fixation has been used increasingly in older people. We consider three specific comparisons in this section: internal fixation versus conservative treatment; volar versus dorsal plating; and early versus delayed mobilisation after internal fixation.
Internal fixation versus conservative treatment
Conservative treatment, comprising closed reduction and cast immobilisation, of distal radius fractures can be successful, but anatomical restoration may not be optimal and some fracture redisplacement within the cast is common. The latter occurs more frequently in older patients who present with bone shortening, angulation and comminution on the initial radiographs (Mackenney 2006). Reduction of the redisplaced fracture may be attempted if early on (within two weeks of injury). However, while there remains a general perception that anatomical restoration improves outcome following fracture (Ruedi 2007) and that functional outcomes correlate with residual deformity (McQueen 1988), the findings of recent studies challenge these perceptions for the majority of distal radius fractures (Bentohami 2013; Finsen 2013). Bentohami 2013 reported "no effect of radiographic parameters on the functional outcome" of extra-articular distal radial fractures and Finsen 2013 found that the final alignment of the distal radius had only a small influence on the clinical outcome of 'Colles’ type' distal radius fractures. Nonetheless, some patients with malunion have a very poor outcome and may go on to have a corrective osteotomy (where a segment of bone is removed to improve alignment) that aims to improve function and relieve pain (Patton 2004).
Open reduction where the fracture fragments are directly visualised and manoeuvred should improve anatomical restoration and internal fixation such as via plate fixation should provide better stability than cast immobilisation and thus reduce the frequency of redisplacement and malunion. Improved stabilisation may allow earlier mobilisation and reduce the complications (e.g. stiffness and inconvenience of protracted immobilisation in a cast while the fracture heals). However, surgery is associated with an increased risk of surgery-related complications such as infection and tendon rupture, and there is an increased risk of fixation failure in osteoporotic bone.
Volar versus dorsal plating
Internal fixation via a dorsal approach can irritate the extensor tendons (for straightening the fingers) resulting in tenosynovitis and rupture, along with reduced flexion (bending the wrist downwards) from the dorsal scarring (Bassett 1987). This is most likely due to a combination of issues including the minimal soft-tissue cover, the close proximity of the tendons to the bone and the convex nature of the distal radius, all of which leave the tendon prone to abrading over the implant (Carter 1998; Downing 2008; Jakob 2000; Ring 1997). Unfortunately, these complications do not all resolve following implant removal (Fitoussi 1997).
The volar approach (from the front of the wrist) has gained popularity in recent years (Downing 2008). However, this can also irritate the extensor tendons from screw penetration of the dorsal cortex (Al-Rashid 2006; Benson 2006). The flexor tendons (for bending the fingers) are also at risk from this approach, though it is considered that this usually occurs from incorrect implant placement (Arora 2007; Downing 2008). Screws can also be inadvertently placed into the radiocarpal joint through a volar approach as the joint surface is less easily visualised than with the dorsal approach (Arora 2007). This may also lead to less accurate reduction of dorsal articular fragments.
Early versus delayed mobilisation post internal fixation
Early mobilisation is thought to improve outcome following fracture (Ruedi 2007). Hypothetically, early mobilisation such as within two weeks post surgery, should speed recovery and avoid the problems of joint stiffness, swelling and the additional inconvenience often associated with wrist immobilisation such as in a cast. However, while the use of internal fixation in the treatment of distal radius fractures has been built on the principle that stable anatomical fixation and early mobilisation improves outcomes (Downing 2008), delayed mobilisation such as four to six weeks, may be considered better as it is likely to help safeguard the fixation and reduction and enable fracture healing. Decisions over timing are likely to be affected by factors influencing the stability of a fracture or surgical fixation; these include fracture comminution and osteoporosis commonly seen in older people (Mackenney 2006).
Why it is important to do this review
Distal radius fractures are one of the most common injuries in adults. However, there is a lack of consensus on their management (Lichtman 2010). Because of the significant increase in the use of internal fixation (e.g. Mattila 2011 reported a 13-fold increase between 1998 and 2008 in Finland), it is important to assess the role that internal fixation plays in managing these injuries and which type of internal fixation method should be used to reliably restore function with the lowest risk of complications. In particular, there is a need to examine the evidence for the increased use of internal fixation using locking plates for older people (Day 2012).