Similar results for cast and surgical wrist fractures

For elderly patients with distal radius wrist fractures, compared with the other three most common treatment strategies, there is no significant difference in results after 2 years of non-surgical casting treatment-all surgeries, new research shows.

"The conclusion drawn from these 24 months of data is that despite the malunion, older patients who chose non-surgical treatment adapted to their deformity and functioned similarly to those who chose surgical treatment," the authors of the study report, The research was published online in JAMA Network Open on June 18.

"This effect is maintained for 2 years, which ensures that the overall function does not deteriorate over time," they wrote.

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

"In view of the fact that surgical treatment has been the backbone of most patients for many years, I suspect that current research will be tilted towards non-surgical treatment for a large number of patients as the work spreads in the future," Johnning, who also wrote a comment on the study, Tell Medscape Medical News.

Although distal radius wrist fractures are one of the most common fractures in adults, there is a lack of evidence-based fracture management guidelines and treatment options vary widely.

To study the long-term results of the most common methods, the first author, Kevin C. Chung, MD, of the University of Michigan Medical Comprehensive Hand Center, and his colleagues conducted the Wrist and Radius Injury Surgical Trial (WRIST), an international multicenter study , Including 304 adults 60 years of age or older with isolated, unstable distal radius wrist fractures.

Patients recruited between April 2012 and December 2016 were randomly assigned to receive any of the four main management strategies: volar locking plate (n = 65); external fixation with or without pins (n ​​= 64 ); closed reduction with percutaneous nailing (n = 58); and non-surgical closed reduction and casting (n = 117).

After multivariate adjustments, an evaluation of 182 patients at 24 months showed that the main results of the summary score of the Michigan Hand Outcome Questionnaire were not significantly different between the four groups. The average score of the volar locking plate was 88, the external fixation was 83, and the percutaneous pinning and casting were 85 (P = .70). All of these represent good overall hand function.

These groups had low pain scores, good recovery from activities of daily living, and good satisfaction scores, but there was no significant difference. The results at 12 months and 24 months are similar.

"Although most patients recover from a wrist fracture within 6 months, we assume that the results such as imaging and anatomical appearance may be different at 24 months, which may change the results, but fortunately, This is not the case," Chung told Medscape Medical News.

It is worth noting that although the rate of deformity healing in the casting group (59%) was significantly higher compared to the other groups (8% to 17%; P <.001), similar results were observed.

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

In his comments, Johanning emphasized the additional benefits of non-surgical methods.

"[There is] the advantage of avoiding general anesthesia and a 15% to 20% surgical complication rate, which is very low but still present," he wrote.

Johnning told Medscape that these findings should help advance treatment decisions, and he acknowledged the benefits of surgical options for some patients.

"I do believe that there are still patients who will benefit from surgical treatment," he said. "The goal of the research team now should be to clearly describe who will benefit from [the method of surgery]," Johnning said.

The key to this effort is to adopt a more patient-centric view, rather than simply relying on X-rays to guide decision-making.

"It needs to be clearly emphasized that imaging abnormalities have nothing to do with future functional results," Johanning said.

"It is intuitive to see that the fracture has an incorrect reflection on the line and the need to readjust the fracture, but the research clearly shows that the functional outcome has nothing to do with the radiological appearance," he said.

Zhong agreed. "There are no guidelines for this kind of management, but if there is a common decision, the patient will be more satisfied," he said.

He pointed out that the trial showed that in the first few months after surgery, patients in the volar locking plate group showed greater improvement in activities of daily living and satisfaction, and recovered more strength compared with other groups. And wrist movement.

Although these differences disappeared after 6 months, this option may be preferable for patients who need rapid improvement.

"For example, elderly patients who are independent and still very active may prefer surgical options that provide a faster chance of recovery," Zhong said.

"Ultimately, the message to take home should be to treat the patient, not X-ray," he added.

The research was supported by the National Institute of Arthritis, Musculoskeletal, and Skin Diseases and the National Institute of Aging of the National Institutes of Health. Chung reported that it received book royalties from Wolters Kluwer and Elsevier, and received personal fees from Axogen and Integra. Johnning did not disclose any relevant financial relationships.

JAMA Internet Open. Published online on June 17, 2021. Full text, comments

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Quote this content: Cast and surgical wrist fractures have similar results-Medscape-June 28, 2021.

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