This randomized controlled trial compared operative treatment using volar locking plate fixation versus non-operative treatment with casting for displaced and unstable distal radial fractures in patients aged 65 and older. 73 patients were randomly assigned to either operative fixation or non-operative treatment. At one-year follow up, while operative treatment led to better grip strength and anatomical restoration, there were no significant differences in range of motion, pain levels, or patient-rated wrist/functional scores between the groups. However, operative treatment did result in a higher rate of complications. Therefore, for older patients, this study suggests that operative management may not provide clear functional benefits over non-operative treatment for distal radial fractures.

1. A PROSPECTIVE RANDOMIZED TRIAL COMPARING
NONOPERATIVE TREATMENT WITH VOLAR LOCKING
PLATE FIXATION FOR DISPLACED AND UNSTABLE
DISTAL RADIAL FRACTURES IN PATIENTS SIXTYFIVE YEARS OF AGE AND OLDER

2.  Investigation performed at the Department of Trauma
Surgery and Sports Medicine, Medical University
Innsbruck, Innsbruck, Austria
 Published by: THE JOURNAL OF BONE & JOINT
SURGERY , December 7,2011.

3. Background
Increased tendency for ORIF of displaced and
unstable fracture ,despite the lack of adequate
prospective randomized trials examining
whether open reduction and internal fixation
(ORIF) with a volar locking plate is superior to
non-operative (cast) treatment.

4. Study design
Prospectiverandomizedtrialwithoneyearfellowup.
Therapeuticlevel I evidence.

5. Selectioncriteria
 Patients over 65 year old with initial inadequate
reduction and patients with subsequent loss of
reduction at the one-week follow-up
examination.
 dorsal radial tilt >10°and/or
 radial shortening > 3 mm and/or
 intra- articular step-off > 2 mm

6. Study power
 The sample sizecalculated to provide 80% power
to detect a difference of 10 points in the PRWE
score, which they consider to be clinically
relevant is 68 patients .
 Number of patients includedwas 73 patients .
36 patients treatedoperatively ORIF with a
volarlockingplate and 37 patients treated by
closedreduction and cast immobilization .

7. Randomization
The patients were randomized to either ORIF
or non-operative treatment with use of
sequentially numbered, sealed envelopes.

8. OutcomeEvaluation
 Patient-RatedWristEvaluation (PRWE) score
 Disabilitiesof the Arm, Shoulder and Hand




(DASH) score
The painlevel
The range of wristmotion
The rate of complications
Radiographicmeasurementsincludingdorsal
radial tilt, radial inclination, and ulnarvariance.

9. Results

There were no significant differences in range of motion or the level of pain during the
entire follow-up period (p> 0.05).

Patients in the operative treatment group had lower DASH and PRWE scores, indicating
better wrist function, in the early postoperative time period (p< 0.05), but there were no
significant differences between the groups at six and twelve months.

Grip strength was significantly better at all times in the operative treatment group (p<
0.05).

Dorsal radial tilt, radial inclination, and radial shortening were significantly better in the
operative treatment group than in the nonoperative treatment group at the time of the
latest follow-up (p< 0.05).

The number of complications was significantly higher in the operative treatment group
(thirteen compared with five, p< 0.05).

posttraumatic osteoarthritis in patients with intra-articular fractures was significantly
higher in the nonoperative treatment group than in the operative treatment group (p<
0.05)

10. Conclusions
 At the 12 month follow up examination, the range of
motion, the level of pain, and the PRWE and DASH scores
were not different between the operative and nonoperative treatment groups.
 Patients in the operative treatment group had better grip
strength through the entire time period.
 Achieving anatomical reconstruction did not convey
anyimprovement in terms of the range of motion or the
ability to perform daily living activities in the study.

12.  The outcome is at 1 year fellow up , may be too early for
arthritis pain and we do not know how bad are these pains ,
and their impaction on DASH and PRWE

13.  What is the study power for DASH score ??? is it
still 80% with the same number of patients
???!Because the studymensionedonly PRWE
score
 Is it dobble blind oronly the patients is blined.

14. From thistable
TABLE III Radiographic Outcomes

15. The WORST fracture X-ray in this study
after one year was
Normal
Operative
Non-operative
Palmer tilt degree 12
-4.2
-22,7
23
18,6
6,9
Ulnavariance mm 0.9
2.5
6,1
Step-off mm
0.7
1,7
Radial
inclinationdegree
0

16. The worst case is as
thisfracture
Dorsal tilt of 22° , a radial shortening of 7 mm
and radial inclination 6° , ulna variance 4 mm

17. But not thisone….

18. May be there should be an other acceptable
range for people over 65,but not the usual
one for younger patients !!

19. Sylvester Stallon, 66 year