Surgery May Not Be Better Than Casting for Some Wrist Fractures

Jonathan Gelber, MD

February 01, 2022

In a multicenter, randomized trial in the United Kingdom, fixing wrist fracture with Kirschner wires (K-wires) did not improve patient outcomes at 1 year when compared with well-molded casting without surgery.

There are around 100,000 adult distal radius fractures in the UK each year. Current National Health Service (NHS) guidelines in the UK recommend using K-wires to stabilize wrist fractures when closed reduction is possible or there is no involvement of the articular surface. This is in contrast to fractures that require open reduction and internal fixation with a plate and screws to align the joint articular surface.

As a result, the use of K-wires for surgical fixation has been increasing since 2010 with a comparable decrease of the use of plates and screws.

Even though fixation with wires can provide reliable functional outcomes for patients after reduction of a displaced wrist fracture, surgery still carries risks for the patient and adds an additional expense. A well-molded plaster cast is a safer and cheaper intervention, but it is unclear if it could provide the same functional outcome as pinning.

Therefore, researchers in the UK conducted a multicenter, randomized trial among 36 hospitals within the NHS as part of the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2). Investigators randomly assigned 500 patients age 16 years and older with dorsally displaced distal radius fractures to manipulation followed by a molded cast or manipulation followed by surgical fixation with K-wires plus a cast.

The study was published online January 19 in The BMJ.

At 1 year, there were no significant differences between the groups in Patient Rated Wrist Evaluation (PRWE) scores centered on pain and function.

Dr Matthew Costa

In an interview with Medscape Medical News, Matthew Costa, PhD, professor of orthopaedic trauma at the University of Oxford and the study's lead author, said, "If a closed reduction of the fracture can be achieved, clinicians may consider the application of a molded plaster cast as a safe and cost-effective alternative to surgical fixation."

However, in referencing the data his group published, he did find one thing surprising: "One in eight patients treated with a molded cast required later surgery for loss of fracture position in the first 6 weeks after their injury."

Costa added, "This was indeed the key bit of information that patients need when making their decision about surgery. Initial feedback from our patient and public involvement group is that they would be happy to take this chance given that 7 out of 8 patients didn't need any form of surgical fixation."

Philip Blazar, MD, chief of the Hand and Upper Extremity Service, Brigham and Women's Faulkner Hospital in Boston, Massachusetts, commended the UK authors on completing a challenging randomized controlled trial.

Dr Philip Blazar

Speaking to Medscape, Blazar observed a critical difference between UK and US  guidelines. "It is important to remember that a sizable number of these patients had surgery," said Blazar, who was not involved with the study. "They had pins inserted under an anesthetic, and would not have [had] surgery compared to current practice as recommended by many authorities, including the American Academy of Orthopedic Surgeon's Clinical Practice Guidelines on Distal Radius Fractures."

Like Costa, Blazar expressed concerns with the secondary surgeries in the study group. "27% of patients had a second surgery: 13% in the first 6 weeks after manipulation for loss of reduction, and the remaining 14% had carpal tunnel releases, tendon transfers, tenolysis and/or capsulectomy for limited range of motion."

In addition, Blazar is worried that although recovery is generally considered to be only 12 months for these type of injuries — the duration of follow-up time in the DRAFFT2 study — "the probable outcome is that in the second 12 months after the injury, there will continue to be more of these types of surgeries."

Costa agreed that close follow-up is warranted, "It does suggest that patients treated in a molded cast do need to be followed-up carefully to spot those that do need later surgery."

Still, for Blazar, the largest takeaway of the study is that "At 12 months, disability scores between these two groups are not different, but the group treated nonsurgically had 10 times the number of secondary surgeries (27% vs 2%-3%)."

Moving forward, Blazar would like to see more specific indications for who would benefit from pinning. He told Medscape, "The greatest limitation is that this study provides no information on which patients with distal radius fractures where reduction is indicated would benefit from surgery. Looking at the details of this study, all patients with displaced fractures from age 16 to the elderly were treated as one indication. My impression is that most surgeons operate on patients taking into account radiographic and patient factors such as age, hand dominance, occupation, overall medical health, and activity level."

The DRAFFT2 study was funded by the UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme and was supported by NIHR Oxford Biomedical Research Centre. Blazar and Costa have disclosed no relevant financial relationships.

BMJ. Published online January 19, 2022. Full text

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