A comparison of early fixation of distal radius fractures versus late corrective osteotomy of distal radius malunion

Abstract

Background

Fractures of the distal radius are common. Closed reduction and moulded casting is often the first line treatment. Malunion after casting is not uncommon and can lead to discussion on acute surgical fixation versus delayed corrective osteotomy if symptomatic. However, it is unclear if late surgery will provide similar outcomes as early intervention.

Methods

We performed a single centre, age matched, case series comparison study, comparing outcomes of patients who had undergone early fixation (ORIF) versus those who had undergone late corrective osteotomy (CO) following distal radius fracture.

Results

Twenty‐six patients were available for review, 13 in each group. Fracture patterns were similar. Reviewing CO versus ORIF; patients achieved a mean DASH; 22 versus 18 (P = 0.355), PRWE; 35 versus 26 (P = 0.237), and VAS 2 versus 2 (P = 0.490). Grip strength was significantly better in those who had undergone ORIF; 2% versus −22% (P ≤ 0.001). Range of motion was generally better with primary fixation but of doubtful clinical importance, reviewing CO versus ORIF; Flexion 46° versus 60° (P = 0.045), extension 55° versus 64° (P = 0.137), pronation 73° versus 85° (P = 0.078), supination 84° versus 84° (P = 0.747), flexion/extension arc 101 versus 124 (P = 0.017), ulnar/radial deviation arc 42° versus 59° (P = 0.01), pronation/supination arc 157° versus 168° (P = 0.118). Ulnar variance was significantly improved in the ORIF group; +0.5 mm versus +2 mm in the CO group (P = 0.023). Radial inclination, radial height and volar tilt were not significantly different between either group.

Conclusion

Our findings suggest that patient measured outcome of corrective osteotomy is not inferior to early internal fixation.

Level of Evidence

III (Case Series Comparison).

Fractures of the distal radius are common, however in circumstances whereby the patient may require surgical intervention, it is unclear if necessitated late surgery will provide similar outcomes as early intervention. We performed a single centre, age matched, retrospective cohort comparison study, comparing outcomes of patients who had undergone early fixation (ORIF) versus those who had undergone late corrective osteotomy (CO) following distal radius fracture. Our findings suggest that the patient measured outcome of corrective osteotomy is comparable with early internal fixation.

Introduction

Fractures of the distal radius are common; with a reported incidence of 125 in 10 000 people. ¹ Closed reduction and moulded casting is often the first line of treatment especially in fractures without comminution or articular extension. Following initial reduction, some collapse of the fracture is likely with loss of radial height and dorsal angulation resulting in malunion as high as 54%. ² , ³ , ⁴ , ⁵ , ⁶ While radiographic malunion after casting is not uncommon and can occur in up to 23% of cases, not all patients are symptomatic. Forward et al. 2008 report that in their study, looking at the long term follow up (mean 38 years) of 106 patients, under 40 years old at the time of injury, all of whom developed malunited distal radius fractures, few had functional limitation. ⁷ Depending on the patient and their functional requirements, malunion of the distal radius can cause variable symptoms, including pain, deformity, reduced range of motion, nerve compression, tendon rupture and diminished grip with resulting functional impairment. Should malunion occur, distal radius corrective osteotomy may be employed in symptomatic patients with resolution of symptoms and favourable outcomes. ⁸ , ⁹ , ¹⁰ , ¹¹

Following an acceptable initial closed reduction, the surgeon and patient must make the informed choice of continuing with closed treatment in a cast while considering the possibility of loss of reduction and subsequent malunion. The following questions often arise, if the fracture goes on to heal with angulation, how much collapse is acceptable, and will this be a problem for the given patient? If then the malunion is symptomatic, will the outcome of surgery for a corrective osteotomy be comparable to surgery undertaken primarily before malunion?

The answer to the first question is not clearly defined. A recent study has utilized expert opinion to define the thresholds for surgical intervention based on radiographic parameters and patient age. ¹² The answer to the second question is not known, as there exists no direct population matched study comparing outcomes of primary internal fixation versus corrective osteotomy for distal radius fracture.

The aim of this study is to compare the results of corrective osteotomy of the malunited distal radius versus primary open reduction and internal fixation of the distal radius. This information may help the surgeon counsel a patient who is concerned or at risk of losing reduction after non‐operative treatment.

Methods

This was a single centre age matched, case series comparison study, comparing the outcomes of patients who had undergone early open reduction and internal fixation (ORIF) versus those who had undergone late corrective osteotomy (CO) to the distal radius. Gender and operative times were matched as able; patients were first matched by date of operative care; all were within 14 days of their osteotomy counterpart, then were matched by age, then were matched with gender and finally by fracture pattern. Please see Figure 1.

Fig. 1.

Flow diagram of patient recruitment.

Ethical approval was granted by our institution's review board. All subjects provided written consent at the time of data collection.

We performed a review of 18 patients who had undergone corrective distal radius osteotomy for symptomatic post traumatic malunion, with pain or functional impairment, in the period 2011–2015. Inclusion and exclusion criteria are shown in Table 1. Patients were clinically assessed by one of three investigators, radiographs were reviewed by two investigators for consensus, in the instance of discrepancy a third investigator was employed. We hypothesised that early fixation provides significantly improved outcomes than delayed corrective osteotomy.

Table 1.

Inclusion and exclusion criteria

Osteotomy patients
Inclusion	Exclusion
Opening wedge distal radius corrective osteotomy	Patients who underwent concomitant ulnar shortening
Established malunion impairing function	Unable to complete the assessments
Volar plate fixation	Additional untreated radiocarpal pathology
	Contralateral pathology to the wrist, hand or nerves of the upper limb
ORIF
All distal radius fracture patterns	Multi‐trauma patients
Volar plate osteosynthesis	Prior fracture of the ipsilateral wrist or forearm
	Fragment specific fixation
	Supplementary K‐wires
	Dorsal plating
	Diaphyseal fractures
	Significant post‐operative complications requiring additional surgery

Osteotomies were performed by one of five fellowship‐trained hand surgeons. A comparable cohort group of patients who had undergone primary ORIF of the distal radius, following departmental peer review of their imaging and case history.

For both groups demographic data, a retrospective chart review was performed for surgical data, pre‐ and post‐operative radiographic parameters (volar tilt, radial inclination, ulnar variance and radial length), time to union, AO fracture classification.

The patients were invited back for clinical assessment including range of motion (flexion, extension, pronation, supination, ulnar and radial deviation) and grip strength as a percentage of the uninjured side. Other patient reported outcomes gathered included: pain visual Analogue Score (VAS), Disabilities of the Arm, Shoulder and Hand (DASH), Patient Rated Wrist Evaluation (PRWE) and Modified Mayo Scores were collected. Patients were also asked to answer in plain language ‘Are you happy you underwent surgery?’, with the binary answer of ‘Yes’ or ‘No’.

In the corrective osteotomy group, a distal radius opening wedge osteotomy was performed with volar locking plate fixation. Bone graft was used depending on the operating surgeon's preference.

All distal radius ORIFs were performed via a modified Henry approach with internal fixation using a volar locking plate.

SPSS Version 24 was used for statistical analysis, with Shapiro–Wilk used to test for normal distribution, and either Student's T‐test or Mann–Whitney U test for continuous data, and Chi squared for dichotomous data to assess statistical significance. Median scores were also reported with Interquartile Range (IQRs).

Results

Thirteen out of 18 patients from the CO group were available for follow up (Table 2). Five patients were excluded; four had left the region and one had a stroke.

Table 2.

Demographic data and fracture characteristics

	Osteotomy	ORIF	P‐value
Gender			0.691
Female	7	8
Male	6	5
Age (years)	Mean 51 (18–71)	Mean 51 (18–78)	0.951
	Median 56	Median 61
	CI: 41–60	CI: 31–66
Age at surgery (years)	Mean 48 (15–69)	48 (16–76)	0.925
	Median 51	Median 54
	CI: 40–56	CI: 28–64
Right:Left hand dominance	11:2	10:3
Right:Left surgical side	7:6	7:6
Diabetics	2	2
Smoker	1	4
Osteoporosis	2	3
Follow up	2.6 years	3.5 years	0.144
	(1.3‐5 years)	(2.2–7.1 years)
	Median: 723 days	Median: 1098 days
	CI: 615–1418 days	CI: 920–1331 days
AO classification			0.328
A	6	5
B	1	1
C	6	7
Plate type			0.318
Acumed	6	4
Trimed	6	3
Synthes	1	4
Mechanism			0.685
Fall from standing height	8	10
Fall greater than standing height	3	2
MBA/MVA	2	1

Abbreviations: CI, 25%–75% confidence intervals; MBA, motorbike accident; MVA, motor vehicle accident.

The mean age of the patients was comparable across both groups. In the CO group mean age was 51 years (18–71) and in the ORIF group mean age was also 51 years (18–78) (P = 0.951). There were seven females in the CO group and eight females in the ORIF group. Mean time from injury to surgery was 2.4 yrs., median 306 days, in the CO group (43–1834 days), and 9 days, median 7 days, in the ORIF group ² , ³ , ⁴ , ⁵ , ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ (P = 0.170). Mean time of follow up was 2.6 years in the osteotomy group, and 3.5 years in the ORIF group. There were comparable demographics across both groups pertaining to employment, activity level, operative side, hand dominance and co‐morbidities of diabetes and smoking status.

Sixty‐two percent of patients in the CO group had bone graft, with 23% autologous and 39% bone substitutes. None of the ORIF group required bone graft.

Patients achieved a mean DASH scores of 22 (0–54) for CO and 18 (0–50) for ORIF (P = 0.355) or median of 23.3 versus 5.8 (IQRs 39.2 and 35.8) respectively, a mean PRWE score of 35 (2–94) for CO and 26 (0–96) for ORIF (P = 0.237) or median of 30.5 versus 13 (IQRs 72.5 and 48), respectively, a mean VAS of 2 for both the CO and ORIF groups (P = 0.490) or median of 1.5 versus 1 (IQRs 3.5 and 2.5), respectively.

Relating to modified Mayo scores, patients in the ORIF group had significantly improved scores, mean 91 (70–100), compared to the CO group, mean 77 (55–100) (P = 0.025), or median of 80 and 95 (IQRs 28.75 and 15), respectively.

With regard patient satisfaction, 92% were ‘happy’ they had undergone surgery and 8% were unsure in the ORIF group. 82% were ‘happy’ they had undergone surgery, 9% were unsure, and 9% (one patient) were unhappy in the CO group.

When grip strength was expressed as a percentage of the contralateral side; grip strength was significantly improved in those who had undergone CO when compared to ORIF; −22% versus −2% (P ≤ 0.001), or median −20% versus −3.5 (IQRs 28.4 and 7.2), respectively. The range of motion is indicated in Table 3. While range of motion was generally better in the ORIF group, only palmar flexion and radial/ulnar deviation reached statistical significance. The differences, however, were of doubtful clinical importance.

Table 3.

Range of motion (ROM) outcome measures

Range of motion	CO mean	CO median	CO range	ORIF mean	ORIF median	ORIF range	P‐value	CO IQRs	ORIF IQRs
Flexion	45.92	45	12–75	60.23	65	30–85	0.045	20	28.5
Extension	55.31	50	40–75	63.62	60	45–90	0.137	22.5	23.5
Pronation	73.08	80	40–90	84.62	90	60–90	0.078	35	5
Supination	83.85	90	65–90	83.85	90	70–90	0.747	17.5	12.5
Radial Deviation (RD)	17.69	18	10–25	24.38	22	10–40	0.37	6.5	10
Ulnar Deviation (UD)	24.31	25	10–35	34.62	35	10–55	0.013	13	10
Flex/Ex Arc	101.23	95	67–140	123.85	130	85–170	0.017	35	34.5
Prono/Sup Arc	156.92	160	130–180	168.46	170	145–180	0.118	42.5	20
UD/RD Arc	42	43	25–60	59	57	25–70	0.01	19.5	17.5

Note: Bold indicating significance.

Pre‐operative radiographs were compared; with regards the ORIF group, these radiographs were obtained following closed reduction and casting. On radiographic assessment, ulnar variance was significantly improved (closer to neutral) in the ORIF group' +0.5 mm versus +2 mm in the CO group (P = 0.023). Pre‐operatively, ulnar variance was significantly worse (more positive) in the osteotomy group; +3.5 mm versus +1.5 mm (P = 0.027). Radial inclination was similar post operatively in both groups; ORIF 23°, osteotomy 25° (P = 0.180), as was radial height; ORIF 11.5 mm, osteotomy 13 mm (P = 0.082), and in volar tilt; ORIF 9°, osteotomy 6°. Pre‐operatively however it should be noted that there was significantly more dorsal tilt within the osteotomy group; 10° versus 1° (P = 0.032). The radiographic data is shown in Table 4.

Table 4.

Radiographic outcome measures

	Osteotomy	ORIF	P‐value	IQR Osteotomy	IQR ORIF
Volar tilt (°)
Preop mean	−10	1	0.032
Pre‐op median	−11	3.5		18.25	14.78
Postop mean	6	9	0.108
Post op median	6	9.5		7.8	8
Radial Inclination (°)
Preop mean	21	24	0.092
Preop median	19.8	25.4		8.38	7.25
Postop mean	25	23	0.180
Post op median	24.7	23		6.8	3.33
Ulnar variance (mm)
Preop mean	3.5	1.5	0.027
Preop median	3	0.38		3.6	3
Postop mean	2	0.5	0.023
Post op median	2.4	0		2.19	3.22
Radial Height (mm)
Preop mean	10.5	12	0.153
Preop median	9.9	12.5		4.99	2.88
Postop mean	13	11.5	0.082
Post op median	12.8	11.4		3.26	2.13

Note: Bold indicating significance.

Discussion

The decision to operatively intervene after a distal radius fracture partially loses reduction is a complex one and is based on prediction of the level of symptoms from the resulting malunion. Recent literature suggests that certain population groups, often the elderly and low‐demand individuals will tolerate distal radius malunion well. ⁷ , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ In active, younger individuals, the question often raised is if a corrective osteotomy done later should it be required, would have the same outcome as early operative fixation. Several corrective osteotomy techniques have been described with good outcomes as isolated series without comparing with a cohort of early fixation. ⁸ , ⁹ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²²

Our results suggest that patients who undergo distal radius corrective osteotomy seem to have PROMs and satisfaction comparable to those who undergo early fixation. However, osteotomy also has significant economic implications to healthcare systems, and psychosocial implications to the individual. These should be included in any informed consent. Patients who undergo ORIF may have objective higher scores that may be more clinically relevant in younger active individuals including, grip strength, wrist flexion, ulnar and radial deviation and better restoration of neutral ulnar variance.

Grip strength is shown to be statistically and clinically significantly improved should the patient be able to undergo primary ORIF, when compared to delayed corrective osteotomy by a noticeable 20%. Minimal Clinically Important Difference of percentage difference grip strength to contralateral side has been shown to be 19.5%. ²³

Post‐op DASH and PRWE are comparable to prior literature. ²⁴ There was no significant difference between either treatment arm. Neither group was significantly different to what is considered the normal DASH for the mean population; when taking into consideration minimal clinically important difference (MCID); in that the mean population have a DASH score of 11, and MCID for DASH score is 10. ²⁵ However, with physician reported outcome measures, in the form of Modified Mayo Scores those who had undergone early ORIF had significantly improved function to those that had undergone osteotomy. Modified Mayo Scores achieved had a mean difference of 14 in favour of early ORIF. These scores placed ORIF within ‘excellent’ bracket, but only ‘fair’ in the case of osteotomy.

Results regarding movement favoured ORIF, but not all measurements were better to a level of clinical relevance. The most notable benefit was more flexion in the ORIF group by 14°. This stands to reason with prolonged malunion of a mean duration of 2.4 years with a deformity predominated by significant dorsal angulation, leading to dorsal capsular and soft tissue tightness limiting the full recovery of flexion.

It has been demonstrated that the radiographic parameters of palmar tilt and ulnar variance correlate most with clinical outcome. ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ Radiographic malunion after casting is not uncommon and can occur in up to 23% of cases, not all patients are symptomatic. ⁷ Whilst both treatment groups in this study had correction of these parameters to within normal ranges, the ORIF group had better correction of ulna variance closer to neutral. This is likely related to the preoperative values being significantly higher in the osteotomy group. Despite these numerically less favourable data, the overall satisfaction was similar in both groups.

The limitations of this study are the retrospective nature, including the matching process, and small numbers introducing bias. It would be difficult to conduct a prospective study and randomize patients to allow them to develop a malunion. The current series had a large dropout rate of 5 of 18 cases in the CO group, this is a common challenge with long term follow up studies. Sample size is in keeping with recently published research articles surrounding distal radius osteotomy. Osteotomy also has significant economic implications to healthcare systems, and psychosocial implications to the individual. These should be included in any informed consent. Other weaknesses include lack of complication data, operative duration data and variability between surgeons in the ORIF group.

Conclusion

When examining patient outcomes, our findings suggest that the outcome of corrective osteotomy is comparable with early internal fixation. Objective measurements of motion and strength favour internal fixation. Despite out findings, guided by other literature, when counselling a patient with distal radius fracture about internal fixation versus late osteotomy we would recommend that early ORIF may be better in younger active individuals than a delayed osteotomy. Our results may allow us a more fully informed consent to patients in higher risk groups, or who are themselves reluctant to undertake primary ORIF.

Author contributions

Conor Gouk: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; software; writing – original draft; writing – review and editing. Melissa Bairstow: Data curation; investigation; writing – original draft. Michael Thomas: Resources; supervision; writing – original draft. Ezekiel Tan: Resources; supervision. Fraser Taylor: Resources; supervision. Randy Bindra: Methodology; resources; supervision; writing – original draft; writing – review and editing.

Funding information

The authors received no financial support for the research, authorship, and/or publication of this article.

Conflict of interest

Prof Bindra is a consultant for Acumed LLC and Integra LifeSciences. None declared.

Ethical approval

Ethical approval was granted by our local Human Research and Ethics Committee (HREC), Ref. No.: HREC/16/QGC/106.