Is Immobilization Necessary After Open Reduction and Internal Fixation of Distal Radius Fractures? A Meta-Analysis of Randomized Controlled Trials

Abstract

Distal radius fractures (DRFs) are the most common fractures in adults. With the increased trend in open reduction and internal fixation (ORIF) using a volar locking plate, the postoperative rehabilitation course remains debated and whether or not a postoperative immobilization is necessary is unknown. PubMed, Cochrane, and Google Scholar (pages 1-20) were queried through August 2024. Inclusion criteria consisted of studies that compared patients undergoing immediate mobilization after ORIF for DRF with patients undergoing postoperative immobilization. Adverse events, patient-reported outcomes measures, and range of motion (ROM) were all compared between the 2 groups at various postoperative time points. Four randomized controlled trials were included in this study. No difference was seen in the risk of complications (odds ratio = 1.17, P = .70) and reoperations (odds ratio = 1.35, P = .53) between the 2 groups. The immediate mobilization group had lower pain scores at 6 months (mean difference = −0.46, P = .005) and lower Disabilities of the Arm, Shoulder, and Hand at 3 months (mean difference = −0.45, P = .002), and 6 months (mean difference = −0.46, P = .005). As for ROM, better forearm rotation was seen in the immediate mobilization group at 6 months (mean difference = 3.43, P = .004).

Introduction

Distal radius fractures (DRFs) are the most common fractures in adults, having an overall frequency of 17.5% among all fractures. ¹ Many reasons, including lifestyle, environment, increased childhood obesity, life expectancy, and osteoporosis rate in the elderly population, have been cited as the causes of the rising incidence of DRFs.^{2 -5} Prior studies have indicated that DRFs are most common in postmenopausal women and young men. Nevertheless, these fractures were also often noted in young adult men between the ages of 19 and 49.^{6 -10} Younger patients’ fracture mechanism has been described as high-energy trauma, but low-energy trauma remains the most common cause of injury among the elderly.^{2,7 -9}

Management of DRFs has frequently been questioned, especially when it comes to older individuals. ¹¹ Nevertheless, it has been shown that open reduction and internal fixation (ORIF) using a volar locking plate produces noticeably superior outcomes in reduction and function compared with other surgical techniques such as percutaneous pinning and external fixation.^{12 -16} In fact, ORIF using a plate allows the patient to have an early mobilization of the affected limb, eliminating the need for a long period of immobilization. Nonetheless, there are still unanswered questions about the duration of immobilization after ORIF.^{17 -20} Surgeons differ in their postoperative immobilization regimens; some apply a cast for 2 to 7 weeks, while others do not use any external immobilization at all.^21,22

While early mobilization is preferred by some surgeons to minimize joint stiffness and encourage an early return to daily activities, postoperative immobilization is preferred by others to prevent fracture displacement and reduce discomfort following surgery. ¹⁷ Therefore, this meta-analysis of randomized controlled trials (RCTs) will assess whether or not a postoperative immobilization is required after ORIF using volar plating for DRF.

Material and Methods

Search Strategy

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed, Cochrane, and Google Scholar (pages 1-20) were searched through August 2024 ²³ to find articles comparing immediate postoperative mobilization to postoperative immobilization in the setting of DRF ORIF. The following keywords and Boolean terms “rehab*,” “mobili*,” and “distal radius” were used. Supplementary articles were added by going through reference lists from articles and Internet searches. One author extracted the data and another confirmed the choice of the included articles. The process is summarized in the PRISMA flowchart (Figure 1).

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart for article selection process.

Inclusion criteria consisted of RCTs comparing immediate postoperative mobilization with postoperative immobilization in the setting of ORIF for DRF. Exclusion criteria consisted of cohort studies, non-comparative studies, studies comparing immobilization to early mobilization instead of immediate mobilization, or studies with non-relevant outcomes. ²⁴

Data Extraction

Eligibility of the included studies was determined by 2 reviewers independently. Extracted data consisted of adverse events (complications, reoperations), patient-reported outcome measures (PROMs; pain and Disabilities of the Arm, Shoulder, and Hand [DASH] at 2-3 weeks, 6 weeks, 3 months, and 6 months postoperatively), and range of motion (ROM) (flexion extension [FE], and forearm rotation at 2-3 weeks, 6 weeks, 3 months, and 6 months postoperatively).

Risk of Bias Assessment

Two authors assessed the risk of bias using the Cochrane risk-of-bias tool independently. Each trial was assessed and scored as high, low, or unclear risk of bias (Supplementary Figure 1). Trials with high risk of bias for more than 1 domain were considered to be at high risk of bias, whereas trials with low risk of bias for all domains were considered to be at low risk of bias; otherwise, they were considered to be at unclear risk of bias (Supplementary Figure 2).

Statistical Analysis

Review Manager 5.4 (The Cochrane Collaboration, 2020) was implemented for all statistical analysis. Mean differences (MDs) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were used for continuous data while odds ratios (ORs) were used for dichotomous data. Heterogeneity was evaluated by Q tests and I² statistics, using a random-effects model in case of considerable heterogeneity (defined by P ≤ .05 or I² > 50%) and a fixed-effect model if P greater than .05 or I² less than 50%. A statistically significant result was denoted by P less than .05.

Results

Characteristics of the Included Studies

Four RCTs met the inclusion criteria.^{17 -20} These trials included 228 patients, with 110 being in the immediate mobilization group and 118 being in the immobilization group. The main characteristics of the included studies are summarized in Table 1.

Table 1.

Characteristics of the Included Trials.

Author	Methods	Surgery	Participants		Age (y, mean)		Follow-up (mean)	Adverse events		Reasons for reoperations
			Immediate mobilization	Immobilization	Immediate mobilization	Immobilization		Immediate mobilization	Immobilization	Immediate mobilization	Immobilization
Andrade-Silva et al 18	RCT	Volar locked plating	17	19	51	48	6 months	1 loss of reduction	—	1 loss of reduction	—
Laohaprasitiporn et al 17	RCT	Volar locked plating	21	23	54	56	12 months	2 carpal tunnel syndrome	2 carpal tunnel syndrome	—	1 carpal tunnel syndrome
Quadlbauer et al 19	RCT	Volar locked plating	56	60	56	58	12 months	2 carpal tunnel syndrome 1 complex regional pain syndrome 1 loss of reduction 1 intra-articular screw 1 tendon irritation 1 impaired wound healing	3 complex regional pain syndrome 3 carpal tunnel syndrome 1 loss of reduction 1 tendon rupture 1 tendon irritation	1 tendon irritation 1 intra-articular screw 2 carpal tunnel syndrome	1 tendon rupture 1 tendon irritation 3 carpal tunnel syndrome
Zeckey et al 20	RCT	Volar locked plating	16	16	80	82	12 months	—	—	2 plate removal due to pain 1 plate removal requested by patient	1 screw loosening

Note. RCT = randomized controlled trial.

Adverse Events

Four trials comprising 228 patients reported complication and reoperation data (110 in the immediate mobilization group and 118 in the immobilization group). No difference was noted in complications (OR = 1.17; 95% CI: 0.52-2.66, P = .70, Figure 2a) and reoperations (OR = 1.21; 95% CI: 0.45-3.26, P = .70, Figure 2b) between the 2 groups.

Figure 2.

(a) Forest plot showing the difference in the rate of complications. (b) Forest plot showing the difference in the rate of reoperations.

Note. CI = confidence interval.

Patient-Reported Outcome Measures

Two trials comprising 80 patients reported on pain at 2 to 3 weeks postoperatively (38 in the immediate mobilization group and 42 in the immobilization group), 3 trials comprising 196 patients reported on pain at 6 weeks and 3 months postoperatively (94 in the immediate mobilization group and 102 in the immobilization group), and 2 trials comprising 152 patients reported on pain at 6 months postoperatively (73 in the immediate mobilization group and 79 in the immobilization group). No difference was seen between the 2 groups in pain at 2 to 3 weeks (SMD = 0.06; 95% CI: −0.38 to 0.49, P = .80, Figure 3a), pain at 6 weeks (SMD = −0.19; 95% CI: −0.96 to 0.57, P = .62, Figure 3b), and pain at 3 months (SMD = −0.26; 95% CI: −0.79 to 0.27, P = .33, Figure 3c). However, the immediate mobilization had lower postoperative pain at 6 months (SMD = −0.46; 95% CI: −0.78 to −0.14, P = .005, Figure 3d).

Figure 3.

(a) Forest plot showing the difference in pain at 2 to 3 weeks postoperatively. (b) Forest plot showing the difference in pain at 6 weeks postoperatively. (c) Forest plot showing the difference in pain at 3 months postoperatively. (d) Forest plot showing the difference in pain at 6 months postoperatively.

Note. CI = confidence interval.

Three trials comprising 196 patients reported on DASH at 6 weeks and 3 months postoperatively (94 in the immediate mobilization group and 102 in the immobilization group), and 2 trials comprising 152 patients reported on DASH at 6 months postoperatively (73 in the immediate mobilization group and 79 in the immobilization group). No difference was seen between the 2 groups in DASH at 6 weeks (SMD = −0.41; 95% CI: −1.12 to 0.31, P = .27, Figure 4a). However, the immediate mobilization had lower DASH scores at 3 months (SMD = −0.45; 95% CI: −0.73 to −0.16, P = .002, Figure 4b), and 6 months (SMD = −0.46; 95% CI: −0.78 to −0.14, P = .005, Figure 4c).

Figure 4.

(a) Forest plot showing the difference in Disabilities of the Arm, Shoulder, and Hand (DASH) at 6 weeks postoperatively. (b) Forest plot showing the difference in DASH at 3 months postoperatively. (c) Forest plot showing the difference in DASH at 6 months postoperatively.

Note. CI = confidence interval.

ROM

Two trials comprising 80 patients reported on ROM at 2 to 3 weeks postoperatively (38 in the immediate mobilization group and 42 in the immobilization group), 3 trials comprising 196 patients reported on ROM at 6 weeks and 3 months postoperatively (94 in the immediate mobilization group and 102 in the immobilization group), and 2 trials comprising 152 patients reported on ROM at 2 to 3 weeks postoperatively (73 in the immediate mobilization group and 79 in the immobilization group). No difference was seen between the 2 groups in FE at 2 to 3 weeks (MD = 4.89; 95% CI: −5.88 to 15.67, P = .37, Figure 5a), FE at 6 weeks (MD = 15.33; 95% CI: −8.32 to 38.97, P = .20, Figure 5b), FE at 3 months (MD = −5.94; 95% CI: −13.70 to 25.59, P = .55, Figure 5c), and FE at 6 months (MD = 16.93; 95% CI: −1.78 to 35.64, P = .08, Figure 5d). Furthermore, no difference was seen between the 2 groups in forearm rotation at 2 to 3 weeks (MD = 2.21; 95% CI: −16.29 to 20.72, P = .81, Figure 6a), forearm rotation at 6 weeks (MD = 4.52; 95% CI: −18.58 to 27.61, P = .70, Figure 6b), forearm rotation at 3 months (MD = 4.61; 95% CI: −6.45 to 15.67, P = .41, Figure 6c). However, the immediate mobilization had better forearm rotation at 6 months (MD = 3.43; 95% CI: 1.08-5.79, P = .004, Figure 6d).

Figure 5.

(a) Forest plot showing the difference in flexion extension at 2 to 3 weeks postoperatively. (b) Forest plot showing the difference in flexion extension at 6 weeks postoperatively. (c) Forest plot showing the difference in flexion extension at 3 months postoperatively. (d) Forest plot showing the difference in flexion extension at 6 months postoperatively.

Note. CI = confidence interval.

Figure 6.

(a) Forest plot showing the difference in rotation at 2 to 3 weeks postoperatively. (b) Forest plot showing the difference in rotation at 6 weeks postoperatively. (c) Forest plot showing the difference in rotation at 3 months postoperatively. (d) Forest plot showing the difference in rotation at 6 months postoperatively.

Note. CI = confidence interval.

Discussion

With the high prevalence of DRFs and the absent consensus regarding the postoperative course, a meta-analysis of RCTs is needed. The present meta-analysis of level I evidence found no difference in adverse events and early PROMs and ROM. However, the immediate mobilization group had lower pain at 6 months, lower disability at 3 and 6 months, and better rotation at 6 months.

No difference was observed in complications and reoperations between the 2 groups. Despite the previously perceived risk of fracture displacement with early mobilization, none of the included studies were able to demonstrate this outcome. In fact, only 2 cases of reduction loss were noted in the immediate mobilization group, compared with one case in the immobilization group. Furthermore, in a survey of fellowship-trained hand surgeons, only 3.9% did not perform immobilization, and only 8.1% initiated postoperative ROM exercises immediately, due to concerns about fixation stability and fear of fracture displacement over time. ²⁵ Thus, there is hesitation in implementing early rehabilitation and immediate mobilization as standard care following DRF ORIF.

As for PROMs, the differences started to appear around 3 and 6 months. The early mobilization group was favored around that period, showing reduced pain and disability. This finding could be explained by the lower stiffness experience in the immediate mobilization group, reducing swelling, edema, and scar tissue and pain in addition to allowing patients an earlier return to daily activities which could reduce the experienced disability. Other studies examining the impact of immobilization over a short period of time revealed improved ROM and decreased pain in the early functional rehabilitation group with comparable radiographic outcomes, highlighting the idea of successful volar locking plate osteosynthesis and the needless long postoperative immobilization. ²⁶ Furthermore, the reduced stiffness in the immediate mobilization group could lead to improved ROM. This was shown in our results, demonstrating a better rotation in the immediate mobilization group at 6 months postoperatively. However, one should note that the only improvement in ROM in the immediate mobilization group was seen in forearm rotation at 6 months.

Strengths and Limitations

The present study has several limitations. As a meta-analysis, findings depend on the variables examined by the studies meeting inclusion criteria. In addition, there was a high heterogeneity in some of the performed analyses, especially in the ROM. This may be due to the difference in the immobilization protocols. However, this was accounted for by using a random-effects model. Furthermore, the results of this meta-analysis are pooled, as granular data was not available, which precludes performing subgroup analysis based on demographics such as age. Furthermore, some types of fractures might make patients more suitable for immediate mobilization than others. Nevertheless, the included studies were RCTs which reduces this potential selection bias. In addition, one of the 4 included studies had their patients in the immediate mobilization group in a removable splint for only 1 week. Nevertheless, these patients had wrist mobilization on the first day after surgery, making them qualify to being in the immediate mobilization group. Finally, the low number of included trials in this meta-analysis may render it to be under-powered to find a difference in some of the analyzed outcomes. However, one must note that we only included RCTs to offer the best level of evidence, and outcomes in which the difference did not reach statistical significance tended to be in favor of the immediate mobilization group.

Conclusion

The present meta-analysis of RCTs showed that patients undergoing immediate mobilization after DRF ORIF had better PROMs and comparable radiographic outcomes compared with patients undergoing postoperative immobilization. Furthermore, patients in the immediate mobilization group had better rotation at 6 months postoperatively. The present study suggests that immediate mobilization after ORIF for DRF has some benefits over postoperative immobilization.