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. 2025 Oct 28;6(10):1330–1342. doi: 10.1302/2633-1462.610.BJO-2025-0098.R1

Operative management of displaced fractures of the distal radius is associated with improved function but not in older adults

systematic review and meta-analysis of randomized controlled trials

Katrina R Bell 1, William M Oliver 1, Timothy O White 1, Samuel G Molyneux 1, Nicholas D Clement 1, Andrew D Duckworth 1,2,✉
PMCID: PMC12560059  PMID: 41147259

Abstract

Aims

This systematic review and meta-analysis aimed to compare the patient-reported outcomes of operative and nonoperative management in adults with a fracture of the distal radius, with a focus on the outcomes in older patients (aged ≥ 65 years).

Methods

Randomized controlled trials comparing operative and nonoperative management of patients aged ≥ 18 years with dorsally displaced distal radius fractures were included. Operative management included open reduction and internal fixation (ORIF), manipulation and Kirschner-wiring, or external fixation. Nonoperative management included cast/splint immobilization with or without closed reduction. Primary outcome was the 12-month Patient-Rated Wrist Evaluation (PRWE). Additional outcomes included the Disabilities of Arm, Shoulder and Hand (DASH), pain, complications, and radiological parameters. A sub-group analysis was undertaken for studies that reported outcomes in older adults (aged ≥ 65 years).

Results

After screening 1,635 studies, 19 trials with 2,178 patients (mean age 63 years (18 to 98), 74% female) were included. Seven studies reported outcomes in older patients (n = 773). There were statistical but not clinically significant differences favouring surgery for PRWE at three months (mean difference (MD) -8.70, 95% CI -14.45 to -2.95; p = 0.003) and 12 months (MD -2.96, 95% CI -5.15 to -0.77; p = 0.008). There was a statistical but not clinically significant difference in DASH at three months (MD -10.58, 95% CI -13.15 to -8.01; p < 0.00001) and 12 months (MD -4.17, 95% CI -6.05 to -2.30; p < 0.001) favouring surgery. There was no difference in complications (odds ratio (OR) 0.95, 95% CI 0.52 to 1.76; p = 0.880). For older adults, there was no difference in the PRWE at three months (MD -8.53, 95% CI -18.13 to 1.07; p = 0.080) or 12 months (MD -2.13, 95% CI -4.60 to 0.33; p = 0.090), with no difference in complications (OR 0.73, 95% CI 0.21 to 2.49; p = 0.620).

Conclusion

Operative management of adult dorsally displaced distal radius fractures was associated with superior functional outcomes according to the PRWE and DASH, but whether these are clinically meaningful is debatable. However, in older adults there was no significant or clinically meaningful benefit of surgery.

Cite this article: Bone Jt Open 2025;6(10):1330–1342.

Keywords: Meta-analysis; Systematic review; Distal radius fracture; Elderly; Surgery; Non-operative; Fractures of the distal radius; Disabilities of the Arm, Shoulder and Hand (DASH); Wrist; Nonoperative management; open reduction and internal fixation (ORIF); patient-reported outcome measures; functional outcomes; external fixation; immobilization; Kirschner-wiring

Introduction

Fractures of the distal radius are the most common fracture presenting to orthopaedic services1 and with an ageing population the numbers are predicted to increase over the next two decades.2 There is a bimodal distribution in the incidence, with peaks occurring in younger males and older females.1-3 For dorsally displaced fractures, nonoperative management consists of cast or splint immobilization with or without closed reduction. There are a number of operative techniques including open reduction and internal fixation (ORIF) with volar locked plating (VLP), percutaneous Kirschner (K-) wire fixation, and external fixation, with the use of VLP fixation rising in recent decades.3-5

The operative indications for dorsally displaced fractures of the distal radius remain controversial, particularly in older patients where the functional consequences of malunion are debated. As the evidence from randomized controlled trials (RCTs) grows, there is an increasing amount of work synthesizing these data together in the form of meta-analyses.6-20 However, there is significant heterogeneity in terms of the patients and studies included, as well as the methodology used. Some reviews, despite having been carried out recently, include data from prospective cohort or retrospective studies.21-26

When considering systematic reviews focusing on the outcomes in the older adults, a small number have included level one evidence only.8-10,12,18 However, all of these studies used the age cut-off of 60 years and older, despite 65 years being conventionally used to define ‘elderly’,27 and the fact that the mean age of fractures of the distal radius was recently reported from registry data as 63 years.28 Hustedt et al19 included patients of all ages, although used meta-regression to examine the moderating effects of age. Due to changes in health and life expectancy, whether the age threshold of ≥ 65 years and older should be increased or an alternative definition for older adults be used is unknown.29 Only Ju et al25 used an aged ≥ 65 years; however, they included retrospective studies. The review by Jayaram et al20 looked at ‘older adults’ but defined this as those aged ≥ 50 years. To our knowledge, this review is the first to use exclusively level one studies, employ an age threshold of ≥ 65 years to define older adults, and include several recent level one studies that were not part of previously published reviews.30,31

The aim of this systematic review and meta-analysis was to compare the outcomes of operative and nonoperative management at 12 months following a dorsally displaced fracture of the distal radius using the Patient-Rated Wrist Evaluation (PRWE).32 Additional aims were to compare the PRWE at three months, as well as the Disabilities of Arm, Shoulder and Hand (DASH) score33 and/or the abbreviated DASH (QuickDASH), grip strength, range of motion (ROM), complications, and radiological parameters at three months and 12 months. A sub-group analysis of outcomes in older adult patients (aged ≥ 65 years) was also undertaken while acknowledging that the definition of this would vary between studies.

Methods

This review was prospectively registered with PROSPERO International Prospective Register of Systematic Reviews on 14 December 2020 (CRD42020226077).34 It is reported according to the PRISMA guideline.35

Selection criteria

Randomized controlled studies involving human patients aged 18 years and older with a fracture of the distal radius that was either closed or Gustilo grade I open were included. Those including volar displaced fractures were excluded. Both published and non-published studies were considered, provided they were available in English. Studies were to compare at least one form of operative intervention with one form of nonoperative management. Operative management could include ORIF, manipulation and K-wiring, or a form of external fixation. Nonoperative management was in the form of either a cast or splint immobilization, with or without prior closed reduction. Provided that studies reported on at least one of the outcome measures being assessed, they were eligible for inclusion.

Search strategy

An online search was carried out in March 2021, and was then repeated in March 2022 and January 2024. Studies available in English were included. Searches were performed using MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, International Clinical Trials Registry Platform (ISRCTN), and OpenGrey (the system for information on grey literature in Europe).

Study selection

A combined search of MEDLINE and EMBASE produced 1,210 results. A search of CINAHL produced 448 results, PubMed 541 results, CENTRAL 288 results, ClinicalTrials.gov 200 results, ISRCTN 79 results, and OpenGrey 78 results. The searches were imported into the Covidence systematic review software (Veritas Health Innovation, Australia)36 to exclude duplicates and facilitate screening. Two reviewers (KRB, WMO) carried out the abstract screening and full-text reviews, blinded to the decisions of the other. A third more senior reviewer (ADD) resolved any conflicts that arose. Reference lists of included studies were examined but no additional trials were identified.

Data extraction

Included studies were examined and the title, lead author contact details, county of origin, aims, start and end date, funding sources, possible conflicts of interest, population description, inclusion/exclusion criteria, and number or participants was recorded. Patient age, sex, and AO/OTA fracture classification37 were also recorded. Details regarding the sub-grouping of older adult patients and how this was defined was noted.

Quality assessment

Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2)38 was used to assess the studies with regard to randomization (both sequence generation and allocation concealment), blinding of participants and personnel, blinding of outcomes assessment, incomplete outcome data, and selective reporting. Other sources of bias were also considered, including whether studies were registered with an international registry, had published their protocol, had any crossovers between groups, and whether the analysis was per protocol, intention to treat or both. Risk of bias was assessed by two reviewers (KRB, WMO), scoring each study as low, high, or unsure for each domain. A consensus was reached by a third reviewer (ADD).

Outcome assessment

The joint-specific PRWE is scored from 0 to 100, with lower scores equating to a better outcome.39 Wrist pain and function assessed by the PRWE score at 12 months was selected as the primary outcome, with the score at three months also included in the meta-analysis. The limb-specific DASH and QuickDASH are scored similarly, and scores at both three and 12 months were included. The minimal clinically important difference (MCID) is the smallest difference in score resulting in what patients feel to be an appreciable change.40 For the PRWE, this is reported to be 11.5 for distal radius fractures,41,42 and for the DASH is 10.83.43 Other outcomes included grip strength in kg (MCID 6.5 kg)44 at three months and 12 months, ROM (in degrees) at three and 12 months, pain (measured using a visual analogue scale (VAS), 0 to 100 with zero being no pain) at three and 12 months, complications at 12 months, and radiological parameters at three months.

Statistical analysis

Meta-analysis was performed using Review Manager (RevMan) v. 5.4.1 (The Cochrane Collaboration, UK). The PRWE, DASH, QuickDASH, grip strength, ROM, pain, complications, and radiological measurements were assessed using inverse variance. For all outcomes except complications, the mean difference was presented as the effect measure using 95% CIs. For complications, odds ratio (OR) was used. The chi-squared test and I² were used to assess heterogeneity among studies. Due to clinical variability and effect sizes between the studies, random effects models were employed to assess to influence on the outcome measures. A planned analysis of a sub-group of older adult patients was carried out, using an age threshold of ≥ 65 years to define this group.

A p-value < 0.05 was considered statistically significant in cases in which trials had no event in one arm or another. Missing data were not entered for meta-analysis. Attempts were made to convert data to a format that could be incorporated into meta-analysis when this was feasible. When mean and SD were not available they were calculated using the third method described by Wan et al,45 selected due to its performance with skewed data. The method described by Hozo et al46 was used when IQR was not available. The Cochrane Handbook was also consulted to aid with the conversion of published outcomes to values that could be incorporated into the meta-analysis.47

Results

Patients and studies

After screening 1,635 studies, 35 studies were eligible for inclusion, reporting on at least one outcome of interest. However, due to the use of combined scoring systems, only 19 trials with 2,178 patients (mean age 63 years (18 to 98), 74% female (n = 1,624)) were included in the meta-analysis (Figure 1). Seven of these studies reported on older adults aged 65 years and above (n = 773, 67% female).48-54 Of the 12 studies to report AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification (1,168 patients), 45% of fractures were type A (n = 520) and the remainder type C (n = 648). Most trials studied volar plate fixation as the mode of operative management (Table I). Azzopardi et al,55 Costa et al,56 and Wong et al54 used closed reduction and K-wire fixation. Hegeman et al,57 Kreder et al,58 and Merchan et al59 used bridging external fixation.

Fig. 1.

PRSIMA flowchart showing study selection for a systematic review: 2,844 records identified, 1,635 screened, 89 assessed for eligibility, 35 included in the review, and 19 in the meta-analysis. PRISMA flowchart illustrating the study selection process for a systematic review and meta-analysis. It begins with 2,844 records identified from seven databases and registers. After removing duplicates (1,209 total), 1,635 records were screened. Of these, 1,546 were excluded, and 89 reports were assessed for eligibility. Overall, 54 reports were excluded for reasons such as wrong study design, population, or intervention. Ultimately, 35 studies were included in the review, and 19 in the meta-analysis.

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PRISMA flow diagram. CENTRAL, Cochrane Central Register of Controlled Trials; CINAHL, Cumulative Index to Nursing and Allied Health Literature; ISRCTN, International Clinical Trials Registry Platform.

Table I.

Summary of studies included in meta-analysis.

Study Mean age, yrs
(op/non-op)		 Inclusion age, yrs, range Female,% (op/non-op) Patients, n (op/non-op) Operative intervention Nonoperative intervention Outcomes Time points, wks
Ahmed 202360 42.7/41.6 18 to 65 73/65 96 (30/66) ORIF with VLP, removable wrist splint Closed reduction and ‘U’ splint application for six wks, one repeat manipulation if needed within first three wks DASH 12
Arora 201148 75.9/77.4 ≥ 65 38.4/37.0 73 (36/37) ORIF with VLP, below-elbow cast for 10 days followed by removable splint for 7 days Closed reduction and casting (short arm cast in neutral position for 5 wks), no re-manipulation P: PRWE (no timepoint specified)
S: ROM, grip power, wrist pain, DASH, wrist deformity, wrist appearance, satisfaction		 6, 12, 26, 52
Azzopardi 200555 72/71 ≥ 60 85/93 54 (27/27) Closed reduction then fixed using 2 K-wires, well-moulded short arm cast for 5 wks Closed reduction under fluoroscopic guidance and casting (well-moulded, short arm cast for 5 wks) Functional assessment, ROM, grip strength, activities of daily living assessment, pain, SF-36,61 radiological assessment 1, 2, 5, 16, 52
Bartl 201449 75.3/74.4 ≥ 65 90/86 174 (86/88) ORIF with VLP Closed reduction and casting (dorsoradial plaster cast followed by closed forearm cast for 6 wks) P: SF-36 PCS
S: DASH, EQ-5D, ROM, radiological assessment		 12, 52
Costa 202262 60.7/59.6 ≥ 16 84/83 500 (255/245) Closed reduction and K-wire fixation, cast for 6 wks Closed reduction and casting (moulded below-elbow cast for 6 wks) P: PRWE at 52 wks
S: PRWE at 12 and 26 wks, EQ-5D-3L at 12, 26 and 52 wks, complications at 52 wks, cost-effectiveness		 12, 26, 52
Dehghani 202231 37.7/33.7 18 to 55 36/44 50 (25/25) ORIF with VLP, long-arm splint in neutral for 2 wks Closed reduction and casting (long-arm cast with three-point moulding for 6 wks) ROM, DASH, pain, grip strength 12, 36, 52, 104
Hassellund 202150 73.4/73.9 ≥ 65 94/84 100 (50/50) ORIF with VLP, dorsal splint for 2 wks Unacceptable closed reduction or re-displacement in the 20 days following this, below elbow cast for 5 to 6 wks P: QuickDASH at 52 wks
S: PRWE, EQ-5D-5L, EQ-VAS, satisfaction, ROM, grip strength, adverse events, complications		 12, 26, 52
Hegeman 200457 71/69 55 to 80 87/94 32 (15/17) Reduction and bridging external fixation for 6 wks Closed reduction and casting (below elbow plaster for 6 wks) Radiological outcome, ROM, grip strength, Gartland and Werley score 6, 12, 52
Kreder 200658 52.4/53.4 16 to 75 63/68 103 (54/59) Closed reduction and bridging external fixation for 6 to 8 wks, additional K-wires at surgeon’s discretion Closed reduction under fluoroscopic guidance and casting (long arm splint, then long arm cast within 14 days followed by short arm cast at 3 to 4 wks removed at 6 to 8 wks) P: Musculoskeletal Function Assessment, SF-36
S: Jebsen Taylor hand function test,
grip strength, pinch strengths, ROM, radiological assessment		 6, 26, 52, 104
Lawson 202163 70.5/71/3 ≥ 60 86/88 166 (81/85) ORIF with VLP, plaster splint for up to 2 wks Closed reduction and casting (for 6 wks) P: PRWE at 52 wks
S: PRWE at 12 wks, DASH at 52 wks, EQ-5D-5L at 12 and 52 wks, wrist pain at 12 and 52 wks, treatment success at 12 and 52 wks, patient-rated bother at 12 and 52 wks, complications at 12 to 52 wks, radiological assessment		 12, 26, 52
Merchan 199259 37/35 20 to 45 20/14 70 (35/35) Reduction and dynamic bridging external fixation for 7 weeks, additional K-wires and plaster casting if unstable reduction Closed reduction and casting (split forearm cast), re-manipulation possible Radiological assessment, functional assessment 1, 3, 7, 52
Mulders 201964 55.67/59 18 to 75 66/84 90 (47/43) ORIF with VLP Closed reduction and casting (dorsal splint changed to circular Plaster of Paris after minimum 1 wk for 4 to 5 wks) P: DASH score at 52 wks
S: PRWE, SF-36, ROM, grip strength, radiological assessment, complications		 1, 3, 6, 12, 26,52
Saving 201951 80/81 ≥ 70 (≥ 75 at one centre) 95/ 8 122 (58/64) ORIF with VLP, dorsal plaster splint for 2 wks Closed reduction and casting (dorsal or dorsoradial short-arm plaster splint for 4 to 5 wks) P: PRWE at one site and DASH at second site
S: EQ-5D, ROM, grip strength, radiological assessment, complications		 12, 52
Selles 202165 59/59.67 18 to 75 82/87 90 (44/46) ORIF with VLP Closed reduction and casting (4 to 5 wks) P: PRWE
S: DASH, SF-36, pain, ROM, grip strength, radiological outcomes, complications		 6, 12, 26, 52
Sharma 201466 52.39/48.1 25 to 55 63/56 64 (32/32) ORIF with VLP, plaster splint (below- elbow wrist brace) for 1 wk Closed reduction under C-arm guidance and casting (above elbow Plaster of Paris for 4 wks) ROM, grip strength, radiological assessment, Gartland and Werley (modified by Sarmiento), DASH 6, 12, 26, 52, 78, 104
Sirniö 201967 62/64 ≥ 50 97/93 80 (38/42) ORIF with VLP, dorsal plaster cast for 10 days Closed reduction and casting (below-elbow cast for 6 wks, ORIF offered if re-displaced) P: DASH at 104 wks
S: ROM, grip strength, subjective assessment of wrist function, radiological assessment, complication, reoperation rate		 12, 26, 52, 104
Tahir 202152 81/81 ≥ 75 18/24 159 (87/72) ORIF with VLP Closed reduction and casting (dorsal splint for minimum 10 days then complete plaster for 4 to 5 wks) P: PRWE at 52 wks
S: SF-12,68 QuickDASH, Mayo wrist score, ROM, grip strength, adverse events, radiological outcome		 1, 3, 6, 12, 26, 52
Thorninger 202253 75/75 ≥ 65 82/80 85 (43/42) ORIF with VLP, dorsal plaster cast for 2 wks then removable orthosis for 3 wks Closed reduction and casting (dorsal plaster cast 5 wks) P: complication rate at 52 wks
S: QuickDASH, pain, PRWHE, ROM, grip		 2, 5, 26, 52
Wong 201054 70/71 ≥ 65 80/83 60 (30/30) Closed reduction and fixation with 3 K-wires, no plaster cast but removable palmar splint. Wires removed at 6 wks Closed reduction and casting (three-point moulded Plaster of Paris for 6 wks) Functional assessment, ROM, grip strength, Mayo wrist score, subjective satisfaction score, World Health Organization Quality of Life (WHOQoL) questionnaire, radiological assessment 1, 2, 4, 6, 12, 26, 52
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DASH, Disabilities of the Arm, Shoulder and Hand; EQ-5D-3L, EuroQol five-dimension three-level questionnaire; EQ-5D-5L, EuroQol five-dimension five-level questionnaire; EQ-VAS, EuroQol visual analogue scale; K-wire, Kirschner wire; non-op, nonoperative management; Op, operative management; ORIF, open reduction and internal fixation; P, primary outcome measure; PRWE, Patient-Rated Wrist Evaluation; ROM, range of motion; S, secondary outcome measures; SF-36 MCS, 36-Item Short-Form Health Survey questionnaire Mental Component Score; SF-36 PCS, 36-Item Short-Form Health Survey questionnaire Physical Component Score; VLP, volar locked plating.

Risk of bias in included studies

Of the 19 studies included in the meta-analysis, a number had a high48,66,69 or unclear51,54,57,60 risk of selection bias with regards randomization sequence generation. Two studies had a high risk of bias in allocation concealment59,66 and it was unclear in three.48,49,57 Blinding of participants and personnel was not possible due to the nature of the interventions so this was an issue for all studies. Lawson et al,63 Wong et al,54 and Thorninger et al53 were the only studies to blind outcome assessment, with the use of telephone assessment, a bandage covering the patients’ wrist, and a glow to conceal scars respectively, thus minimizing detection bias. There was a high risk of bias relating to incomplete outcome data in seven studies49,52,54,55,59,60,66 and unclear in three.31,57,70 Selective reporting was felt to be at a high risk of bias in eight studies.52,54,55,57,59,60,66,70 Other sources of bias identified included a lack of central trial registration, lack of protocol publication, unclear methods of data analysis (whether intention-to-treat or per protocol), and a high numbers of crossovers between treatment arms (see Supplementary Material).

PRWE

Eight studies reported the PRWE at three and 12 months,48,50-52,62-65 with the addition of Thorninger et al53 reporting at 12 months. There was a statistical but not clinically significant difference in PRWE score at three months (MD -8.70, 95% CI -14.45 to -2.95; p = 0.003; Figure 2A) and 12 months (MD -2.96, 95% CI -5.15 to -0.77; p = 0.008; Figure 2B) when taken in the context of the MCID. Four of these studies reported on PRWE in older adults48,50-52 at both three and 12 months with the addition of a fifth reporting at 12 months.53 There was no clinically significant difference at three months (MD -8.53, 95% CI -18.13 to 1.07; p = 0.080; Figure 2C) or at 12 months (MD -2.13, 95% CI -4.60 to 0.33; p = 0.090; Figure 2D).

Fig. 2.

Figure showing four forest plots for the PRWE score, comparing operative vs non-operative treatments across multiple studies. Each plot displays mean differences with 95% confidence intervals and overall effect sizes, along with heterogeneity statistics. Figure with four forest plots for the patient-rated wrist evaluation (PRWE) score, comparing outcomes of operative versus non-operative treatments across multiple studies. Each plot displays individual study estimates with mean differences and 95% confidence intervals, along with pooled effect sizes and heterogeneity statistics. Plot A includes seven studies (n = 346 operative, n = 347 non-operative) with high heterogeneity (I² = 86%) and a significant overall effect (Z = -8.70). Plot B includes nine studies (n = 629 per group), showing moderate heterogeneity (I² = 48%) and a significant effect (Z = -2.96). Plot C includes four studies (n = 218 per group), with high heterogeneity (I² = 88%) and a strong effect (Z = -8.53). Plot D includes four studies (n = 269 per group), with low heterogeneity (I² = 42%) and a less conclusive effect (Z = -21).

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A) Forest plot for the patient-rated wrist evaluation (PRWE) score at three months (all patients). B) Forest plot for the PRWE score at 12 months (all patients). C) Forest plot for the PRWE score at three months (older adults). D) Forest plot for the PRWE score at 12 months (older adults). df, degrees of freedom; IV, weighted mean difference.

DASH

Analyzing the results from the six studies which reported on the DASH score at three months, there was a statistical difference at three months favouring operative management (MD -10.58, 95% CI -13.15 to -8.01; p < 0.00001; Figure 3A).31,48,49,60,64,65 This persisted at 12 months (MD -4.17, 95% CI -6.05 to -2.30; p < 0.001; Figure 3B), but did not reach the MCID.31,48,49,64,65,71 Two trials reported on the outcome in older adult patients,48,49 with a statistically, but not clinically, significant difference at three months favouring operative management (MD -7.07, 95% CI -11.77 to -2.37; p = 0.003; Figure 3C), but with no difference at 12 months (MD -3.32, 95% CI -7.03 to 0.38; p = 0.080; Figure 3D).

Fig. 3.

Figure with four forest plots for the DASH score at threee months, comparing operative vs non-operative treatments across studies. Each plot shows mean differences with 95% confidence intervals, study weights, and heterogeneity statistics. Figure with four forest plots for the Disabilities of the Arm, Shoulder and Hand (DASH) score, comparing outcomes of operative versus non-operative treatments across multiple studies. Each plot includes columns for study name, mean, standard deviation, and total participants in both groups, along with the weight of each study and the mean difference with 95% confidence intervals. The right side of each plot visually represents the mean differences. Plot A includes studies such as Arora (2011) and Bartl (2014), showing individual and pooled estimates. Each plot also reports heterogeneity statistics (Tau², Chi², I²) and overall effect tests (Z-score and p-value), summarizing the comparative effectiveness of treatments.

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A) Forest plot for the Disabilities of the Arm, Shoulder and Hand (DASH) score at three months (all patients). B) Forest plot for the DASH score at 12 months (all patients). C) Forest plot for the DASH score at three months (older adults). D) Forest plot for the DASH score at 12 months (older adults). df, degrees of freedom; IV, weighted mean difference.

QuickDASH

In terms of the QuickDASH, both studies reporting at three and 12 months only included older adult patients.50,52 Again, there was a statistical but not clinically significant difference at three months (MD -4.66, 95% CI -7.77 to -1.56; p = 0.003; Figure 4A) with neither at 12 months (MD -0.76, 95% CI -4.65 to 3.13; p = 0.700; Figure 4B).

Fig. 4.

Two forest plots for the QuickDASH score at three months, comparing operative vs non-operative treatments across two studies. Each plot shows mean differences with 95% confidence intervals, study weights, and heterogeneity statistic Figure with two forest plots for the abbreviated Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, comparing outcomes of operative versus non-operative treatments across two studies: Hassellund (2021) and Tahir (2021). Each plot presents mean, standard deviation, and total participants per group, along with study weights and mean differences with 95% confidence intervals. Plot A shows a pooled mean difference of -4.66 with low heterogeneity (I² = 0%) and a significant overall effect (Z = -2.94, p = .003), while Plot B shows a pooled mean difference with high heterogeneity (I² = 85%) and a less conclusive overall effect (Z = 38, p = 0.70).

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A) Forest plot for the abbreviated Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) score at three months. B) Forest plot for the QuickDASH score at 12 months. df, degrees of freedom; IV, weighted mean difference.

Grip strength

There was an early difference in terms of improved grip strength (kg) favouring operative management based on the findings of the three studies that reported on this outcome at three months (MD 2.80, 95% CI 1.30 to 4.30; p = 0.0003; Supplementary Material).31,48,67 However, this did not reach clinical significance. This trend persisted based on the findings of seven studies who reported on grip strength at 12 months (MD 1.49, 95% CI 0.22 to 2.75; p = 0.020).31,48,53,54,64,65,67 When considering just older adult patients, only one study reported on this at three months.48 At 12 months there was no statistically significant difference (MD 1.60, 95% CI -0.61 to 3.81; p = 0.160).48,53,54

Range of motion

At three months, wrist flexion in patients of all ages (MD 4.53, 95% CI 0.62 to 8.43; p = 0.020) was superior in the operatively managed group, but wrist extension in older adults (MD -2.03, 95% CI -3.57 to -0.48; p = 0.010) was superior in the non-operatively managed group (Supplementary Material). At 12 months, surgery resulted in better wrist flexion (MD 4.87, 95% CI 1.34 to 8.40; p = 0.007) and supination (MD 1.93, 95% CI 0.45 to 3.40; p = 0.010). The clinical significance of these differences is unclear.

Pain

There was no significant difference in pain scores (scored 0 to 100, with 0 being no pain) at three months (MD -5.96, 95% CI -15.49 to 3.57; p = 0.220; Figure 5A)31,48,49,63 nor at 12 months (MD -4.20, 95% CI -9.53 to 1.14; p = 0.120; Figure 5B).31,48,49,55,63 When considering just older adult patients, there remained no significant difference in pain scores at either timepoint (at three months, MD -0.31, 95% CI -3.12 to 2.51; p = 0.830; 12 months, MD -0.60, 95% CI -2.95 to 1.75; p = 0.620).48,49

Fig. 5.

Two forest plots for pain score, comparing operative vs non-operative treatments across two studies, showing mean differences and confidence intervals. Figure with two forest plots for pain score, comparing operative versus non-operative treatments across multiple studies. Each plot lists studies with their means, standard deviations, sample sizes, weights, and standardized mean differences with 95% confidence intervals. Plot A includes studies such as Arora (2011), Bartl (2014), Lawson (2021) and Dehghani (2022), showing a pooled standardized mean difference of -5.96 with high heterogeneity (I² = 94%). Plot B includes five studies with a pooled effect size and high heterogeneity (I² = 83%). Both plots visually represent individual and overall effect sizes.

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A) Forest plot of pain score for four studies at three months. B) Forest plot of pain score for five at 12 months. df, degrees of freedom; IV, weighted mean difference.

Complications

There was no difference in complications at 12 months between the groups (OR 0.95, 95% CI 0.52 to 1.76; p = 0.880; Figure 6).30,48-52,54,55,57-60,62-66,70 Due to differences in the complications included, it was not possible to compare at individual complication level. Six studies reported on the complication rate at 12 months in older adult patients48-52,54 and there was no significant difference found (OR 0.73, 95% CI 0.21 to 2.49; p = 0.620).

Fig. 6.

Forest plot for complications at 12 months, showing odds ratios for operative versus non-operative treatments across studies, with some data not estimable and confidence intervals displayed graphically. Forest plot for complications at 12 months, comparing odds ratios of operative versus non-operative treatments across multiple studies. The table includes study names, number of events and total participants in each group, study weights, and odds ratios with 95% confidence intervals. Some studies are marked as "not estimable" due to missing data. The right side of the plot visually displays the odds ratios and confidence intervals. Overall effect and heterogeneity statistics are listed at the bottom.

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Forest plot for complications at 12 months (all patients). df, degrees of freedom; IV, weighted mean difference.

Radiological

Operative management was associated with improved restoration of radial inclination at three months when including all ages49,51,52,54,57 (MD 3.58, 95% CI 1.46 to 5.69; p = 0.0009) and also for the older adult sub-group49,51,52,54 (MD 3.48, 95% CI 1.30 to 5.65; p = 0.002; Supplementary Material). Studies reporting on dorsal angulation in older adults found that surgery resulted in significantly less dorsal angulation (MD -12.74, 95% CI -24.49 to 1.00; p = 0.030).50,51,54

Discussion

This systematic review and meta-analysis examining 19 trials and including 2,178 adult patients with a dorsally displaced fracture of the distal radius has found that operative management was associated with superior outcomes according to the PRWE and DASH scores, but whether these are clinically meaningful is debatable. Surgery was also associated with improved ROM (flexion and supination) and restoration of radial inclination, but no differences in pain scores were found. However, in older adult patients, there was no significant or clinically relevant differences in functional outcomes, ROM, or pain between the two interventions at one year, but not unsurprisingly those undergoing operative management had improved restoration of radiological inclination and dorsal angulation.

Two previous meta-analyses examining level one evidence for all age groups reached a similar conclusion to the current review, demonstrating a significant functional benefit with operative management.11,14 Four reviews considered level one evidence in those aged 60 years and older, with three finding significantly better functional outcomes with operative management, acknowledging that these did not reach a clinically significance difference,9,10,18 and one finding no significant difference.12 However, some reviews in patients of all ages did conclude that surgical management yielded superior outcomes, although without consideration of the MCID.6,13 Despite these and the current review demonstrating a statistically significant difference at three and 12 months for the PRWE and DASH, the observed differences were less than the MCID and therefore may not be clinically meaningful. The greatest differences were observed at three months, which approached the MCID but did not exceed it, but by 12 months the differences were less than 30% of the MCID. It could be concluded that operative management is associated with some early functional benefit but by 12 months these are not likely to be clinically meaningful. This is consistent with the findings in relation to pain with no significant differences in scores being observed at either timepoint, in accordance with the conclusions of Zhang et al10 and Yang et al.16 Again, there is no MCID for pain and it is incorporated into the PRWE, DASH, and QuickDASH scores.

Operative management conferred improved ROM at three months for wrist flexion, along with better wrist flexion and supination at 12 months. Pre-existing systematic reviews have drawn mixed conclusions, with Stephens et al9 finding better supination in the operative group, Yu et al17 better pronation, and Chen et al6 and Lawson et al11 all planes of movement. Conversely, a number of reviews found no significant differences.7,10,12,16,18 The clinical significance of a difference in aspects of ROM is difficult to ascertain, as there is no MCID and their correlation with function is unclear. However, as the observed wrist-specific functional outcome was not greater than the MCID at three or 12 months, the observed difference in RoM is not likely to be clinically meaningful.

Grip strength was associated with superior outcomes following operative management, although this did not reach the threshold of clinical significance. However, reviews by Zhang et al10 and Shen et al8 did find what they deemed to be a significant benefit, although the clinical significance of this is not explored. Grip strength is related to age, peaking at 35 to 39 years for men and 40 to 44 years for women,72 and is also a biomarker of frailty.73,74 This may in part explain why a significant difference, which may not be clinically meaningful, was observed when including all age groups but no difference was found in the older adult sub-group.

As might be expected, some reviews reported a higher rate of complications in the operative group.6,16 However, this was not observed in this analysis, which is supported by others.7,8,14 A number of included trials reported fracture displacement as a nonoperative complication, which potentially disproportionately influenced this outcome. Restoration of some radiological parameters were better in operatively managed fractures, something which has been observed in other reviews and is intuitive.7,11 This was observed in palmar tilt/inclination, radial inclination, and ulnar variance in both reviews, although was something this review only observed in radial inclination. However, consistent with the current literature, this does not seem to correlate with patient-reported outcomes.51,75-79

The strength of this review includes the addition of two level one studies which have recently published their findings that, to the authors’ knowledge, are not included in any pre-existing systematic review and meta-analysis. Additionally, in the older adult sub-group analysis, this study focuses only on data relating to patients aged 65 years and older, which is currently the most widely used definition of older adults/the elderly in the UK.

Limitations include the wide-ranging inclusion and exclusion criteria of the included studies, as well as only 12 of the 19 studies including a breakdown by AO/OTA type (A versus C), and only half of these (n = 6) including details of AO/OTA group. Although it was anticipated that the definition of ‘older adults’ or ‘elderly’ would vary between studies, none of the studies that included patients aged ≥ 65 years as part of a wider cohort of patients separately reported these results for older adults in the available materials published. It was thus not possible to include these sub-groups in the meta-analyses for older adults. The definition of fracture displacement, something which plays a considerable role in management decisions, also varied between studies, thus limiting the generalization of findings and their application in the clinical setting. There is also considerable heterogeneity in the outcome measures used to assess function in RCTs studying fractures of the distal radius, which makes integrating data as part of the meta-analysis a challenge. Mitigating this is the use of recommended patient-reported outcome measures by organizations such as the UK-based Health Research Authority.80 However, the MCID of outcomes reported here is key in interpreting the appreciable change to patients and although there were several statistically significant relationships found, these did not reach the threshold of clinical significance. Unfortunately, there is no agreed-upon MCID for ROM or for radiological parameters and with regard to the DASH, there are a range of MCIDs reported in the literature. Given this, we decided to utilize the 'minimal' value that may be clinically meaningful to a patient’s outcome. Finally, complication rates are variably reported. Some studies included loss of fracture position a complication in either group; however, as the ideology is shifting in the nonoperative group to tolerate radiological malunion, it could be said that this is not a complication in itself.

In conclusion, operative management was associated with significantly better functional outcomes according to the PRWE and DASH scores, but whether these are clinically meaningful is not clear. However, in the older adult sub-group there was no significant or clinically meaningful advantage associated with operative management.

Take home message

- Operative management was associated with significantly better functional outcomes according to the Patient-Rated Wrist Evaluation and Disabilities of Arm, Shoulder and Hand scores, but it remains unclear as to whether these are clinically meaningful.

- In the older adult sub-group, there was no significant or clinically meaningful advantage associated with operative management.

Author contributions

K. R. Bell: Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

W. M. Oliver: Data curation, Formal analysis, Investigation, Methodology, Writing – review & editing

T. O. White: Supervision, Writing – review & editing

S. G. Molyneux: Supervision, Writing – review & editing

N. D. Clement: Conceptualization, Supervision, Writing – original draft, Writing – review & editing

A. D. Duckworth: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

Funding statement

The author(s) received no financial or material support for the research, authorship, and/or publication of this article, other than the open access funding outlined below.

ICMJE COI statement

N. D. Clement is an editorial board member of The Bone & Joint Journal (BJJ) and Bone & Joint Research (BJR). A. D. Duckworth reports research grants from the National Institute for Health and Care Research (NIHR), Orthopaedic Trauma Association (OTA), and the Scottist Orthopaedic Research Trust into Trauma (SORT IT); book royalties from Taylor & Francis and Elsevier; payments for a hip fracture lecture from AgNovos Healthcare, as well as elbow courses from Swemac Medartis and Smith & Nephew; participation on a data Safety monitoring board or advisory board for the WHITE NIHR trials, AFTER NIHR trial, METEOR NIHR trial, ODDSOCKS NIHR trial, and HIPPY; he is also an editorial board member and specialty/associate editor for BJJ, BJR, Bone & Joint Open, and BJ360; associate editor for Trials, OTA Iternational, and JBJS Case Connector, a specialty editor for the Journal of Orthopaedic Trauma, and a member of the OTA Research Committee and the Orthopaedic Trauma Society Research Committee, all of which is unrelated to this work. S. G. Molyneux discloses unrelated support from Smith & Nephew for a presentation on periprosthetic hip fractures. T. O. White reports an educational grant from Smith & Nephew, and participation on a data safety monitoring board or advisory board for the FAME study, both of which are also unrelated.

Data sharing

The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.

Open access funding

The authors report that they received open access funding for this manuscript from Edinburgh Orthopaedics and NHS Lothian Charity.

Supplementary material

Tables showing risk of bias in studies included in the meta-analysis, range of motion, and radiological parameters. Figures showing risk of bias graph, forest plot for grip strength at three months (all patients), and forest plot for grip strength at 12 months (all patients).

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© 2025 Bell et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/

Data Availability

The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.

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