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. 2021 Feb 9;10(5):440–457. doi: 10.1055/s-0041-1723793

Interventions for Distal Radius Fractures: A Meta-analysis of Comparison Studies

Julia Beyer 1, Emily Wynkoop 1, Jiayong Liu 1,✉, Nabil A Ebraheim 1
PMCID: PMC8489996  PMID: 34631298

Abstract

Background  Distal radius fractures are one of the most frequent orthopaedic injuries. There are many effective treatment methods, such as volar plate, dorsal plate, percutaneous pins, external fixation, and casting; however, comparison of the treatment outcomes has not been thoroughly investigated. Our purpose is to determine if volar plating is the superior treatment method for distal radius fractures. We will address this through the following questions: First, is volar plating superior to dorsal plating, percutaneous pins, external fixation, or casting in terms of reported complications? Second, does volar plating produce superior functional outcomes to dorsal plating, percutaneous pins, external fixation, or casting? Third, are the radiographic outcomes superior for volar plating when compared with dorsal plating, percutaneous pins, external fixation, or casting?

Methods  MEDLINE, Academic Search Ultimate, Academic Search Complete, CINAHL Plus, and JSTOR databases, as well as manual search, were used to identify papers comparing complications and functional results of volar plating to other treatment methods for distal radius fractures published after the year 2000. Complication data and function scores were recorded. Risk of bias was assessed using the Cochrane Risk of Bias Tool and data was analyzed for meta-analysis using Cochrane ReviewManager software.

Results  Compared with dorsal plate, volar plate performed significantly better in Gartland and Werley score. Volar plating outperformed percutaneous pins for loss of reduction, infection, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and ulnar deviation. Loss of reduction, malunion, Patient Related Wrist Evaluation (PRWE) score, DASH score, grip strength, ulnar deviation, and supination were significantly better for volar plating when compared with casting. When compared with external fixation, volar plating had significantly less cases of infection, lower QuickDASH score, and higher range of motion for flexion, pronation, and supination. All other complication and functional outcomes were not significantly different.

Conclusions  Distal radius fractures treated with volar plating showed relatively better measures of complications, function scores, and range of motion than other treatment methods; however, there was no significant difference in healing time when compared with percutaneous pins. More studies are needed to compare the rest of the treatment methods with each other.

Keywords: distal radial fracture, volar or dorsal plate, percutaneous pins, external fixation, casting

Distal radius fractures are frequent orthopaedic injuries, comprising the most common upper extremity fracture. 1 2 3 4 5 6 There are many effective treatment methods, but little consensus on which volar plating is most successful. Volar plating is widely used because of its stability, early movement, and quick return to activity. 2 3 5 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Dorsal plating may be preferred for buttressing of comminuted fractures, but risks extensor tendon injury. 3 21 22 23 24 25 26 27 Percutaneous pins are a less invasive, cheaper surgical option, but may lack stability. 9 15 28 29 External fixation is another less invasive procedure and may be augmented with Kirschner-wires for added stability. 2 13 17 18 29 30 31 Casting is less costly and avoids surgical complications, but may not provide adequate reduction. 16 32

Several treatment methods for distal radius fractures have been proven effective, but none have emerged as a clear treatment of choice. Volar plating has gained popularity, 27 33 34 so we chose to compare volar plating to other methods to determine if it is truly the superior approach to treatment. Numerous studies have established that radiological outcomes are poor predictors of functional outcomes in elderly patients, 7 8 14 35 36 37 so we will focus on functional outcome for our analysis, as many included studies report on this age group. Comparison of these treatment outcomes has not yet been thoroughly investigated.

The purpose of this meta-analysis is to determine if volar plating is the superior method for the treatment of distal radius fractures, as it has emerged as a popular choice. We will address this through the examination of complications, function scores and assessments, and radiographic data and the following questions: First, is volar plating superior to dorsal plating, percutaneous pins, external fixation, or casting for distal radius fractures in terms of complications such as malunion, loss of reduction, hardware failure, and infection? Second, does volar plating produce superior functional outcomes to dorsal plating, percutaneous pins, external fixation, or casting for distal radius fractures? Third, are the radiographic outcomes superior for volar plating when compared with dorsal plating, percutaneous pins, external fixation, or casting?

Methods

Literature Search

A search was conducted of the University Libraries Database using the EBSCOhost search tool. Search included MEDLINE, Academic Search Ultimate, Academic Search Complete, CINAHL Plus, and JSTOR databases. Search terms were as follows: distal radius fracture AND volar plate OR dorsal plate OR percutaneous pins, K-wires, pinning OR external fixation OR nonoperative, casting, conservative. Results were restricted to full text, scholarly/peer reviewed journals, papers written in the English language, and published after the year 2000.

Inclusion and Exclusion Criteria

Inclusion criteria were comparative studies for distal radius fracture treatment, papers reporting on functional outcomes and complications, and human subjects. Exclusion criteria were review and meta-analysis papers, study protocols, comparison studies that did not compare volar plate to another treatment method, and repeated data.

Literature Review

Initial search identified 8,035 results. Relevant titles were screened and papers meeting inclusion criteria were subject to full-text review. Full-text review yielded 38 studies to be included for meta-analysis 38 ( Fig. 1 ). Study quality was evaluated using the Cochrane Risk of Bias 2 tool 39 for randomized controlled trials ( Fig. 2 ). Studies were reviewed and evaluated independently by one author (JB). Any questions or inconsistencies were discussed with a second author (JL).

Fig. 1.

Fig. 1

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Study selection—flow diagram showing study selection process according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 guidelines. 38

Fig. 2.

Fig. 2

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Risk of bias—summary of the risk of bias assessment conducted with the Cochrane RoB2 tool.

Outcome Measures

Data was sought for complications reported, including revision, delayed union, nonunion, malunion, loss of reduction, hardware failure, infection, and other complications. Functional outcome data was also recorded, including grip strength, range of motion, and Patient Related Wrist Evaluation (PRWE), Disabilities of the Arm, Shoulder, and Hand (DASH), and Gartland and Werley scores. Radiographic assessment information was documented, including radial inclination, radial height, volar tilt, and ulnar variance.

Statistical Methods

The principal summary measure used for complication data was odds ratio (OR). Mean difference (MD) was the principal summary measure used for functional and radiographic outcomes. Results of studies were synthesized for meta-analysis using Cochrane Review Manager 5.3 40 and I 2 was calculated as a measure of consistency. A random effects model was used for analysis and the significance level was p  = 0.05.

Results

Healing Time

Healing time was reported for volar plate versus percutaneous pins. There was no significant difference between groups for this comparison ( Fig. 3A ; MD = 0.70; confidence interval [CI] = –0.80,2.20; p  = 0.36).

Fig. 3.

Fig. 3

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Healing time and complications— forest plots showing ( A ) healing time (in weeks), ( B ) revision, ( C ) malunion, and ( D ) loss of reduction reported at final follow-up. CI, confidence interval; IV, intravenous.

Complications

Volar plates outperformed various other treatment methods for many of the recorded types of complications at final follow-up. There was no significant difference between volar plates and external fixation for patients requiring revision surgery ( Fig. 3B ; OR = 0.81; CI = 0.24,2.67; p  = 0.73). There was not sufficient data to compare revision outcomes for dorsal plate, percutaneous pins, or casting. Nonoperative treatment resulted in significantly more instances of malunion than volar plating ( Fig. 3C ; OR = 0.01; CI = 0.00,0.09; p  = 0.0002). No other treatment method reported enough malunion data for calculation. Loss of reduction was significantly higher for patients treated with percutaneous pins (OR = 0.13; CI = 0.03,0.71; p  = 0.02) and casting (OR = 0.03; CI = 0.01,0.10; p  < 0.00001), but showed no significant difference when compared with external fixation ( Fig. 3D ; OR = 0.76; CI = 0.20,2.88; p  = 0.69). There was insufficient data to make this comparison for dorsal plating. There was no significant difference between volar plate and external fixation in terms of hardware failure ( Fig. 4A ; OR = 0.79; CI = 0.22,2.91; p  = 0.73). Volar plating resulted in significantly less reports of infection compared with percutaneous pins (OR = 0.54; CI = 0.31,0.95; p  = 0.03) and external fixation (OR = 0.14; CI = 0.07,0.30; p  < 0.00001), but showed no significant difference when compared with casting ( Fig. 4B ; OR = 3.52; CI = 0.71,17.44; p  = 0.12). There was not sufficient infection data for the dorsal plate group. There was no significant difference between volar plate and dorsal plate (OR = 0.84; CI = 0.31,2.26; p  = 0.73), percutaneous pins (OR = 1.37; CI = 0.89,2.11; p  = 0.15), external fixation (OR = 0.74; CI = 0.46,1.17; p  = 0.20), or casting (OR = 0.64; CI = 0.26,1.60; p  = 0.34) for the sum of all other complications ( Fig. 5 ).

Fig. 4.

Fig. 4

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Complications—forest plots showing ( A ) hardware failure and ( B ) infection reported by final follow-up. CI, confidence interval; IV, intravenous.

Fig. 5.

Fig. 5

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Other complications—forest plot showing total other complications reported at final follow-up. CI, confidence interval; IV, intravenous.

Function Scores

Volar plates also showed a trend toward superior function scores at final follow-up when compared with other treatment modalities.

PRWE Score

In terms of the PRWE score, patients treated with volar plate had significantly better scores than those treated by casting (MD = –9.07; CI = –14.57, –3.57; p  = 0.001), but there was no significant difference when compared with patients receiving percutaneous pins (MD =  − 1.40; CI =  − 4.41,1.61; p  = 0.36) or external fixation ( Fig. 6A ; MD =  − 2.01; CI =  − 5.04,1.03; p  = 0.20). There were too few studies reporting PRWE scores for dorsal plating to perform calculations.

Fig. 6.

Fig. 6

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Function scores—forest plot showing ( A ) Patient Related Wrist Evaluation (PRWE) score and ( B ) Disabilities of the Arm, Shoulder, and Hand (DASH) score reported at final follow-up. CI, confidence interval; IV, intravenous; SD, standard deviation.

DASH Score

Volar plating showed superior results for the DASH score when compared with percutaneous pinning (MD =  − 3.29; CI =  − 6.10, −0.49; p  = 0.02) and casting (MD =  − 4.81; CI =  − 8.93, −0.70; p  = 0.02), but scores were not significantly different from patients treated with dorsal plates (MD =  − 0.23; CI =  − 6.11, 5.64; p  = 0.94) or external fixation ( Fig. 6B ; MD =  − 1.96; CI =  − 4.30, 0.38; p  = 0.10).

QuickDASH Score

The QuickDASH score was also significantly better for volar plating when compared with external fixation ( Fig. 7A ; MD =  − 2.34; CI =  − 3.86, −0.81; p  = 0.003). There was not enough QuickDASH data to perform calculations for the other treatment groups.

Fig. 7.

Fig. 7

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Function scores—forest plot showing ( A ) Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, ( B ) Gartland and Werley score, and ( C ) grip strength (as percent of uninjured hand) reported at final follow-up. CI, confidence interval; IV, intravenous; SD, standard deviation.

Gartland and Werley Score

Volar plating outperformed dorsal plating for Gartland and Werley score (MD =  − 1.18; CI =  − 2.37,0.00; p  =  − 0.05), but was not significantly different from external fixation ( Fig. 7B ; MD =  − 0.71; CI =  − 1.66,0.24; p  = 0.14). Other treatment methods had insufficient Gartland and Werley score data for analysis.

Functional Outcomes

Grip Strength

There was no significant difference in grip strength when volar plating was compared with dorsal plating (MD = 0.47; CI =  − 0.21,1.14; p  = 0.18), percutaneous pinning (MD = 0.04; CI =  − 0.30,0.38; p  = 0.84), or external fixation (MD =  − 0.14; CI =  − 0.87,0.60; p  = 0.72). However, when compared with nonsurgical treatment, volar plating showed significantly higher grip strength at final follow-up ( Fig. 7C ; MD = 0.95; CI = 0.11,1.79; p  = 0.03).

Range of Motion

Many of the range of motion measures showed no significant difference, but any comparison with significant results favored those treated with volar plate.

Flexion: For flexion, there was no significant difference between volar plate and percutaneous pins (MD = 0.74; CI =  − 0.66,2.14; p  = 0.30) or nonsurgical treatment (MD = 0.62; CI =  − 0.33,1.58; p  = 0.20). Volar plating showed significantly better flexion when compared with external fixation ( Fig. 8A ; MD = 0.68; CI = 0.12,1.24; p  = 0.02).

Fig. 8.

Fig. 8

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Range of motion—forest plot showing ( A ) flexion and ( B ) extension, measured in degrees, reported at final follow-up. CI, confidence interval; IV, intravenous; SD, standard deviation.

Extension: There was no significant difference in extension measurements for any comparison group: volar plate versus percutaneous pins (MD = 0.53; CI =  − 0.30,1.36; p  = 0.22), nonsurgical treatment (MD = 0.74; CI =  − 0.29,1.77; p  = 0.16), or external fixation ( Fig. 8B ; MD = 0.49; CI =  − 0.04,1.03; p  = 0.07).

Radial deviation: For radial deviation, there was no significant difference when volar plate was compared with percutaneous pins (MD = 0.15; CI =  − 0.19,0.50; p  = 0.39), nonsurgical treatment, (MD = 0.62; CI =  − 0.50–1.74; p  = 0.28), or external fixation ( Fig. 9A ; MD = 0.61; CI =  − 0.15,1.37; p  = 0.12).

Fig. 9.

Fig. 9

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Range of motion—forest plot showing ( A ) radial deviation and ( B ) ulnar deviation, measured in degrees, reported at final follow-up. CI, confidence interval; IV, intravenous; SD, standard deviation.

Ulnar deviation: When ulnar deviation was analyzed, there was a significantly higher result for volar plate when compared with percutaneous pins (MD = 0.83; CI =  − 0.01,1.67; p  = 0.05) and nonsurgical treatment (MD = 1.01; CI = 0.01,2.02; p  = 0.05), but not external fixation ( Fig. 9B ; MD =  − 0.14; CI =  − 0.93,0.65; p  = 0.73).

Pronation: The volar plate group showed significantly higher values for pronation when compared with external fixation (MD = 0.55; CI = 0.20,0.91; p  = 0.002, but no significant difference was apparent when compared with percutaneous pins (MD = 0.03; CI =  − 0.30,0.35; p  = 0.86) or nonsurgical treatment ( Fig. 10A ; MD = 0.42; CI =  − 0.03,0.86; p  = 0.07).

Fig. 10.

Fig. 10

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Range of motion—forest plot showing ( A ) pronation and ( B ) supination, measured in degrees, reported at final follow-up. CI, confidence interval; IV, intravenous; SD, standard deviation.

Supination: When compared with nonsurgical treatment (MD = 0.37; CI = 0.02,0.73; p  = 0.04) and external fixation (MD = 0.74; CI = 0.23,1.25; p  = 0.004), volar plating showed significantly higher degrees of supination. This significant difference was not observed for the volar plate versus percutaneous pins group ( Fig. 10B ; MD = 0.48; CI =  − 0.08,1.04; p  = 0.09). There was not sufficient data to analyze range of motion for the remaining treatment groups.

Radiographic Assessment

Radial inclination: When volar plating was compared with percutaneous pinning (MD = 0.37; CI =  − 0.52,1.26; p  = 0.42) and external fixation (MD = 0.21; CI =  − 0.13,0.55; p  = 0.23), there was no significant difference in radial inclination. Radial inclination was significantly higher in the volar plate group when compared with dorsal plate (MD = 0.28; CI = 0.05,0.51; p  = 0.02) and nonsurgical treatment ( Fig. 11A ; MD = 1.50; CI = 0.76,2.23; p  < 0.0001).

Fig. 11.

Fig. 11

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Radiographic outcomes—forest plot showing ( A ) radial inclination (degrees) and ( B ) radial height (mm) reported at final follow-up. CI, confidence interval; IV, intravenous; SD, standard deviation.

Radial height: Volar plate showed significantly higher values for radial height when compared with nonsurgical treatment (MD = 1.50; CI = 0.67,2.33; p  = 0.0004), but not external fixation ( Fig. 11B ; MD = 0.05; CI =  − 0.32,0.42; p  = 0.79). There was insufficient data to analyze radial height for the other treatment groups.

Volar tilt: The volar plate group had significantly lower volar tilt measurements than the dorsal plate group (MD =  − 0.39; CI =  − 0.63, −0.14; p  = 0.002), while volar plating showed significantly lower measurements when compared with nonsurgical treatment (MD = 1.25; CI = 0.49, 2.02; p  = 0.001). There was no significant difference when volar plating was compared with percutaneous pinning (MD = 0.05; CI =  − 0.56,0.66; p  = 0.87) or external fixation ( Fig. 12A ; MD =  − 0.67; CI =  − 1.46,0.12; p  = 0.10).

Fig. 12.

Fig. 12

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Radiographic outcomes—forest plot showing ( A ) volar tilt (degrees) and ( B ) ulnar variance (mm) reported at final follow-up. CI, confidence interval; IV, intravenous; SD, standard deviation.

Ulnar variance: Volar plating compared with dorsal plating (MD =  − 0.09; CI =  − 0.61,0.43; p  = 0.72), nonsurgical treatment (MD =  − 1.13; CI =  − 2.83,0.57; p  = 0.19), and external fixation ( Fig. 12B ; MD =  − 0.33; CI =  − 0.75,0.08; p  = 0.12) showed no significant difference in ulnar variance. There was insufficient data to analyze ulnar variance for the percutaneous pin group. A summary of these findings can be found in Tables 1 and 2 .

Table 1. Summary of outcome and function results.

Outcome measure Comparison group Result
Revision VP vs. EF No significant difference ( p  = 0.73)
Malunion VP vs. nonsurgical Significantly higher for nonsurgical ( p  = 0.0002)
Loss of reduction VP vs. PP
VP vs. nonsurgical
VP vs. EF		 Significantly higher for PP ( p  = 0.02)
Significantly higher for nonsurgical ( p  < 0.00001)
No significant difference ( p  = 0.69)
Hardware failure VP vs. EF No significant difference ( p  = 0.73)
Infection VP vs. PP
VP vs. EF
VP vs. nonsurgical		 Significantly higher for PP ( p  = 0.03)
Significantly higher for EF ( p  < 0.00001)
No significant difference ( p  = 0.12)
Other complications VP vs. DP
VP vs. PP
VP vs. nonsurgical
VP vs. EF		 No significant difference ( p  = 0.73)
No significant difference ( p  = 0.15)
No significant difference ( p  = 0.34)
No significant difference ( p  = 0.2)
PRWE score VP vs. nonsurgical
VP vs. PP
VP vs. EF		 Significantly higher for nonsurgical ( p  = 0.001)
No significant difference ( p  = 0.36)
No significant difference ( p  = 0.2)
DASH score VP vs. DP
VP vs. PP
VP vs. nonsurgical
VP vs. EF		 No significant difference ( p  = 0.94)
Significantly higher for PP ( p  = 0.02)
Significantly higher for nonsurgical ( p  = 0.02)
No significant difference (p-0.1)
QuickDASH score VP vs. EF Significantly higher for EF ( p  = 0.003)
Gartland and Werley score VP vs. DP
VP vs. EF		 Significantly higher for DP ( p  = 0.05)
No significant difference ( p  = 0.14)
Grip strength VP vs. DP
VP vs. PP
VP vs. nonsurgical
VP vs. EF		 No significant difference ( p  = 0.18)
No significant difference ( p  = 0.84)
Significantly higher for VP ( p  = 0.03)
No significant difference ( p  = 0.72)
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Abbreviations: DASH, Disabilities of the Arm, Shoulder, and Hand; DP, dorsal plate; EF, external fixation; PP, percutaneous pins; PRWE, Patient Related Wrist Evaluation; VP, volar plate.

Table 2. Summary of range of motion and radiographic results.

Outcome measure Comparison group Result
Flexion VP vs. PP
VP vs. nonsurgical
VP vs. EF		 No significant difference ( p  = 0.3)
No significant difference ( p  = 0.2)
Significantly higher for VP ( p  = 0.02)
Extension VP vs. PP
VP vs. nonsurgical
VP vs. EF		 No significant difference ( p  = 0.22)
No significant difference ( p  = 0.16)
No significant difference ( p  = 0.07)
Radial deviation VP vs. PP
VP vs. nonsurgical
VP vs. EF		 No significant difference ( p  = 0.39)
No significant difference ( p  = 0.28)
No significant difference ( p  = 0.12)
Ulnar deviation VP vs. PP
VP vs. nonsurgical
VP vs. EF		 Significantly higher for VP ( p  = 0.05)
Significantly higher for VP ( p  = 0.05)
No significant difference ( p  = 0.73)
Pronation VP vs. PP
VP vs. nonsurgical
VP vs. EF		 No significant difference ( p  = 0.86)
No significant difference ( p  = 0.07)
Significantly higher for VP ( p  = 0.002)
Supination VP vs. PP
VP vs. nonsurgical
VP vs. EF		 No significant difference ( p  = 0.09)
Significantly higher for VP ( p  = 0.04)
Significantly higher for VP ( p  = 0.004)
Radial inclination VP vs. DP
VP vs. PP
VP vs. nonsurgical
VP vs. EF		 Significantly higher for VP ( p  = 0.02)
No significant difference ( p  = 0.42)
Significantly higher for VP ( p  < 0.0001)
No significant difference ( p  = 0.23)
Volar tilt VP vs. DP
VP vs. PP
VP vs. nonsurgical
VP vs. EF		 Significantly higher for DP ( p  = 0.002)
No significant difference ( p  = 0.87)
Significantly higher for VP ( p  = 0.001)
No significant difference ( p  = 0.1)
Radial height VP vs. nonsurgical
VP vs. EF		 Significantly higher for VP ( p  = 0.0004)
No significant difference ( p  = 0.79)
Ulnar variance VP vs. DP
VP vs. nonsurgical
VP vs. EF		 No significant difference ( p  = 0.72)
No significant difference ( p  = 0.19)
No significant difference ( p  = 0.12)
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Abbreviations: DP, dorsal plate; EF, external fixation; PP, percutaneous pins; VP, volar plate.

Discussion

For patients with distal radius fractures, there are several effective treatment options, but none have emerged as the clear treatment of choice. Recently, volar plating has gained momentum as a popular treatment choice. Therefore, we have chosen to compare volar plating to other accepted treatment methods for distal radius fractures to determine if volar plating is the superior method of treatment. We will accomplish this by addressing the following questions: First, is volar plating superior to dorsal plating, percutaneous pins, external fixation, or casting for distal radius fractures in terms of complications such as malunion, loss of reduction, hardware failure, and infection? Second, does volar plating produce superior functional outcomes to dorsal plating, percutaneous pins, external fixation, or casting for distal radius fractures? Third, are the radiographic outcomes superior for volar plating when compared with dorsal plating, percutaneous pins, external fixation, or casting?

One limitation to the literature is that there are relatively few prospective randomized trials for each treatment method. As a result, both prospective and retrospective studies were used for our analysis. Of the 38 included studies, 17 were prospective randomized trials, 4 used nonrandom allocation methods, and 17 were retrospective studies. According to the risk of bias assessment, randomization bias may be present due to the use of these nonrandomized studies ( Fig. 2 ). In the future, the analysis should be limited to prospective randomized controlled trials to ensure that treatment and data collection methods are standardized and controlled. The literature was limited in reported outcomes such that there was not sufficient data to examine all outcome variables for each treatment comparison. Another limitation to the literature is that authors may have differed in what outcomes were considered complications for reporting, which could also affect the results. Most comparison articles regarding treatment of distal radius fractures include volar plating. There are far fewer articles that compare other treatment methods to each other, so more studies should be done to establish a hierarchy of treatment methods as opposed to one superior method. A limitation to our analysis is that the comparison of “other complications” may be skewed due to extraction of specific outcomes for independent analysis. Separating outcomes such as infection and hardware failure from total complications may cause the analysis to be misleading, especially if the complications from one treatment method were dominated by those that were separated. In the future, total complications could be analyzed as opposed to other complications. This analysis examined patients of all ages with all classes of fractures. To make more accurate and applicable treatment recommendations, more specific analyses should be done to address different age groups and fracture types. Our analysis provides a more general overview of treatment results for all patients. It is also important to address the publication bias of this meta-analysis, as the included studies and subsequent results may not be representative of the full body of data relating to treatment of distal radius fractures.

Volar plating had less complications when compared with many of the other treatment methods for distal radius fractures. There was no significant difference when compared with dorsal plating, but volar plating had significantly less instances of loss of reduction and infection than percutaneous pin treatment. There were also significantly less instances of loss of reduction and malunion for volar plating than for nonoperative treatment. When compared with external fixation, volar plating had significantly less cases of infection. While there was no significant difference between groups for many complication measures, there was no occurrence of any treatment method performing significantly better than the volar plate group.

Volar plating showed superior function scores on many occasions as well. When compared with dorsal plating, volar plating had significantly superior Gartland and Werley scores. The volar plate group had a significantly lower DASH score than the percutaneous pin group. Volar plating outperformed nonoperative treatment in the PRWE and DASH scores. When compared with external fixation, volar plating had a significantly lower QuickDASH score. As with complications, there were no instances of other treatment methods outperforming volar plating in terms of function score, while many showed no significant difference.

Volar plating showed superior functional outcomes when compared with other treatment methods as well. Many measures showed no significant difference between treatment groups, but any comparison showing a significant difference favored volar plating. The volar plate group outperformed the percutaneous pin group for ulnar deviation. Volar plating showed superior outcomes for grip strength, ulnar deviation, and supination when compared with casting. Compared with external fixation, volar plates showed superior results for flexion, pronation, and supination. These superior functional outcomes associated with volar plating may be a result of earlier movement ability.

Many radiologic measures showed no significant difference between treatment types. There were no significant differences for any radiologic parameter when volar plating was compared with percutaneous pins or external fixation. For the volar plate versus dorsal plate group, volar plates showed significantly higher radial inclination and lower volar tilt. When compared with casting, volar plating showed significantly higher radial inclination, radial height, and volar tilt. Numerous studies have established that radiological outcomes are poor predictors of functional outcomes in elderly patients, 7 8 14 35 36 37 so it is important to focus more on functional outcomes for these patients, which make up a significant portion of distal radius fractures.

Based on our analysis, volar plating is the most successful treatment method for distal radius fractures in terms of complications and functional outcomes. All variables that resulted in a significant difference between groups favored volar plates. Therefore, open reduction internal fixation with volar plates should be considered in cases when surgical treatment is indicated. The other methods examined—dorsal plate, percutaneous pins, external fixation, and nonoperative treatment—are still acceptable forms of treatment and should be considered based on the patient's needs. Casting may be preferred for patients with undisplaced, stable fractures, 28 41 but could require later surgical treatment if satisfactory results are not achieved. 16 While volar plates were superior to other treatment methods in certain measures of complications and functional outcomes, many comparisons showed no significant difference between groups. Therefore, all treatment methods analyzed should be considered for patients with distal radius fractures.

In conclusion, treatment decisions should be made based on fracture type and stability, patient goals and preferences, and cost as all methods examined provide acceptable results. Further studies are needed to compare the various methods of treatment with each other, not just with volar plates, to establish a hierarchy of preferred treatment methods as opposed to one superior one.

Footnotes

Conflict of Interest None declared.

References

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